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{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 0, 235 ] ], "word_ranges": [ [ 0, 42 ] ], "text": "He describes S1 root involvement by the inability to tiptoe and the absence of the Achilles reflex, in addition to the distribution of pain down the leg. Of our options, the cause that can produce damage to S1 is L5-S1 disc herniation." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Right L2-L3 disc herniation.", "2": "Right L3-L4 disc herniation.", "3": "Right L4-L5 disc herniation.", "4": "Right L5-S1 disc herniation.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1111_17694", "title": "Spontaneous regression of a large sequestered lumbar disc herniation: a case report and literature review.", "score": 0.0166532366371206, "content": "Lumbar disc herniation is a common disorder in adults that is accompanied by lower back and radicular pain. A 32-year-old man visited our clinic with 1-week history of persistent lower back pain and weakness in his right big toe. Magnetic resonance imaging (MRI) of his lumbar spine revealed herniated discs at L3/L4, L5/S1 and L4/L5, where a right-sided intraspinal mass lesion deep to the L4 vertebral body was causing compression of the nerve root. The patient underwent conservative treatment and reported no symptoms referrable to his back or leg 4 months later. Follow-up MRI showed no herniation of the nucleus pulposus at the L4/L5 level or lesion deep to the vertebral body of L4, whereas no changes had occurred to the status of the herniated L3/L4 and L5/S1 discs. The present case and a literature review show that a sequestered lumbar disc herniation can regress within a relatively short timeframe without surgery. The authors emphasise the utility of conservative therapy for patients who do not have a definitive surgical indication." }, { "id": "pubmed23n0968_3045", "title": "Report of an Isolated L5 Radiculopathy Caused by an L2-3 Disc Herniation and Review of the Literature.", "score": 0.01464346349745331, "content": "Intervertebral disc herniation is a common cause of radiculopathy. Disc herniations occurring in the lumbar spine typically affect the nerve root exiting under the pedicle of the vertebral body, one level caudal. However, in rare cases, a disc herniation can cause remote isolated radicular symptoms. The authors present the case of a 70-year-old male who presented with an acute, new-onset, left-sided foot drop, low back pain, and a classic L5 monoradiculopathy. Imaging revealed a large, left-sided paracentral extruded L2-3 disc and the absence of any pathology at the L4/5 level. Although the patient's clinical presentation and imaging did not classically correlate, it was felt that the L2-L3 disc was the etiology of the patient's L5 radiculopathy and a left L2-3 microsurgical discectomy was performed. At the six-week follow-up, his foot drop was near normal, sensation was intact with minimal paresthesias, and he remained pain-free. At the one-year follow-up, he experienced full resolution of his foot drop and remained symptom-free. Although rare, disc herniations may cause isolated, remote, painful mononeuropathies not related to the direct level of nerve root compression and should be considered along with other etiologies of peripheral neuropathies." }, { "id": "article-24453_19", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.014328808446455506, "content": "A straight leg raise test is a neurological maneuver performed while examining a patient presenting with lower back pain. It is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner slowly elevates the leg progressively at a slow pace. The test is positive when it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 45 degrees with radiation below the knee (Lasegue sign). It is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner is raising the leg (Bragaad's sign) to increase the sensitivity of the test." }, { "id": "article-24453_17", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.014067656765676569, "content": "L5 nerve root exits at the L5-S1 foramina. When compressed by a herniated disc, it causes back pain that radiates into the buttock, lateral thigh, lateral calf, the dorsum of the foot, and the great toe. Sensory loss is present on the web space between the big toe and second toe, the dorsum of the foot, and lateral calf. There is a weakness in hip abduction, knee flexion, foot dorsiflexion, big toe dorsiflexion, foot inversion, and eversion. Patients present with decreased semitendinosus/semimembranosus reflex. Weakness in foot dorsiflexion makes it challenging to walk on the heels. Chronic L5 radiculopathy may cause atrophy of the extensor digitorum brevis and the tibialis anterior of the anterior leg." }, { "id": "pubmed23n0264_16158", "title": "Extreme lateral lumbar disc herniation: clinical presentation in 178 patients.", "score": 0.013306982872200264, "content": "A retrospective analysis of clinical characteristics of 178 consecutive patients with extreme lateral lumbar disk herniation, amongst 3047 patients operated on for herniated lumbar disc, is presented. The level specific incidence of extreme lateral disc herniation (ELLDH) ranged from a low of 4.5% at L4-5 to peak of 17.4% at L3-4 although the largest number of ELLDH occurred at L4-5 and L5-S1 for a total number of 139 cases (78.1%). 43.6% of all L3 radiculopathies were caused by an L3-4 ELLDH, whereas only 4.4% of all L5 radiculopathies were caused by an L5-S1 ELLDH. Leg pain, either of the sciatic or the femoral type, was the first and dominant clinical symptom of radiculopathy, but pain radiation occurred not always in the appropriate dermatomal segment. ELLDH at upper levels (L2-3 and L3-4) caused usually none or only minor low back signs (76.2%), whereas ELLDH at lower levels more often caused moderate or major lumbar symptoms and signs (59.6%). Positive femoral nerve traction test with upper ELLDH showed a high frequency (84.4%) and reliability and is therefore an important clinical parameter in this situation. Motor deficits occurred more often (78.8%) than sensory deficits (46.6%), were usually of the monoradicular type and were therefore a more reliable clinical sign than sensory disturbances." }, { "id": "article-24453_16", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.01322841829170943, "content": "L4 nerve root exits at the L4-L5 foramina. L4 has a reflex assessed with a patellar reflex. When compressed by a herniated disc, it causes back pain that radiates into the anterior thigh and the medial aspect of the leg, accompanied with sensory loss in the same distribution, weakness in the hip flexion and adduction, weakness in knee extension, and a decreased patellar reflex." }, { "id": "article-28772_11", "title": "Sciatica -- History and Physical", "score": 0.013178561851128222, "content": "Another maneuver is the crossed straight leg test, similar to the straight leg raise test but is conducted on the asymptomatic leg instead. The crossed straight leg test is considered positive if the patient reports pain in the symptomatic leg while the asymptomatic leg is at a 40° angle, representing a central disc herniation with severe nerve root irritation. L3 radiculopathy includes weakness of hip adduction, knee extension, and sensory pain in the anteromedial dermatome of the thigh. Ankle dorsiflexion weakness and absent patellar reflex are present in L4 radiculopathy. Hip abduction and big toe extension weakness show L5 radiculopathy. S1 nerve root compression presents as absent ankle reflexes." }, { "id": "article-20584_16", "title": "Disc Herniation -- History and Physical -- Physical Examination", "score": 0.012966066854305682, "content": "L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf, and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex. S1 Nerve - back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex." }, { "id": "InternalMed_Harrison_1475", "title": "InternalMed_Harrison", "score": 0.012535367644425345, "content": "The straight leg–raising (SLR) maneuver is a simple bedside test for nerve root disease. With the patient supine, passive flexion of the extended leg at the hip stretches the L5 and S1 nerve roots and 113 CHAPTER 22 Back and Neck Pain 4th Lumbar vertebral body 5th Lumbar vertebral body 4th Lumbar pedicle L4 root Protruded L4-L5 disk L5 Root S1 Root S2 Root Protruded L5-S1 disk FIguRE 22-3 Compression of L5 and S1 roots by herniated disks. (From AH Ropper, MA Samuels: Adams and Victor’s Principles of Neurology, 9th ed. New York, McGraw-Hill, 2009; with permission.) the sciatic nerve. Passive dorsiflexion of the foot during the maneuver adds to the stretch. In healthy individuals, flexion to at least 80° is normally possible without causing pain, although a tight, stretching sensation in the hamstring muscles is common. The SLR test is positive if the maneuver reproduces the patient’s usual back or limb pain. Eliciting the SLR sign in both the supine and sitting positions can help" }, { "id": "article-24475_12", "title": "Lumbosacral Disc Injuries -- History and Physical", "score": 0.012481693516176274, "content": "L5 at the L5/S1 level, a disc herniation far laterally into the left/right neural foramen would compress the L5 nerve, resulting in weakness of hip abduction muscles, ankle dorsiflexion (anterior tibialis muscle), and/or extension of the great toe (extensor hallucis longus muscle). S1 at the L5/S1 level, a disc herniation centrally into the canal would compress the S1 nerve, resulting in weakness of ankle plantar flexion (gastrocnemius muscle)." }, { "id": "article-24453_15", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.012442830239440409, "content": "L1 nerve root exits at the L1-L2 foramina, assessed with a cremasteric reflex (male). When compressed by a herniated disc, it causes pain, and sensory loss in the inguinal region rarely causes weakness in the hip flexion. The L2 and L3 nerve roots exit at the L2-L3 and L3-L4 foramina, respectively. Symptoms worsen with sneezing, coughing, or leg straightening." }, { "id": "pubmed23n0751_23524", "title": "Intradural lumbar disc herniation associated with degenerative spine disease and rheumatoid arthritis.", "score": 0.012340600575894693, "content": "A case report. To demonstrate a case of intradural lumbar disc herniation including imaging studies, intraoperative imaging, and an intraoperative video. The first case of lumbar intradural disc herniation was reported as early as 1942; since then more than 150 cases have been reported, mostly in the lumbar spine. Gadolinium-enhanced magnetic resonance image (MRI) is considered the \"gold standard\" for diagnosing this entity, although it is rarely performed routinely in lumbar disc disease and diagnosis is often made intraoperatively. A 70-year-old man presented to the emergency department as a referral complaining of lower back pain, loss of sensation in the right thigh, and difficulty walking. On examination, he showed uneven gait, right-sided foot drop (1/5), hypesthesias in the right inguinal area and ventral thigh, and a positive straight leg raise test on the right. Anal sphincter tone was within normal limits. A magnetic resonance image of the lumbar spine showed a large mediolateral herniated disc at L3-L4, with caudal displacement and unclear signal changes intradurally. Intraoperatively, the herniated disc was found upon opening the dural sac. Intradural disc herniations are a rare entity. The opening and inspection of the dural sack should be considered when the correct spinal level can be confirmed and insufficient herniated disc material can be visualized extradurally." }, { "id": "article-24453_14", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.012232415902140673, "content": "A careful and thorough neurological examination can help to localize the level of lumbar disc herniation if it is causing radiculopathy. The correct knowledge of the anatomy of nerve roots and lumbar disc herniations would allow a proper interpretation of the clinical findings associated with this condition. The radiculopathy associated with LDH varies based on the herniation type and the level at which the herniation occurred. In paracentral or lateral herniation, the transversing nerve root is usually affected; a lateral herniation at L4-L5 would cause L5 radiculopathy. Extreme lateral (far lateral) herniations typically result in the exiting nerve root being affected; extreme lateral herniation at L4-L5 would cause L4 radiculopathy." }, { "id": "article-20584_15", "title": "Disc Herniation -- History and Physical -- Physical Examination", "score": 0.011981413873216063, "content": "A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location, and reflex loss associated with the different levels are described in Table 2. Table 2 . Typical findings of solitary nerve lesion due to compression by a herniated disc in the lumbar spine L1 Nerve - pain and sensory loss are common in the inguinal region. Hip flexion weakness is rare, and no stretch reflex is affected. L2-L3-L4 Nerves - back pain radiating into the anterior thigh and medial lower leg; sensory loss to the anterior thigh and sometimes medial lower leg; hip flexion and adduction weakness, knee extension weakness; decreased patellar reflex." }, { "id": "article-24453_18", "title": "Lumbar Disc Herniation -- History and Physical", "score": 0.011940224406712342, "content": "S1 nerve root exits at the S1-S2 foramina, assessed with the Achilles reflex. When compressed with a herniated disc, it presents with sacral or buttock pain that radiates into the posterolateral thigh, the calf, plantar or lateral foot or the perineum. Sensory loss is present on the calf, lateral, or plantar aspect of the foot. There is weakness on foot plantar flexion, hip extension, and flexion of the knee. Weakness in foot plantar flexion causes an inability to tiptoe walk. It could also cause urinary and fecal incontinence and sexual dysfunction. [5] [8] [9]" }, { "id": "pubmed23n0385_1694", "title": "Intraradicular disc herniations in the lumbar spine and a new classification of intradural disc herniations.", "score": 0.011904761904761904, "content": "A case report of intraradicular disc herniation. Intraradicular disc herniation is a special type of intradural disc herniations. In this report, we present the tenth case of intraradicular lumbar disc herniation and suggest a new classification for intradural disc herniations. A 32-year-old male was admitted to hospital having experienced pain in the lower back and right leg for 1 month prior to admission. Neurological examination revealed weakness of the extensor hallucis longus, positive Laségue's sign, decreased ankle reflex in his right lower extremity, and bilateral paravertebral muscle spasm. Magnetic resonance imaging (MRI) revealed a disc herniation with a posterolateral extruded fragment on the right at the level of the L5-S1 space. He underwent L5 laminectomy. During the operation, the right S1 root was found to be swollen and immobile. A longitudinal incision was made in the dura of the right S1 root and an intradural free disc fragment was removed, and the S1 root was relieved. The patient was free of pain postoperatively. We suggest a new classification for intradural disc herniations with this unusual case presentation and review the literature for pathogenesis, clinical picture, diagnosis and treatment." }, { "id": "InternalMed_Harrison_1471", "title": "InternalMed_Harrison", "score": 0.011115813231767527, "content": "PART 2 Cardinal Manifestations and Presentation of Diseases FIguRE 22-1 Vertebral anatomy. (From A Gauthier Cornuelle, DH Gronefeld: Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998; with permission.) Radicular pain is typically sharp and radiates from the low back to a leg within the territory of a nerve root (see “Lumbar Disk Disease,” below). Coughing, sneezing, or voluntary contraction of abdominal muscles (lifting heavy objects or straining at stool) may elicit the radiating pain. The pain may increase in postures that stretch the nerves and nerve roots. Sitting with the leg outstretched places traction on the sciatic nerve and L5 and S1 roots because the nerve passes posterior to the hip. The femoral nerve (L2, L3, and L4 roots) passes anterior to the hip and is not stretched by sitting. FIguRE 22-2 Spinal column. (From A Gauthier Cornuelle, DH Gronefeld: Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998; with permission.)" }, { "id": "article-28772_16", "title": "Sciatica -- Differential Diagnosis -- Herniated Lumbosacral Disc", "score": 0.01083283897758634, "content": "A careful and thorough neurological examination can help localize the level of lumbar disc herniation if causing radiculopathy. The radiculopathy associated with lumbar disc herniation varies based on the herniation type and the level at which the herniation occurred. In paracentral or lateral herniation, the transversing nerve root is usually affected. A lateral herniation at L4 to L5 would cause L5 radiculopathy. Extreme lateral (far lateral) herniations typically affect the exiting nerve root; far lateral herniation at L4 to L5 would cause L4 radiculopathy. A straight leg raise test at an angle lower than 70° suggests radiculopathies." }, { "id": "pubmed23n1139_11102", "title": "Pediatric lumbar disc herniation: a report of two cases and review of the literature.", "score": 0.010777922642329421, "content": "Lumbar disc herniation (LDH) is not a common condition in children. Most reports on pediatric LDH concern the outcomes of surgeries performed in children in whom nonsurgical treatment failed while the outcome of nonsurgical treatment of LDH in children was rarely reported. Case 1: a 10-year-old girl presented with back pain and sciatica in her left leg for over 3 months. The physical examination revealed exacerbation of back pain by waist extension or flexion, and a positive Lasegue's sign was revealed in her left leg. Magnetic resonance imaging (MRI) revealed lumbar disc herniation at the L5/S1 level. She was diagnosed with LDH. After receiving nonsurgical treatment of traditional Chinese medicine (TCM) for 30 days, the girl had mild low back pain and sciatica and the symptoms had resolved completely at the 3-month follow-up. There was no recurrence within the following 2 years. MRI performed 30 months later revealed that the herniated disc did not shrink significantly. However, she was totally asymptomatic at the follow-up performed 30 months later. Case 2: a 13-year-old boy presented with sciatica in his left leg for over 3 months. The physical examination revealed that Lasegue's sign was positive in the left leg, the level of muscle strength in the left ankle plantar flexors was grade 4. MRI revealed a lumbar disc herniation at the L5/S1 level. He was diagnosed with LDH. The boy underwent 2 weeks of TCM treatment, and exhibited a favorable outcome: only mild pain was noticed in his left buttocks after walking for more than 15 min. He was asymptomatic at the 3-month follow-up and there was no recurrence within the next 3 years. MRI scan performed at 40 months later showed no significant resorption of the herniated disc. However, he was totally asymptomatic at the follow-up performed 40 months later. For the nonsurgical treatment of pediatric LDH, resorption of herniated discs is not necessary for favorable long-term outcomes, and children with symptomatic LDH may become asymptomatic without resorption." }, { "id": "wiki20220301en108_15323", "title": "Nerve root", "score": 0.01054520358868185, "content": "Lower limb radiculopathies The cause is a herniated intervertebral disc, often on a single nerve root. The first sign of the nerve root sickness is usually lumbago, which usually occurs with periods of remission. The time to develop a full radicular syndrome may take several months or several years. Pain generally increases gradually, but it can also be sudden. Cold causes muscle contraction, which leads to increased previously hidden symptoms. Symptoms Scoliosis Paraspinal muscle contracture The reduction of lumbar lordosis Tingling or numbness Increased sensitivity Other inflammatory diseases L4 radiculopathy Pain located on the front of the thigh and shin further radiates towards the inner ankle, sometimes the medial toe Occasionally, failure of the quadriceps muscle and reflex weakness L5 radiculopathy Pain radiates to the side of the thigh and lower leg towards the back of the foot and toes 1–3 All reflexes are preserved" }, { "id": "pubmed23n0914_16904", "title": "Percutaneous endoscopic lumbar discectomy: minimally invasive technique for multiple episodes of lumbar disc herniation.", "score": 0.009900990099009901, "content": "Although open lumbar discectomy is a gold standard surgical technique for lumbar disc herniation (LDH), surgery-induced tissue injury may actually become a source of postsurgical pain. Percutaneous endoscopic lumbar discectomy (PELD) is introduced as a minimal invasive spinal technique for LDH. The PELD has gained popularity and shown successful results. The authors report the clinical usefulness of the PELD technique in two patients with the serial multilevel LDHs. A 32-year-old man suffered from radicular pain at the L5 dermatome due to the down migrated soft LDH at the L4-5 level. The PELD was performed to remove the ruptured fragments, yielding a complete decompression of the L5 nerve root. Four years later, he visited the clinic because of right leg radiating pain along the S1 dermatome. An MRI scan revealed the LDH at the L5-S1 level. The PELD with foraminoplasty was also performed successfully at the L5-S1 level. Two months after the second PELD, he visited the clinic again because of severe pain along the left L4 dermatome; consequently, the PELD was also performed at the L3-4 level without any complications. A 34-year-old man presented with radiating pain in the back and both legs at the L5 dermatome. The MR images show a disc extrusion at the L4-5. The patient underwent the PELD at the L4-5 via the left approach. After the PELD, the back and leg pain both improved. One year later, the patient suffered from severe pain in the back and the left anterior thigh. The MR images show a left paramedian LDH at the L2-3. After the PELD was performed at the L2-3, the pain was relieved. The final MR images show no signs of any aggravated degeneration of the intervertebral discs or the facet joints at all of the treated levels. When multiple episodes of LDH occur in a patient's life span, PELD could be considered as an alternative good technique to treat LDH in each step by preserving normal anatomic structures." }, { "id": "pubmed23n1133_12403", "title": "Total Resorption of a Chronic L4-L5 Disc Extrusion After Application of the Atlasprofilax Method: A Case Report.", "score": 0.009708737864077669, "content": "BACKGROUND The intervertebral disc extrusion resorption has been described in the literature by various authors. It occurs in up to 75% of patients with symptomatic extruded lumbar discs. The Atlasprofilax method favors osteo-musculo-articular rehabilitation processes, mainly impacting on 2 levels: the first is the bone anatomy of the atlanto-occipital joint, and the second is the fasciae located in the cervical region. CASE REPORT A 42-year-old male patient diagnosed by MRI with dehydration of L2-L3 to L5-S1 intervertebral discs, disc bulging at L2-L3 and L3-L4, and disc extrusion at L4-L5, received a one-time neuromuscular treatment, called the Atlasprofilax method, to the suboccipital region. In a repeat MRI 6 months later, the disc extrusion at L4-L5 was totally resorbed and improvement in the L3-L4 and L4-L5 disc bulges was seen. The patient's symptoms prior to the Atlasprofilax treatment included bilateral trapezius pain, right brachialgia, constant chronic low back pain, right sciatica, gait claudication, and paresthesia and dysesthesias in the lower limbs with associated pain and numbness in the calves. These symptoms were ameliorated after the treatment. The sciatica disappeared 1 week after the treatment and did not recur. In a follow-up 5 years later, the remaining symptoms had improved even further. CONCLUSIONS We propose that alterations of the cervical musculature and deep fascia could predispose to the development of lumbar disc abnormalities. We therefore also propose that improvements in this patient, both in symptoms and in imaging findings, are due to a reduction of the asymmetric distribution of forces and elastic loading as a result of the Atlasprofilax treatment." }, { "id": "Neurology_Adams_1600", "title": "Neurology_Adams", "score": 0.009639953542392568, "content": "The pain of herniated intervertebral disc varies in severity from a mild aching discomfort to severe knife-like stabs that radiate the length of the leg and are superimposed on a constant intense ache. Sciatic pain is perceived by the patient as originating deep in the buttock and radiating to the posterolateral thigh; it may progress to the calf and ankle—to the medial malleolus (L4), lateral malleolus (L5), or heel (S1). Distal radiation to the foot is infrequent and should raise concern of an alternative process. Abortive forms of sciatica may produce aching discomfort only in the lower buttock or proximal thigh and occasionally only in the lower hamstring or upper calf. With the most severe pain, the patient is forced to stay in bed, avoiding the slightest movement; a cough, sneeze, or strain is intolerable. The most comfortable position is lying on the back with legs flexed at the knees and hips and the shoulders raised on pillows to obliterate the lumbar lordosis. For some" }, { "id": "pubmed23n0683_6766", "title": "Segmental lumbar rotation in patients with discogenic low back pain during functional weight-bearing activities.", "score": 0.009615384615384616, "content": "Little information is available on vertebral motion in patients with discogenic low back pain under physiological conditions. We previously validated a combined dual fluoroscopic and magnetic resonance imaging system to investigate in vivo lumbar kinematics. The purpose of the present study was to characterize mechanical dysfunction among patients with confirmed discogenic low back pain, relative to asymptomatic controls without degenerative disc disease, by quantifying abnormal vertebral motion. Ten subjects were recruited for the present study. All patients had discogenic low back pain confirmed clinically and radiographically at L4-L5 and L5-S1. Motions were reproduced with use of the combined imaging technique during flexion-extension, left-to-right bending, and left-to-right twisting movements. From local coordinate systems at the end plates, relative motions of the cephalad vertebrae with respect to caudad vertebrae were calculated at each of the segments from L2 to S1. Range of motion of the primary rotations and coupled translations and rotations were determined. During all three movements, the greatest range of motion was observed at L3-L4. L3-L4 had significantly greater motion than L2-L3 with left-right bending and left-right twisting movements (p < 0.05). The least motion occurred at L5-S1 for all movements; the motion at this level was significantly smaller than that at L3-L4 (p < 0.05). Range of motion during left-right bending and left-right twisting at L3-L4 was significantly larger in the degenerative disc disease group than in the normal group. The range of motion at L4-L5 was significantly larger in the degenerative group than in the normal group during flexion; however, the ranges of motion in both groups were similar during left-to-right bending and left-to-right twisting. The greatest range of motion in patients with discogenic back pain was observed at L3-L4; this motion was greater than that in normal subjects, suggesting that superior adjacent levels developed segmental hypermobility prior to undergoing fusion. L5-S1 had the least motion, suggesting that segmental hypomobility ensues at this level in patients with discogenic low back pain." }, { "id": "pubmed23n0229_9875", "title": "[Electromyographical study of the straight leg raising test in lumbar disc herniation].", "score": 0.009615384615384616, "content": "The straight leg raising test is one of the most reliable test for the diagnosis of the disc herniation. It is well known that the pain is produced by the increased tension of the affected root. However, the patient's response to the pain evoked by the straight leg raising test is not uniform. In some patients the leg is raised beyond the straight leg raising positive angle without resistance and some young patients show the tight hamstrings phenomenon. To elucidate these phenomena, the muscle action of erector spinae, gluteus maximus and biceps femoris evoked by this test was studied electromyographically. The results are as follows: 1) The muscle action patterns in the patients of disc herniation which are not observed in normal group are classified into four groups, namely LGB type (erector spinae, gluteus maximus and biceps femoris act), GB type (gluteus maximus and biceps femoris act), G type (gluteus maximus only acts), B type (biceps femoris only act). These abnormal muscle actions disappear under general anesthesia and are different from the actions which are recorded when the patients resist passive straight leg raising intentionally. 2) In the case of L4-5 intervertebral disc herniation mainly gluteus maximus acts as the resisting force against the passive straight leg raising. On the other hand, biceps femoris acts mainly in the case of L5-S1 disc herniation. 3) The group of younger age and less degenerated disc shows more resistance against straight leg raising and records the action potential of resisting muscles in earlier stage of the leg raising test." }, { "id": "article-29356_9", "title": "Spinal Stenosis -- History and Physical", "score": 0.0095547829987664, "content": "Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathy symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Patients will present with complaints of cramping pain in the leg, calf, and or buttocks. They might report an increase in pain with walking or standing for prolonged periods and relief when sitting or leaning forward while using a shopping cart. [9] Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh." }, { "id": "pubmed23n0966_16069", "title": "Successful Endoscopic Surgery for L5 Radiculopathy Caused by Far-Lateral Disc Herniation at L5-S1 and L5 Isthmic Grade 2 Spondylolisthesis in a Professional Baseball Player.", "score": 0.009523809523809525, "content": "We report the case of a professional baseball player who had severe leg pain due to lumbar lateral disc herniation at L4-5 and isthmic spondylolisthesis at L5 (double crash syndrome). For early recovery to competitive level, we performed minimally invasive endoscopic decompression surgery without fusion. There are few reports to discuss the usefulness of minimally invasive treatment for top athletes. A 29-year-old professional baseball player who played catcher was referred to us with a complaint of right leg pain. The previous doctor diagnosed far-lateral disc herniation and Grade 2 isthmic spondylolisthesis and recommended arthrodesis at L5-S1 as treatment for both pathologies. Radiological imaging showed that the right L5 nerve root was impinged by the 2 lumbar disorders, namely, far-lateral disc herniation and a ragged edge around a pars defect. We had taken into account the patient's occupation and his wish to avoid a lengthy sick leave, and we had performed endoscopic decompression surgery during the offseason. The far-lateral disc herniation at L5-S1 was removed under local anesthesia by percutaneous endoscopic discectomy, after which the ragged edge at the pars defect was removed under general anesthesia using a microendoscopic discectomy system. Given that the patient did not have any low back pain, arthrodesis was not considered. The leg pain resolved after surgery. The following year (2015), the patient resumed playing baseball from the beginning of the season and played in 41 games. In the 2016 season, he played in 71 games without any symptoms. No further slippage was observed at radiological follow up 1 year after the surgery. Minimally invasive endoscopic surgery is an option for radiculopathy in very active patients who need an early return to their previous level of physical activity." }, { "id": "article-18089_27", "title": "Back Pain -- History and Physical", "score": 0.009523809523809525, "content": "Some provocative exercises can help provide clues about the cause of back pain. One is the straight-leg-raising (SLR) test, which is useful for diagnosing lumbar disk herniation. The test is performed by raising the patient’s leg to 30° to 70°. The result is positive if ipsilateral leg pain develops at less than 60°. A crossed SLR test raises the leg contralateral to the side of disk herniation. A positive crossed SLR test result is even more specific than a positive SLR test. [15] [16]" }, { "id": "InternalMed_Harrison_1490", "title": "InternalMed_Harrison", "score": 0.00947851966873706, "content": "Fever, constant pain uninfluenced by position, sphincter abnormali-115 ties, or signs of spinal cord disease suggest an etiology other than lumbar disk disease. Absence of ankle reflexes can be a normal finding in persons older than age 60 years or a sign of bilateral S1 radiculopathy. An absent deep tendon reflex or focal sensory loss may indicate injury to a nerve root, but other sites of injury along the nerve must also be considered. For example, an absent knee reflex may be due to a femoral neuropathy or an L4 nerve root injury. A loss of sensation over the foot and lateral lower calf may result from a peroneal or lateral sciatic neuropathy or an L5 nerve root injury. Focal muscle atrophy may reflect injury to the anterior horn cells of the spinal cord, a nerve root, peripheral nerve, or disuse." }, { "id": "pubmed23n0982_9242", "title": "A Novel Treatment Combination for Failed Back Surgery Syndrome, With a 41-Month Follow-Up: A Retrospective Case Report.", "score": 0.009433962264150943, "content": "The purpose of this retrospective case report was to describe chiropractic management of a patient with failed back surgery syndrome. A 45-year-old woman presented 2 years after L4-L5 and L5-S1 fusion surgery with low back and sciatic pain. Her physical exam included a positive straight leg raise and diminished lower-extremity reflexes and muscle strength. The patient's magnetic resonance imaging showed right disc bulging and annular tearing at L2-L3 and L3-L4 disc bulging with foraminal impingement. A total of 52 treatments were provided over 28 weeks consisting of multidirectional functional decompression (FD) unweighted gait training, core exercises while in FD, strengthening exercises on a vibration platform, and supine spinal FD with vibration and chiropractic spinal manipulative therapy. Over the course of treatment, the patient noted gradual improvement in function (Oswestry Disability Index) and pain (Numeric Rating Scale), with a reduction in pain medications. Follow-up of 41 months posttreatment revealed an Oswestry Disability Index score of 0 and Numeric Rating Scale score of 0, and the patient no longer was using any pain medication. After a course of care, the patient in this study reported resolution of symptoms, decrease in pain medications, and improvement of function." }, { "id": "article-20584_18", "title": "Disc Herniation -- History and Physical -- Physical Examination", "score": 0.009433962264150943, "content": "The contralateral (crossed) straight leg raise test: As in the straight leg raise test, the patient is lying supine, and the examiner elevates the asymptomatic leg. The test is positive if the maneuver reproduces the patient's typical pain and paresthesia. The test has a specificity higher than 90%." }, { "id": "pubmed23n0568_16469", "title": "Combined extraforaminal and intradiscal cement leakage following percutaneous vertebroplasty.", "score": 0.009345794392523364, "content": "A case report and review of the literature are presented. To describe an extremely rare case of combined extraforaminal and intradiscal cement leakage in different vertebral levels following percutaneous vertebroplasty. Cement leaks in vertebroplasty are relatively common but generally not clinically significant. To our knowledge, this is the first report of extraforaminal cement leakage inducing radiculopathy combined with intradiscal cement leakage evoking acute adjacent compression fracture. A 78-year-old woman with L2 and L5 osteoporotic compression fractures received vertebroplasty. Two weeks after surgery, the patient presented severe low back pain radiating to the right thigh, with associated weakness and numbness in the right thigh and lower leg. Roentgenographic images revealed cement leakage into the right extraforamen of L2-L3 as well as leakage into L4-L5 disc with acute adjacent compression fracture of L4. Surgical intervention was required to relieve discomfort. One-stage posterior approach was performed: right L2-L3 intertransverse process approach with removal of extraforaminal leaked cement and posterior instrumentation from L3-L5 and posterior fusion. The severe low back pain, leg pain, and neurologic deficit associated weakness all improved after surgery. Although considered a minimally invasive procedure, percutaneous vertebroplasty with polymethylmethacrylate is not risk free. Intractable neurologic complications can occur if it is not performed by experienced physicians under appropriate indications and cautionary safeguards." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 204, 511 ] ], "word_ranges": [ [ 32, 80 ] ], "text": "Since he is a young male, with a history of previous respiratory infections, a relationship between these infections and renal pathology is established. Based on this we think about IgA nephropathy, which besides being the most frequent glomerulonephritis, it is presented in most of the cases as described." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Minimal change nephropathy.", "2": "Membranous glomerulonephritis.", "3": "IgA nephropathy.", "4": "Proliferative and diffuse glomerulonephritis.", "5": "Focal and primary segmental glomerulosclerosis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0346_15699", "title": "Long-term outcome of adult patients with minimal urinary abnormalities and normal renal function.", "score": 0.017331932773109245, "content": "To define the long-term outcome of patients with minimal urinary abnormalities (defined by the presence of microscopic hematuria with no or less than 1 gm/day proteinuria), and normal renal function (defined by a serum creatinine &lt; 1.3 mg/dl), we retrospectively studied patients who fulfilled the above criteria and had a kidney biopsy done before the year of 1992 (i.e. at least followed up for 5 years), with a definite pathological diagnosis. A total of 41 cases among 719 cases of primary glomerulonephritis (5.7%) were enrolled into the study. There were 19 males and 22 females with a mean age of 35.4+/-14.7 years at biopsy. The duration of renal disease was 116.0+/-60.5 months and the duration of follow-up post biopsy was 100.2+/-38.1 months. The pathological diagnosis was: IgA nephropathy (21 cases), focal glomerulosclerosis (9 cases), mesangial proliferative glomerulonephritis (8 cases), membranous glomerulonephritis (2 cases) and acute glomerulonephritis (1 case). At the end of follow-up, 8 cases (19.5%) had a certain degree of renal insufficiency including 2 (4.9%) in end-stage renal disease. The other cases were either in complete remission (6 cases) or stable condition (27 cases) with persistent microscopic hematuria and normal renal function. The long-term outcome was not correlated with any of the following parameters: age, sex, disease duration, serum creatinine at presentation, daily protein loss at presentation, degree of glomerular change and degree of interstitial inflammatory cell infiltration. However, a poor long-term outcome was correlated with tubular atrophy (p &lt; 0.05) and interstitial fibrosis (p &lt; 0.05). We conclude that a minimal urinary abnormality with normal renal function at presentation does not necessarily imply a favorable long-term outcome in certain patients. Tubular atrophy and interstitial fibrosis but not glomerular change correlates with a worse prognosis. This further emphasizes the importance of renal biopsy in such cases." }, { "id": "pubmed23n0091_10148", "title": "[Clinicopathological correlation of young onset chronic glomerulonephritis].", "score": 0.016950369891546364, "content": "In a retrospective analytical study involving 98 children with primary glomerulonephritis who were seen by us at our hospital during a 2-year period from 1984 through 1985 and who had renal biopsy performed previously, attempts were made to correlate pathological findings with both clinical findings and prognosis. The results are summarized as follows: 1) Of 87 patients with asymptomatic chronic glomerulonephritis, glomerular findings were those of minimal change lesion, mesangial proliferative nephritis, MPGN, membranous nephropathy and FGS or sclerosing nephritis in 29.9%, 51.7%, 13.8%, 1.1% and 3.5%, respectively. Among the other 11 patients in whom the diagnosis was made after manifesting the nephritic symptoms, minimal change was noted less frequently and MPGN was detected more frequently than in the aforementioned asymptomatic group. IgA nephropathy was estimated to account for 44.2% of cases of asymptomatic chronic nephritis. 2) Mild mesangial proliferation was observed relatively frequently and severe mesangial proliferation or MPGN rather infrequently in hematuria cases without proteinuria while in those with severe proteinuria minimal change lesion was uncommon and severe mesangial proliferative changes, MPGN or FGS were relatively frequent. 3) In 22 patients with IgA nephropathy and 11 with non-IgA nephritis the severity of glomerular changes was related to the intensity of proteinuria at the time of renal biopsy. 4) A 3 to 5 years' follow-up study of patients with mesangial proliferative nephritis inclusive of IgA nephropathy disclosed that 26-28% of patients became free from urinary abnormalities, 27-37% had persistent hematuria without proteinuria and 24-32% still had proteinuria of 2 plus or above. Patients with milder glomerular changes had a definitely better prognosis than those with severe glomerular lesions." }, { "id": "pubmed23n0212_17134", "title": "Crescentic IgA nephropathy.", "score": 0.015936507936507936, "content": "We report five cases of crescentic IgA nephropathy. All are males, 16-60 years of age. One case each came to medical attention with uremia, nephrotic syndrome, and gross hematuria; two cases presented with microhematuria and proteinuria on routine urinalysis. All had hypertension, azotemia (serum creatinine 1.6-9.4 mg/dl), proteinuria (greater than 6 g/24 hr in four cases), hypoalbuminemia (less than 3 g/dl), and hematuria (gross in two cases). All progressed to end-stage renal failure renal failure ending in dialysis (three cases) or death from unrelated causes (two cases). Prednisone, 60 mg/day for 1 month in two patients (with two 1-g doses of iv methylprednisolone in 1 case) did not improve the serum creatinine level, but one patient subsequently experienced a less rapid fall in renal function. A crescentic glomerulonephritis was present in all biopsies (crescents in 31-80% of glomeruli; mean, 50%). The size and stage of the crescents were variable. Numerous glomeruli had focal or diffuse sclerosis. In all cases, there was a 3 or 4+ deposition of IgA. Low-intensity staining for IgG and IgM was noted in four and three patients, respectively. On electron microscopy, dense granular mesangial deposits were noted in all cases and in four patients capillary subepithelial deposits were also observed. This form of IgA nephropathy is not common, but some studies indicate that it may occur in about 5% of patients with IgA nephropathy." }, { "id": "pubmed23n0129_12792", "title": "Berger's disease in children. Natural history and outcome.", "score": 0.015537488708220417, "content": "The clinical course and outcome of 91 children less than 15 years of age at onset and followed for at least 1 year have been retrospectively analyzed. The course has been characterized by recurrent macroscopic hematuria in 74 patients, by proteinuria-microscopic hematuria and a single episode of macroscopic hematuria occurring either at onset or a few months later in 8, by proteinuria-microscopic hematuria in 7, and by proteinuria only in 1. Lastly, one patient showed rapidly progressive renal failure. Four groups were identified by light microscopy: minimal glomerular changes (26), focal and segmental glomerulonephritis (41), pure mesangial proliferation (3) and proliferative glomerulonephritis with crescents (21). A good correlation was found between the glomerular lesions observed by light microscopy and the outcome. In this series we have not observed a dramatic clinical deterioration suggesting a transformation from one histologic type to another, as reported by others. None of the 70 patients belonging to the first three groups has impaired renal function but two with focal and segmental glomerulonephritis have developed hypertension. Although the clinical course is benign, many patients have, at the last observation, an abnormal urinalysis characterized by microscopic hematuria and/or mild proteinuria; the proteinuria is over 1 g/24 h in six patients with focal and segmental glomerulonephritis. Ten patients remained in clinical remission for several years, but mesangial IgA deposits were still present in the only patient who had a repeat biopsy while in remission. In contrast, none of the patients with proliferative glomerulonephritis with crescents has had a prolonged remission. Six patients developed terminal renal failure 0.7, 0.11, 2, 4, 8 and 10 years after onset. Two additional patients are in moderate chronic renal failure with hypertension 10 and 12 years after onset. Most children show a persistent nephropathy, (in five proteinuria is over 1 g/24 h), and two of them have developed hypertension. Therapeutic trials using drugs with side-effects should, therefore, be used only in this group of patients." }, { "id": "pubmed23n0064_5606", "title": "[A case of childhood IgA nephropathy who developed rapidly progressive glomerulonephritis in one-year clinical course].", "score": 0.015407319952774497, "content": "A 10-year-old girl who presented with microscopic hematuria, proteinuria and normal renal function has been followed up for the past two years. At the first examination, renal biopsy revealed focal/segmental lesions accompanying by occaisional necrosis and small crescents. Diagnosis of IgA nephropathy was given by light, electron and immunofluorescent microscopic findings. She started on the treatment with dipyridamol and was followed up for one year without any serious complications. Thereafter, she suddenly developed severe deterioration of renal function (serum creatinine 2.7 mg/dl) with nephrotic syndrome and hypertension. The second renal biopsy done at this time indicated the presence of typical crescentic glomerulonephritis with mesangial proliferation. No vasculitis was noted. She was intensively treated with steroids, anticoagulants and other medication and responded fairly well clinically. The third renal biopsy performed 5 months afterwards demonstrated marked histological improvement, but there was still present mesangial proliferation and varied degrees of sclerotic changes with fibrocellular crescents. Focal interstitial fibrosis and collapsed tubules were also seen. At present, 5 months after the last renal biopsy, she has improved much better and her serum creatinine decreased to 1.9 mg/dl, although proteinuria of 3 g/day still persists. It is suggested that only a small segmental necrosis with crescent formation in IgA nephropathy should be considered as an important indicator of disease activity in the evaluation of prognosis." }, { "id": "pubmed23n0731_16523", "title": "Clinical outcomes and predictors for ESRD and mortality in primary GN.", "score": 0.015053523639607493, "content": "Relatively little is known about the long-term outcomes of different histologic types of primary glomerulonephritis in Asian populations. From 1993 to 2006, 987 patients undergoing renal biopsy were studied, and 580 patients (mean age=44.4 years, male=58.5%) with the four most common forms of glomerulonephritis (membranous nephropathy, focal and segmental glomerulosclerosis, IgA nephropathy, and minimal change disease) were selected for analysis. Median follow-up period was 5.9 (interquartile range=5.7) years. The focal and segmental glomerulosclerosis group displayed the highest incidence of ESRD (25.8%) and the fastest decline of estimated GFR (4.6 ml/min per 1.73 m(2) per year). The IgA nephropathy group also had a higher rate of ESRD than the membranous nephropathy patients (19.2% versus 4.3%, P&lt;0.001). In contrast, the membranous nephropathy group exhibited an overall death rate similar to the focal and segmental glomerulosclerosis group (17.2% versus 14.4%) but higher than the IgA nephropathy and minimal change disease patients (4.6% and 3.7%, respectively, P&lt;0.001). The most powerful predictor for ESRD was focal and segmental glomerulosclerosis, whereas the strongest predictor for all-cause mortality was membranous nephropathy with higher proteinuria. Protectors against ESRD included male sex and higher hemoglobin. Most predictors for ESRD and overall mortality found in this ethnic Chinese cohort were similar to other studies. However, some risk factors linked with distinct glomerular pathologies displayed differential clinical outcomes." }, { "id": "pubmed23n0820_14586", "title": "Renal biopsy findings and clinical indicators of patients with hematuria without overt proteinuria.", "score": 0.014359900654775343, "content": "Whether to perform a renal biopsy for isolated hematuria remains a matter of controversy. We performed renal biopsy in hematuria without overt proteinuria patients and reported the proportion of glomerulonephritis, pathological activities, and statistical analysis of indicators associated with glomerulonephritis. Among 203 patients who underwent renal biopsy in Okubo Hospital, Japan, between January 2008 and October 2013, we identified 56 patients who fulfilled the criteria: (1) urine dipstick examination shows equal to or greater than ± blood on three or more visits, (2) proteinuria &lt;0.3 g/day (g/g Cr), (3) eGFR ≧60 ml/min/1.73 m(2), and (4) no current medication for renal disease. We investigated biopsy findings and compared the clinical indicators in the IgA nephropathy (IgAN) and non-IgAN group. The pathological diagnosis was IgAN in 35 cases (62 %), thin basement membrane disease (TBMD) in 7 (13 %), minor glomerular abnormality (MGA) in 6 (11 %), glomerular basement membrane (GBM) abnormality in 5 (9 %), and others in 3 (5 %). The histological grade of IgAN was I in 90 % and II in 10; 31 % of patients had some crescentic lesions. Comparisons between the IgAN and non-IgAN group revealed significant differences in age of onset (26 ± 13 vs. 34 ± 17 years, p = 0.04), serum IgA (340 ± 114 vs. 220 ± 101 mg/dl, p &lt; 0.01), proteinuria (0.08 [0-0.25] vs. 0 [0-0.23] g/day [g/gCr], p &lt; 0.01), and the presence of poikilocytes (40 vs. 10 %, p = 0.02). The proportion of IgAN in hematuria without overt proteinuria was high and the pathological activities were variable. Patients with hematuria without overt proteinuria should continue their medical follow-up and the best timing of biopsy may be controversial for these patients who have multiple risk factors of IgAN." }, { "id": "wiki20220301en026_25242", "title": "IgA nephropathy", "score": 0.013763806287170773, "content": "For an adult patient with isolated hematuria, tests such as ultrasound of the kidney and cystoscopy are usually done first to pinpoint the source of the bleeding. These tests would rule out kidney stones and bladder cancer, two other common urological causes of hematuria. In children and younger adults, the history and association with respiratory infection can raise the suspicion of IgA nephropathy. A kidney biopsy is necessary to confirm the diagnosis. The biopsy specimen shows proliferation of the mesangium, with IgA deposits on immunofluorescence and electron microscopy. However, patients with isolated microscopic hematuria (i.e. without associated proteinuria and with normal kidney function) are not usually biopsied since this is associated with an excellent prognosis. A urinalysis will show red blood cells, usually as red cell urinary casts. Proteinuria, usually less than 2 grams per day, also may be present. Other renal causes of isolated hematuria include thin basement" }, { "id": "pubmed23n0977_267", "title": "Development of anti-glomerular basement membrane glomerulonephritis during the course of IgA nephropathy: a case report.", "score": 0.013626298756600238, "content": "Anti-glomerular basement membrane (GBM) glomerulonephritis does not usually coexist with another glomerulonephritis such as IgA nephropathy. We present a rare case having a combination of these two diseases, and furthermore, histological evaluation could be performed before and after the development of anti-GBM glomerulonephritis over a period of only10 months. A 66-year-old woman was admitted with complaints of microscopic hematuria and mild proteinuria for the past 3 years. Serum creatinine level was normal at that time. The first renal biopsy was performed. Light microscopy revealed mesangial proliferative glomerulonephritis with fibro-cellular crescents in one out of 18 glomeruli, excluding one global sclerotic glomerulus. Immunofluorescence (IF) showed IgA and C3 deposition in the mesangium. Therefore, the diagnosis was IgA nephropathy. Eight months later, the patient's serum creatinine suddenly rose to 4.53 mg/dL and urinalysis showed 100 red blood cells per high power field with nephrotic range proteinuria (12.3 g/g<subCr</sub). The serological tests revealed the presence of anti-GBM antibody at the titer of 116 IU/mL. Treatments were begun after admission, consisting of hemodialysis, plasma exchange, and intravenous methylprednisolone pulse therapy. At 4 weeks after admission, the second renal biopsy was performed. Light microscopy revealed crescents in 18 of 25 glomeruli, excluding six global sclerotic glomeruli. IF showed linear IgG deposition along the GBM in addition to granular IgA and C3 deposition. Based on these findings, the diagnosis of anti-GBM glomerulonephritis and IgA nephropathy was confirmed. Renal function was not restored despite treatment, but alveolar hemorrhage was prevented. We report a patient with a diagnosis of anti-GBM disease during the course of IgA nephropathy. This case strongly suggests that the presence of autoantibodies should be checked to rule out overlapping autoimmune conditions even in patient who have previously been diagnosed with chronic glomerulonephritis, such as IgA nephropathy, who present an unusually rapid clinical course." }, { "id": "wiki20220301en037_3240", "title": "Glomerulonephritis", "score": 0.013472418670438472, "content": "Proliferative Proliferative glomerulonephritis is characterised by an increased number of cells in the glomerulus. These forms usually present with a triad of blood in the urine, decreased urine production, and hypertension, the nephritic syndrome. These forms usually progress to end-stage kidney failure (ESKF) over weeks to years (depending on type). IgA nephropathy IgA nephropathy, also known as Berger's disease, is the most common type of glomerulonephritis, and generally presents with isolated visible or occult hematuria, occasionally combined with low grade proteinuria, and rarely causes a nephritic syndrome characterised by protein in the urine, and visible blood in the urine. IgA nephropathy is classically described as a self-resolving form in young adults several days after a respiratory infection. It is characterised by deposits of IgA in the space between glomerular capillaries." }, { "id": "wiki20220301en026_25230", "title": "IgA nephropathy", "score": 0.013433756166314306, "content": "A smaller proportion (20–30%), usually the older population, have microscopic hematuria and proteinuria (less than 2 gram/day). These patients may be asymptomatic and only picked up due to urinalysis. Hence, the disease is more commonly diagnosed in situations where screening of urine is compulsory (e.g., schoolchildren in Japan). Very rarely (5% each), the presenting history is: Nephritic syndrome Acute kidney failure (either as a complication of the frank hematuria, when it usually recovers or due to rapidly progressive glomerulonephritis which often leads to chronic kidney failure) Chronic kidney failure (no previous symptoms, presents with anemia, hypertension and other symptoms of kidney failure, in people who probably had longstanding undetected microscopic hematuria and/or proteinuria)" }, { "id": "wiki20220301en024_10167", "title": "Kidney disease", "score": 0.013282802266539112, "content": "IgA nephropathy IgA nephropathy is the most common glomerulonephritis throughout the world Primary IgA nephropathy is characterized by deposition of the IgA antibody in the glomerulus. The classic presentation (in 40-50% of the cases) is episodic frank hematuria which usually starts within a day or two of a non-specific upper respiratory tract infection (hence synpharyngitic) as opposed to post-streptococcal glomerulonephritis which occurs some time (weeks) after initial infection. Less commonly gastrointestinal or urinary infection can be the inciting agent. All of these infections have in common the activation of mucosal defenses and hence IgA antibody production. Iodinated contrast media" }, { "id": "wiki20220301en229_34356", "title": "Mesangial proliferative glomerulonephritis", "score": 0.013159937888198758, "content": "The kidney biopsy is foundational to informing the diagnosis of mesangial proliferative glomerulonephritis, as it is a morphological pattern. Clinical Presentation Mesangial proliferative glomerulonephritis often presents with hematuria (gross or microscopic) or nephrotic syndrome. Presentation can also include asymptomatic proteinuria. These presenting symptoms are relatively non-specific and are often seen in other glomerular disorders. Preceding upper respiratory tract infection or post-streptococcal glomerulonephritis may contribute to hematuria, as both have been identified in patients presenting with hematuria in the context of mesangial proliferative glomerulonephritis. Preceding infection was not as readily identified in patients presenting with either asymptomatic proteinuria or nephrotic syndrome. However, it is has been shown patients presenting with nephrotic syndrome have some histo- and clinic-pathologic similarities to minimal change disease." }, { "id": "wiki20220301en057_61746", "title": "Nephritic syndrome", "score": 0.012904858299595142, "content": "Children/adolescents IgA nephropathy (Note: Contrast time of onset with Post-streptococcal Glomerulonephritis) - Most commonly diagnosed in children who recently had an upper respiratory tract infection (URI). Symptoms typically present within 1–2 days of a non-specific URI with severe flank/abdominal pain, gross hematuria (characterized by dark brown or red colored urine), and edema of the hands, feet, and/or face. Post-streptococcal glomerulonephritis (PSGN) - Similar to IgA nephropathy, post-streptococcal glomerulonephritis (PSGN) most often occurs in children who have recently had an upper respiratory infection (URI). In contrast with IgA nephropathy, however, PSGN typically presents 2–3 weeks after recovering from an URI that was caused specifically by a Streptococcus bacteria. The symptoms at onset are very similar to IgA nephropathy and include abdominal pain, hematuria, edema, and oliguria." }, { "id": "wiki20220301en012_140513", "title": "Nephrotic syndrome", "score": 0.012870388380989431, "content": "Epidemiology Nephrotic syndrome can affect any age, although it is mainly found in adults with a ratio of adults to children of 26 to 1. The syndrome presents in different ways in the two groups: the most frequent glomerulopathy in children is minimal change disease (66% of cases), followed by focal segmental glomerulosclerosis (8%) and mesangiocapillary glomerulonephritis (6%). In adults the most common disease is mesangiocapillary glomerulonephritis (30-40%), followed by focal and segmental glomeruloesclerosis (15-25%) and minimal change disease (20%). The latter usually presents as secondary and not primary as occurs in children. Its main cause is diabetic nephropathy. It usually presents in a person from their 40s or 50s. Of the glomerulonephritis cases, approximately 60% to 80% are primary, while the remainder are secondary. There are also differences in epidemiology between the sexes, the disease is more common in men than in women by a ratio of 2 to 1." }, { "id": "pubmed23n0970_13741", "title": "Changes in the diagnosis of glomerular diseases in east China: a 15-year renal biopsy study.", "score": 0.012847446670976082, "content": "There have been some gradual changes in the distribution of renal biopsy pathological diagnoses during recent years. This study aimed to show changes in renal disease prevalence in China by investigating 10 patients diagnosed at our Kidney Disease Centre during the last 15 years. All patients aged 15-year-old or older who underwent renal biopsy at the First Affiliated Hospital, Zhejiang University, from 2001 to 2015 were enrolled. There were 5 common types of primary glomerulonephritis: IgA nephropathy (IgA N), membranous nephropathy (MN), mesangial progressive glomerulonephritis (MsPGN), minimal change disease (MCD), and focal segmental glomerulosclerosis (FSGS), which represented 50%, 16.8%, 15.9%, 8.1% and 2.5% of total cases, respectively. IgA nephropathy was the most common type of primary glomerulonephritis (PGN). Our results mostly showed a new trend that the diagnosis of IgA nephropathy was not increasing and the prevalence of membranous nephropathy had increased, becoming the second most common type of primary glomerulonephritis. Key POINTS Distinguished with other domestic studies, IgA nephropathy did not show a trend of continuous growth although it still had about the half proportion of PGN, whereas membranous nephropathy kept rising and became the second common PGN. Concerning SGN, LN peaked in the younger-age and middle-age groups with a significant female prevalence, DN, BANS and SV had a male predominance peaking in the middle-age and old-age groups." }, { "id": "pubmed23n0715_22677", "title": "A case of minimal change nephrotic syndrome with immunoglobulin A nephropathy transitioned to focal segmental glomerulosclerosis.", "score": 0.012698412698412698, "content": "A 50-year-old woman with a 1-month history of lower extremity edema and a 5 kg weight increase was admitted to our hospital with suspected nephrotic syndrome in October 1999. Urine protein level was 3.5 g per day, 10-15 erythrocytes in urine per high-power field, and serum albumin level 2.5 g/dl. Furthermore, an accumulation of pleural effusion was confirmed by chest X-ray. The results of a renal biopsy indicated slight mesangial proliferation in the glomeruli by light microscopy, and an immunofluorescence study confirmed the deposition of immunoglobulin (Ig) A and C3 in the mesangial area. Diffuse attenuation of foot processes and dense deposits in the mesangial area were observed by electron microscopy. Treatment with 40 mg/day of prednisolone was effective, and proteinuria was negative 1 month later. Because of this course, we diagnosed minimal change nephrotic syndrome complicated by mild-proliferative IgA nephropathy. In November 2000, there was a relapse of nephrotic syndrome, which was believed to be induced by an influenza vaccination, but response to increased steroid treatment was favorable, and proteinuria disappeared on day 13 of steroid increase. A second relapse in May 2001, showed steroid resistance with renal insufficiency, and an increase in the selectivity index to 0.195. Light microscopy revealed focal sclerotic lesions of the glomeruli, and an immunofluorescence study revealed attenuation of mesangial IgA and C3 deposition. These findings led to the diagnosis that minimal change nephrotic syndrome had transitioned to focal segmental glomerulosclerosis, whereby mesangial IgA deposition was reduced by immunosuppressive treatment. Subsequently, her renal function gradually worsened to the point of end-stage renal failure by 27 months after the second relapse of nephrotic syndrome." }, { "id": "pubmed23n0511_21460", "title": "Increasing incidence of focal segmental glomerulosclerosis and an examination of demographic patterns.", "score": 0.012386869151710386, "content": "Idiopathic focal segmental glomerulosclerosis (FSGS) is one of the leading causes of the nephrotic syndrome in adults and an important cause of end-stage renal disease. Its incidence has dramatically increased in the last two decades and it is especially prevalent among black patients. The trend of FSGS incidence has not been reported beyond 1997. We retrospectively reviewed all renal biopsies performed at our institution between 1986 and 2002 and identified patients with diagnoses consistent with primary glomerulopathy (PG), which included: minimal-change disease (MCD), idiopathic focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MGN), IgA nephropathy (IgA), membrano-proliferative glomerulonephritis (MPGN) and mesangioproliferative glomerulonephritis. Patients with possible secondary causes for their renal disease were excluded. Clinical data at the time of biopsy and follow-up data were collected and analyzed. During the period from January 1986-December 2002, 299 renal biopsies were performed and 132 patients were diagnosed with PG. FSGS was the most common form of PG representing 37.8% of all PG followed by IgA 27.3%, MGN 16.6% and MCD 9.1%. Among FSGS patients 59% were females, 64% had nephrotic range proteinuria and 54% had the nephrotic syndrome. Mean serum creatinine was 2.0 +/- 0.2 mg/dl and mean protein excretion was 6.1 +/- 1.0 g/day. The incidence of FSGS increased from 19.3% (1986-1991) and 16.6% (1992-1997) to 58.5% in the period from 2002. The increase occurred among black and Hispanic patients (33.3-79.2%) as well as white patients (12.5-51.5%). Black and Hispanic patients with PG presented for renal biopsy at a significantly younger age than white patients (p = 0.003), with mean age 37.5 +/- 2.0 years vs. 50.3 +/- 1.8 years. White FSGS patients were significantly older than white non-FSGS patients (mean age 56.4 +/- 3.2 years vs. 48.0 +/- 2.0 years, p = 0.03). Black and Hispanic FSGS patients were also older when compared to their non-FSGS counter-parts (mean age 40.6 +/- 2.8 years vs. 32.1 +/- 2.0 years, p = 0.04). When patients were stratified by age (&lt; 45 years and &gt; or = 45 years), FSGS was the most common diagnosis in both age groups among black and Hispanic patients (55.1% and 88.8%) but only among older white patients (36.2%). The incidence of FSGS as a proportion of PG in our population has increased markedly in the most recent time period analyzed (1998-2002). The increase has occurred among both white and black and Hispanic patients. We also found that FSGS was most prevalent in patients &gt; or = 45 years." }, { "id": "wiki20220301en046_56929", "title": "Membranous glomerulonephritis", "score": 0.012106886512351906, "content": "Within membranous glomerulonephritis, especially in cases caused by viral hepatitis, serum C3 levels are low. Similar to other causes of nephrotic syndrome (e.g., focal segmental glomerulosclerosis or minimal change disease), membranous nephropathy is known to predispose affected individuals to develop blood clots such as pulmonary emboli. Membranous nephropathy in particular is known to increase this risk more than other causes of nephrotic syndrome though the reason for this is not yet clear." }, { "id": "InternalMed_Harrison_21884", "title": "InternalMed_Harrison", "score": 0.011981082501313715, "content": "The two most common presentations of IgA nephropathy are recurrent episodes of macroscopic hematuria during or immediately following an upper respiratory infection often accompanied by proteinuria or persistent asymptomatic microscopic hematuria. Nephrotic syndrome is uncommon. Proteinuria can also first appear late in the course of the disease. Rarely patients present with acute renal failure and a rapidly progressive clinical picture. IgA nephropathy is a benign disease for the majority of patients, and 5–30% of patients may go into a complete remission, with others having hematuria but well preserved renal function. In the minority of patients who have progressive disease, progression is slow, with renal failure seen in only 25–30% of patients with IgA nephropathy over 20–25 years. This risk varies considerably among populations. Cumulatively, risk factors for the loss of renal function identified thus far account for less than 50% of the variation in observed outcome but include" }, { "id": "pubmed23n0784_24736", "title": "Minimal change disease and IgA deposition: separate entities or common pathophysiology?", "score": 0.011622636622636622, "content": "Introduction. Minimal Change Disease (MCD) is the most common cause of nephrotic syndrome in children, while IgA nephropathy is the most common cause of glomerulonephritis worldwide. MCD is responsive to glucocorticoids, while the role of steroids in IgA nephropathy remains unclear. We describe a case of two distinct clinical and pathological findings, raising the question of whether MCD and IgA nephropathy are separate entities or if there is a common pathophysiology. Case Report. A 19-year old man with no medical history presented to the Emergency Department with a 20-day history of anasarca and frothy urine, BUN 68 mg/dL, Cr 2.3 mg/dL, urinalysis 3+ RBCs, 3+ protein, and urine protein : creatinine ratio 6.4. Renal biopsy revealed hypertrophic podocytes on light microscopy, podocyte foot process effacement on electron microscopy, and immunofluorescent mesangial staining for IgA. The patient was started on prednisone and exhibited dramatic improvement. Discussion. MCD typically has an overwhelming improvement with glucocorticoids, while the resolution of IgA nephropathy is rare. Our patient presented with MCD with the uncharacteristic finding of hematuria. Given the improvement with glucocorticoids, we raise the question of whether there is a shared pathophysiologic component of these two distinct clinical diseases that represents a clinical variant. " }, { "id": "wiki20220301en046_56925", "title": "Membranous glomerulonephritis", "score": 0.011616743471582182, "content": "Membranous glomerulonephritis (MGN) is a slowly progressive disease of the kidney affecting mostly people between ages of 30 and 50 years, usually white people (ie, those of European, Middle Eastern, or North African ancestry.). It is the second most common cause of nephrotic syndrome in adults, with focal segmental glomerulosclerosis (FSGS) recently becoming the most common. Signs and symptoms Most people will present as nephrotic syndrome, with the triad of albuminuria, edema and low serum albumin (with or without kidney failure). High blood pressure and high cholesterol are often also present. Others may not have symptoms and may be picked up on screening, with urinalysis finding high amounts of protein loss in the urine. A definitive diagnosis of membranous nephropathy requires a kidney biopsy, though given the very high specificity of anti-PLA2R antibody positivity this can sometimes be avoided in patients with nephrotic syndrome and preserved kidney function Causes" }, { "id": "pubmed23n0132_15120", "title": "Association of IgA nephropathy with steroid-responsive nephrotic syndrome. A report of the Southwest Pediatric Nephrology Study Group.", "score": 0.011305208699262288, "content": "In a multicenter study of 83 children with IgA nephropathy, we have encountered four patients (three female, one male) who presented with steroid-responsive nephrotic syndrome (NS) 1 to 12 years before the demonstration of IgA nephropathy. Renal biopsies performed within several months of the onset of NS in three of the patients showed changes consistent with minimal change glomerulonephropathy in two and diffuse mesangial hypercellularity in one patient. Immunofluorescence studies performed on two of the biopsies were negative for IgA. Corticosteroid therapy induced remission of NS in all four patients, but this was followed by frequent relapses. IgA nephropathy was diagnosed subsequently by renal biopsies that were performed because of the onset of gross hematuria in three patients and persistent, low-grade proteinuria in the other. Light microscopy studies on these biopsies showed minimal glomerular changes in three and focal proliferative and sclerosing glomerulonephritis in one patient. Subsequent follow-up evaluations have revealed normal serum creatinines and/or glomerular filtration rate (GFR) in all four patients with remission of NS in three and no further episodes of gross hematuria in any patient. These four patients represent either a variant of IgA nephropathy associated with long-standing steroid-responsive NS or development of IgA nephropathy superimposed upon preceding minimal change disease." }, { "id": "wiki20220301en026_25229", "title": "IgA nephropathy", "score": 0.010914760914760915, "content": "Signs and symptoms The classic presentation for the non-aggressive form (in 40–50% of the cases) is episodic hematuria, which usually starts within a day or two of a non-specific upper respiratory tract infection (hence synpharyngitic), as opposed to post-streptococcal glomerulonephritis, which occurs some time (weeks) after initial infection. With both aggressive and non-aggressive Berger's disease loin pain can also occur. The gross hematuria may resolve after a few days, though microscopic hematuria will persist, it is however more common with aggressive Berger's disease for gross hematuria to persist rather than microscopic hematuria. Renal function usually remains normal with non-aggressive Berger's disease, though rarely acute kidney failure may occur (see below). This presentation is more common in younger adults." }, { "id": "wiki20220301en022_61049", "title": "Hematuria", "score": 0.010256410256410256, "content": "Glomerular hematuria Glomerular causes include: IgA nephropathy Thin glomerular basement membrane disease Hereditary nephritis (Alport's disease) Hemolytic uremic syndrome Postinfectious glomerulonephritis Membranoproliferative glomerulonephritis Lupus nephritis Henoch-Shonlein purpura Nephritic syndrome Nephrotic syndrome Polycystic kidney disease Idiopathic hematuria Non-glomerular hematuria Visible blood clots in the urine indicate a non-glomerular cause. Non-glomerular causes include:" }, { "id": "article-23357_25", "title": "IgA Nephropathy (Berger Disease) -- History and Physical", "score": 0.009900990099009901, "content": "Asymptomatic hematuria with mild proteinuria, such as 0.5 g/day, may be picked up on screening programs. A proportion of patients with isolated microscopic hematuria and mild proteinuria will ultimately develop significant proteinuria and hypertension, suggesting that long-term follow-up should be instituted. [34] Progressive chronic kidney disease is a common manifestation observed in many cohorts. Renal survival varies greatly according to biopsy timing and the introduction of lead-time bias. The actual renal 10-year survival is observed to be 57% to 91%. [35]" }, { "id": "article-18222_5", "title": "Berger Disease -- History and Physical", "score": 0.00980722993208757, "content": "Most patients present with asymptomatic microscopic hematuria or proteinuria that can be present for many years. Hypertension is initially found in a minority of patients but becomes common as the disease progresses to chronic kidney disease or end-stage renal disease. IgA nephropathy can present with gross hematuria, nephrotic syndrome, and chronic kidney disease and can escalate to rapidly progressive glomerulonephritis. Episodic gross hematuria is commonly seen in children and young adults after upper respiratory tract infection. Synpharingitic macroscopic hematuria is a classic initial presentation of IgA nephropathy." }, { "id": "wiki20220301en008_72953", "title": "Proteinuria", "score": 0.00980392156862745, "content": "Proteinuria may be a feature of the following conditions: Nephrotic syndromes (i.e. intrinsic kidney failure) Pre-eclampsia Eclampsia Toxic lesions of kidneys Amyloidosis Collagen vascular diseases (e.g. systemic lupus erythematosus) Dehydration Glomerular diseases, such as membranous glomerulonephritis, focal segmental glomerulonephritis, minimal change disease (lipoid nephrosis) Strenuous exercise Stress Benign orthostatic (postural) proteinuria Focal segmental glomerulosclerosis (FSGS) IgA nephropathy (i.e. Berger's disease) IgM nephropathy Membranoproliferative glomerulonephritis Membranous nephropathy Minimal change disease Sarcoidosis Alport syndrome Diabetes mellitus (diabetic nephropathy) Drugs (e.g. NSAIDs, nicotine, penicillamine, lithium carbonate, gold and other heavy metals, ACE inhibitors, antibiotics, or opiates (especially heroin) Fabry disease Infections (e.g. HIV, syphilis, hepatitis, poststreptococcal infection, urinary schistosomiasis)" }, { "id": "pubmed23n0312_16049", "title": "[Thin glomerular membrane nephropathy. Clinico-pathological observations].", "score": 0.00980392156862745, "content": "In two nephrology centres between 1983 and 1993 among 1545 kidney biopsies 34 cases of thin basement membrane nephropathy have been diagnosed. All patients had a varying degree of microscopic dysmorph haematuria, occasional slight proteinuria--except two nephrotic children; and normal blood pressure with one exception. 5 children and 7 adults experienced repeated bouts of macroscopic haematuria mainly after exercise or upper respiratory tract infection, one child after tonsillectomy. All patients had normal renal function and retained it during the follow-up period (mean 61 months, 3 months to 22 years), except a 46 year old patient, who was found to have the joint occurrence of light chain gammopathy and hypertension. Seven patients had positive family history for microscopic haematuria, in four family members of three patients renal biopsy disclosed mesangioproliferative glomerulonephritis with thin GBM segments. As a cut off value for thin basement membrane nephropathy we considered 264 nm. The morphometric analysis of the electron micrographs revealed a mean thickness of 210 nm. No differences in basement membrane thickness were measured regarding gender, age or the presence of macroscopic haematuria. The thin basement membrane is considered to be the pathological basis and predisposing alteration leading to haematuria." }, { "id": "wiki20220301en256_32535", "title": "Diffuse proliferative nephritis", "score": 0.009774825701903148, "content": "Signs and Symptoms Symptoms can be caused directly from DPGN or from a different disease that is causing DPGN. Many of the symptoms, like edema and hypertension, occur due to the decrease in glomerular filtration rate. Patients can experience general systemic symptoms including fatigue, vomiting, nausea. These would all indicate uremia. Other patients can experience: Decreased urine output Hematuria Microscopic or gross Proteinuria Which will present as frothy urine Pedal edema Swelling of the feet and ankles DPGN caused by other diseases If a patient has DPGN due to IgA nephropathy (Berger Disease) then they can experience flank pain, gross hematuria, and upper respiratory infections. If a patient has DPGN with underlying anti-GBM then they can experience alveolar hemorrhage and respiratory issues. If a patient has DPGN with an underlying autoimmune disease then the patient can experience photosensitivity, rash, joint pains, serositis, and oral ulcers." }, { "id": "pubmed23n0699_16116", "title": "Acquired glomerular lesions in patients with Down syndrome.", "score": 0.009708737864077669, "content": "The long-term survival of persons with Down syndrome has dramatically increased over the past 50 years. There are no studies addressing the spectrum of glomerular lesions in these patients. We reviewed the clinical-pathologic characteristics of 17 patients with Down syndrome who underwent renal biopsy. The cohort consisted of 12 whites and 5 African Americans with mean age of 29 years (range, 6-45 years). History of hypothyroidism was present in 8 patients. Renal presentations included renal insufficiency (15 patients, mean serum creatinine 3.4 mg/dL), proteinuria (all patients, including 3 with nephrotic syndrome, mean 24-hour urine protein 4.2 g), and hematuria (14 patients, including 4 with gross hematuria). The glomerular diseases found on biopsy were IgA nephropathy (n = 5 patients), focal segmental glomerulosclerosis (n = 4), membranoproliferative glomerulonephritis (n = 2), acute postinfectious glomerulonephritis (n = 2), pauci-immune crescentic glomerulonephritis (n = 2), membranous glomerulonephritis (n = 1), and lupus nephritis (n = 1). Follow-up (mean, 47 months; range, 2-141 months) was available on 16 patients (94%). Two patients (1 with membranous glomerulonephritis and 1 with acute postinfectious glomerulonephritis) had complete remission; 8 patients (4 with IgA nephropathy, 2 with focal segmental glomerulosclerosis, 1 with lupus nephritis, and 1 with acute postinfectious glomerulonephritis) had chronic kidney disease; and 6 patients (2 with pauci-immune crescentic glomerulonephritis, 2 with membranoproliferative glomerulonephritis, 1 with IgA nephropathy, and 1 with focal segmental glomerulosclerosis) progressed to end-stage renal disease, 4 of whom died. In summary, a wide spectrum of glomerular diseases can be seen in patients with Down syndrome, with IgA nephropathy and focal segmental glomerulosclerosis being the most common. Renal biopsy is necessary to determine the type of glomerular lesion and appropriate treatment." }, { "id": "pubmed23n0106_8490", "title": "Minimal-change glomerulopathy of adulthood.", "score": 0.009615384615384616, "content": "We describe 40 adults with idiopathic minimal-change glomerulopathy. They consisted of 27 females and 13 males, mean age 40.7 +/- (SD) 19.8 years (range 15-78 years). Twenty patients were less than 40 years of age at presentation. They presented with significantly (p less than 0.05) lower serum creatinine (0.9 +/- 0.2 vs. 1.3 +/- 0.5 mg/dl) and serum albumin (1.9 +/- 0.8 vs. 2.4 +/- 0.7 g/dl) levels than patients greater than 40 years. Only 7 patients (18%) presented with a decrease in renal function (serum creatinine greater than 1.3 mg/dl). All patients had nephrotic-range proteinuria at the time of presentation or biopsy. There was no significant difference in presenting proteinuria (8.7 +/- 5.7 g/24 h) or length of follow-up (mean 63.5, range 4-176 months) between the two age groups. Microscopic hematuria and hypertension were each present in 21% of the patients. Thirty-four patients received therapy with prednisone. A complete remission was obtained in 91% of the patients treated with prednisone. The response occurred within 16 weeks in 77% of the patients. The response to prednisone therapy was similar for patients less than 40 years when compared to those greater than 40 years, with a complete remission being obtained in 88 and 94%, respectively. The rate of response, however, differed significantly with 73% of patients less than 40 years versus 32% of patients greater than 40 years achieving a complete remission by 8 weeks. Twenty patients initially responding to prednisone therapy (64.5%) relapsed. A relapse occurred within 3 months of attaining a complete remission in 70% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 394, 591 ] ], "word_ranges": [ [ 71, 103 ] ], "text": "In the examination there are lesions in the macula. With that we can rule out acute posterior vitreous detachment, which does not produce visual loss, nor metamorphopsia, nor lesions in the macula." }, "2": { "exist": true, "char_ranges": [ [ 1270, 1459 ] ], "word_ranges": [ [ 211, 237 ] ], "text": "They describe hard exudates, deep hemorrhages and localized neurosensory retinal detachment. All this in the macula. These are the characteristic findings of neovascular (or exudative) AMD." }, "3": { "exist": true, "char_ranges": [ [ 990, 1269 ] ], "word_ranges": [ [ 164, 211 ] ], "text": "In the case of arterial occlusion, there is intracellular edema that is seen as absence of hemorrhages and a whitish, pale fundus. In addition, the entire retina is globally affected, and a cherry-red spot may appear in the macula. In this case the lesions are totally different." }, "4": { "exist": true, "char_ranges": [ [ 592, 759 ] ], "word_ranges": [ [ 103, 127 ] ], "text": "And also non-arteritic anterior ischemic optic neuropathy, because although it produces visual loss and is typical of older people, it does not produce metamorphopsia." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Acute posterior vitreous detachment.", "2": "Exudative age-related macular degeneration (AMD).", "3": "Central retinal artery obstruction.", "4": "Non-arteritic anterior ischemic optic neuropathy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0816_15660", "title": "[Clinical and pathological observation of seven cases of spontaneous sub-retinal hemorrhage].", "score": 0.01594022415940224, "content": "To improve pathological understanding of massive sub-retinal hemorrhage. Retrospective case series study. The clinical and pathological data of 7 cases of massive sub-retinal hemorrhage which were examined in the Pathological Department of Tianjin Eye Hospital from May 1988 to April 2012 were collected. The serial section of eyeball specimens were made with HE and PAS staining. The pathological section were reviewed under the light microscope. Analysis were made again combining with patients' clinical history, imaging findings and the pathological features. In 7 patients, 6 patients were male, 1 patient was female. The age range was from 60 to 82 years old and the average age was 71.7 years old. Four cases were on the right eye and 3 cases were on the left eye. The main clinical feature was sudden loss of vision and 2 cases had acute glaucoma symptoms. Ultrasound examination showed choroidal tumor in 6 cases and retinal detachment with vitreous hemorrhage in one case. The color Doppler ultrasound examination demonstrated choroidal substantive occupying lesion in 3 cases and two of them were detected with blood flow signal. The MRI were examined in 3 cases which showed iso-high signal in T1W1 and iso-low signal in T2W1 suggesting the choroidal melanoma in 2 cases and sub-retinal hemorrhage in 1 case. Six cases were diagnosed clinically as choroidal tumor or melanoma and 1 case was diagnosed as acute angle-closure glaucoma. The enucleation were performed in 7 cases. In these cases, 6 cases were diagnosed pathologically as vitreous hemorrhage, hemorrhagic RPE detachment and massive subretinal hemorrhage. The related choroidal lesions included soft drusen of Bruch membrane in 3 cases, choriocapillaris wall degeneration in 2 cases, fibrovascular membrane formation under RPE in 2 cases, choroidal chronic non-granulomatous inflammation in 4 cases, choroidal vessels wall thickening and sclerosis in 2 cases and choroidal vessels anomaly in one case. The secondary angle-closure glaucoma or angle-open glaucoma were accompanied respectively in 2 cases. Another case of 7 cases was diagnosed pathologically as the rupture of retinal macroaneurysm with massive sub-retinal hemorrhage. Massive sub-retinal hemorrhage liked to occur in the elderly male patients. The main manifestations were sudden visual loss. A small number of patients had symptoms of acute glaucoma. Ophthalmic ultrasound and imaging characteristics were usually similar to the choroidal substantive neoplasm and were easily misdiagnosed as choroidal melanoma. Pathological examination revealed that the main reasons of massive hemorrhage were from the hemorrhagic RPE detachment and the rupture of retinal macroaneurysm." }, { "id": "pubmed23n0059_11482", "title": "[Preventive treatment using laser of age-related macular degeneration of the contralateral eye after age-related macular degeneration of the first eye].", "score": 0.01399863427958248, "content": "Since 1982, and with informed patient consent, we have photocoagulated confluent drusen and limited serous pigment epithelium detachment (SPED) in the fellow eye of ten patients suffering from advanced, disciform type, age-related macula degeneration (ARMD). This treatment was only carried out on appearance of metamorphopsia. Photocoagulation was performed with either the green ray of the argon laser, or the yellow ray of a dye laser. Spots of about 200 microns were placed in a grid-like fashion among the drusen. No complications were observed due to the treatment. The follow-up period on these ten patients, eight women and two men, mean age 77 years, was two to eight years, and the three patients have died. The drusen disappeared completely in three patients and partially in one. The functional results seemed favorable in three cases. In one case of confluent drusen associated with SPED and serous retinal detachment, vision improved remarkably from 0.3 to 0.5 with a Parinaud 2, with a follow-up of five years. In another case, the improvement was from 0.4 to 0.7 but the patient died after only a few months. In another case, vision has been stable for five years. The vision of the seven remaining patients deteriorated; three cases showed central areolar sclerosis, and one case a localised new vessel with vision less than 0.1. In three cases vision dropped to 0.2 and Parinaud 6, but they have been stable for at least four years (eight years for one patient).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en090_51094", "title": "Drusen", "score": 0.012285983638962382, "content": "Drusen, from the German word for node or geode (singular, \"Druse\"), are tiny yellow or white accumulations of extracellular material that build up between Bruch's membrane and the retinal pigment epithelium of the eye. The presence of a few small (\"hard\") drusen is normal with advancing age, and most people over 40 have some hard drusen. However, the presence of larger and more numerous drusen in the macula is a common early sign of age-related macular degeneration (AMD). Classification Drusen are associated with aging and macular degeneration are distinct from another clinical entity, optic disc drusen, which is present on the optic nerve head. Both age-related drusen and optic disc drusen can be observed by ophthalmoscopy. Optical coherence tomography scans of the orbits or head, calcification at the head of the optic nerve without change in size of globe strongly suggests drusen in a middle-age or elderly patient." }, { "id": "pubmed23n0828_15704", "title": "The causes of hyperreflective dots in optical coherence tomography excluding diabetic macular edema and retinal venous occlusion§.", "score": 0.01228392541173268, "content": "To investigate the causes of hyperreflective dots (HRDs) in spectral domain optical coherence tomography (OCT) excluding diabetic macular edema (DME) and RVO (retinal vein occlusion). The medical records of 56 patients with HRDs documented by OCT were reviewed retrospectively. The patients with DME and RVO were excluded from the study in order to prevent misdiagnosing hard exudates or HRDs. The causes, unilaterality or bilaterality of HRD and demographic properties of the patients with HRD were evaluated. Sixty four eyes of 56 patients having HRDs were included in this study. Of the patients with HRD, 17 (30.36%) were women and 39 (69.64%) were men. The ages of patients were between 13 to 84 years (median 60.18 years). The causes of HRD were as follows: papilledema in 4 eyes (6.25%), active neovascular age related macular degeneration (AMD) in 33 eyes (51.56%), familial dominant drusen in 2 eyes (3.13%), central serous chorioretinopathy in 19 eyes (29.69%) and commotio retina in 2 eyes (3.13%), choroidal folds in one eye (1.56%), branch retinal artery occlusion in one eye (1.56%), central retinal artery occlusion in one patient (1.56%) and Best vitelliform macular dystrophy in one eye (1.56%). The most common cause of HRD was AMD. The causes of HRDs in both eyes were AMD and papilledema. The most common causes of HRDs excluding DME and RVO seem as active exudative AMD. The presence of HRDs in retinal diseases might affect the decisions and the results of the treatment and the prognosis of diseases." }, { "id": "InternalMed_Harrison_2307", "title": "InternalMed_Harrison", "score": 0.01220513756444769, "content": "Impending branch or central retinal vein occlusion can produce prolonged visual obscurations that resemble those described by patients with amaurosis fugax. The veins appear engorged and phlebitic, with numerous retinal hemorrhages (Fig. 39-8). In some patients, venous blood flow recovers spontaneously, whereas others evolve a frank obstruction with extensive retinal bleeding (“blood and thunder” appearance), infarction, and visual loss. Venous occlusion of the retina is often idiopathic, but hypertension, diabetes, and glaucoma CHAPTER 39 Disorders of the Eye FIguRE 39-5 Hollenhorst plaque lodged at the bifurcation of a retinal arteriole proves that a patient is shedding emboli from the carotid artery, great vessels, or heart. FIguRE 39-7 Hypertensive retinopathy with blurred optic disc, scattered hemorrhages, cotton-wool spots (nerve fiber layer infarcts), and foveal exudate in a 62-year-old man with chronic renal failure and a systolic blood pressure of 220." }, { "id": "wiki20220301en564_9633", "title": "Acute visual loss", "score": 0.011554738835059584, "content": "Acute visual loss is a rapid loss of the ability to see. It is caused by many ocular conditions like retinal detachment, glaucoma, macular degeneration, and giant cell arteritis, etc. Main causes Retinal detachment Retinal detachment should be considered if there were preceding flashes or floaters, or if there is a new visual field defect in one eye. If treated early enough, retinal tear and detachment can have a good outcome. Glaucoma Angle-closure glaucoma should be considered if there is painful loss of vision with a red eye, nausea or vomiting. The eye pressure will be very high typically greater than 40 mmHg. Emergent laser treatment to the iris may prevent blindness. Macular degeneration Wet macular degeneration should be considered in older people with new distortion of their vision with bleeding in the macula. Vision can often be regained with prompt eye injections with anti-VEGF agents. Giant cell arteritis" }, { "id": "article-133116_10", "title": "Wet Age-Related Macular Degeneration (Wet AMD) -- History and Physical", "score": 0.011485785998799587, "content": "On examination, patients frequently have decreased best-corrected visual acuity (BCVA), and Amsler grid evaluation may reveal areas of central or paracentral scotoma or visual distortion. Ophthalmic examination of the anterior segment of the eye is usually normal. ARMD-related CNV has several different appearances on the dilated funduscopic exam. [17] These include: A gray-green membrane deep into the retina is usually associated with an overlying neurosensory retinal detachment. There may be the presence of blood, lipid, or subretinal fluid. RPE detachments appear clinically as dome-shaped, sharply demarcated elevations of the RPE; these may also be serous, fibrovascular, drusenoid, or hemorrhagic. [18] There may be massive subretinal hemorrhage with central vision loss or, less commonly, breakthrough vitreous hemorrhage with peripheral vision loss. RPE tears. Disciform scars may be present, which may appear as white or yellow subretinal membranes with or without RPE hyperplasia." }, { "id": "InternalMed_Harrison_2322", "title": "InternalMed_Harrison", "score": 0.011382401509790044, "content": "Optic Disc Drusen These are refractile deposits within the substance of the optic nerve head (Fig. 39-13). They are unrelated to drusen of the retina, which occur in age-related macular degeneration. Optic disc drusen are most common in people of northern European descent. Their diagnosis is obvious when they are visible as glittering particles on the surface of the optic disc. However, in many patients they are hidden beneath the surface, producing pseudopapilledema. It is important to recognize optic disc drusen to avoid an unnecessary evaluation for papilledema. Ultrasound or computed tomography (CT) scanning is sensitive for detection of buried optic disc drusen because they contain calcium. In most patients, optic disc drusen are an incidental, innocuous finding, but they can produce visual obscurations. On perimetry they give rise to enlarged blind spots and arcuate CHAPTER 39 Disorders of the Eye" }, { "id": "InternalMed_Harrison_2316", "title": "InternalMed_Harrison", "score": 0.01120199146514936, "content": "FIguRE 39-9 Anterior ischemic optic neuropathy from temporal arteritis in a 67-year-old woman with acute disc swelling, splinter hemorrhages, visual loss, and an erythrocyte sedimentation rate of 70 mm/h. FIguRE 39-11 Optic atrophy is not a specific diagnosis but refers to the combination of optic disc pallor, arteriolar narrowing, and nerve fiber layer destruction produced by a host of eye diseases, especially optic neuropathies." }, { "id": "InternalMed_Harrison_2319", "title": "InternalMed_Harrison", "score": 0.011198603424581214, "content": "Papilledema This connotes bilateral optic disc swelling from raised intracranial pressure (Fig. 39-12). Headache is a common but not invariable accompaniment. All other forms of optic disc swelling (e.g., 203 from optic neuritis or ischemic optic neuropathy) should be called “optic disc edema”. This convention is arbitrary but serves to avoid confusion. Often it is difficult to differentiate papilledema from other forms of optic disc edema by fundus examination alone. Transient visual obscurations are a classic symptom of papilledema. They can occur in only one eye or simultaneously in both eyes. They usually last seconds but can persist longer. Obscurations follow abrupt shifts in posture or happen spontaneously. When obscurations are prolonged or spontaneous, the papilledema is more threatening. Visual acuity is not affected by papilledema unless the papilledema is severe, longstanding, or accompanied by macular edema and hemorrhage. Visual field testing shows enlarged blind spots" }, { "id": "InternalMed_Harrison_2411", "title": "InternalMed_Harrison", "score": 0.010979605810143296, "content": "FIgURE 40e-3 Superficial flame-shaped hemorrhages, dot hem-orrhages, and microaneurysms in a patient with nonproliferative diabetic retinopathy. patientwithchronicleukemia. Conditions associated with retinal hemorrhages include diseases causing retinal microvasculopathy (Table 40e-3), retinitis, retinal macroaneurysm, papilledema, subarachnoid hemorrhage (Terson’s syndrome), Valsalva retinopathy, trauma (ocular injury, head injury, compression injuries of chest and abdomen, shaken baby syndrome, strangulation), macular degeneration, and posterior vitreous detachment. Hyperviscosity states may produce dot and blot hemorrhages, dilated veins (“string of sausages” appearance), optic disc edema, and exudates; similar changes can occur with adaptation to high altitude in mountain climbers." }, { "id": "Neurology_Adams_1937", "title": "Neurology_Adams", "score": 0.010875428867358608, "content": "In persons older than 50 years of age, a common cause of a persistent monocular loss of vision is ischemic infarction of the optic nerve head (Fig. 12-15). With anterior ischemic optic neuropathy, the optic disc is involved and optic disc edema is visualized in the acute phase. In contrast, with posterior ischemic optic neuropathy, there are no changes of the optic disc until disc pallor develops in the chronic stages. Ischemic optic neuropathy can be either arteritic (discussed in the following text) or nonarteritic. With nonarteritic anterior ischemic optic neuropathy (NAION), the onset is typically abrupt and painless, but on occasion the visual loss is progressive for several days. Usually, there are no premonitory symptoms or episodes of transient visual loss. The field defect is often altitudinal. If the area of central fixation is involved, then acuity can be severely compromised. Swelling of the optic disc is typical, and can be sectoral, with certain portions of the disc" }, { "id": "InternalMed_Harrison_2271", "title": "InternalMed_Harrison", "score": 0.01082333282697858, "content": "Optic nerve disease produces characteristic patterns of visual field loss. Glaucoma selectively destroys axons that enter the superotemporal or inferotemporal poles of the optic disc, resulting in arcuate scotomas shaped like a Turkish scimitar, which emanate from the blind spot and curve around fixation to end flat against the horizontal meridian (Fig. 39-3C). This type of field defect mirrors the arrangement of the nerve fiber layer in the temporal retina. Arcuate or nerve fiber layer scotomas also result from optic neuritis, ischemic optic neuropathy, optic disc drusen, and branch retinal artery or vein occlusion. Damage to the entire upper or lower pole of the optic disc causes an altitudinal field cut that follows the horizontal meridian (Fig. 39-3D). This pattern of visual field loss is typical of ischemic optic neuropathy but also results from retinal vascular occlusion, advanced glaucoma, and optic neuritis." }, { "id": "wiki20220301en168_30187", "title": "Central retinal artery occlusion", "score": 0.009988023952095809, "content": "Central retinal artery occlusion (CRAO) is a disease of the eye where the flow of blood through the central retinal artery is blocked (occluded). There are several different causes of this occlusion; the most common is carotid artery atherosclerosis. Signs and symptoms Central retinal artery occlusion is characterized by painless, acute vision loss in one eye. Upon fundoscopic exam, one would expect to find: cherry-red spot (90%) (a morphologic description in which the normally red background of the choroid is sharply outlined by the swollen opaque retina in the central retina), retinal opacity in the posterior pole (58%), pallor (39%), retinal arterial attenuation (32%), and optic disk edema (22%). During later stages of onset, one may also find plaques, emboli, and optic atrophy. Diagnosis" }, { "id": "wiki20220301en210_15682", "title": "Maculopathy", "score": 0.009900990099009901, "content": "A maculopathy is any pathological condition of the macula, an area at the centre of the retina that is associated with highly sensitive, accurate vision. Forms of maculopathies Age-Related Macular Degeneration is a degenerative maculopathy associated with progressive sight loss. It is characterised by changes in pigmentation in the Retinal Pigment Epithelium, the appearance of drusen on the retina of the eye and choroidal neovascularization. AMD has two forms; 'dry' or atrophic/non-exudative AMD, and 'wet' or exudative/neovascular AMD. Malattia Leventinese (or Doyne’s honeycomb retinal dystrophy) is another maculopathy with a similar pathology to wet AMD. Cellophane Maculopathy A fine glistening membrane forms over the macula, obscuring the vision." }, { "id": "pubmed23n1133_15372", "title": "Long-term follow-up of a case of Coats disease in a 10-year-old boy with spontaneous peeling of preretinal macular fibrosis: a case report.", "score": 0.00980392156862745, "content": "Coats disease is a retinal vascular disorder characterized by aneurysms and telangiectasias. Macular fibrosis is a complication of Coats disease that results in vision loss. Macular fibrosis rarely develops in the natural course and often occurs after treatment with intravitreal bevacizumab, photocoagulation, or cryotherapy. Here, we have described an unusual case of spontaneous peeling of preretinal macular fibrosis in a patient with untreated Coats disease. A 10-year-old Japanese boy presented with vision loss in his left eye. The patient's left visual acuity was 20/28. Fundus examination of his left eye revealed thick preretinal macular fibrosis around the optic disc and macula. In addition, retinal telangiectasis, microaneurysms, hard exudates, and retinal hemorrhages were observed in the left peripheral temporal retina. We diagnosed his condition as Coats disease with preretinal macular fibrosis. Two months later, optical coherence tomography revealed preretinal macular fibrosis detachment at the foveal lesion without any treatment. During follow-up, preretinal macular fibrosis at the macular lesion was completely detached. Further, posterior vitreous detachment was observed and the shape of the macula and the patient's left visual acuity had improved. In our case, both formation and spontaneous peeling of preretinal macular fibrosis occurred without any treatment for Coats disease, which is an unusual finding. Vitreous changes might have occurred during the natural clinical course, causing subsequent posterior vitreous detachment and resulting in spontaneous peeling of fibrosis." }, { "id": "pubmed23n1098_15161", "title": "A Case of Idiopathic Dense Vitreous Hemorrhage: Suspected Rupture of a Large Retinal Arterial Macroaneurysm on the Optic Disc.", "score": 0.00980392156862745, "content": "We report a novel case of vitreous hemorrhage associated with suspected rupture of 2-disc-diameter retinal arterial macroaneurysm on the optic disc. A 90-year-old woman presented with blurred vision (sudden onset) in her left eye. Examination of the fundus revealed acute onset vitreous hemorrhage of unknown origin without retinal detachment. She underwent vitrectomy, but after excision of the dense vitreous hemorrhage, a 2-disc-diameter hematoma appeared on the optic disc and was removed promptly. Because the bleeding at the base of the hematoma was of arterial origin and pulsating, the first vitrectomy could not achieve hemostasis. Five days after the first surgery, we performed a second vitrectomy. This revealed a subretinal hemorrhage along the superior and inferior arcade vessels and a macular hole, which was almost completely closed with an inverted internal limiting membrane flap. Unfortunately, the macular hole reopened 41 days after the second surgery. In patients presenting with only a large hematoma on the optic disc, it might be prudent to leave the hematoma. However, this large retinal arterial macroaneurysm was on a rare location on the optic disc, making it doubly difficult for the surgeons to diagnose and choose the best option intraoperatively. The differential diagnosis for dense vitreous hemorrhage of unknown origin should include a large retinal arterial macroaneurysm on the optic disc." }, { "id": "pubmed23n0892_12025", "title": "Clinical Features and Course of Patients with Peripheral Exudative Hemorrhagic Chorioretinopathy.", "score": 0.009708737864077669, "content": "To evaluate the clinical characteristics of patients who were followed in our clinic with the diagnosis of peripheral exudative hemorrhagic chorioretinopathy (PEHC). Medical records of 12 patients who were diagnosed with PEHC in İstanbul University İstanbul Faculty of Medicine, Department of Ophthalmology between July 2006 and June 2014 were reviewed retrospectively. This study included 21 eyes of 12 patients. Four (33.3%) of the patients were male and 8 (66.7%) were female and ages ranged between 73 and 89 years. Eight (66.7%) of the patients were referred to us with the diagnosis of choroidal mass. Unilateral involvement was found in 3 and bilateral involvement in 9 patients. Temporal quadrants were involved in all eyes. Fifteen eyes (71.4%) had subretinal hemorrhage and hemorrhagic/serous retinal pigment epithelial detachment, 11 (52.4%) had lipid exudation, 5 (23.8%) had chronic retinal pigment epithelium alterations, 2 (9.5%) had subretinal fibrosis and 1 (4.8%) had vitreous hemorrhage. PEHC lesions were accompanied by drusen in 11 eyes (52.4%), geographic atrophy in 2 eyes (9.5%), and choroidal neovascularization scar in 2 eyes (9.5%). Treatment was done in both eyes of a patient for lesions which threatened the macula, in a patient with bilateral macular edema and in a patient with vitreous hemorrhage. The remaining eyes were followed-up without any treatment because the lesions did not threaten the macula and they showed no progression during follow-up. PEHC is a degenerative disease of peripheral retina that is seen in older patients, and signs of age-related macular degeneration (AMD) may accompany this pathology. Especially in patients with AMD findings, the peripheral retina must be evaluated carefully for existing PEHC lesions." }, { "id": "pubmed23n0371_3235", "title": "[Clinical picture of isolated retinal vasculitis].", "score": 0.009708737864077669, "content": "Clinical picture of isolated retinal vasculitis (IRV) in 43 patients (25 men and 18 women) aged 22-42 years is analyzed. IRV was bilateral in 88.4% cases and involved the veins. Two forms of disease were distinguished: peripheral (in 75%) and central-peripheral (25%). Both forms were characterized by a high hemorrhagic activity, occlusion of vessels, ischemic zones and neovascularization of the retina and optic disk, but these signs were more frequent in central peripheral form of IRV. IRV is a grave disease leading to poor vision or blindness in 18% cases. The onset is poorly manifest with floating spots and blurred vision; the main symptom is vitreous hemorrhage. Visual acuity was significantly decreased in patients with occlusive IRV in comparison with those without occlusions (0.32 +/- 0.37 vs. 0.77 +/- 0.28). The earliest changes can be detected mainly in the peripheral parts of the retina. This necessitates special attention of ophthalmologist to seemingly negligible complaints of patients and thorough examination of the fundus oculi, particularly of its peripheral sections, which can be performed only on condition of adequate mydriasis. Only timely diagnosis and early pathogenetic therapy can decrease the probability of such complications as hemophthalmos, retinal neovascularization, detachment of retina, and neovascular glaucoma, and prevent disability." }, { "id": "wiki20220301en067_41614", "title": "Metamorphopsia", "score": 0.009615384615384616, "content": "Pathology The mechanisms that result in the development of metamorphopsia involve structural changes in the retina of the eye (retinal mechanism) as well as processing changes in the cerebral cortex of the brain (cortical mechanism). The retinal mechanism involves the displacement of retinal layers which results in the mislocation of light on the retina. The cortical mechanism, which was discovered after the retinal mechanism, is affected by perceptual “filling-in” and visual crowding effects. The cortical mechanism was found to work in combination with the retinal mechanism to contribute to metamorphopsia in long-standing maculopathy or after the treatment of macular disorders. Causes of Metamorphopsia Metamorphopsia can be a symptom of a number of eye disorders involving the retina or macula. Some of these conditions include the following: Age-related macular degeneration Epiretinal membrane and vitreomacular traction Posterior vitreous detachment Macular hole" }, { "id": "pubmed23n0673_4840", "title": "[Three cases of retinal arterial macroaneurysm on the optic disc].", "score": 0.009615384615384616, "content": "Retinal arterial macroaneurysm typically involves the second order arterioles and is relatively uncommon on the optic disc. Here, we present three cases of retinal arterial macroaneurysm. Case 1 was a 56-year-old woman, Case 2 was a 78-year-old man, and Case 3 was an 86-year-old man. In Cases 1 and 3, the fundus could not be observed visually at the time of initial examination because of vitreous bleeding. Retinal arterial macroaneurysm was revealed during vitrectomy. In Case 2, retinal arterial macroaneurysm was found on the optical disc along with a retinal hemorrhage which disappeared without any treatment. In all three cases, visual acuity was normal after treatment. Since retinal arterial macroaneurysm on the optical disc may be overlooked when treating vitreous bleeding in cases where the cause is not known, we believe that retinal arterial macroaneurysm should be taken into consideration as a possible underlying cause. While photocoagulation of retinal arterial macroaneurysm on the optic disc is infrequently used to, localized photocoagulation retinal arterial macroaneurysm on the optic disk is considered to be difficult. We are of the opinion that progression should be observed carefully till the macroaneurysm is absorbed." }, { "id": "InternalMed_Harrison_2314", "title": "InternalMed_Harrison", "score": 0.00959717365967366, "content": "Anterior Ischemic Optic Neuropathy (AION) This is caused by insufficient blood flow through the posterior ciliary arteries that supply the optic disc. It produces painless monocular visual loss that is sudden in onset, followed sometimes by stuttering progression. The optic disc appears swollen and surrounded by nerve fiber layer splinter hemorrhages (Fig. 39-9). AION is divided into two forms: arteritic and nonarteritic. The nonarteritic form is most common. No specific cause can be identified, although diabetes and hypertension are common risk factors. A crowded disc architecture and small optic cup predispose to the development of nonarteritic AION. No treatment is available. About 5% of patients, especially those age >60, develop the arteritic form of AION in conjunction with giant-cell (temporal) arteritis (Chap. 385). It is urgent to recognize arteritic AION so that high doses of glucocorticoids can be instituted immediately to prevent blindness in the second eye. Symptoms of" }, { "id": "pubmed23n1028_22933", "title": "Severe vision loss secondary to retinal arteriolar occlusions after multiple intravitreal brolucizumab administrations.", "score": 0.009523809523809525, "content": "To describe a case of unilateral retinal arteriolar occlusion following multiple intravitreal brolucizumab injections for neovascular age-related macular degeneration (nAMD). A 92-year-old Caucasian woman presented with blurry vision in her left eye (OS) after receiving the third dose of intravitreal brolucizumab. At the time of presentation, visual acuity (VA) was 20/40 in her right eye (OD) and had decreased from 20/150 to count finger (CF) at 1-foot OS. On examination, there was no evidence of active inflammation in the anterior chamber OU. Dilated fundus examination showed no vitritis in OD and 1+ vitreous cells OS, flame-shaped hemorrhage at the superior optic disc margin, and retinal whitening surrounding the proximal portion of the supero-temporal branch of the central retinal artery. There were drusen in OS and retinal pigment epithelial (RPE) changes in the maculae of OU. Intra-arteriolar greyish deposits were seen OS. Fluorescein angiography (FA) showed hyper-fluorescence in the maculae corresponding to fibrovascular pigment epithelial detachments (PED) OU. No peri-vascular leakage was noted OU. Delayed filling of multiple arterioles in early and late phases OS was observed on FA. The patient was diagnosed with retinal arteriolar occlusion associated with repeated intravitreal brolucizumab administrations. Retinal arteriolar occlusion with severe vision loss, possibly secondary to inflammatory responses, can occur after subsequent intravitreal brolucizumab injections, even if no inflammation occurred after initial administrations. Vaso-occlusive disease should be considered as a potential ocular complication, with acute as well as delayed onset, following intravitreal brolucizumab therapy." }, { "id": "pubmed23n0127_9287", "title": "[Hemorrhagic complications in drusen of the optic papilla].", "score": 0.009523809523809525, "content": "A case of optic disc drusen complicated by retinal hemorrhages similar to those seen in central retinal vein occlusion is presented. While haemorrhagic complications of optic disc drusen are rare, three types have been described: small disk haemorrhages, vitreous haemorrhages and deep peripapillary haemorrhages. This clinical aspect of the haemorrhagic retinopathy presented in this paper has rarely been described; the pathogenesis of this lesion can be attributed to a progressive compression by the drusen on the central vein in the optic disk, causing a venous stasis retinopathy. Since it is impossible to remove the cause of the venous compression, the prognosis of this clinical form is always poor. Finally, the author emphasizes the need to consider this rare complication of drusen of the optic disk, especially in young patients with no systemic pathology who present this ophthalmoscopic picture, in order to avoid useless, time consuming tests and ineffective therapies." }, { "id": "wiki20220301en029_81277", "title": "Macular degeneration", "score": 0.009433962264150943, "content": "AMD-like pathology begins with small yellow deposits (drusen) in the macula, between the retinal pigment epithelium and the underlying choroid. Most people with these early changes (referred to as age-related maculopathy) still have good vision. People with drusen may or may not develop AMD. In fact, the majority of people over age 60 have drusen with no adverse effects. The risk of developing symptoms is higher when the drusen are large and numerous, and associated with the disturbance in the pigmented cell layer under the macula. Large and soft drusen are thought to be related to elevated cholesterol deposits. Early AMD Early AMD is diagnosed based on the presence of medium-sized drusen, about the width of an average human hair. Early AMD is usually asymptomatic. Intermediate AMD Intermediate AMD is diagnosed by large drusen and/or any retinal pigment abnormalities. Intermediate AMD may cause some vision loss, but, like early AMD, it is usually asymptomatic." }, { "id": "pubmed23n0482_8803", "title": "[Acute posterior multifocal epitheliopathy: case report].", "score": 0.009433962264150943, "content": "To present an atypical course of acute posterior multifocal placoid epitheliopathy. 59 years-old diabetic man was seen at emergency because of a few days history of blurred vision in his right eye. Ophthalmologic examination revealed patches of blurred margine, multiple, yellowish lesions 1-2 dd in the fundus in both eyes. There were also lesions typical for non proliferative diabetic retinopathy like microaneurysms, dot and blot intraretinal hemorrhages and hard exudates. Optic discs and blood vessels were normal. We found peripheral drusen extending from the equator to the ora serata in both eyes. During 8 months of observation, we performed three times ophthalmologic examination, fluorescein and indocyanine green angiographies, USG A and B. No treatment was given. There is disagreement about the site of origin of placoid lesions, etiology and pathogenesis in acute posterior multifocal placoid epitheliopathy. In our report we agree with thesis, that the choriocapillaris are the primary site of the break. We propose, that different duration of the APMPPE and recurrences are directly proportional to the state and quality of the blood vessels. The possible explanation for longstanding lesions in our patient is diabetic damage of the capillaries in the retina and choroid." }, { "id": "pubmed23n0407_7043", "title": "[Characteristics of optical coherence tomography for exudative age-related macular degeneration].", "score": 0.009345794392523364, "content": "To observe the characteristics of optical coherence tomography (OCT) for exudative age-related macular degeneration (AMD). Thirty-eight patients (42 eyes) diagnosed as exudative AMD by color fundus photography, fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were examined by OCT. The results of OCT were analyzed and compared with that of FFA and ICGA. The characteristics of OCT for exudative AMD: fibrotic choroidal neovascularization (34 eyes), serous detachment of neurosensory epithelium (38 eyes), detachment of the nerve fiber layer (8 eyes), and hemorrhagic and serous detachment of retinal pigment epithelium (11 eyes and 9 eyes, respectively). The major characteristic of OCT of exudative AMD is fibrotic choroidal neovascularization combined with serous and hemorrhagic detachment of neurosensory epithelium or retinal pigment epithelium, which would be helpful for diagnosing and evaluating exudative AMD." }, { "id": "pubmed23n0620_13664", "title": "[Ophthalmological manifestations of arterial hypertension].", "score": 0.009345794392523364, "content": "Systemic Arterial hypertension (AHT) is one of the most frequent diseases in the industrialised countries, with an incidence reaching 30%, a figure that is rising due to the greater life expectancy of the population. This rise in arterial tension causes, or accelerates, changes in the vascular wall of the target organs such as the kidney, brain, heart and eye. At the ocular level, AHT produces lesions in the retina, the choroids and optic nerve head; this can include a wide range of lesions, from slight vascular narrowing to severe visual loss due to ischaemic optical neuropathy. The primary response of the retinal arteries to systemic arterial hypertension is vascular narrowing and the manifestations that appear at the back of the eye in hypertensive retinopathy are diffuse or focal vasoconstriction, extravasation due to increased vascular permeability and arteriosclerosis with swelling of the wall of the vessels. These three entities are responsible for the appearance of different lesions that characterise the stages of the retinal disease, which are: arteriovenous crossings, hard and cotton-like exudates, thrombosis, embolisms, haemorrhages in the retinal parenchyma, vitreous detachment from the retina, papilla edema and ischaemic optical neuropathy in the more severe cases, such as in case malign arterial hypertension." }, { "id": "pubmed23n0852_20196", "title": "Multimodal imaging findings in a case of severe Central Serous Chorioretinopathy in an uncomplicated pregnancy.", "score": 0.009259259259259259, "content": "Central Serous Chorioretinopathy (CSC) has been previously reported as an infrequent complication of pregnancy that usually resolves spontaneously after delivery, with minimal or no sequel. We report a case of a severe form of CSC in an uncomplicated pregnancy with extensive subfoveal exudates and severe permanent visual loss. Multimodal imaging techniques, including color and red-free photographs, near-infrared reflectance, fluorescein angiography, and spectral-domain optical coherence tomography, were performed and the findings were correlated to the changes in visual acuity. A 35-year-old pregnant woman presented with loss of vision and metamorphopsia in her left eye. Fundus examination showed subfoveal severe exudation with a posterior pole serous detachment. Optical coherence tomography (OCT) showed macular neurosensory detachment with central highly reflective sub-retinal material. Multimodal fundus pictures and angiograms revealed distinct clinical features of the disease during both the acute and final phase. The disease spontaneously resolved after delivery with regression of the subretinal fluid and the disappearance of subfoveal exudates. Nevertheless, because of severe atrophic macular changes and subfoveal fibrosis, no improvement of visual acuity was noted. Severe variants of CSC may also present in cases of uncomplicated pregnancy and result in a poor prognosis. Recognising these presentations of CSC is critical to avoid improper management. Multimodal imaging may help to clarify the diagnosis and highlight the clinical features." }, { "id": "InternalMed_Harrison_2306", "title": "InternalMed_Harrison", "score": 0.009224211423699915, "content": "Retinal arterial occlusion also occurs rarely in association with retinal migraine, lupus erythematosus, anticardiolipin antibodies, anticoagulant deficiency states (protein S, protein C, and antithrombin deficiency), pregnancy, IV drug abuse, blood dyscrasias, dysproteinemias, and temporal arteritis. Marked systemic hypertension causes sclerosis of retinal arterioles, splinter hemorrhages, focal infarcts of the nerve fiber layer (cottonwool spots), and leakage of lipid and fluid (hard exudate) into the macula (Fig. 39-7). In hypertensive crisis, sudden visual loss can result from vasospasm of retinal arterioles and retinal ischemia. In addition, acute hypertension may produce visual loss from ischemic swelling of the optic disc. Patients with acute hypertensive retinopathy should be treated by lowering the blood pressure. However, the blood pressure should not be reduced precipitously, because there is a danger of optic disc infarction from sudden hypoperfusion." }, { "id": "pubmed23n0580_7032", "title": "Posterior vitreomacular adhesion: a potential risk factor for exudative age-related macular degeneration?", "score": 0.009174311926605505, "content": "To compare the state of the posterior vitreous in exudative age-related macular degeneration (AMD) with eyes with nonexudative AMD and controls. Prospective, observational case series. B-scan ultrasonography and optical coherence tomography (OCT) were performed in 163 eyes from 82 subjects older than 55 years, 50 eyes with exudative AMD, 57 with nonexudative AMD, and 56 control eyes. Main outcome measures were the number of eyes with complete posterior vitreous detachment (PVD) by ultrasound and the number of eyes with central vitreomacular adhesion by OCT. By ultrasonography, 17 (34.0%) of 50 eyes with exudative AMD had PVD as compared with 41 (71.9%) of 57 eyes with nonexudative AMD (P = .00002) and 34 (60.7%) of 56 controls (P = .017). OCT detected persistent central vitreoretinal adhesion surrounded by a detached posterior vitreous cortex in 18 (36%) of 50 eyes with exudative AMD, significantly higher than in nonexudative AMD (4/57 [7%]; P &lt; .0001) and in controls (6/56 [10%]; P = .002). Persistent attachment of the posterior vitreous cortex to the macula may be another risk factor for the development of exudative AMD via vitreoretinal traction inducing chronic low-grade inflammation, by maintaining macular exposure to cytokines or free radicals in the vitreous gel, or by interfering in transvitreous oxygenation and nutrition of the macula. Inducing PVD may provide prophylactic benefit against exudative AMD." }, { "id": "InternalMed_Harrison_2407", "title": "InternalMed_Harrison", "score": 0.009161739344666173, "content": "• Next, examine the macula. The macula is the area between the superior and inferior temporal vascular arcades, and its center is the fovea. You can examine the macula by pointing your ophthalmoscope about 15° temporal to the optic disc. Alternatively, ask the patient to look into the center of the light. Note the foveal reflex and the presence of any hemorrhage, exudate, abnormal blood vessels, scars, deposits, or other abnormalities. • Examine the retinal blood vessels by re-identifying the optic disc and following each of the four main branches away from the disc. The veins are dark red and relatively large. The arteries are narrower and bright red. • Ask the patient to look in the eight cardinal directions to allow you to view the peripheral fundus. In a patient with a well-dilated pupil, it is possible to visualize as far as the equator." } ] } } }

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{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0293_15202", "title": "[Infectious thyroiditis as initial manifestation of embolizing endocarditis of the aortic valve].", "score": 0.019424799622819428, "content": "A 47-year-old patient was admitted to hospital with fever (39.2 degrees C), weight loss and sore throat. The right thyroid area was painful on palpation. The erythrocyte sedimentation rate was 56/86 mm, white blood cell count 10,600/l, with shift to the left and toxic granulations. Blood culture grew Streptococcus mitis; the echocardiogram showed vegetations on the aortic valve. Therefore aortic valve endocatidits was suspected. Ultrasound examination of the thyroid gland showed an echo poor area with an enlarged thyroid artery; thyroid cytodiagnosis was unremarkable. The fever quickly subsided on administration of penicillin G (7.5 mill I.U. three times daily) and tobramycin (80 mg three times daily) for two weeks, followed by penicillin G in the same dosage for four more weeks. Vancomycin was then given for two weeks (1 g twice daily intravenously). The aortic valve vegetations were no longer seen three weeks after onset of treatment. Two months after discharge the thyroid and heart were normal on ultrasound examination. Bacterial thyroiditis was caused by embolisation to the thyroid artery from vegetations on the aortic valve in aortic valve endocarditis, probably due to carious teeth." }, { "id": "pubmed23n1054_8084", "title": "Human disease caused by &lt;em&gt;Streptococcus alactolyticus&lt;/em&gt;: a case report of native valve infective endocarditis and review of the literature.", "score": 0.01724646226415094, "content": "Streptococcus alactolyticus, a member of the Streptococcus bovis/Streptoccus equinus complex, is primarily hosted in the gastrointestinal tract of animals and rarely of humans, with only scarce reports relating to human disease. We herein present a case of subacute infective endocarditis (IE) caused by S. alactolyticus in a 64-year old male with pre-existing mitral prolapse. Despite a 10-month history of low-grade fever and weight loss, the diagnosis of IE was triggered by left quadrant abdominal pain which revealed splenic infarcts on computed tomography. A definitive diagnosis of IE was subsequently established by four consecutive blood cultures positive for S.alactolyticus plus demonstration of a vegetation on the mitral valve by trans-esophageal ultrasound. Further workup revealed multiple embolic phenomena including brain and spine. A dental abscess was identified as the most probable origin of the bacteraemia, while colonoscopy revealed no evidence of cancer. The patient recovered uneventfully with antibiotic treatment and underwent successful cardiac surgery post-discharge. Although rare, IE caused by S. alactolyticus may be severe and of obscure origin; oral cavity should not be overlooked as a possible origin. Attention should be given in patients with preexisting risk factors." }, { "id": "pubmed23n0083_18564", "title": "[A case of infective endocarditis due to Streptococcus agalactiae].", "score": 0.01652616084571123, "content": "A 60 year-old woman, who was pointed out as having hyperglycemia, was admitted to our hospital, with a two-week history of fever. Blood sugar on admission was 424 mg/dl and blood cultures yielded Streptococcus agalactiae. Systolic and diastolic heart murmurs were heard. Echocardiography showed aortic regurgitation and vegetation on the aortic valve. Penicillin-G (4 million units every 4 hr) iv and streptomycin (1 g every 12 hr) im were started. Chemotherapy was continued for 48 days. After chemotherapy, aortic valve replacement was done. We reported a very rare infective endocarditis case due to Streptococcus agalactiae." }, { "id": "pubmed23n0289_14177", "title": "[A case of infective aortic valve endocarditis with splenic abscess].", "score": 0.015138865698224523, "content": "A 47-year-old woman was admitted to our hospital with high fever, exertional dyspnea and left flank pain. Echocardiography revealed vegetations attached to the aortic valve and moderate aortic regurgitation. Streptococcus anginosus was identified by blood culture examination. Abdominal CT scan showed a low density area in the spleen. The diagnosis of infective aortic valve endocarditis with splenic abscess was obtained. The splenectomy and the aortic valve replacement were performed simultaneously after the treatment with antibiotics. The postoperative clinical course was uneventful. In the case of infective endocarditis with splenic abscess, the splenectomy concomitant with valve surgery should be performed for removing all of the infected tissues." }, { "id": "pubmed23n0907_14583", "title": "Image of the Month: Concomitant Tricuspid and Mitral Native Valve Infective Endocarditis.", "score": 0.014495028780743067, "content": "A 33-year-old immunocompetent man was admitted to the authors' hospital with a one-month duration of fevers, chills, and non-productive coughs, and suddenonset weakness and ischemic pain of both lower extremities. Physical examination revealed crepitating rales heard over bilateral lung fields. On auscultation, a grade 2~3/6 systolic murmur was heard over the leftlower sternal border and apical area. Transthoracic echocardiography revealed a mobile mass on the tricuspid valve compatible with vegetation, in addition to concomitant mitral valve vegetation (Video 1). Thoracic computed tomography (CT) with contrast revealed cavitary lesions of the left and right lung fields (Fig. 1A and B). Abdominal CT showed a splenic infarction (Fig. 2A), a renal infarction (Fig. 2B), and thromboembolic occlusion of the distal aorta and right common iliac artery (Fig. 3). The patient denied any history of intravenous drug abuse. Blood cultures grew Streptococcus agalactiae (penicillin G-sensitive with a minimal inhibitory concentration ≤0.06 μg/ml). Video 1: Transthoracic echocardiography showing mobile masses on tricuspid and mitral valves compatible with vegetation on the apical four-chamber view." }, { "id": "pubmed23n1056_17288", "title": "Peripheral arterial embolism and pyrexia in a young patient without comorbidities.", "score": 0.014148273910582909, "content": "Peripheral arteries embolism can be located in various organs. It can be caused by many medical conditions, diagnosis and treatment of which allows to prevent further complications. 26-year-old male patient was admitted to the Department of Internal Medicine, Hypertension and Vascular Diseases due to lasting over two months fatigue, recurrent pyrexia, weight loss and abdominal pain. Prior to that, he presented to physician several times. First time because of left foot pain with oedema and fever. USG revealed embolus in anterior tibial artery. Outpatient antibiotic, antithrombotic and anti-inflammatory treatment was given. The symptoms subsided, but appeared in other limb. After a while patient presented with pyrexia, fatigue, abdominal and lumbar region pain and melaena. CT showed infarction of spleen and left kidney. Once again outpatient treatment with amoxicillin with clavulanate was administered. Eventually, at admission to the clinic, infective endocarditis (IE) with dental origin was suspected. Echocardiography showed vegetation on bicuspid aortic valve, causing regurgitation. Blood culture was taken and empiric antimicrobial therapy with ampicillin, gentamicin and cloxacillin was administered. Blood culture was positive for Streptococcus sanguinis. Carious teeth were extracted, then the aortic valve replacement surgery was performed. Ampicillin was replaced with vancomycin, and gentamicin was continued. After the surgery, patient's condition improved. He was discharged on demand without completing antibiotic treatment, so he had follow-up appointment and IE prophylaxis recommended. Despite peripheral embolism is common manifestation of IE, this disease is relatively rare and not suspected in young people. The symptoms can be non-specific, what makes diagnosis challenging, as described in this case." }, { "id": "pubmed23n0974_20914", "title": "Aortic and tricuspid endocarditis due to <i>Streptococcus gallolyticus</i> in an immunocompetent patient with a normal heart.", "score": 0.013768115942028985, "content": "Endocarditis due to <iStreptococcus gallolyticus</i, an agent previously included in the <iStreptococcus bovis</i denomination is a serious disease, often associated with lesions of the colon mucosa. Aortic valve is more often affected and tricuspid involvement is quite rare. We present a case of a 56-year-old man who was admitted with a 2-month history of fever. Echocardiogram revealed vegetations on the aortic and tricuspid valve and blood cultures grew <iS. gallolyticus</i. Thoracic X-ray and computed tomography were consistent with septic pulmonary embolism. Despite optimal antibiotic therapy he developed an ischemic stroke and acute aortic regurgitation, which led to emergent surgery. Colonoscopy found a benign adenoma which was excised, and the patient had a full recovery." }, { "id": "pubmed23n0386_8381", "title": "Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens.", "score": 0.01346448087431694, "content": "The aim of our study was to compare the clinical, echographic, and prognostic features of Streptococcus bovis (S. bovis) endocarditis with those caused by other streptococci and pathogens in a large sample of patients with definite endocarditis by Duke criteria, using transesophageal echocardiography. Two hundred six patients (149 men, mean age 57 +/- 15 years) with a diagnosis of infective endocarditis formed the study population. All patients underwent multiplane transesophageal echocardiography and blood cultures. Cerebral, thoracoabdominal computed tomographic scan was performed in almost all patients (95%). All patients with S. bovis endocarditis underwent colonoscopy. Incidence of S. bovis endocarditis in our sample was 19%. Patients with S. bovis endocarditis were older than other groups. Multiple valve involvement, native valves, and large vegetations (&gt;10 mm) were more frequent in patients with S. bovis. There was a significantly higher occurrence of embolism in the S. bovis group. Splenic embolism and multiple embolisms were significantly more frequent in patients with S. bovis. Gastrointestinal lesions, anemia, and spondylitis were observed more frequently with S. bovis endocarditis. In addition to the requirement for gastrointestinal examination for S. bovis endocarditis, our study underlines the need for systematic screening for vertebral and splenic localizations, and suggests the use of early surgery to prevent the high risk of embolism in these patients." }, { "id": "pubmed23n0805_19349", "title": "[A case of Streptococcus gallolyticus subsp. gallolyticus infective endocarditis with colon adenoma].", "score": 0.01275369185816947, "content": "An 80-year-old Japanese man had a fall presented with a 3-week history of right lumbago exacerbated by body movement as well as a 1-week history of anomalous behavior and appetite loss. He visited our hospital complaining of difficulty in standing up. He had a history of mitral prolapse due to an unknown rupture of the chordae tendineae 3 years earlier, which resulted in moderate mitral valve regurgitation and atrial fibrillation. Upon visiting the hospital, he had petechial hemorrhage and jaundice of the conjunctiva, a systolic murmur (Levine II/VI) at the apex and 4th interspace of the left sternal border, and a positive right straight leg raising test result. Moderate bilirubinemia and disseminated intravascular coagulation which were considered to have been produced secondarily were observed. Infective endocarditis was suspected, and 3 sets of blood culture were extracted. The patient was admitted on the same day. Blood cultures were positive for Streptococcus gallolyticus subsp. gallolyticus (6/6) on the following day. Transesophagela echocardiography was carried out on the same day, and vegetation with a diameter of 4mm was observed in the anterior mitral leaflet; the patient was subsequently diagnosed as having infective endocarditis. Colonic endoscopy was performed after hospitalization. Twelve colonic adenomata were found, and endoscopic mucosal resection was performed on one polyp. The bacterium found in the culture was classified as Streptococcus bovis type I, which causes infective endocarditis and bacteremia. Furthermore, this bacteria is a relatively rare causative organism of infective endocarditis. Tolerance to macrolide and tetracycline are reported in the literature. Moreover, the cell wall of this bacterium may have low pathogenicity as well as cause chronic inflammation in the large intestine mucous membrane, colonic polyps, and colorectal cancer. Several colonic adenomata and a partial shift to a malignant pathology were observed in this case. When this bacterium is detected, searching for a pathological change in the large intestine is believed to be indispensable." }, { "id": "pubmed23n0625_13116", "title": "[A case of brucellosis complicated with endocarditis, pyelonephritis, sacroileitis and thyroiditis].", "score": 0.012726556343577621, "content": "Brucellosis which is a endemic in Turkey, is a systemic infection which can affect any organ or system in the body. Since signs and symptoms of brucellosis resemble many other diseases, misdiagnosis and related increase in morbidity rate, are common. In this report, a case of brucellosis complicated with endocarditis, pyelonephritis, sacroileitis and thyroiditis, was presented. The case was a 32-years-old female patient in whom the diagnosis of brucellosis was delayed by 12 months since it was not taken into consideration during the clinical follow-up of the patient in various clinical centers. The patient was admitted to our center with the complaints of fever, headache, back pain, night sweats, fatigue, loss of appetite, weight loss, dysuria and polyuria. The patient had a history of consumption of raw milk and dairy products. Positive Brucella tube agglutination test (1/1280) and isolation of Brucella spp. in blood cultures led to the diagnosis of brucellosis. Sacroileitis was diagnosed upon pain on right hip joint movements, pain and restriction at the same joint in FABER test. The detection of vegetation during echocardiography, cardiac murmur during physical examination and the determination of increased ESR and CRP levels led to the diagnosis of endocarditis. Abdominal ultrasonography and urinalysis results (hematuria, proteinuria and pyuria) revealed pyelonephritis and increased free T3 and T4, decreased TSH and positive anti-thyroid autoantibodies (anti-TG, anti-TPO) revealed thyroiditis. Treatment was started with combination of rifampisin (1 x 600 mg/day) and doxycycline (2 x 100 mg/day). After the diagnosis of endocarditis, trimethoprim-sulfamethoxazole (3 x 960 mg/day) and streptomycin (1 x 1 g/day) were added to the treatment. Valve replacement surgery was planned, however, the patient didn't accept surgical intervention and antimicrobial treatment continued with streptomycin for 21 days and other antibiotics for six months. The patient exhibited significant improvement after the medical treatment. Although sacroileitis is a frequent complication of brucellosis, endocarditis, thyroiditis and pyelonephritis are among the rare complications. In cases of brucellosis with multiorgan involvement including endocarditis, successful results may be achieved by aggressive antimicrobial treatment. In endemic areas, brucellosis should always be taken into consideration in patients with fever of unknown origin and multisystem involvement." }, { "id": "pubmed23n0045_12865", "title": "Streptococcus bovis endocarditis associated with colonic adenocarcinoma: report of a case.", "score": 0.011710323574730355, "content": "Streptococcus bovis (S. bovis) endocarditis has been increasing over recent decades, especially among the senile population. A 74-year-old man presented with intermittent fever for two months. He had a past history of aortic dissection and underwent a Bentall operation one year before admission. A Janeway lesion was noted on his right hand and six blood cultures grew S. bovis. He was treated with penicillin-G, 3 microU intravenously, every six hours, and became afebrile three days later. A colonofiberoscopy was carried out despite the absence of any gastrointestinal symptoms, and a 2 x 2 cm mass was found at the cecum, with pathologic proof of adenocarcinoma. The patient died from a massive intracranial hemorrhage on the 23rd hospital day. Review of the literature revealed an intimate association between S. bovis bacteremia (or endocarditis) and underlying colonic neoplasia. Failure to be aware of the possible consequences of this combination may lead to detrimental patient prognosis. We strongly advise that every patient presenting with bacteremia or endocarditis due to this organism, even if they are free from gastrointestinal symptoms, should undergo a thorough lower gastrointestinal investigation to rule out colonic neoplasia." }, { "id": "article-28906_20", "title": "Septic Emboli -- History and Physical -- Right-sided endocarditis vegetations embolize to the lungs causing septic pulmonary emboli present with fever, dyspnea, pleuritic chest pain, cough, and occasionally hemoptysis. Left-sided endocarditis may result in systemic emboli in different organs with different clinical presentations :", "score": 0.010847913216694267, "content": "Also, there is a case outlining infective endocarditis caused by Streptococcus bovis with complications including systemic septic emboli and superior mesenteric artery mycotic aneurysm in a patient with colon diverticulitis who received successful treatment with surgical resection of the mycotic aneurysm, removal of the mycotic thrombi, and mitral valve replacement. [24]" }, { "id": "wiki20220301en023_11612", "title": "Heyde's syndrome", "score": 0.009900990099009901, "content": "Heyde's syndrome is now known to be gastrointestinal bleeding from angiodysplasic lesions due to acquired vWD-2A deficiency secondary to aortic stenosis, and the diagnosis is made by confirming the presence of those three things. Gastrointestinal bleeding may present as bloody vomit, dark, tarry stool from metabolized blood, or fresh blood in the stool. In a person presenting with these symptoms, endoscopy, gastroscopy, and/or colonoscopy should be performed to confirm the presence of angiodysplasia. Aortic stenosis can be diagnosed by auscultation for characteristic heart sounds, particularly a crescendo-decrescendo (i.e., 'ejection') murmur, followed by echocardiography to measure aortic valve area (see diagnosis of aortic stenosis). While Heyde's syndrome may exist alone with no other symptoms of aortic stenosis, the person could also present with evidence of heart failure, fainting, or chest pain. Finally, Heyde's syndrome can be confirmed using blood tests for vWD-2A, although" }, { "id": "pubmed23n0222_4321", "title": "Endocarditis due to a penicillin-tolerant streptococcus bovis: microbiological findings and echocardiographic follow-up.", "score": 0.00980392156862745, "content": "We are presenting a case of endocarditis due to a penicillin-tolerant Streptococcus bovis in a 65-year-old patient. The minimal bactericidal concentration of penicillin (40 mg/l) was more than 100-fold the minimal inhibitory concentration (0.08 mg/l). The MBC of penicillin was 0.31 mg/l in the presence of 1.25 mg/l gentamicin. Cross-sectional echocardiography revealed endocarditis of the anterior leaflet of the tricuspid valve and a vegetation on the aortic valve which appeared to be pedunculated and which prolapsed into the left ventricular outflow tract during diastole. During therapy, the pedunculated part of the vegetation disappeared without signs of embolization. After initial clinical improvement, the patient died of cerebral bleeding caused by a mycotic aneurysm of the left median cerebral artery. The patient's final outcome suggested an asymptomatic embolus. Cross-sectional echocardiography was distinctly superior to M-mode echocardiography in estimating changes in the size and shape of the valve vegetation. The results of the post-mortem examination of the aortic and tricuspid valves corresponded to the echocardiographic findings." }, { "id": "pubmed23n0728_2220", "title": "Thirteen square centimetre mass causing syncope in a patient with device related infective endocarditis.", "score": 0.00980392156862745, "content": "A 68-year-old man presented with anorexia, weight loss and severe asthenia starting 2 months before and fever lasting over 2 weeks. Analytical study revealed increased C reactive protein and sedimentation velocity. While thoracic x-ray and urinalysis were unremarkable, blood cultures were consistently positive for Enterococcus faecalis. A thoracic echocardiogram revealed a very large vegetation adherent to the ventricular electrocatheter of the patient's pacemaker, so parenteral antibiotics were started. During his stay at the internal medicine ward, patient suffered three syncopal episodes and maintained intermittent fever. A transesophageal ECG performed at a tertiary centre on the 14th day unmasked a 9-12 cm(2) organised mass, ovoid and with regular borders, adherent to the ventricular electrocatheter at right atrium level and protruding to the ventricle at systole. Patient was referred for cardiothoracic surgery and a 13 cm(2) mass was removed alongside the ventricular electrocatheter. Two weeks following surgery, patient remains stable and asymptomatic." }, { "id": "pubmed23n0273_13539", "title": "[Endocarditis caused by Cardiobacterium hominis].", "score": 0.009708737864077669, "content": "The incidence of endocarditis due to Cardiobacterium hominis is probably underestimated because clinical presentations vary greatly and culture of this Gram negative germ is difficult. A 48-year-old man with a past history of post-streptococcic aortic regurgitation was hospitalized twice within 1 week for fever (38 degrees C) and junctional tachycardia which responded to amiodarone. Subsequently, infero-apical necrosis was documented. Based on the result of the laboratory tests, coronary embolism was suspected although 12 blood cultures were negative. The patient recovered well with a standard antibiotic treatment. Fifteen days later, the blood cultures revealed Cardiobacterium hominis. Antibiotic therapy was adapted and aortic valve replacement was programmed. Two months later the patient died from uncontrollable left heart failure. A 63-year-old man who had had mitral valve replacement 10 years earlier for Streptococcus mitis endocarditis was hospitalized for fever (38 degrees C) and a painful left calf. Phlebocavography eliminated deep vein thrombosis and a complete cardiac work-up was inconclusive. Endocarditis was suspected although blood cultures were negative. The patient was given oral penicillin and discharged after one week. Three months later, the patient was again febrile (38 degrees C) and suffered a cerebral vascular event. Fourteen days after blood sampling, cultures revealed Cardiobacterium hominis. The patient's haemodynamic status worsened and valve replacement with atrioplasty was performed. Outcome after 4 years follow-up has been favourable. Endocarditis due to Cardiobacterium hominis, a saprophitic germ of the upper airway and the female genital tract, has been reported in 64 cases in the literature. The clinical picture is often limited to fever and a heart murmur and laboratory tests show an accelerated erythrocyte sedimentation rate and hyperleukocytosis. Inflammatory type anaemia is often found due to the latency of the endocarditis. Complications are frequent and can be fatal due to massive pulmonary emboli, cerebral vascular events or irreversible heart failure. C. hominis is sensitive to amoxycillin and netilmicin. Surgical treatment of the valvulopathy is indicated." }, { "id": "pubmed23n0498_10941", "title": "[A 34-year-old male presented with fatigue, weight loss, double vision and extra heart sounds].", "score": 0.009708737864077669, "content": "The diagnosis of culture-negative endocarditis, defined as an active infection of the endocardium in the absence of positive blood cultures, is challenging. A 34-year-old male presented with persistent fever and negative blood cultures. The echocardiogram showed a bicuspid aortic valve, severe aortic regurgitation, an abscess cavity in the aortic root, and a mass on the anterior leaflet of the mitral valve. The abscess cavity could be visualised only with transoesophageal echocardiography. The diagnosis of infective endocarditis could be established clinically with the Duke criteria. The echocardiographic findings were confirmed at surgery. Cultures of the excised tissue were negative, but histology showed strong evidence of infection. The Duke criteria can be useful in the assessment of a clinical diagnosis in subjects with endocarditis and negative blood cultures. Transoesophageal echocardiography is especially important in this setting." }, { "id": "article-28906_21", "title": "Septic Emboli -- History and Physical -- Right-sided endocarditis vegetations embolize to the lungs causing septic pulmonary emboli present with fever, dyspnea, pleuritic chest pain, cough, and occasionally hemoptysis. Left-sided endocarditis may result in systemic emboli in different organs with different clinical presentations :", "score": 0.009639862234201857, "content": "Pylephlebitis: portal vein thrombosis due to intrabdominal infection such as ascending cholangitis or diverticulitis usually presents with non-specific symptomatology of fever and abdominal pain and diagnosed with CT abdomen with contrast and abdominal ultrasound, and the etiology is often polymicrobial. Pyogenic liver abscesses could experience complications with metastatic infections, including septic embolism. [25]" }, { "id": "article-41931_6", "title": "Tricuspid Valve Endocarditis -- History and Physical", "score": 0.009628302731751009, "content": "History and physical exam are essential towards making an adequate diagnosis in cases of TVIE. Establishing diagnosis can be more difficult in these cases because presentation can often be subacute or present with absence of typical IE features. Peripheral phenomenon such as splinter hemorrhages is less common, as is a cardiac murmur. However, clinicians must always be aware of potential complications of this disease process that are manifested by the various embolic phenomenon. Characteristics, which should lead clinicians to consider TVIE, include: Fever Chills Anorexia Weight loss Fatigue Malaise Arthralgia Dyspnea on exertion A cough Pleuritic pain Abdominal Pain" }, { "id": "pubmed23n0841_12612", "title": "Urgent splenectomy in the course of prosthetic valve endocarditis.", "score": 0.009615384615384616, "content": "We present a case of a 51-year-old male patient hospitalized due to acute coronary syndrome requiring stent implantation to the left main stem. Double antiplatelet therapy was commenced. After 2-3 days, the patient presented with high fever, dyspnea on exertion, pain in the chest, myalgia, and general weakness. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed abnormal, turbulent flow across the aortic prosthesis, which was probably caused by the presence of a pathological smooth and mobile structure (10 × 9 × 5 mm) in front of the aortic annulus. Blood cultures were positive and staphylococcal prosthetic valve endocarditis (PVE) was diagnosed. Despite antibiotic treatment, the patient's condition deteriorated, and he was referred for prosthesis reimplantation. After being transferred to the Cardiac Surgery Clinic, he presented with nausea, vomiting, and abdominal pain. The results of imaging examinations suggested spleen hematoma. The patient underwent an urgent splenectomy. Histopathological examination revealed a spleen infarction consequent to an embolic event and subscapular hematoma. On the 10(th) day after the laparotomy, cardiac surgery was performed. No large vegetations were found on the aortic prosthesis. The mechanical valve, implanted 20 years earlier, was functioning properly; it was intact and well healed. Several fragments of a thrombus and fibrous tissue, resembling a pannus and covered with minor calcifications, were removed from the ventricular surface of the discs. A decision was reached to leave the aortic prosthesis in situ. The valvular material culture revealed the presence of Streptococcus anginosus, and the antibiotic scheme was modified. The postoperative period was uneventful. " }, { "id": "pubmed23n0102_3540", "title": "Echocardiographic demonstration of Escherichia coli endocarditis restricted to the pulmonary valve.", "score": 0.009615384615384616, "content": "A 25 year old man with no history of heart disease presented with sweats and rigors. Echocardiography showed a large vegetation on the pulmonary valve and blood cultures grew Escherichia coli. Because of recurrent pulmonary emboli a large vegetation on the anterior leaflet of the pulmonary valve was excised. He recovered after a full course of antibiotics." }, { "id": "pubmed23n0267_12936", "title": "[Case report: infective endocarditis caused by Streptococcus agalactiae].", "score": 0.009523809523809525, "content": "A 42-year-old male was admitted to our hospital because of high grade fever on October 6, 1992. He had no history of cardiac and underlying disease. For the past 10 days, he had complained of high grade fever and noticed arthralgia on his left shoulder. Physical examination on admission revealed that there was a body temperature of 39.0 degrees C and tenderness in the left shoulder. There were no abnormal findings for the chest or abdomen. On the second hospital day, he developed a diastolic murmur which had not been present on admission. And blood culture was positive for Streptococcus agalactiae. Ultrasonic-cardiogram indicated the presence of vegetation. He was diagnosed as infective endocarditis and treated with PCG 20 million units/day, IPM/CS 2 g/day and ISP 400 mg/day. But he was not responding to the chemotherapy. Aortic valve replacement was done on 22nd, October. Valve surgery succeeded and he became well after that time. Endocarditis caused by S. agalactiae is extremely rare, and is an important condition which carries a high mortality. Only seven cases of S. agalactiae endocarditis have been reported in Japan. It is difficult to treat these cases with antibiotic therapy alone. Therefore, we suggest that early surgery should be considered in infective endocarditis caused by S. agalactiae." }, { "id": "pubmed23n0827_6236", "title": "Iatrogenic aortic insufficiency following mitral valve replacement: case report and review of the literature.", "score": 0.009345794392523364, "content": "We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences. " }, { "id": "pubmed23n0580_8192", "title": "Pulmonary embolism and fever: an indication for urgent echocardiography not reported in clinical guidelines?", "score": 0.009345794392523364, "content": "We report the case of a 39-year-old woman who developed worsening dyspnea and abdominal pain 4 days after subtotal gastroresection. She underwent thoracic computed tomography scan and lung scintigraphy and was diagnosed with pulmonary embolism. Despite the fact that she was feverish, she was treated by the insertion of a vena cava filter and transferred to our Emergency Department. Twelve hours later, a beta-haemolytic Streptococcus agalactiae was reported to be growing in both bottles of blood cultures that had been taken. The patient underwent transthoracic two- and three-dimensional echocardiography, which showed a large pulmonary valve vegetation prolapsing into the main and right pulmonary artery during systole." }, { "id": "pubmed23n0568_21905", "title": "Native triple-valve endocarditis caused by penicillin-resistant Streptococcus sanguis.", "score": 0.009259259259259259, "content": "A 26-year-old man with known but untreated ventricular septal defect was admitted to the emergency ward with abdominal pain, fever and weight loss. Transthoracic echocardiography showed multiple vegetations on the anterior mitral leaflet, a mobile vegetation on the surface of the aortic noncoronary cusp and another on the tricuspid valve. His blood cultures grew Streptococcus sanguis with a penicillin minimum inhibitory concentration of 3 microg/ml. Physical examination, echocardiography, blood cultures, minimal inhibitory concentration detection. Multivalvular infective endocarditis caused by S. sanguis with a high penicillin resistance. A combination of intravenous vancomycin and gentamicin, followed by early surgery." }, { "id": "pubmed23n0739_23716", "title": "[Multivalvular infective endocarditis with Enterococcus faecalis].", "score": 0.009259259259259259, "content": "Infective endocarditis (IE) is a relatively rare disease that can take part of sepsis and may be a diagnostic and therapeutic challenge. Polyvalvular location of El is rare. We present a patient of 60 years diagnosed with plurivalvular infective endocarditis by Enterococcus faecalis with septic complications, visceral, dragged, hospitalized for a psychiatric pathology, who raised the problems of diagnosis and treatment, without being able to make assessments on the entrance gate. For help in diagnosing this case proved that cardiac ultrasound studies recommended that a screening method for patients with bacteremia, but the presence of vegetation is the major criterion for diagnosis of EI. Blood cultures and echocardiography led to the diagnosis of infectious endocarditis. Also abdominal ultrasound confirmed the clinical suggestion of gravity, the septic multiviscerale release by splenic abscess image objectivity. Under vigorous antibiotic treatment and symptomatic treatment in combination evolution was to worse, death occurring after 15 days of hospitalization, toxic-septic shock being irreversible. Our case is particular by locating polyvalvular vegetation, the germ involved, the court altered the immunological and disseminator septic complications that have limited therapeutic options and made predictable fatal diagnosis." }, { "id": "pubmed23n0758_18843", "title": "HACEK-induced endocarditis.", "score": 0.009174311926605505, "content": "A 61-year-old patient with diabetes had a bio-prosthetic aortic valve replacement 3 years before admission. He complained of lethargy, night sweats, decreased appetite and erratic blood glucose with no weight loss. He had splinter haemorrhage and a systolic ejection murmur at the aortic area. Chest and abdominal examination revealed no abnormality. The erythrocyte sedimentation rate and C reactive protein were raised. He had several sets of blood cultures and he was started on empirical vancomycin, rifampicin and gentamicin. Transthoracic echocardiography showed vegetation on the base of the anterior mitral leaflet, which was confirmed by a trans-oesophageal echocardiography. Blood culture was positive for Haemophilus aphrophilus, and he was started on ceftriaxone for 6 weeks instead of vancomycin and rifampicin and continued gentamicin for 2 weeks. Follow-up echocardiography showed no evidence of vegetations. The patient recovered completely and he was discharged home." }, { "id": "pubmed23n0075_21659", "title": "[Value of echocardiography in detection of vegetation and their clinical significance].", "score": 0.009174311926605505, "content": "The aim of the study was to assess usefulness of echocardiography in bacterial vegetations detection as well as their clinical value as the indicator for surgical treatment. 44 patients aged 16-65 (mean 37.6) with infective mitral and aortic valve endocarditis underwent the study. Authors assessed clinical state taking into consideration blood culture tests as well as M-mode and parasternal and apical projections two-dimensional echocardiographic examinations. Data were compared with intraoperative or pathomorphological findings to estimate specificity and sensitivity of echocardiography in bacterial vegetation detection. Vegetations were pathomorphologically or intraoperatively stated in 21 patients (48%). M-mode echocardiography revealed changes in 16 patients, and two-dimensional one in the next 3. In the group of 23 patients without vegetations, concordance between intraoperative findings and echocardiographic results was stated in 19 subjects. Therefore, sensitivity and specificity of two-dimensional echocardiography were respectively 91% and 83%. Vegetations stated in two-dimensional echocardiographic examination had an unfavourable prognosis. Embolic complications were observed in 14, and myocardial infarction in 7 of 21 patients with bacterial vegetations. Authors thought it advisable to early operate on such patients. Whereas in patients without vegetations embolic complications were stated only in 3, and myocardial infarction in 1 patient. Therefore two-dimensional echocardiography making bacterial vegetations detection possible in patients with infective valve endocarditis allows to identify patients with higher risk of thromboembolic complication or death." }, { "id": "pubmed23n1007_21511", "title": "Infective endocarditis caused by Streptococcus acidominimus.", "score": 0.00909090909090909, "content": "A case of infective endocarditis caused by Streptococcus acidominimus is reported. An 81-year-old Caucasian man underwent an elective transcatheter aortic valve implantation due to his severe aortic valve stenosis. He presented to the hospital 3 weeks later with a 1-week history of fever (39ºC) that did not resolve following a 3-day course of azithromycin and a 5-day course of ciprofloxacin. Three sets of blood sample cultures were taken. Empirical antimicrobial treatment was initiated to target gram-positive and gram-negative microorganisms and consisted of vancomycin 1 g intravenous (i.v.) every 12 hours and imipenem-cilastatin 500 mg i.v. every 6 hours. After 48 hours, the blood culture was positive for S. acidominimus. The strain was sensitive to ampicillin, cephalosporins, tetracycline, and vancomycin. It was resistant to penicillin, macrolides, trimethoprim-sulfamethoxazole, and fosfomycin. Transesophageal echocardiography showed a small mobile vegetation attached to the anterior mitral valve leaflet, along with mild mitral regurgitation. The patient was diagnosed with native mitral valve infective endocarditis, and imipenem-cilastatin was discontinued. The patient showed clinical and laboratory improvement during his 2-week hospitalization. A peripherally inserted central catheter was put in place, and the patient was discharged on i.v. vancomycin to complete a total of 6 weeks treatment, after which the infection resolved. An 81-year-old man diagnosed with mitral valve endocarditis caused by S. acidominimus was successfully treated with vancomycin." }, { "id": "pubmed23n0814_24613", "title": "[A case of isolated pulmonary valve infective endocarditis in a 78-year-old woman].", "score": 0.00909090909090909, "content": "A 78-year-old woman was admitted to our hospital with lumbago. Her activities of daily living had previously been completely independent. However, she developed temporary chills in January 2009, that improved without treatment, but recurred on February 7, 2009 in association with left lumbago and loss of appetite. She was then referred to our hospital with a disturbance of consciousness and high fever on February 14. A blood test performed on admission revealed an elevated inflammatory response, coagulation disorder and low platelet count, and abdominal computed tomography demonstrated findings suggestive of pyogenic spondylitis. The patient was therefore admitted and treated with antibiotic therapy; however, she died on day 8 due to complications of disseminated intravascular coagulation. An autopsy showed isolated pulmonary valve endocarditis. The patient's history was later found to include regular dental treatment, and the same Streptococcus group G was detected in cultures of the sputum, blood and vegetation. It is important to interview patients regarding their history of dental treatment, particularly elderly individuals with fever of unknown origin. " }, { "id": "pubmed23n0707_5089", "title": "Prosthetic valve endocarditis caused by Staphylococcus capitis: report of 4 cases.", "score": 0.009009009009009009, "content": "Although Staphylococcus capitis is considered to be a rare causative organism for prosthetic valve endocarditis, we report 4 such cases that were encountered at our hospital over the past 2 years. Case 1 was a 79-year-old woman who underwent aortic valve replacement with a bioprosthetic valve and presented with fever 24 days later. Transesophageal echocardiography revealed an annular abscess in the aorto-mitral continuity and mild perivalvular regurgitation. We performed emergency surgery 5 days after the diagnosis of prosthetic valve endocarditis was made. Case 2 was a 79-year-old woman presenting with fever 40 days after aortic valve replacement with a bioprosthesis. Transesophageal echocardiography showed vegetation on the valve, and she underwent urgent surgery 2 days after prosthetic valve endocarditis was diagnosed. In case 3, a 76-year-old man presented with fever 53 days after aortic valve replacement with a bioprosthesis. Vegetation on the prosthetic leaflet could be seen by transesophageal echocardiography. He underwent emergency surgery 2 days after the diagnosis of prosthetic valve endocarditis was made. Case 4 was a 68-year-old woman who collapsed at her home 106 days after aortic and mitral valve replacement with bioprosthetic valves. Percutaneous cardiopulmonary support was started immediately after massive mitral regurgitation due to prosthetic valve detachment was revealed by transesophageal echocardiography. She was transferred to our hospital by helicopter and received surgery immediately on arrival. In all cases, we re-implanted another bioprosthesis after removal of the infected valve and annular debridement. All patients recovered without severe complications after 2 months of antibiotic treatment, and none experienced re-infection during 163 to 630 days of observation. Since the time interval between diagnosis of prosthetic valve endocarditis and valve re-replacement ranged from 0 to 5 days, early surgical removal of the infected prosthesis and an appropriate course of antibiotics were attributed to good clinical outcomes in our cases." }, { "id": "pubmed23n0317_5122", "title": "[Infective endocarditis--a review of 21 cases in last 10 years].", "score": 0.009009009009009009, "content": "Twenty one cases of infective endocarditis in last 10 years were re-evaluated by Duke's criteria. Fourteen strains of Streptococcus viridans, 4 of Enterococcus faecalis, 1 of Haemophilus parainfluenzae were isolated from blood culture. As to the minimum inhibitory concentration (MIC) of 8 strains of Streptococci, imipenem revealed the lowest MIC value, following penicillin G, ceftriaxon not equal to ampicillin, vancomycin and gentamicin. One strain of them was penicillin-resistant (0.8 micrograms/ml). Serum inhibitory test (SIT) and serum bactericidal test (SBT) were undergone for 6 cases. The assay was efficient to determine penicillin-tolerance of causative bacterium. Vegetations were observed in 18 cases of 21 by the echo-cardiography, especially transesophageal echocardiography had better diagnostic sensitivity compared to transthoracic echocardiography. However, it took 12 weeks from the first febrile episode to achieve definite diagnosis. One of reasons to take such a long time to reach diagnosis was that major causative organism was S. sanguis, whose inflammatory reaction to the host was said to be strikingly weak." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 38, 171 ] ], "word_ranges": [ [ 6, 22 ] ], "text": "Pancreatic neuroendocrine tumor + pituitary adenoma (prolactinoma) + hyperparathyroidism (renoureteral colic in young people): MEN 1." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Multiple endocrine neoplasia type 1 or Wermer's syndrome.", "2": "Multiple endocrine neoplasia type 2 A or Sipple's syndrome.", "3": "Multiple endocrine neoplasia type 2B.", "4": "Somatostatinoma.", "5": "A PTH-producing neuroendocrine tumor." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0928_6812", "title": "A primary hepatic gastrinoma accompanied by hyperplasia of multi-nodular Brunner's glands.", "score": 0.017336309523809525, "content": "Primary hepatic gastrinoma causing severe ulcerogenic syndrome is extremely rare. Herein, we report a case of primary hepatic gastrinoma accompanied by hyperplasia of multi-nodular Brunner's glands in a patient who instead, preoperatively, was suspected of having multiple duodenal gastrinomas and hepatic metastasis. A 57-year-old woman consulted a clinic complaining of melena, intermittent abdominal pain, diarrhea, and vomiting which had persisted for about 3 years. Six months before her presentation, she underwent segmental resection of the jejunum for acute peritonitis due to the spontaneous jejunal perforation. A blood test revealed that her serum immunoreactive gastrin (IRG) level was 12,037 pg/mL. Subsequently, she was transferred to our hospital. On computed tomography (CT), a hypervascular tumor of 23 mm in the segment 5 (S5) region of the liver was visualized. A selective arterial secretagogue injection test (SASI test) was performed twice. The first SASI test revealed that the hepatic tumor was a gastrinoma, and there was no gastrinoma in the duodeno-pancreatic region. Additionally, somatostatin receptor scintigraphy only visualized the tumor in the liver. However, the second SASI test, which was performed during the administration of a proton pump inhibitor and a somatostatin analog (octreotide acetate), revealed that there may have been gastrinomas existing not only in the liver but also in the upper part of the duodenum or the head of the pancreas. Duodenal endoscopy revealed multiple submucosal tumors in the first and the second portion of the duodenum, although a pathological examination of biopsied specimens obtained from the duodenal lesions was negative for malignant cells. Multiple endocrine neoplasia type 1 (MEN1) was excluded from her family history, and serum levels of both intact parathyroid hormone (iPTH) and calcium were within normal ranges. An anterior segmentectomy of the liver and pancreas-preserving total duodenectomy were performed on September 9, 2013. Postoperatively, her serum immunoreactive gastrin level decreased to less than 50 pg/mL. Pathological study of the resected specimens revealed a gastrinoma in the liver, but no gastrinoma in the duodenum. Interestingly, the duodenal submucosal tumor-like lesions were hyperplastic Brunner's glands. Postoperatively, she has been well without recurrence of hypergastrinemia for 4 years. We report a case of primary hepatic gastrinoma in a patient who has been cured for 4 years postoperatively. The diagnosis was somewhat difficult due to the coexisting, multiple hyperplastic Brunner's glands of the duodenum mimicking the submucosal neuroendocrine tumors, which might have developed due to long-term hypergastrinemia." }, { "id": "pubmed23n0884_5842", "title": "[Multiple Endocrine Neoplasia I (Wermers Syndrome), Forms of Clinical Manifestation, 5 Case Studies].", "score": 0.01595873786407767, "content": "Multiple Endocrine Neoplasia (MEN) is a condition in which several endocrine organs of an individual are affected by adenoma, hyperplasia and less often carcinoma, either simultaneously or at different stages of life. Two existing syndromes, MEN1 and MEN2 (2A, 2B), in literature is also mentioned MEN4, are associated also with other non-endocrine disorders. MEN1 (Wermer syndrome) affects the pituitary, parathyroid, and pancreatic area. 95 % of patients show very early manifestation of hyperparathyroidism, often before 40 years of age. Multiple adenomas gradually involve all four parathyroid glands. The first clinical sign of MEN1 includes recurrent nephrolithiasis. The second most frequent manifestation of MEN1 is pancreatic area (pancreas, stomach and duodenum), again multiple malignancies of varying degree which can metastasize. Most often gastrinomas and insulinomas are involved. Pituitary adenomas occur in about one third of MEN1 patients and tend to be larger and less responsive to treatment. Tumors appearing most often are prolactinomas, tumors producing growth hormone, or afunctional adenomas. The other endocrine tumors include carcinoids and adrenal lesions. In the last year we have registered four MEN1 syndrome patients in our center and one patient has been already followed since 2008. In four out of five patients, nephrolithiasis after 30 years of age was the first clinical symptom, but only one of theses cases resulted in MEN1 diagnosis. In all patients, the clinical symptoms intensified and the diagnosis was established between 36 and 40 years of age. A crutial factor is a cooperation with the urology examination of kidney stones formation in young individuals with nephrolithiasis in order to reveal the potential cases of MEN1 syndrome very early on. Consider the MEN1 genetic diagnostics if recurrent primary hyperparathyroidism or recurrent gastroduodenal ulcer disease appear in patients under 40 years of age.Key words: carcinoid - gastrinoma - hyperparathyroidism - insulinoma - MEN1 - multiple endocrine neoplasia - nefrolithiasis - neuroendocrine tumor - pancreatic area - pituitary gland." }, { "id": "pubmed23n0993_4785", "title": "[Diagnosis of pancreatic neuroendocrine tumor led to diagnosis of multiple endocrine neoplasia type 1:a report of two cases].", "score": 0.015756302521008403, "content": "Two cases of multiple endocrine neoplasia type 1 are reported. In both cases, computed tomography (CT) showed hypervascular lesions of the pancreas. Endoscopic ultrasound showed multiple lesions in the pancreas, and each case was diagnosed as pancreatic neuroendocrine tumor by EUS-FNA. In addition to a pancreatic neuroendocrine tumor, case 1 had hyperparathyroidism and case 2 had a history of parathyroid tumor. Furthermore, case 1 had a family history of pancreatic tumor and case 2 had a family history of pancreatic tumor and parathyroid resection. From these indications, multiple endocrine neoplasia type 1 was diagnosed by genetic testing. As demonstrated in these two cases, it is important to consider multiple endocrine neoplasia type 1 when diagnosing pancreatic neuroendocrine tumor." }, { "id": "pubmed23n0894_21419", "title": "[Multiple Endocrine Neoplasia Type 1(MEN1)Presenting with Hypoglycemic Attacks - A Case Report].", "score": 0.014282244352683993, "content": "A woman in her 60s visited our hospital because of frequent hypoglycemia and episodes of unconsciousness over the last 6 years. A 4 cm tumor was detected on the pancreatic tail using abdominal computed tomography and ultrasonography. An insulinoma was strongly suspected from the results of the fasting test and glucagon load test, and a distal pancreatectomy with splenectomy was performed. Pathological examination indicated an insulinoma and neuroendocrine tumor(NET)G2 based on the WHO 2010 classification. The patient's blood sugar and insulin levels returned to normal, and hypoglycemic attacks disappeared postoperatively. Six months later, a total parathyroidectomy was performed because of primary hyperparathyroidism with hypertrophy of the parathyroid glands. Furthermore, pituitary swellingwas also detected usinghead MRI. However, the patient has been under observation because the tumor was non-functional without any associated symptoms. Thus, we diagnosed the patient with multiple endocrine neoplasia type 1(MEN1). In patients with pancreatic NET, it is necessary to consider the possibility of MEN1." }, { "id": "wiki20220301en063_67849", "title": "Multiple endocrine neoplasia type 2", "score": 0.014229994428014231, "content": "Multiple endocrine neoplasia type 2 (also known as \"Pheochromocytoma and amyloid producing medullary thyroid carcinoma\", \"PTC syndrome,\" and \"Sipple syndrome\") is a group of medical disorders associated with tumors of the endocrine system. The tumors may be benign or malignant (cancer). They generally occur in endocrine organs (e.g. thyroid, parathyroid, and adrenals), but may also occur in endocrine tissues of organs not classically thought of as endocrine. MEN2 is a sub-type of MEN (multiple endocrine neoplasia) and itself has sub-types, as discussed below. Signs and symptoms MEN2 can present with a sign or symptom related to a tumor or, in the case of multiple endocrine neoplasia type 2b, with characteristic musculoskeletal and/or lip and/or gastrointestinal findings. Medullary thyroid carcinoma (MTC) represents the most frequent initial diagnosis. Occasionally pheochromocytoma or primary hyperparathyroidism may be the initial diagnosis." }, { "id": "pubmed23n0544_18521", "title": "[Pancreatic endocrine tumors].", "score": 0.013873970640887932, "content": "Incidence of the endocrine tumors of the pancreas is about 4 to 10/1.000.000 peoples. We present 10 cases of endocrine pancreatic tumors which were operated in the First Surgical Clinic Iaşi in the last 20 years (1984-2003); these cases represent about 2.21% from all the pancreatic tumors (454 cases). It was 4 insulinoma, 2 gastrinoma, 2 gastrinoma associated with other endocrine neoplasia (Wermer syndrome) and 2 non-functioning endocrine pancreatic tumors. Female/men ratio was 9/1 and median age was about 41.9 yo (27-67 yo). In the four cases of insulinoma (all females) the diagnosis was delayed by two to five years due to misinterpretation of neurological symptoms generated by hypoglycemia. The diagnosis of insulinoma was based on Whipple triad, high plasma insulin levels associated with low plasma glucose levels, as well as the symptomatic relief after intravenous glucose injection. The surgical option was based on biological data, ultrasonography, computed tomography and arteriography. In two cases the localization of the insulinoma was established only by intraoperative ultrasonography. All tumors were localized in the tail of pancreas. In three cases we decided for a distal pancreatic resection with splenectomy and in one case for spleen preserving left pancreatectomy. Postoperative course was uneventful and all the symptoms disappeared. The diagnosis was confirmed on pathological examination in all cases. We also present two cases of gastrinoma with multiple ulcers and multiple surgical interventions for haemorrhage and perforation with peritonitis. Both patients died and diagnosis of pancreatic endocrine tumors was post-mortem. The two patients with Wermer syndrome also had ulcers complicated with haemorrhage and peritonitis and parathyroid adenoma. One case also had ante-hypophyseal and pituitary adenoma and the other had thyroid colloid hypertrophy. We performed left pancreatectomy with spleen preservation in one case and enucleation associated with total gastrectomy in the second case. The two cases of non-functioning pancreatic endocrine tumors had a non-specific symptoms. Diagnostic was established by abdominal ultrasound exam. We performed spleno-pancreatectomy in one case and pancreatectomy with spleen preservation in the other patient. Postoperative course was un-eventful." }, { "id": "pubmed23n0399_10897", "title": "[An unusual case of multiple endocrine neoplasia].", "score": 0.013822558726460881, "content": "The patient A.M., woman, presented Multiple Endocrine Neoplasia, associating hyperparathyroidism, an adrenal tumor and pancreatic tumor; one can observe that the disease had features of Multiple Endocrine Neoplasia type-1 (pancreatic tumor), as well as Multiple Endocrine Neoplasia type-2 (MEN-2, pheochromocytoma), while the hyperparathyroidism is common for both two types of the syndrome. The development of the disease is extended over approximate forty years of life and finally led to death. The first symptoms appeared during pregnancy, at age 26, when the severe hyperparathyroidism determined bone mass acute loose, with decrease in height by affecting columnary vertebrae, severe bone pain due to bone resorption and soon after symptoms of renal stone disease. The patient suffered two surgical interventions for renal lithiasis. The biliary symptoms required also the surgical removal of the gall bladder, putting the diagnosis of active metabolic stone disease. At age 56, was established the diagnosis of carcinoma of the adrenal cortex, which was solved with surgical therapy. At age 66, digestive symptoms suggested the presence of a carcinoid tumor. Abdominal ultrasonography revealed a well-lined pancreatic tumor of 2-3 centimeters in diameter, probably adenoma. The malignant evolution of this tumor was rapid, leading to death in less than two years. The constant refuse of other investigations, by the patient, made us incapable to determine the type of secretion of the pancreatic tumor; we rather suspected a VIPoma, because of the watery diarrhea and severe weight loss. The most difficult to treat was anyway the hyperparathyroidism and its complications." }, { "id": "wiki20220301en027_57428", "title": "Insulinoma", "score": 0.013639035861258085, "content": "Prognosis Most patients with benign insulinomas can be cured with surgery. Persistent or recurrent hypoglycemia after surgery tends to occur in patients with multiple tumors. About 2% of patients develop diabetes mellitus after their surgery. Incidence Insulinomas are rare neuroendocrine tumors with an incidence estimated at one to four new cases per million persons per year. Insulinoma is one of the most common types of tumors arising from the islets of Langerhans cells (pancreatic endocrine tumors). Estimates of malignancy (metastases) range from 5 to 30%. Over 99% of insulinomas originate in the pancreas, with rare cases from ectopic pancreatic tissue. About 5% of cases are associated with tumors of the parathyroid glands and the pituitary (multiple endocrine neoplasia type 1) and are more likely to be multiple and malignant. Most insulinomas are small, less than 2 cm." }, { "id": "pubmed23n0846_10102", "title": "[A Case of Von Hippel-Lindau Disease with Nonfunctioning Pancreatic Neuroendocrine Tumors Treated by Duodenum-Preserving Resection of the Head of the Pancreas and Spleen-Preserving Resection of the Tail of the Pancreas].", "score": 0.013532763532763533, "content": "A 26-year-old woman presented to our department with a diagnosis of multiple nonfunctioning pancreatic neuroendocrine tumors. She had a family history of pheochromocytoma and a medical history of bilateral adrenalectomy for pheochromocytoma at the age of 25 years. During follow-up treatment for adrenal insufficiency after the surgery, highly enhanced tumors in the pancreas were detected on contrast-enhanced CT. Other examinations found that the patient did not satisfy the clinical criteria for von Hippel-Lindau (VHL) disease. Considering her age and risk of developing multiple heterotopic and heterochronous tumors, we performed a duodenum-preserving resection of the head of the pancreas and spleen-preserving resection of the tail of the pancreas with informed consent. The histopathological findings revealed that all of the tumors were NET G1. She underwent genetic testing postoperatively and was diagnosed with VHL disease. This diagnosis meant that we were able to create an optimal treatment plan for the patient. If a tumor predisposition syndrome is suspected, VHL disease should be borne in mind and genetic testing after genetic counseling should be duly considered." }, { "id": "wiki20220301en063_67743", "title": "Multiple endocrine neoplasia type 1", "score": 0.013113218592670648, "content": "The two major forms of multiple endocrine neoplasia are called type 1 and type 2. These two types are often confused because of their similar names. However, type 1 and type 2 are distinguished by the genes involved, the types of hormones made, and the characteristic signs and symptoms. These disorders greatly increase the risk of developing multiple cancerous and noncancerous tumors in glands such as the parathyroid, pituitary, and pancreas. Multiple endocrine neoplasia occurs when tumors are found in at least two of the three main endocrine glands (parathyroid, pituitary, and pancreatico-duodenum). Tumors can also develop in organs and tissues other than endocrine glands. If the tumors become cancerous, some cases can be life-threatening. The disorder affects 1 in 30,000 people." }, { "id": "pubmed23n0637_20743", "title": "Late recurrence after surgical resection of a pancreatic tumor in von Hippel-Lindau disease.", "score": 0.012960662525879917, "content": "Patients with von Hippel-Lindau syndrome, a dominantly inherited familial cancer syndrome, develop a variety of tumors in different organ systems which make the clinical management of these patients complex. The long clinical history of a 45-year-old woman started at 22 years of age when she had surgery for a right adrenal pheochromocytoma. Two years later, a pancreaticoduodenectomy was performed to remove a pancreatic mass which turned out to be a pancreatic neuroendocrine tumor. After a long period of relative wellness, 21 years after the surgical resection of her primary pancreatic neuroendocrine tumor, abdominal lymph node metastases of pancreatic neuroendocrine origin occurred. In fact, three abdominal nodules were removed by laparoscopic surgery, and the histological examination showed well-differentiated neuroendocrine tumors with similar immunohistochemical characteristics and Ki67 below 1%. Considering the patient's clinical history, an inherited cause was postulated and multiple endocrine neoplasia type 1 was first investigated, but the result was negative. Then, a missense mutation in exon 3 of the VHL gene (ACT&gt;ATT; Thr157Ile) was found. Although no local and/or distant tumor recurrences are usually reported in radically operated on von Hippel-Lindau pancreatic neuroendocrine tumor patients after a median time of five years of follow-up, the present patient had a recurrence after a very long period of time, suggesting that a pancreatic neuroendocrine tumor associated with von Hippel-Lindau syndrome may behave more aggressively than that has previously been described, thus requiring a life-long follow-up." }, { "id": "wiki20220301en063_67746", "title": "Multiple endocrine neoplasia type 1", "score": 0.012676096914522773, "content": "Treatment The treatment of choice of parathyroid tumors is open bilateral exploration with subtotal (3/4) or total parathyroidectomy. Autoimplantation may be considered in case of a total parathyroidectomy. Optimal timing for this operation has not yet been established but it should be performed by an experienced endocrine surgeon. Endocrine pancreatic tumor are treated with surgery and cytotoxic drugs in case of malignant disease. Pituitary tumors are treated with surgery (acromegaly and Mb. Cushing) or medicins (prolactinomas). Culture and society In the video game Trauma Team, Gabriel Cunningham's son, Joshua Cunningham, is diagnosed with Wermer's syndrome. It is also mentioned in the South Korean drama \"Medical Top Team\", as Dr. Choi Ah Jin (Oh Yeon-seo) is diagnosed with MEN-1. See also Acromegaly Multiple endocrine neoplasia Multiple endocrine neoplasia type 2a Multiple endocrine neoplasia type 2b Prolactinoma References" }, { "id": "pubmed23n1015_2360", "title": "Gastrinoma in multiple endocrine neoplasia type 1 after total pancreatectomy: A case report.", "score": 0.012469306322897483, "content": "Surgery for patients with multiple endocrine neoplasia type 1(MEN-1) related gastrinoma remains controversial and total pancreatectomy (TP) has rarely been performed. We reported a case of patient with MEN-1 related gastrinoma treated by TP. A 46-year-old female was admitted to our hospital due to abdominal distension and diarrhea for 2 years. The patient underwent pituitary tumor resection and kidney stone lithotripsy 10 years ago. Abdominal computed tomography showed single lesion in the duodenum and multiple lesions throughout the pancreas. The patient's gastrin level was significantly increased (1080 pg/ml). These findings in combination with the pituitary tumor history suggested the presence of gastrinoma associated with MEN-1 syndrome. An exploratory laparotomy was performed. Intraoperative ultrasound confirmed the numerous tumors diffusely distributed throughout the pancreas and the patient eventually underwent TP. Twelve months later, the patient was hospitalized again for anastomotic fistula and underwent a partial gastrectomy, small bowel resection and drainage of the abscess. One month later, she received gastrostomy and jejunostomy due to digestive tract fistula, and died a month later (14 months after TP). There still might be the possibility of recurrence even after radical surgical resection of gastrinomas, and we suggest the need to measure the basal acid output and maintain regular anti-acid therapy in the long-term follow-up of patients with MEN-1 related gastrinoma." }, { "id": "wiki20220301en334_33132", "title": "Endocrine oncology", "score": 0.01195664320035758, "content": "Endocrine tumors There are many different kinds of endocrine tumors, some of which are listed below: Gastrointestinal ECLoma Midgut carcinoid Appendix carcinoid Hindgut carcinoid sometimes also referred to as Rectal carcinoid Pulmonary Typical bronchial carcinoid Atypical bronchial carcinoid Large cell neuroendocrine carcinoma Small cell lung cancer Endocrine pancreatic tumors Non-functioning endocrine pancreatic tumors Insulinoma Gastrinoma Glucagonoma VIPoma Adrenals Adrenocortical carcinoma Pheochromocytoma Endocrine tumor syndromes Multiple Endocrine Neoplasia I, MEN1 Multiple Endocrine Neoplasia II, MEN2 von Hippel Lindau syndrome References Endocrine neoplasia Rare cancers Oncology Oncology" }, { "id": "wiki20220301en106_3374", "title": "Neuroendocrine tumor", "score": 0.0117430441898527, "content": "Other In addition to the two main categories of GEP-NET, there are rarer forms of neuroendocrine tumors that arise anywhere in the body, including within the lung, thymus and parathyroid. Bronchial carcinoid can cause airway obstruction, pneumonia, pleurisy, difficulty with breathing, cough, and hemoptysis, or may be associated with weakness, nausea, weight loss, night sweats, neuralgia, and Cushing's syndrome. Some are asymptomatic.Animal neuroendocrine tumors include neuroendocrine cancer of the liver in dogs, and devil facial tumor disease in Tasmanian devils. Familial syndromes Most pancreatic NETs are sporadic. However, neuroendocrine tumors can be seen in several inherited familial syndromes, including: multiple endocrine neoplasia type 1 (MEN1) multiple endocrine neoplasia type 2 (MEN2) von Hippel-Lindau (VHL) disease neurofibromatosis type 1 tuberous sclerosis Carney complex" }, { "id": "wiki20220301en100_5870", "title": "List of MeSH codes (C04)", "score": 0.011721091304637377, "content": "– endocrine gland neoplasms – adrenal gland neoplasms – adrenal cortex neoplasms – adrenocortical adenoma – adrenocortical carcinoma – multiple endocrine neoplasia – multiple endocrine neoplasia type 1 – multiple endocrine neoplasia type 2a – multiple endocrine neoplasia type 2b – pancreatic neoplasms – adenoma, islet cell – insulinoma – carcinoma, islet cell – gastrinoma – glucagonoma – somatostatinoma – vipoma – carcinoma, pancreatic ductal – ovarian neoplasms – granulosa cell tumor – luteoma – meigs syndrome – sertoli-leydig cell tumor – thecoma – paraneoplastic endocrine syndromes – parathyroid neoplasms – pituitary neoplasms – acth-secreting pituitary adenoma – nelson syndrome – growth hormone-secreting pituitary adenoma – prolactinoma – testicular neoplasms – sertoli-leydig cell tumor – thyroid neoplasms – thyroid nodule" }, { "id": "wiki20220301en063_67742", "title": "Multiple endocrine neoplasia type 1", "score": 0.01165734079403144, "content": "Diagnosis In a diagnostic workup individuals with a combination of endocrine neoplasias suggestive of the MEN1 syndrome are recommended to have a mutational analysis of the MEN1 gene if additional diagnostic criteria are sufficiently met, mainly including: age <40 years positive family history multifocal or recurrent neoplasia two or more organ systems affected Types Multiple endocrine neoplasia or MEN is part of a group of disorders that affect the body's network of hormone-producing glands (the endocrine system). Hormones are chemical messengers that travel through the bloodstream and regulate the function of cells and tissues throughout the body. Multiple endocrine neoplasia involves tumors in at least two endocrine glands; tumors can also develop in other organs and tissues. These growths can be noncancerous (benign) or cancerous (malignant). If the tumors become cancerous, some cases can be life-threatening." }, { "id": "wiki20220301en100_5514", "title": "List of MeSH codes (C19)", "score": 0.011656184486373166, "content": "– multiple endocrine neoplasia – multiple endocrine neoplasia type 1 – multiple endocrine neoplasia type 2a – multiple endocrine neoplasia type 2b – ovarian neoplasms – granulosa cell tumor – luteoma – meigs syndrome – sertoli-leydig cell tumor – thecoma – pancreatic neoplasms – adenoma, islet cell – insulinoma – carcinoma, islet cell – gastrinoma – glucagonoma – somatostatinoma – vipoma – carcinoma, pancreatic ductal – paraneoplastic endocrine syndromes – parathyroid neoplasms – pituitary neoplasms – acth-secreting pituitary adenoma – nelson syndrome – growth hormone-secreting pituitary adenoma – prolactinoma – testicular neoplasms – sertoli-leydig cell tumor – thyroid neoplasms – thyroid nodule – gonadal disorders – hypogonadism – eunuchism – kallmann syndrome – klinefelter syndrome – sexual infantilism" }, { "id": "wiki20220301en063_67852", "title": "Multiple endocrine neoplasia type 2", "score": 0.011361941226194619, "content": "Inheritance When inherited, multiple endocrine neoplasia type 2 is transmitted in an autosomal dominant pattern, which means affected people have one affected parent, and possibly affected siblings and children. Some cases, however, result from spontaneous new mutations in the RET gene. These cases occur in people with no family history of the disorder. In MEN2B, for example, about half of all cases arise as spontaneous new mutations. Diagnosis Diagnosis is suspected when a patient with family history of two of the three classical tumors (medullary thyroid cancer, pheochromocytoma, parathyroid adenoma) or MEN2 presents with one of the classical tumors. It is confirmed by genetic testing for mutation in RET gene. Differences in presentation As noted, all types of MEN2 include pheochromocytoma and medullary thyroid carcinoma. MEN2A is additionally characterized by the presence of parathyroid hyperplasia." }, { "id": "pubmed23n0798_10856", "title": "Gastrinoma and neurofibromatosis type 2: the first case report and review of the literature.", "score": 0.011292605260054253, "content": "Gastroenteropancreatic neuroendocrine tumors have occasionally been described in association with neurofibromatosis type 1, whereas an association with neurofibromatosis type 2 has never been reported. This report refers to an Italian 69 year old woman with neurofibromatosis type 2 and a pancreatic gastrinoma. In the past she had encephalic meningiomas, a tongue schwannoma and bilateral acoustic neurinomas. She presented with weight loss and a long-term history of diarrhea, responsive to proton pump inhibitors. Upper gastrointestinal endoscopy revealed peptic ulcer of the duodenal bulb. Blood tests were normal, except for the elevation of plasma gastrin (1031 pg/ml; reference value &lt;108) and chromogranin A (337 U/L; reference value &lt;36). After secretin stimulation testing, the plasma gastrin level rose to 3789 pg/ml. The abdomen magnetic resonance imaging and gallium68-DOTATOC positron emission tomography scan demonstrated the presence of a 1.2 x 2 cm lesion in the pancreatic head and a liver metastatis. Pancreatic endoscopic ultrasound with fine needle aspiration revealed cytomorphologic features suggestive of pancreatic gastrinoma. Brain magnetic resonance showed a pituitary microadenoma. There was no evidence of hyperparathyroidism. The genetic test for multiple endocrine neoplasia type 1 syndrome mutation was negative. This report focuses on the first case of coexistence of gastrinoma with neurofibromatosis type 2. Although the clinical relevance of this association remains to be determined, our case report will surely give cause for due consideration." }, { "id": "pubmed23n0726_2754", "title": "Surgical treatment of pancreatic endocrine tumors in multiple endocrine neoplasia type 1.", "score": 0.011074639646068217, "content": "Surgical approaches to pancreatic endocrine tumors associated with multiple endocrine neoplasia type 1 may differ greatly from those applied to sporadic pancreatic endocrine tumors. Presurgical diagnosis of multiple endocrine neoplasia type 1 is therefore crucial to plan a proper intervention. Of note, hyperparathyroidism/multiple endocrine neoplasia type 1 should be surgically treated before pancreatic endocrine tumors/multiple endocrine neoplasia type 1 resection, apart from insulinoma. Non-functioning pancreatic endocrine tumors/multiple endocrine neoplasia type 1 &gt;1 cm have a high risk of malignancy and should be treated by a pancreatic resection associated with lymphadenectomy. The vast majority of patients with gastrinoma/multiple endocrine neoplasia type 1 present with tumor lesions at the duodenum, so the surgery of choice is subtotal or total pancreatoduodenectomy followed by regional lymphadenectomy. The usual surgical treatment for insulinoma/multiple endocrine neoplasia type 1 is distal pancreatectomy up to the mesenteric vein with or without spleen preservation, associated with enucleation of tumor lesions in the pancreatic head. Surgical procedures for glucagonomas, somatostatinomas, and vipomas/ multiple endocrine neoplasia type 1 are similar to those applied to sporadic pancreatic endocrine tumors. Some of these surgical strategies for pancreatic endocrine tumors/multiple endocrine neoplasia type 1 still remain controversial as to their proper extension and timing. Furthermore, surgical resection of single hepatic metastasis secondary to pancreatic endocrine tumors/multiple endocrine neoplasia type 1 may be curative and even in multiple liver metastases surgical resection is possible. Hepatic trans-arterial chemo-embolization is usually associated with surgical resection. Liver transplantation may be needed for select cases. Finally, pre-surgical clinical and genetic diagnosis of multiple endocrine neoplasia type 1 syndrome and localization of multiple endocrine neoplasia type 1 related tumors are crucial for determining the best surgical strategies in each individual case with pancreatic endocrine tumors." }, { "id": "wiki20220301en072_63521", "title": "Gastrinoma", "score": 0.01103827606992164, "content": "Gastrinomas are neuroendocrine tumors (NETs), usually located in the duodenum or pancreas, that secrete gastrin and cause a clinical syndrome known as Zollinger-Ellison syndrome (ZES). A large number of gastrinomas develop in the pancreas or duodenum, with near-equal frequency, and approximately 10% arise as primary neoplasms in lymph nodes of the pancreaticoduodenal region (gastrinoma triangle). Most gastrinomas are sporadic (75%–80%), whereas approximately 20% to 25% are associated with multiple endocrine neoplasia type 1(MEN-1). Over 50% of gastrinomas are malignant and can metastasize to regional lymph nodes and liver. One fourth of gastrinomas are related to multiple endocrine neoplasia type 1, Zollinger–Ellison syndrome, peptic ulcer disease." }, { "id": "InternalMed_Harrison_28117", "title": "InternalMed_Harrison", "score": 0.011037058044999055, "content": "Insulinomas are uncommon, with an estimated yearly incidence of 1 in 250, 000. Because more than 90% of insulinomas are benign, they are a treatable cause of potentially fatal hypoglycemia. The median age at presentation is 50 years in sporadic cases, but the tumor usually presents in the third decade when it is a component of multiple endocrine neoplasia type 1 (Chap. 408). More than 99% of insulinomas are within the substance of the pancreas, and the tumors are usually small (<2.0 cm in diameter in 90% of cases). Therefore, they come to clinical attention because of hypoglycemia rather than mass effects. CT or MRI detects ∼70–80% of insulinomas. These methods detect metastases in the roughly 10% of patients with a malignant insulinoma. Transabdominal ultrasound often identifies insulinomas, and endoscopic ultrasound has a sensitivity of ∼90%. Somatostatin receptor scintigraphy is thought to detect insulinomas in about half of patients. Selective pancreatic arterial calcium" }, { "id": "wiki20220301en013_41682", "title": "Multiple endocrine neoplasia", "score": 0.011015300488984699, "content": "Recommended cancer surveillance A recommend surveillance program for Multiple Endocrine Neoplasia Type 1 has been suggested by the International Guidelines for Diagnosis and Therapy of MEN syndromes group. History In 1903 Erdheim described the case of an acromegalic patient with a pituitary adenoma and three enlarged parathyroid glands. In 1953 Underdahl et al. reported a case series of 8 patients with a syndrome of pituitary, parathyroid, and pancreatic islet adenomas. In 1954 Wermer noted that this syndrome was transmitted as a dominant trait. In 1959 Hazard et al. described medullary (solid) thyroid carcinoma. In 1961 Sipple described a combination of a pheochromocytoma, medullary thyroid carcinoma and parathyroid adenoma. In 1966 Williams et al. described the combination of mucosal neuromas, pheochromocytoma and medullary thyroid carcinoma." }, { "id": "pubmed23n0690_21868", "title": "Biochemically curative surgery for gastrinoma in multiple endocrine neoplasia type 1 patients.", "score": 0.010926773455377573, "content": "To search for the optimal surgery for gastrinoma and duodenopancreatic neuroendocrine tumors in patients with multiple endocrine neoplasia type 1. Sixteen patients with genetically confirmed multiple endocrine neoplasia type 1 (MEN 1) and Zollinger-Ellison syndrome (ZES) underwent resection of both gastrinomas and duodenopancreatic neuroendocrine tumors (NETs) between 1991 and 2009. For localization of gastrinoma, selective arterial secretagogue injection test (SASI test) with secretin or calcium solution was performed as well as somatostatin receptor scintigraphy (SRS) and other imaging methods such as computed tomography (CT) or magnetic resonance imaging (MRI). The modus of surgery for gastrinoma has been changed over time, searching for the optimal surgery: pancreaticoduodenectomy (PD) was first performed guided by localization with the SAST test, then local resection of duodenal gastrinomas with dissection of regional lymph nodes (LR), and recently pancreas-preserving total duodenectomy (PPTD) has been performed for multiple duodenal gastrinomas. Among various types of preoperative localizing methods for gastrinoma, the SASI test was the most useful method. Imaging methods such as SRS or CT made it essentially impossible to differentiate functioning gastrinoma among various kinds of NETs. However, recent imaging methods including SRS or CT were useful for detecting both distant metastases and ectopic NETs; therefore they are indispensable for staging of NETs. Biochemical cure of gastrinoma was achieved in 14 of 16 patients (87.5%); that is, 100% in 3 patients who underwent PD, 100% in 6 patients who underwent LR (although in 2 patients (33.3%) second LR was performed for recurrence of duodenal gastrinoma), and 71.4% in 7 patients who underwent PPTD. Pancreatic NETs more than 1 cm in diameter were resected either by distal pancreatectomy or enucleations, and no hepatic metastases have developed postoperatively. Pathological study of the resected specimens revealed co-existence of pancreatic gastrinoma with duodenal gastrinoma in 2 of 16 patients (13%), and G cell hyperplasia and/or microgastrinoma in the duodenal Brunner's gland was revealed in all of 7 duodenal specimens after PPTD. Aggressive resection surgery based on accurate localization with the SASI test was useful for biochemical cure of gastrinoma in patients with MEN 1." }, { "id": "wiki20220301en013_41684", "title": "Multiple endocrine neoplasia", "score": 0.01057101232988665, "content": "In 1993 mutations in the RET oncogene were shown to be the cause of MEN 2A by Lois Mulligan, working in the laboratory of Bruce Ponder in Cambridge. In 1998 the MEN1 gene was cloned. Terminology The older names, \"multiple endocrine adenomas\" and \"multiple endocrine adenomatosis\" (MEA), have been replaced by the current terminology. The term multiple endocrine neoplasias are used when two or more endocrine tumor types, known to occur as a part of one of the defined MEN syndromes, occurs in a single patient and there is evidence for either a causative mutation or hereditary transmission. The presence of two or more tumor types in a single patient does not automatically designate that individual as having MEN because there is a small statistical chance that the development of two \"sporadic\" tumors that occur in one of the MEN syndromes could occur by chance. The term \"multiple endocrine neoplasia\" was introduced in 1968, but descriptions of the condition date back to 1903." }, { "id": "wiki20220301en063_67855", "title": "Multiple endocrine neoplasia type 2", "score": 0.010568839392946828, "content": "Prognosis Prognosis of MEN2 is mainly related to the stage-dependant prognosis of MTC indicating the necessity of a complete thyroid surgery for index cases with MTC and the early thyroidectomy for screened at risk subjects. See also Multiple endocrine neoplasia Multiple endocrine neoplasia type 1 Multiple endocrine neoplasia type 2b Multiple mucosal neuromata References External links MEN2 (RET) gene variant database GeneReview/NIH/UW entry on Multiple Endocrine Neoplasia Type 2 Endocrine system Autosomal dominant disorders Endocrine-related cutaneous conditions Syndromes affecting the endocrine system" }, { "id": "wiki20220301en015_105768", "title": "Zollinger–Ellison syndrome", "score": 0.010309509401824336, "content": "Gastrinomas may occur as single tumors or as multiple small tumors. About one-half to two-thirds of single gastrinomas are malignant tumors that most commonly spread to the liver and to lymph nodes near the pancreas and small bowel. Nearly 25 percent of patients with gastrinomas have multiple tumors as part of a condition called multiple endocrine neoplasia type 1 (MEN 1). MEN I patients have tumors in their pituitary gland and parathyroid glands, in addition to tumors of the pancreas." }, { "id": "wiki20220301en015_105766", "title": "Zollinger–Ellison syndrome", "score": 0.010297561647609864, "content": "Zollinger–Ellison syndrome (Z-E syndrome) is a disease in which tumors cause the stomach to produce too much acid, resulting in peptic ulcers. Symptoms include abdominal pain and diarrhea. The syndrome is caused by a gastrinoma, a neuroendocrine tumor that secretes a hormone called gastrin. Too much gastrin in the blood (hypergastrinemia) results in the overproduction of gastric acid by parietal cells in the stomach. Gastrinomas most commonly arise in the duodenum, pancreas or stomach. In 75% of cases Zollinger–Ellison syndrome occurs sporadically, while in 25% of cases it occurs as part of an autosomal dominant syndrome called multiple endocrine neoplasia type 1 (MEN 1)." }, { "id": "wiki20220301en013_41674", "title": "Multiple endocrine neoplasia", "score": 0.010028397565922921, "content": "Multiple endocrine neoplasia (abbreviated MEN) is a condition which encompasses several distinct syndromes featuring tumors of endocrine glands, each with its own characteristic pattern. In some cases, the tumors are malignant, in others, benign. Benign or malignant tumors of nonendocrine tissues occur as components of some of these tumor syndromes. MEN syndromes are inherited as autosomal dominant disorders. Presentation Related conditions Although not officially categorized as multiple endocrine neoplasia syndromes, Von Hippel-Lindau disease and Carney complex are two other autosomal dominant endocrine tumor syndromes with features that overlap the clinical features of the MEN syndromes. Although not transmitted in the germline, McCune-Albright syndrome is a genetic disorder characterized by endocrine neoplastic features involving endocrine glands that overlap with those involved in MEN1 or MEN2." }, { "id": "wiki20220301en072_35436", "title": "VIPoma", "score": 0.009845487092519315, "content": "Prognosis Surgery can usually cure VIPomas. However, in one-third to one-half of patients, the tumor has spread by the time of diagnosis and cannot be cured. References Jensen RT, Norton JA. Endocrine tumors of the pancreas and gastrointestinal tract. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease . 9th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 32. National Cancer Institute. Islet cell tumors (pancreatic) treatment PDQ. Updated October 31, 2008. External links Endocrine neoplasia Rare cancers Syndromes" }, { "id": "wiki20220301en218_4113", "title": "List of skin conditions", "score": 0.00980392156862745, "content": "Hyperparathyroidism Hyperprolactinemic SAHA syndrome Hyperthyroidism Hypoparathyroidism Hypothyroidism Leydig cell tumor Multiple endocrine neoplasia type 1 (Wermer syndrome) Multiple endocrine neoplasia type 2 (multiple endocrine neoplasia type 2A, pheochromocytoma and amyloid-producing medullary thyroid carcinoma, PTC syndrome, Sipple syndrome) Multiple endocrine neoplasia type 3 (mucosal neuromata with endocrine tumors, multiple endocrine neoplasia type 2B, multiple mucosal neuroma syndrome, Wagenmann–Froboese syndrome) Myxedema Panhypopituitarism Persistent adrenarche syndrome (adrenal SAHA syndrome) Polycystic ovarian syndrome Seborrhoea–acne–hirsutism–alopecia (SAHA syndrome) Thyroid acropachy" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 84 ] ], "word_ranges": [ [ 0, 15 ] ], "text": "Answer 1 is incorrect because the imaging tests of choice would be ultrasound or CT;" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 85, 169 ] ], "word_ranges": [ [ 15, 28 ] ], "text": "answer 3 is incorrect because the laparoscopic approach is indicated from the start;" }, "4": { "exist": true, "char_ranges": [ [ 170, 383 ] ], "word_ranges": [ [ 28, 66 ] ], "text": "answer 4 is incorrect because the indication in the first episode is for those under 50 years of age, in the rest it is indicated after the second episode or in cases of persistent symptoms or suspected neoplasia;" }, "5": { "exist": true, "char_ranges": [ [ 384, 556 ] ], "word_ranges": [ [ 66, 94 ] ], "text": "and answer 5 is incorrect because surgery in cases of perforation with peritonitis should always resect the affected segment of colon to control the focus of the infection." } }

{ "1": "The safest and best performing complementary examination is the barium contrast enema.", "2": "In case of contained pelvic abscess, percutaneous drainage guided by CT or ultrasound is indicated.", "3": "If surgical intervention is required after resolution of the acute episode, the laparoscopic approach is contraindicated.", "4": "In case of acute uncomplicated diverticulitis, elective sigmoidectomy is indicated after cure of the first acute episode.", "5": "If generalized peritonitis occurs, the most appropriate surgical technique is the practice of a derivative colostomy without resection of the affected sigmoid segment." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0592_21971", "title": "[Management of complications of sigmoid diverticulosis].", "score": 0.01809771141048531, "content": "Computed tomography (CT) with contrast enhancement for vascular and bowel opacification is the reference examination for suspected sigmoid diverticulitis because it makes it possible to confirm the diagnosis and look for signs of severity (pericolic abscess, or presence of air or extraintestinal contrast product). Therapeutic management depends on the patient's general condition and on the severity of the intraperitoneal infection, assessed according to Hinchey's 4-stage classification. For Hinchey stages I and II (pericolic or pelvic abscess), radiologically guided puncture-drainage is an effective treatment, combined with antibiotic therapy. Emergency surgery is only indicated if this drainage fails. Two to three months later, elective prophylactic sigmoidectomy, by laparoscopy, is indicated. In stage III or IV diverticulitis (generalized purulent or fecal peritonitis), the surgical treatment of reference is a Hartmann procedure (sigmoidectomy and left iliac colostomy with closure of the rectal stump). But because of burden of the procedure and the risk of failing to re-establish gastrointestinal continuity, it is preferable, if local conditions allow, to propose resection-anastomosis with a temporary protective stoma. Prophylactic sigmoidectomy is controversial. It is indicated regardless of the number of episodes and regardless of age in patients at high risk of recurrence, that is, those with a complicated clinical form or radiologic signs of severity. There is no consensus for patients aged younger than 75 years with a first uncomplicated episode, for whom the risk of recurrence is also elevated. Finally, for patients older than 50 years with an uncomplicated episode on CT, the role of prophylactic surgery, even after 2 or 3 episodes, has not been demonstrated, because of the very low risk (&lt;5%) of subsequent complications. More than 80% of diverticular hemorrhages stop spontaneously but their rate of recurrence is high (25% of cases) and they sometimes require emergency colectomy." }, { "id": "pubmed23n0753_20953", "title": "[Sigmoid diverticulitis].", "score": 0.01647457627118644, "content": "The sigmoid diverticulitis is the most common complication of diverticulosis of the colon. The remaining questions concern the current risk factors for recurrence after a first acute episode, radiological asking immediately upon suspicion of diverticulitis and therapeutic management including the indications of surgical treatment, what to conduct and its principles. Literature review. Risk factors of recurrence are: persistent or recurrent diverticulitis, abscess, stenosis and / or fistula. Abdominal CT is recommended in all patients clinically suspected diverticulitis of the colon. Treatment of acute diverticulitis is medical. The emergency surgical treatment depends on the stage of Hinchey. Stage I: In case of failure of medical treatment, resection-anastomosis in an emergency time delay to be proposed. Stage II: a percutaneous drainage followed by resection-anastomosis in 1 time. Stage III: surgery in emergency sigmoid colectomy based on. Stage IV: Hartmann procedure is the procedure of reference. Prophylactic colectomy is proposed in the case of presence of risk factors of recurrence. Comparison with other literature review were allowed to find that ultrasound made by an experienced radiologist could replace abdominal CT, and for stage III and IV Hinchey, laparoscopic resection can be performed with an immediate restoration of digestive continuity in well selected patients." }, { "id": "pubmed23n0767_16828", "title": "Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis.", "score": 0.01617933723196881, "content": "The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed. A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities. The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein &gt;50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy. Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD." }, { "id": "pubmed23n0945_24632", "title": "[Diverticulosis and diverticulitis of the vermiform appendix. Report of a case and review of the literature].", "score": 0.015123088293820003, "content": "Diverticulitis of the vermiform appendix is a rare disease with clinical features often similar to conventional acute appendicitis. The importance of appendiceal diverticulosis is the fact that it can lead to an early and a higher incidence of perforation and therefore a higher mortality rate, in contrast to acute appendicitis alone. In this study we present the clinicopathology, diagnosis and therapy of the disease with a review of the literature. A 65-year-old woman presented to the emergency department with a 48-hour history of intermittent pain in the right iliac fossa. Abdominal ultrasound raised the possibility of acute appendicitis but because of the relative asymptomatic state of the patient, the lack of fever and rebound tenderness we started observation. After 2 days with episodic abdominal pain, the patient was taken to the operating theatre for laparoscopic exploration. Intraoperatively, multiple diverticula were noted on the appendix and appendectomy was performed. Histopathological examination revealed diverticulosis and inflammation of the appendiceal wall. Due to the possible complications, the difficult preoperative diagnosis and its frequent association with appendiceal neoplasm, appendiceal diverticulosis requires special attention. For asymptomatic cases, incidentally diagnosed intraoperatively or discovered by radiology prophylactic appendectomy is recommended. Orv Hetil. 2018; 159(19): 768-772." }, { "id": "pubmed23n0049_6959", "title": "Computed tomography in the initial management of acute left-sided diverticulitis.", "score": 0.014831869779396016, "content": "Computed tomography (CT) was used in place of contrast enemas as the initial imaging study to evaluate patients with the clinical diagnosis of acute sigmoid diverticulitis. This report attempts to clarify the role of CT in the management of acute sigmoid diverticulitis by reviewing its usefulness in the diagnosis and treatment of 59 patients. CT established that three patients (5 percent) were hospitalized with an incorrect clinical diagnosis. Thirty-seven patients (62.7 percent) were identified as having uncomplicated acute diverticulitis. These patients were all treated successfully with nonsurgical therapies and were discharged in an average of 6.8 days. In the remaining 19 patients (32.2 percent), CT revealed complicated acute diverticulitis by identifying abscess, fistula, peritonitis, or obstruction. Eleven of these 19 patients required urgent surgery or CT-guided percutaneous drainage of an abscess. The four patients whose abscesses were drained percutaneously responded favorably and underwent an elective single-stage resection. The average hospital stay for patients with complicated diverticulitis was 13.6 days. Computed tomography is a useful aid in the initial management of patients with acute diverticulitis. It is a noninvasive test that recognizes and stratifies patients according to the severity of their disease. It has the further advantage of providing information about extracolonic pathology and anatomic variation useful for surgical planning. Additionally, early CT-guided needle drainage allowed downstaging of complicated diverticulitis, avoided emergent surgery, and permitted single-stage elective surgical resection." }, { "id": "wiki20220301en026_25410", "title": "Diverticulitis", "score": 0.014705882352941176, "content": "Antibiotics Mild uncomplicated diverticulitis without systemic inflammation should not be treated with antibiotics. For mild, uncomplicated, and non-purulent cases of acute diverticulitis, symptomatic treatment, IV fluids, and bowel rest have no worse outcome than surgical intervention in the short and medium term, and appear to have the same outcomes at 24 months. With abscess confirmed by CT scan, some evidence and clinical guidelines tentatively support the use of oral or IV antibiotics for smaller abscesses (<5 cm) without systemic inflammation, but percutaneous or laparoscopic drainage may be necessary for larger abscesses (>5 cm). Emergency surgery is required for perforated diverticulitis with peritonitis." }, { "id": "wiki20220301en026_25406", "title": "Diverticulitis", "score": 0.014634846238461906, "content": "Diagnosis People with the above symptoms are commonly studied with computed tomography, or a CT scan. The CT scan is very accurate (98%) in diagnosing diverticulitis. In order to extract the most information possible about the person's condition, thin section (5 mm) transverse images are obtained through the entire abdomen and pelvis after oral and intravascular contrast have been administered. Images reveal localized colon wall thickening, with inflammation extending into the fat surrounding the colon. The diagnosis of acute diverticulitis is made confidently when the involved segment contains diverticula. CT may also identify people with more complicated diverticulitis, such as those with an associated abscess. It may even allow for radiologically guided drainage of an associated abscess, sparing a person from immediate surgical intervention. Barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis because of the risk of perforation." }, { "id": "wiki20220301en026_25414", "title": "Diverticulitis", "score": 0.014608952287260207, "content": "However, most surgeons prefer performing the bowel resection laparoscopically, mainly because postoperative pain is reduced with faster recovery. Laparoscopic surgery is a minimally invasive procedure in which three to four smaller incisions are made in the abdomen or navel. After incisions into the abdomen are done, placement of trocars occurs which allows a camera and other equipment entry into the peritoneal cavity. The greater omentum is reflected and the affected section of the bowel is mobilized. Alternately, laparoscopic sigmoid resection (LSR) compared to open sigmoid resection (OSR) showed that LSR is not superior over OSR for acute symptomatic diverticulitis. Furthermore, laparoscopic lavage was as safe as resection for perforated diverticulitis with peritonitis." }, { "id": "pubmed23n0066_19412", "title": "Therapeutic options in acute diverticulitis.", "score": 0.014348447712418302, "content": "Diverticulitis is a serious intra-abdominal infection that ultimately afflicts about one in four patients having colonic diverticulosis. The illness may be indolent or fulminant, depending on the degree of colonic spillage and its containment. Most patients require hospitalization, and medical therapy suffices in about three fourths. Those who fail aggressive medical management and those with recurrent acute attacks, diffuse peritonitis, abscess, persistent obstruction, or fistulization require surgical intervention. Abdominal CT scanning has supplanted the contrast enema as the acute diagnostic procedure of choice and allows guided percutaneous drainage of large abscesses in selected cases. This approach helps realize the surgical ideal of a single elective operation without a temporary colostomy. For those patients still requiring emergency surgery, the two-stage approach employing resection of the diseased colon at the initial operation is far superior to the older three-stage approach." }, { "id": "wiki20220301en026_25411", "title": "Diverticulitis", "score": 0.014113628191298093, "content": "Surgery Indications for surgery are abscess or fistula formation; and intestinal rupture with peritonitis. These, however, rarely occur. Surgery for abscess or fistula is indicated either urgently or electively. The timing of the elective surgery is determined by evaluating factors such as the stage of the disease, the age of the person, their general medical condition, the severity and frequency of the attacks, and whether symptoms persist after the first acute episode. In most cases, elective surgery is deemed to be indicated when the risks of the surgery are less than the risks of the complications of diverticulitis. Elective surgery is not indicated until at least six weeks after recovery from the acute event. Emergency surgery is indicated for an intestinal rupture with peritonitis." }, { "id": "pubmed23n0861_21903", "title": "Emergency Surgery for Acute Complicated Diverticulitis.", "score": 0.014087301587301586, "content": "The optimal treatment of acute complicated diverticulitis is a matter of debate and has undergone significant changes. Currently, the main focus of surgical treatment concepts is on controlling the emergency situation triggered by acute complicated sigmoid diverticulitis through interventional and minimally invasive measures. This article presents the current data and recommendations on differentiated treatment of acute complicated sigmoid diverticulitis, which are also summarized in a decision tree. In general, resection of the diverticular sigmoid is needed to treat acute complicated sigmoid diverticulitis, because without resection the recurrence rate is too high at 40%. Since the morbidity and mortality rates associated with emergency resection are extremely high, resulting in the creation of a stoma, efforts are made to control the acute situation through interventional and laparoscopic measures. Therefore, pericolic and pelvic abscesses (Hinchey stages I, II) are eliminated through percutaneous or laparoscopic drainage. Likewise, laparoscopic lavage and drainage are performed for purulent and feculent peritonitis (Hinchey stages III, IV). After elimination of the acute septic situation, interval elective sigmoid resection is conducted. If emergency resection cannot be avoided, it is performed, while taking account of the patient's overall condition, with primary anastomosis and a protective stoma or as discontinuity resection using Hartmann's procedure. Thanks to the progress made in interventional and laparoscopic treatment, differentiated concepts are now used to treat acute complicated sigmoid diverticulitis." }, { "id": "pubmed23n0502_1965", "title": "[Sonographic diagnosis of diverticulitis: the burdensome way to acceptance].", "score": 0.013696831787152109, "content": "Since the middle to the end of the 80 s, the sonographic detection of diverticulitis has been increasingly improved. In a paper including a larger number of patients published in 1992, W. B. Schwerk demonstrated a high sensitivity and specificity. The detection of diverticulitis was the final entry into the chapter of acute abdominal sonography, after the diagnosis of gastrointestinal perforation, acute appendicitis and ureterolithiasis had been achieved with high reliability. Until then, diverticulitis was a classic surgical disease and a contrast enema with water-soluble contrast medium the diagnostic method of choice. Invariably, the radiologist added the well known comment: Cancer of the sigmoid colon cannot be excluded with certainty. What has changed in the 12 years after Schwerk's publication? Many internists practising sonography have discovered the sonographic diagnosis of this condition and, depending on the severity, treat the less complicated cases with intravenous antibiotics and parental nutrition or with oral antibiotics and low-ballast diet. Soon, abscesses were healed with sonographically guided aspiration and drainage. For a long time, the older generation of surgeons stayed with contrast enemas and prolonged parenteral therapy and, in case of complications, surgical interventions, though surgeons early recognized the diagnostic contribution of sonography. Influenced by radiologists and the Anglo-American literature, surgeons increasingly used computed tomography (CT) as standard method for the initial diagnostic work-up for the last five to eight years. A physician dedicated to gastrointestinal sonography cannot accept this approach, in particular, since sonography is easy and reliable, provides a reasonable differential diagnosis and was found to help the surgeons. An exception is the deep-seated diverticulitis in the sometimes barely accessible distal sigmoid colon. Furthermore, an experienced clinician will anyhow proceed to CT in any unexplained discrepancy between clinical and sonographic findings. It reflects the high value given to sonography if our surgical colleagues use this diagnostic method in the primary diagnosis of acute diverticulitis and achieve results that are as good as the results of the expensive and by all criteria more elaborate CT. The extended application of ultrasound for the omentum and in necrotic epiploic appendagitis should be mentioned here as well. Altogether, CT can be easily refrained from in 80 % to 90 % of cases with suspected diverticulitis. In view of the DRG era, this is an important argument, and emphasizes the economic role of sonography, the necessity of correct coding of sonographic procedures and the need of more sonographic training. Only quality will increase the acceptance of sonography as diagnostic tool as repeatedly demanded and presented in this journal. If this fails, it is highly likely that the diagnostic potential of sonography will remain unexploited or, under the best of circumstances, rediscovered after a 5-year expiration date in a new literature search in 10 years." }, { "id": "pubmed23n0258_15730", "title": "[Radiological and endoscopic diagnosis of sigmoid diverticulitis].", "score": 0.013656633221850612, "content": "In emergency, the most commonly used examination, other than plain radiographs of the abdomen, is the water-soluble contrast enema (Gastrografin). It demonstrates three different pictures, which may be more or less associated one to the other: \"peridiverticulitis\", featuring serrate lesions, abnormal stiffness and fixity and, in some cases, a long narrowing or stricture of the colon; diverticula, mainly in the sigmoid colon, becoming sharp-pointed or spark-liked; spillage of contrast material out of the colic lumen or into a neighbouring organ (fistula). Ultrasonography may be a useful emergency procedure to secure a hesitating diagnosis in a patient with a febrile abdominal pain or with a abdominal-pelvic mass, especially in women. Colonoscopy and barium enema are both usually contra-indicated in the acute setting of diverticulitis because of their potential hazards. On the other hand, after resolution of the acute event, these tests may allow to rule out carcinoma or associated adenomas (which coexist in more than 15% of the patients). Endoscopic control appears more especially important as initial accurate diagnosis in sometimes impossible to assess between adenocarcinoma and diverticulitis. CT scan has found an increasing place in both diagnosis and evaluation of infectious complications of diverticular disease. It is most recommended to assess the diagnosis of severe episodes, failing to clearly improve after medical treatment, and most particularly when an abscess in suspected. CT scan may demonstrate a thickening of the colic wall, high densities of pericolic fat and a tissular mass which may enclose gas bubbles." }, { "id": "wiki20220301en003_107193", "title": "Appendicitis", "score": 0.01360062893081761, "content": "Rovsing's sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain. Sitkovskiy (Rosenstein)'s sign: Increased pain in the right iliac region as the person is being examined lies on their left side. Perman's sign: In acute appendicitis palpation in the left iliac fossa may produce pain in the right iliac fossa.Emil Samuel Perman 1856-1946 \"About the indications for surgery in appendicitis and an account of cases of Sabbatsberg Hospital in Hygiea 1904" }, { "id": "pubmed23n0934_6127", "title": "Acute diverticulitis and surgical treatment.", "score": 0.012809802283486493, "content": "Diverticulitis is a common condition in industrialized countries and an important cause of hospital admissions. Its growing trend is a challenge for the surgeons who perform emergency surgery, because approximately 15-25% of the patients will require surgery, being the surgical management of complicated acute diverticulitis controversial. The past decade has seen a paradigm shift in the treatment of sigmoid diverticulitis based on new epidemiological studies and refinement of surgical techniques that has produced a reassessment of our guidelines. CT imaging and sepsis scores allows to stratify the patients and better define the therapeutic strategies in each case. Special considerations must also be made for patients with a high surgical risk, such as immunosuppressed ones. The recommendations to perform surgery after two episodes of uncomplicated diverticulitis have been re-evaluated and the belief that new episodes may be complicated and associated with high morbidity and mortality has been rejected, since the clinical manifestations of this disease are usually defined by the first attack. In complicated cases, more patients can be treated with resection and primary anastomosis with or without an associated stoma, whose reversal rate is much higher than that of a Hartmann's procedure. Likewise, laparoscopic surgery performing a peritoneal lavage and drainage without associated resection may have an increasing role in the management of these patients, although with controversial results, having become laparoscopic colon resection the approach of choice for the treatment of this pathology in elective settings." }, { "id": "pubmed23n0297_7792", "title": "[Surgical treatment of colonic diverticulitis].", "score": 0.011925465838509317, "content": "Colonic diverticulitis is a serious disease that may require surgical treatment. Early diagnosis and management are necessary to reduce the rates of morbidity-mortality. This review article was performed in order to discuss the most recent advances in the diagnosis and management of colonic diverticulitis. Patients with acute diverticulitis should be categorized based upon the presence or absence of complications. Patients with complicated diverticulitis should be further categorized into I) pericolonic abscess, II) distant abscess (retroperitoneum or pelvis), III) purulent peritonitis, and IV) fecal peritonitis. In the absence of complications, elective treatment is mainly indicated in patients with recurrent episodes of diverticulitis. In complicated diverticulitis, the surgical alternatives will depend upon the clinical category. The current tendency is to attempt a percutaneous drainage of the abscess, followed by a semi-elective resection. In patients operated upon on emergency basis, resection with a diverting colostomy, with or without anastomosis, is the most widely used procedure. Surgical treatment for acute diverticulitis should be based upon the presence of complications and their clinical category." }, { "id": "pubmed23n0307_11291", "title": "[Colonic diverticulitis. Primary clinical and ultrasound diagnosis--report of 47 cases from general practice].", "score": 0.011863932246097851, "content": "Clinical and sonographic diagnosis-Report on 47 cases From 1993 to 1996, 47 patients with/after acute diverticulitis were examined in our practice by abdominal ultrasound. In all 36 cases with acute diverticulitis, a dolent non-echous wall thickening of descendent/sigmoid colon was seen. In five cases, we found other sonographic signs suspicious of penetration. Elevation of CRP and sometimes leukocytosis assisted the diagnosis in acute cases. In 39 of the 47 patients, colonoscopy was performed in the practice mostly during intermissions. Diverticula were confirmed in 31 patients whereas sigmoid stenosis from chronic diverticulitis could not be passed in 6 cases. 32 patients were treated with antibiotics and 10-including those with stenosis-underwent surgery. Except in one particular case (tubar abscess involving the sigmoid), operation confirmed sonographic findings of severe inflammation (stenosis and sealed perforation, respectively, in five cases). In patients presenting with pain in the left lower quadrant of the abdomen, colonic diverticulitis has to be considered especially if signs of inflammation are present. After clinical examination the first diagnostic measures should be venopuncture (CRP, leukocytes) and at the same time abdominal ultrasound by an experienced clinician. Due to its high accuracy, abdominal ultrasound is sufficient for primary diagnosis and evaluation of the course of colonic diverticulitis. Colonoscopy and barium enema follow after resolution of acute inflammation." }, { "id": "wiki20220301en026_25522", "title": "Diverticulosis", "score": 0.01177536231884058, "content": "Imaging Barium enema is inferior to colonoscopy in terms of image quality and is usually only performed if the patient has strictures or an excessively tortuous sigmoid colon where colonoscopy is difficult or dangerous. Colonoscopy will show the diverticulum and rule out malignancy. A colonoscopy should be performed 4–6 weeks after an acute episode. Contrast CT is the investigation of choice in acute episodes of diverticulitis and where complications exist. MRI provides a clear picture of the soft tissue of the abdomen, however, its expense often outweighs the benefits when compared to contrast CT or colonoscopy. Plain abdominal X-ray may show signs of a thickened wall, ileus, constipation, small bowel obstruction or free air in the case of perforation. Plain X-rays are insufficient to diagnose diverticular disease. There is no blood test for diverticulosis." }, { "id": "pubmed23n1164_4332", "title": "Elective surgery for conservatively treated acute uncomplicated diverticulitis: a systematic review of postoperative outcomes.", "score": 0.010808785380757479, "content": "Elective surgery has been proposed, after at least two episodes of acute diverticulitis, initially treated conservatively, in order to prevent further episodes or chronic complaints. However, prophylactic surgery has been questioned, due to the associated risks of postoperative mortality and morbidity, as well as the risk of recurrent diverticulitis. This systematic review attempts to assess the role of prophylactic left colonic resection, after episodes of uncomplicated acute diverticulitis treated either conservatively with antibiotics and/or other supportive measures. A systematic search was performed using Medline, Embase, Ovid, and Cochrane databases for studies reporting on the treatment of acute uncomplicated diverticulitis (Hinchey I). The main endpoint was treatment failure, defined as persistent/recurrent symptoms or need for readmission and/or reintervention. Secondary endpoints were the immediate postoperative outcomes. In total, 24 studies with 2855 patients were included in the analysis. Intra- and postoperative complications rate were 5% and 16%, respectively. Anastomotic leak was 1.3% and emergency reoperation was 2.4%. Long-term symptomatic resolve was reported at 91%. Persistent or recurrent symptoms were observed in 5.4% of cases. Meta-analysis showed no significant difference in recurrence rates between surgical and conservative management. Elective surgery to prevent recurrent diverticulitis is not recommended, irrespective of the number of previous episodes. Generally, elective sigmoidectomy should not be recommended to patients with ongoing atypical lower abdominal symptoms after acute diverticulitis, but should aim primarily at improving quality of life. It should be offered to patients with ongoing inflammation, or diverticular complications." }, { "id": "wiki20220301en026_25407", "title": "Diverticulitis", "score": 0.010611995444064784, "content": "Barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis because of the risk of perforation. Classification by severity Four classifications by severity have been published recently in the literature. The most recent and widely accepted is as follows: Stage 0 – asymptomatic diverticulosis Stage 1a – uncomplicated diverticulitis Stage 1b – diverticulitis with phlegmonous peridiverticulitis Stage 2a – diverticulitis with concealed perforation, and abscess with a diameter of one centimeter or less Stage 2b – diverticulitis with abscess greater than one centimeter Stage 3a – diverticulitis with symptoms but without complications Stage 3b – relapsing diverticulitis without complications Stage 3c – relapsing diverticulitis with complications The severity of diverticulitis can be radiographically graded by the Hinchey Classification." }, { "id": "pubmed23n0404_1434", "title": "[Standards in diagnosis of diverticulitis].", "score": 0.009900990099009901, "content": "The diagnostic procedure is determined by the severity of the diverticulitis. In complicated cases of diverticulitis, it is necessary to detect those patients with obstructive ileus, perforation, and peritonitis who require instant emergency surgery. In all other cases, diagnostic procedures serve as a tool to determine the best therapeutic options. The CT scan of the abdomen seems to have the highest reliability for determining therapy. Other investigations such as barium enema and coloscopy are not indicated in emergency cases or cannot exactly describe the stage of the diverticular disease. Many surgeons still prefer an enema with water-soluble contrast medium in emergency cases to visualize a perforation. CT scans have the same ability to answer this question, but they are more expensive and are not available everywhere at any given time." }, { "id": "pubmed23n0502_1967", "title": "[Primary diagnostics of acute diverticulitis of the sigmoid].", "score": 0.00980392156862745, "content": "The initial diagnostics of acute diverticulitis of the sigmoid should render the correct diagnosis as well as assisting in the decision on the options of conservative or surgical treatment by ruling out or demonstrating complications. At present, sonography or computed tomography (CT) are the two competing diagnostic options. This study was designed to demonstrate that sonography could be used as the method of choice. 63 patients with clinical suspicion of acute diverticulitis of the sigmoid were examined initially by sonography or CT in a prospective study. Sonography and CT showed a 97 % sensitivity and specificity for reaching the accurate and clinically plausible diagnosis. As to the demonstration of complications of the disease, sensitivity and specificity were comparably high for both diagnostic methods. Sonography can compete with the more complex CT examination and therefore represents the recommended primary diagnostic procedure." }, { "id": "pubmed23n0542_19750", "title": "[Sonography in acute diverticulitis of the sigmoid colon].", "score": 0.009708737864077669, "content": "Sonography is the primary diagnostic method in the painful left lower quadrant. Experienced investigators can diagnose an acute diverticulitis in more than 90%. In unclear cases or when complications are suspected, CT should be performed. Sonography can diagnose most differential diagnosis of the painful left lower quadrant as colitis, appenagitis or haematomas." }, { "id": "pubmed23n0329_5193", "title": "Radiological diagnosis and management of diverticulitis.", "score": 0.009615384615384616, "content": "Thirteen (13) patients with proven diverticulitis are presented with the aim of demonstrating the current evaluation and management. Radiological evaluation were obtained with plain abdominal x-rays and computed tomography (CT) in all cases, abdominal ultrasonography (US) in 8 cases and contrast enema in 5 patients. Radiological percutaneous abscess drainage (PAD) were performed in 5 cases, two of which preceded surgery. A clinical suspicion of diverticulitis was made in only 3 of the 13 cases. CT provided the diagnosis in all cases and helped in directing the appropriate management. Ultrasound was also useful but to a lesser extent. CT or US guided PAD reduced the surgical operation to a single stage procedure instead of the former 2- to 3-stage surgical management. Plain abdominal x-ray were only useful for the diagnosis in intestinal obstruction and vesical fistula. Contrast enema provided supporting information when necessary. CT clearly diagnosed both suspected and totally unsuspected cases of diverticulitis and provides guidance for the appropriate management. When CT is unavailable US with accurate colonic imaging and abscesses identification can also be useful in diagnosing and guiding drainage. Plain abdominal x-rays are less helpful but mandatory since the presentation is usually that of acute abdomen. Water soluble contrast enema also provides supportive features when necessary. In areas where diverticular disease is uncommon, diverticulitis should be suspected in cases with left iliac fossa or pelvic pain with mass and tenderness." }, { "id": "pubmed23n0522_18103", "title": "[Treatment of acute diverticulitis].", "score": 0.009615384615384616, "content": "In Western countries, diverticular disease is a frequent condition and the prevalence of which increases with age. Acute diverticulitis is its most frequent complication. CT-scan is now the best exam for diagnosis of acute diverticulitis, classification of its severity, and for follow-up. It can also, when necessary, allow percutaneous drainage of pericolic abscesses. Treatment of acute diverticulitis is most often conservative. Surgery outside acute events is now considered as a technique with extremely low morbidity and mortality. In this situation, laparoscopy represents nowadays the technique of choice for safe sigmoid surgery." }, { "id": "pubmed23n0724_25325", "title": "Danish national guidelines for treatment of diverticular disease.", "score": 0.009523809523809525, "content": "In order to elaborate evidence-based, national Danish guidelines for the treatment of diverticular disease the literature was reviewed concerning the epidemiology, staging, diagnosis and treatment of diverticular disease in all its aspects. The presence of colonic diverticula, which is considered to be a mucosal herniation through the intestinal muscle wall, is inversely correlated to the intake of dietary fibre. Other factors in the genesis of diverticular disease may be physical inactivity, obesity, and use of NSAIDs or acetaminophen. Diverticulosis is most common in Western countries with a prevalence of 5% in the population aged 30-39 years and 60% in the part of the population &gt; 80 years. The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5-4/100,000. Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis. Complicated diverticulitis is staged by the Hinchey classification 1-4 (1: mesocolic/pericolic abscess, 2: pelvic abscess, 3: purulent peritonitis, 4: faecal peritonitis). Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and/or CRP; but the clinical diagnosis is not sufficiently precise. Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey. The distinction between Hinchey 3 and 4 is done by laparoscopy or, when not possible, by laparotomy. Uncomplicated diverticulitis is treated by conservative means. There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis, but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection. Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics. When the abscess is &lt; 3 cm in diameter, drainage may be unnecessary, and only antibiotics should be instituted. The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies: The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or, alternatively, resection of the sigmoid with primary anastomosis. Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease. Evidence so far for the lavage regime is promising, comparing favourably with resection strategies, but lacking in solid proof by randomized, controlled investigations. In recent years, morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities. Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed. Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures, since prophylactic resection of the sigmoid, evaluated from present evidence, confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society. Any recommendation for routine resection following multiple cases of diverticulitis should await results of randomized studies. Laparoscopic resection is preferred in case of need for elective surgery. When malignancy is ruled out preoperatively, a sigmoid resection with preservation of the inferior mesenteric artery, oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended. Fistulae to bladder or vagina, or stenosis of the colon may be dealt with according to symptoms and comorbidity. Resection of the diseased segment of colon is preferred when possible and safe; alternatively, a diverting stoma can be the best solution." }, { "id": "pubmed23n0759_4878", "title": "Effectiveness of clinical guidelines in the management of acute sigmoid diverticulitis. Results of a prospective diagnostic and therapeutic clinical trial.", "score": 0.009523809523809525, "content": "Evidence-based criteria in the therapeutic choice for sigmoid acute diverticulitis (AD) are lacking. It is necessary to differentiate an acute episode of diverticular disease, not complicated (NCAD) and complicated (CAD) because these stages of diverticular disease needs different approach. In a prospective study on 377 consecutive patients admitted for AD, 265 had NCAD and 112 CAD diagnosed with CT scan. Thirty-six of 265 with NCAD were operated on due to two or more previous episodes of AD. On 188 patients with NCAD followed-up, 35 had further episodes of NCAD and 2 had CAD. On 112 CAD patients, 61 had Hinchey I and were submitted to colonic resection. Twenty-three of 24 patients with Hinchey II were treated with percutaneous drainage. All Hinchey II patients were operated on. All the 13 patients with Hinchey III and IV had emergency surgery. We had no mortality and respectively 9.8% and 30% morbidity in Hinchey I and II patients. In Hinchey II patients percutaneous drainage was successful in 21 on 23 (91.3%). In 13 Hinchey III and IV patients the mortality rate was 25%. The comparison of CT findings and pathological results showed a sensitivity of 100% and predictive positive value of respectively 94.4, 96.7, 100 and 100% for NCAD, Hinchey I, Hinchey II and Hinchey III-IV. The therapeutic approach of diverticular disease needs to differentiate among an acute episode, NCAD and CAD. Evidence-based therapeutic choices can be reached only by homogeneous diagnostic criteria obtained by CT scan." }, { "id": "pubmed23n0089_2695", "title": "[Sonography in the diagnosis of acute colonic diverticulitis].", "score": 0.009433962264150943, "content": "Acute colonic diverticulitis is mainly diagnosed clinically, as endoscopy or coloncontrast enema might be dangerous. In this study diagnostic criteria and typical sonographic findings of acute diverticulitis are summarized. The comparison of these findings - in stadium IIa of diverticulitis - to other sonographic colon findings shows high sensitivity (0.96), specificity (0.98) and predictive values (pV +0.85, pV -0.99) for sonographic findings of acute colonic diverticulitis. Thus sonography can improve diagnostic and follow-up controls of acute diverticulitis." }, { "id": "pubmed23n0418_6750", "title": "The role of ultrasound in the diagnosis, management and evolutive prognosis of acute left-sided colonic diverticulitis: a review of 208 patients.", "score": 0.009345794392523364, "content": "The aim of this study was to evaluate the role of ultrasound in the diagnosis and management of acute diverticulitis and its capacity to predict posterior complications in patients undergoing medical treatment. A review was made of the histories of 208 hospitalized patients (262 admissions) initially diagnosed with acute diverticulitis over a 5-year period. Ultrasound was performed in all patients upon first admission. Diverticulitis was retrospectively classified as either simple or complicated, the latter being defined by the presence of extraluminal air and/or abscesses. Diverticulitis was finally diagnosed in 203 patients. Ultrasound exhibited a sensitivity of 86% in 77 cases subjected to surgery, and of 94% in the global 203 patients (192 true-positive and 11 false-negative findings). Of 34 patients with diverticulitis and emergency surgery, 10 had false-negative US exams. Twenty of the 73 cases (27%) with signs of complicated diverticulitis in the initial ultrasound study required emergency surgery, compared with only 4 of the 119 patients (3%) with US evidence of simple diverticulitis (p&lt;0.001). Of the 169 patients with diverticulitis undergoing conservative management, 54 (32%) developed complications during follow-up. The patients under age 50 years with signs of complicated diverticulitis suffered more complications (65%) than the rest of groups (p&lt;0.001). In subjects with recurrences (26%), these were either similar to or less than the first episode in 84% of the cases. The present study shows that ultrasound constitutes a feasible technique for diagnosing acute diverticulitis. The severity of diverticulitis according to US is statistically predictive of surgical risk during the acute phase. Severity is also related to the appearance of posterior complications in patients undergoing conservative management, although only in younger patients (&lt;50 years)." }, { "id": "pubmed23n0684_20085", "title": "[Accurate predictors for acute diverticulitis].", "score": 0.009259259259259259, "content": "In a relatively high percentage of patients with a clinically suspected diverticulitis a different diagnosis is established after imaging tests, such as 'appendicitis' or 'intestinal obstruction'. The clinical diagnosis 'acute diverticulitis' is correct for between 43% and 68% of suspected patients. Strongly predictive variables for the diagnosis are tenderness in the left lower abdomen only, CRP &gt; 50 mg/l and absence of vomiting. This triad has a positive predictive value of 97% (95% CI: 83-99) for the final diagnosis 'diverticulitis'. The negative predictive value is much lower, namely 47%: the absence of 1 of the 3 factors does not (sufficiently) exclude 'diverticulitis'. This triad can be an easy-to-use decision rule to rule in diverticulitis." }, { "id": "pubmed23n0818_18629", "title": "Management of acute diverticulitis and its complications.", "score": 0.009174311926605505, "content": "Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases. " }, { "id": "pubmed23n0328_3946", "title": "[Value of ultrasonography as the initial diagnostic method in acute sigmoid diverticulitis].", "score": 0.009174311926605505, "content": "We herein describe the ultrasonographic findings of 19 patients with clinical suspicion of acute diverticulitis. The criteria considered as evidence of the disease included the identification of the diverticuli, thickening of the wall of the loop, alteration of local mesenterium and selective pain. Diagnosis was complemented by CT scan, barium enema and, in determined cases, colonoscopy. Of the 19 cases studied, 18 corresponded to acute diverticulitis of the sigma and one to acute salpingitis. The former 18 cases were correctly diagnosed by ultrasonography (uncomplicated diverticulitis) and the posterior CT scan did not provide additional information. In conclusion, ultrasonography is a highly sensitive and specific technique for the diagnosis of acute diverticulitis when the sigmoid colon is involved." } ] } } }

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{ "1": "Genetic mutational and linkage study.", "2": "Abdomino-pelvic ultrasound.", "3": "Helical computed axial tomography with iodinated contrast.", "4": "Abdominal and cerebral MRI.", "5": "Periodic clinical controls." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en001_68231", "title": "Autosomal dominant polycystic kidney disease", "score": 0.017973200673995025, "content": "Diagnosis Usually, the diagnosis of ADPKD is initially performed by renal imaging using ultrasound, CT scan, or MRI. However, molecular diagnostics can be necessary in the following situations: 1- when a definite diagnosis is required in young individuals, such as a potential living related donor in an affected family with equivocal imaging data; 2- in patients with a negative family history of ADPKD, because of potential phenotypic overlap with several other kidney cystic diseases; 3- in families affected by early-onset polycystic kidney disease, since in this cases hypomorphic alleles and/or oligogenic inheritance can be involved; and 4- in patients requesting genetic counseling, especially in couples wishing a pre-implantation genetic diagnosis." }, { "id": "wiki20220301en244_6278", "title": "Polycystic kidney disease", "score": 0.01592508648455207, "content": "Diagnosis Polycystic kidney disease can be ascertained via a CT scan of abdomen, as well as, an MRI and ultrasound of the same area. A physical exam/test can reveal enlarged liver, heart murmurs and elevated blood pressure Natural history Most cases progress to bilateral disease in adulthood. Treatment There is no FDA-approved treatment. However, recent research indicates that mild to moderate dietary restrictions slow the progression of autosomal dominant polycystic kidney disease (ADPKD) in mice. If and when the disease progresses enough in a given case, the nephrologist or other practitioner and the patient will have to decide what form of renal replacement therapy will be used to treat end-stage kidney disease (kidney failure, typically stage 4 or 5 of chronic kidney disease)." }, { "id": "pubmed23n0398_7695", "title": "The Jeremiah Metzger Lecture. Polycystic kidney disease: old disease in a new context.", "score": 0.012834821428571428, "content": "I want to thank the organizers for inviting me to present the Jeremiah Metzger Lecture at this, the 114th meeting of the ACCA. It is a high honor, indeed, to join a list of very distinguished predecessors. And for this opportunity to tell you about my passion in medicine and science, I am most grateful. Most of you in this room have passing knowledge of polycystic kidney disease, probably hearing about it in your medical school Pathology course where you were shown an especially grotesque, enormously enlarged kidney either encased in transparent plastic or submerged in a bucket of formaldehyde. In that minute or two when PKD was discussed in lecture, you may have been told that this is a rare, hereditary disorder that causes kidney failure and that nothing can be done to alter that course. Unless you chose to specialize in General Internal Medicine or Nephrology, you may not have encountered PKD again until today, despite the fact there are approximately 600,000 PKD patients in the USA and over 10,000,000 worldwide, and it accounts for approximately 5% of non-diabetic dialysis and renal transplant patients (Table 1). I might have overlooked PKD as well had it not been for a close friend that I grew up with who had inherited the disease from his mother. He was very open about the fact that he had cysts in his kidneys that caused bleeding into the urine from time to time, especially after a solid hit during a game of tackle football. We remained friends long after I left home for college and medical school. At an early stage of my research career in medicine, while wondering how nephron segments processed glomerular filtrate, I inadvertently discovered that renal tubules could secrete as well as reabsorb salt and water. This was quite an unexpected finding at the time (1). But it occurred to [table: see text] me that this might be a means to fill renal cysts with fluid and so I decided to learn more about the pathology and pathogenesis of PKD. This didn't take long, because there wasn't much literature on the subject. The clinical manifestations of PKD were described in the 19th century European medical literature and Sir William Osler had published on the topic in this country, but by and large only a few descriptions of small groups of patients were reported through the middle of the 20th century. In 1957, Dalgaard (2) reported in a classic doctoral thesis that the most common type of hereditary PKD is transmitted as an autosomal dominant trait (ADPKD) with complete penetrance. It is a bilateral renal condition, but cysts also occur in the liver (approximately 60%), pancreas (approximately 10%) and various other organs, and it is associated with cerebral aneurysms in approximately 5% of patients. A recessive form that affects infants and children primarily (ARPKD), is much rarer than ADPKD and commonly leads to death in infancy in association with massively enlarged kidneys (Table 2). I was also attracted to the study of PKD because the etiology was not in question: it had to be mutated DNA. Yet that fact proved to be a hindrance in attaining research support. As some of you will recall, not too long ago genetic diseases were viewed by kidney-oriented NIH review panels to be incurable. I was advised that a young scientist's time would be better spent determining how the kidneys excrete salt and water. Fortunately, the era of molecular genetics and biology was upon us, and we quickly learned that uncommon genetic disorders could lead to the discovery of novel molecules in metabolic and structural pathways. And that is just what happened in the PKD field. The autosomal dominant form of PKD led to the discovery of a unique family of highly complex proteins long before they would have been selected from a gene or proteomic micro-array by some desperate graduate student or fellow. The chromosomal location of the major ADPKD genotype, PKD1, was defined in 1985 (3), a date that marks the beginning of a remarkable period of discovery." }, { "id": "InternalMed_Harrison_22004", "title": "InternalMed_Harrison", "score": 0.011164372336938708, "content": "is because there is an increased frequency of developing simple renal cysts with age. Conversely, in subjects between age 30 and 59 years, the absence of at least two cysts in each kidney, which is associated with a false-negative rate of 0%, can be used for disease exclusion. These criteria have a lower sensitivity for patients with a PKD2 mutation because of a late onset of ADPKD2. CT scan and T2-weighted MRI, with and without contrast enhancement, are more sensitive than ultrasonography and can detect cysts of smaller size. However, a CT scan exposes the patient to radiation and radiocontrast, which may cause serious allergic reactions and nephrotoxicity in patients with renal insufficiency. T2-weighted MRI, with gadolinium as a contrast agent, has minimal renal toxicity and can detect cysts of only 2–3 mm in diameter. However, a large majority of cysts may still be below the detection level. Genetic testing by linkage analyses and mutational analyses is available for ambiguous" }, { "id": "wiki20220301en466_1670", "title": "Glomerulocystic kidney disease", "score": 0.010813953488372094, "content": "Diagnosis There must be a differential diagnosis done for GCKD because it can appear so similar to other kidney disease. To differentiate it from autosomal recessive polycystic disease it is found there is abnormal medullary pyramids in autosomal recessive polycystic kidney disease but not GCKD. Imaging of small renal cysts with sub scapular distribution also help to separate it from other diseases. In ADPKD cysts can be observed in the cortex and medulla, while GCKD they just present in the cortex. Diagnosis for GCKD can be confirmed if 5 percent or more of glomeruli are cystic. CT scans are one way to test but are not able to make distinctions between other diseases. MRI's are recommended because they are able to make definitive diagnosis of GCKD. Ultra sonographs can also be useful. A biopsy may also help differentiate from other cysts because in GCKD there will be tubular and glomerular atrophy, and interstitial fibrosis." }, { "id": "pubmed23n0706_5446", "title": "[Bright's disease is mentioned in an official Hungarian medical document in the 19th century].", "score": 0.009900990099009901, "content": "The World Kidney Day was announced for the fifth time in 2011, that calls attention to chronic renal failure as it attains the title of endemic. Richard Bright (1789-1858), a British doctor was the first to recognize and describe the uremic state and the kidney diseases leading to it. There are many aspects that the readers should remember him about especially in connection with the World Kidney Day. During his European study tour's stage in Hungary, he was not so much interested in the country's medical and health conditions, rather in its economic and cultural life, natural history and geography. He travelled to Hungary on two occasions and recorded his experiences in a personal travel documentation illustrated with his own drawings. He finally established himself in London in 1820 and together with Thomas Addison and Thomas Hodgkin they formed the Guy's Hospital's world-famous \"scientist trio\". Bright described the nephritis's classical image, nowadays known as Bright's disease for the first time at the age of 38 years in 1827. A presently turned up Hungarian medical certificate from 1870 contains the Bright's disease described by Richard Bright as a written diagnosis. This 140-year-old document also confirms that we can be proud of our predecessors concerning our knowledge of kidney diseases and their application in daily use in Hungary, because in the past they were the ones who used the most advanced knowledge in their practices. One of today's greatest challenges for us is to be able to inform healthy and ill people alike properly about kidney diseases and their prevention or management. Place this in order to stem the epidemic of chronic renal failure and still pay homage to this disease's greatest scientist, Richard Bright." }, { "id": "pubmed23n0763_14041", "title": "History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).", "score": 0.00980392156862745, "content": "It is spring and you are meeting for the first time, Eddie, a recently turned 6-year-old boy who moved to the area in September of the previous year and is here for his 6-year-old health maintenance visit. Eddie's mother is concerned that although he is \"only\" in kindergarten, he is not retaining any information at school. His mother reports he knew some of his letters before kindergarten. Currently, when he is trying to write a word, for example, \"daddy\" he will need to ask his mother: \"what letter is the letter D?\" Before kindergarten, he knew his numbers 1 to 10. At times now, Eddie will forget these numbers. For example, \"if he is counting he will forget what comes after 4 and what comes after 9.\" Mother reports he will start crying for no apparent reason and if she asks why, he will say \"I don't know why.\" Mother is worried that Eddie is sad, although she denies suicidal ideation. She reports he used to like making noise with other kids, and now he cannot stand when the children are noisy. Eddie will comment he does not want to go to school because the kids make lots of noise and his head hurts. He complains of headaches as often as 2 to 3 times a month. She next states, \"This was not an issue before his head trauma.\" At this point, she reveals to you that in August, before the family relocated, Eddie fell from a 7-foot deck onto concrete while playing. He struck his head on the left side and lost consciousness for several seconds until shaken awake. He was nauseous and disoriented initially but without emesis or incontinence. He was taken to the local emergency department where he was admitted for 1 day and diagnosed with closed head injury, left frontal epidural hematoma, and question of postconcussive syndrome. Eddie has gone back to see the neurosurgeon twice over the last 6 months for scheduled visits and since the accident has had no further treatment.Eddie's mother reports that before the accident, if she read him a story from a book, he could remember the details from the story. Currently, he does not have good memory recall. Before the trauma, he did not attend a preschool program but stayed home with his mother full time. Eddie's first formal schooling has been kindergarten this year. When they moved, the neurosurgeon recommended he start school at the end of September given his head trauma in August. He had a recent computed tomography completed 3 months ago showing the epidural hematoma had completely resolved and the study was otherwise normal. His mother reports he had an evaluation the spring before the accident for a kindergarten screening test and was reported as \"excellent.\" Eddie's birth and medical history are otherwise unremarkable except for some seasonal allergies. He has not had a loss in language skill, although his mother reports he did not speak during his hospitalization. He would just stare and nod his head if someone would ask him a question. No family history of any learning or behavioral difficulties on either side of the family. Eddie has 2 older brothers, 10 and 7 years of age, with no learning issues.What would you do next?" }, { "id": "pubmed23n0224_13833", "title": "Age at clinical onset and at ultrasonographic detection of adult polycystic kidney disease: data for genetic counselling.", "score": 0.00980392156862745, "content": "Few reports are available on the age-related risk of relatives of affected persons to manifest adult polycystic kidney disease (APKD). For 371 persons in 17 kindreds, at risk for APKD by virtue of having an affected first degree relative, we calculated the estimated probability of clinical diagnosis of APKD to be 0.011 by age 20, 0.041 by age 30, 0.115 by age 40, 0.299 by age 50, and 0.404 by age 60 years (expected = 0.50). Ultrasonographic examination of 172 asymptomatic persons at risk showed definite APKD in 60. The probability of ultrasonographic detection of asymptomatic APKD is estimated as 0.222, 0.657, and 0.855 at age 5, 15, and 25 years, respectively. The probability of having APKD following normal ultrasonogram results (conservatively assuming 90% specificity) is estimated as 0.46, 0.28, and 0.14 for persons at 50% risk in their first, second, or third decade. The marginal benefit of ultrasound as a diagnostic test for APKD for persons in the second or third decade is estimated as 0.37 and 0.41, respectively for a \"positive\" test and 0.22 and 0.37 for a \"negative\" test." }, { "id": "pubmed23n0885_24724", "title": "[Diagnosis in Polycystic Kidney Disease].", "score": 0.009708737864077669, "content": "The diagnosis of ADPKD should be based on a thorough assessment of the family history, radiological study and when indicated, genetic study. The anamnestic definition of 'negative family history' should be accepted only after a full clinical-instrumental assessment of close relatives of the subject . Ultrasound is the diagnostic modality of choice in at-risk patients with a positive family history of ADPKD. In some clinical scenarios (screening kidney donation, family planning and others) misdiagnosis based on morphological criteria may be too high. For this reason, it is not recommended to use the kidney ultrasound in order to rule out the diagnosis in patients younger than 40 years. In the cases with a positive family history in which the renal ultrasonography has not been able to clarify the diagnosis, either as confirmation or exclusion, MRI is indicated, given the increased sensitivity and specificity of the technology. The molecular genetic analysis can help establish the diagnosis. In the cases with negative family history, it is necessary to evaluate the presence of syndromic elements non-characteristic of ADPKD. In the presence of these elements, it is recommended to send the patient to a tertiary center for a differential diagnosis based on clinical and molecular assessment." }, { "id": "wiki20220301en363_29571", "title": "Persian cat", "score": 0.009615384615384616, "content": "Polycystic kidney disease (PKD) which causes kidney failure in affected adult cats has an incidence rate of 36–49% in the Persian breed. The breed – and derived ones, like the British Longhair and Himalayan – are especially prone to autosomal dominant polycystic kidney disease (ADPKD). Cysts develop and grow in the kidney over time, replacing kidney tissues and enlarging the kidney. Kidney failure develops later in life, at an average age of 7 years old (ranging from 3 to 10 years old). Symptoms include excessive drinking and urination, reduced appetite, weight loss and depression. The disease is autosomal dominant and DNA screening is the preferred method of eliminating the gene in the breed. Because of DNA testing, most responsible Persian breeders now have cats that no longer carry the PKD gene, hence their offspring also do not have the gene. Before DNA screening was available, ultrasound was done. However, an ultrasound is only as good as the day that it is done, and many cats" }, { "id": "pubmed23n0974_23104", "title": "[Screening for intracranial aneurysms].", "score": 0.009615384615384616, "content": "This review states the reasons for considering screening for intracranial aneurysms in Denmark: if patients have two first-degree relatives with intracranial aneurysms, are 30-70 years old, do not have competing disorders, which could significantly shorten life expectancy, and subsequently in patients with autosomal dominant kidney disease and a family history of subarachnoid haemorrhage. MR angiography should be the imaging study of choice, unless contraindicated. Generally, the ethical consequences ought to be considered before carrying out screening." }, { "id": "wiki20220301en244_6272", "title": "Polycystic kidney disease", "score": 0.009523809523809525, "content": "Signs and symptoms Signs and symptoms include high blood pressure, headaches, abdominal pain, blood in the urine, and excessive urination. Other symptoms include pain in the back, and cyst formation (renal and other organs). Cause PKD is caused by abnormal genes which produce a specific abnormal protein which has an adverse effect on tubule development. PKD is a general term for two types, each having their own pathology and genetic cause: autosomal dominant polycystic kidney disease (ADPKD) and autosomal recessive polycystic kidney disease (ARPKD). Autosomal dominant Autosomal dominant polycystic kidney disease (ADPKD) is the most common of all the inherited cystic kidney diseases with an incidence of 1:500 live births. Studies show that 10% of end-stage kidney disease (ESKD) patients being treated with dialysis in Europe and the U.S. were initially diagnosed and treated for ADPKD." }, { "id": "InternalMed_Harrison_22003", "title": "InternalMed_Harrison", "score": 0.009523809523809525, "content": "Diagnosis Diagnosis is typically made from a positive family history consistent with autosomal dominant inheritance and multiple kidney cysts bilaterally. Renal ultrasonography is often used for presymptomatic screening of at-risk subjects and for evaluation of potential living-related kidney donors from ADPKD families. The presence of at least two renal cysts (unilateral or bilateral) is sufficient for diagnosis among at-risk subjects between 15 and 29 years of age with a sensitivity of 96% and specificity of 100%. The presence of at least two cysts in each kidney and the presence at least four cysts in each kidney are required for the diagnosis of at-risk subjects age 30 to 59 years and age 60 years or older, respectively, with a sensitivity of 100% and specificity of 100%. This is because there is an increased frequency of developing simple renal cysts with age. Conversely, in subjects between age 30 and 59 years, the absence of at least two cysts in each kidney, which is" }, { "id": "wiki20220301en116_33470", "title": "Medullary cystic kidney disease", "score": 0.009433962264150943, "content": "Medullary cystic kidney disease (MCKD) is an autosomal dominant kidney disorder characterized by tubulointerstitial sclerosis leading to end-stage renal disease. Because the presence of cysts is neither an early nor a typical diagnostic feature of the disease, and because at least 4 different gene mutations may give rise to the condition, the name autosomal dominant tubulointerstitial kidney disease (ADTKD) has been proposed, to be appended with the underlying genetic variant for a particular individual. Importantly, if cysts are found in the medullary collecting ducts they can result in a shrunken kidney, unlike that of polycystic kidney disease. There are two known forms of medullary cystic kidney disease, mucin-1 kidney disease 1 (MKD1) and mucin-2 kidney disease/uromodulin kidney disease (MKD2). A third form of the disease occurs due to mutations in the gene encoding renin (ADTKD-REN), and has formerly been known as familial juvenile hyperuricemic nephropathy type 2." }, { "id": "wiki20220301en051_29169", "title": "Jimmy Little", "score": 0.009433962264150943, "content": "In 1958 Little married fellow singer, Marjorie Rose Peters and they had one child, Frances Claire Peters-Little (born ca. March 1958), who is a documentary film-maker, writer and historian. In 1990 Little was diagnosed with kidney disease, \"Unfortunately, I didn't get check-ups often enough or soon enough to realise the possibility that my kidneys could fail\". In 2002 he was diagnosed with kidney failure and was placed on dialysis and, in 2004, had a kidney transplant. As a result of immunosuppressants Little developed type 2 diabetes. He also developed a heart condition. Marjorie Rose Little died on 25 July 2011, aged 74, in Dubbo – she had been under medical care since early that year for an unspecified illness. On 2 April 2012 Little died at his home in Dubbo, aged 75 years. He is survived by his daughter, Frances, and his grandson, James Henry Little. In 2005 Little told Peter Thompson, on the ABC-TV program Talking Heads, how he would like to be remembered, \"I just want people to" }, { "id": "pubmed23n0984_8677", "title": "Features of Catatonia in a 12-Year-Old Boy with Autism Spectrum Disorder.", "score": 0.009345794392523364, "content": "Thomas is a 12-year-old boy with autism spectrum disorder who presents to his primary care clinician with symptoms of worsening mood in the last 3 months. On review of his last school testing, his cognitive abilities are found to be within the average range, with a relative vulnerability with his processing speed. He can speak in sentences to communicate and answer questions, but he rarely picks up on conversational bids. He has had difficulties developing friendships and often prefers to play by himself.Thomas has a long history of some features of anxiety and depression for which it was recommended that he establish care with a therapist, but his family has had a hard time finding a provider for him. At this visit, the mother reports that for the past several months he has been more anxious, sad, and easily overwhelmed. He seems irritable at home and school and cries often. His family has been advocating for him to receive increased school supports, as school is a source of anxiety for him, but there are no recent changes in school services. There is a family history of both anxiety and depression. Given his worsening mood functioning, Thomas was started on selective serotonin reuptake inhibitor (SSRI) medication in addition to again recommending a therapist. Weekly phone call check-ins and an in-person clinic visit in 1 month are planned.About 1 month after starting the SSRI medication, he is still not showing any improvement in mood functioning, and his family reports he seems more \"sluggish\" than usual. There are no side effects reported with the medication, and the dose is increased to see whether it will help. However, about 2 weeks later, he is seen again in the clinic because there are increasing concerns. He continues to be \"sluggish.\" During the clinic visit, he lies down on the examination table, sometimes holding his head off the edge of the table, which he has never done before. He responds very slowly to the questions and often says \"I don't know, I don't know,\" almost in an automatic way. His mother reports that he is now engaging in some repetitive hand movements which he had not done previously. He is no longer able to shower independently. He is still eating and drinking adequately. What would you do next?" }, { "id": "pubmed23n0061_9817", "title": "[Echographic screening for autosomal dominant polycystic kidney disease from intrauterine life to adult life].", "score": 0.009345794392523364, "content": "ADPKD is the most widespread genetic nephropathy. Only twenty-five per cent of patients are symptomatic. In order to prevent the disease it is important early screening by ultrasonography that shows a typical picture only in adults. Familiar history is determinant for diagnosis in intrauterine age, in newborns and in infants. Ultrasonographic diagnosis is certain only after twenty-five weeks of pregnancy." }, { "id": "pubmed23n0646_1200", "title": "[Adult male with chronic renal failure due to reflux nephropathy that was possibly induced by neurogenic bladder since childhood].", "score": 0.009259259259259259, "content": "A 38-year-old male with impaired renal function and serious anemia was admitted to our hospital. He had suffered from a disorder of urination since early childhood and been diagnosed as having neurogenic bladder by an urologist when he was 20 years old. Since February 2007, general fatigue emerged and gradually worsened. In addition, he began to feel nauseous around February 2008. He visited a family doctor and was diagnosed with renal failure and anemia both of which were serious. H e was referred t o our office and admitted immediately because his blood test showed a serum creatinine level of 4.4 mg/dL and hemoglobin of 3.1 g/dL. The initial study with ultrasonograhy suggested that both kidneys contained multiple cysts for the most part, likely due to hereditary polycystic kidney disease. However, a subsequent series of diagnostic imaging tests, including computed tomography and magnetic resonance urography, determined that the cause of renal failure was most likely reflux nephropathy due to secondary vesicouretral reflux induced by the chronic neurogenic bladder. Moreover, the upper gastrointestinal endoscopic examination showed that the cause of anemia was probably the persistent bleeding from gastric antral vascular ectasia. Reflux nephropathy emerges in early childhood and slowly progresses to chronic renal failure in some cases. According to the literature, it is not rare as a cause of end-stage kidney failure even among adult populations. Diagnostic imaging of severe reflux nephropathy is apparently similar to that of polycystic kidney disease. We herein present an adult male with chronic renal failure due to reflux nephropathy, the images of which were similar to polycystic kidney disease." }, { "id": "pubmed23n0229_12371", "title": "[Prevention and clinical course of polycystic kidney disease in adults. Examination and case report of 134 patients].", "score": 0.009259259259259259, "content": "Adult polycystic kidney disease is inherited in an autosomal dominant fashion and it ranks third as the cause of end-stage renal disease, with 9% of patients in dialysis treatment. It is possible to achieve an effective primary or secondary preventive action because of its clinical, evolutive and hereditary features. We studied 134 patients with different degrees of renal function, considering the beginning and the evolution of the disease. The collected data were compared with other reports. Furthermore the finding of cysts in organs other than the kidney, the coexistence of intracranial aneurysms, high blood pressure and pregnancy were examined. We report a study carried out on 17 families of patients in hemodialysis because of MPRA, which included 118 subjects. We were only able to examine 40 adults (34%) completely and among these five patients were discovered to have MPRA. For 29 of the subjects (41%) didn't complete the examinations or refused further investigations. The contemporary presence of suggestive family history and data obtained by urography, nephrotomography, nephrosonography and the study of renal function permit a reliable diagnosis. The incidence of the disease could only be reduced by a constant prevention, but there are considerable difficulties caused by the little attention given to the disease by the medical class and people in general." }, { "id": "wiki20220301en136_38098", "title": "Polycystic liver disease", "score": 0.009174311926605505, "content": "Polycystic liver disease (PLD) usually describes the presence of multiple cysts scattered throughout normal liver tissue. PLD is commonly seen in association with autosomal-dominant polycystic kidney disease, with a prevalence of 1 in 400 to 1000, and accounts for 8–10% of all cases of end-stage renal disease. The much rarer autosomal-dominant polycystic liver disease will progress without any kidney involvement. Presentation Pathophysiology Associations with PRKCSH and SEC63 have been described. Polycystic liver disease comes in two forms: autosomal dominant polycystic kidney disease (with kidney cysts) and autosomal dominant polycystic liver disease (liver cysts only). Diagnosis Most patients with PLD are asymptomatic with simple cysts found following routine investigations. After confirming the presence of cysts in the liver, laboratory tests may be ordered to check for liver function including bilirubin, alkaline phosphatase, alanine aminotransferase, and prothrombin time." }, { "id": "pubmed23n0482_1251", "title": "Imaging kidneys: unknown documents in the history of nephrology. Five consulti by Marcello Malpighi.", "score": 0.009174311926605505, "content": "Consulti are one of the most interesting sources for reconstructing a true outline of the state of the medical art in the Early Modern period. They were epistulae--in Latin as well as in vernacular--sent to famous physicians to receive a more correct diagnosis, and better therapeutical prescriptions. They collect and illustrate case studies, therapeutical uses, as well as the patient's attitude towards disease. This article concerns five urological consulti by Marcello Malpighi." }, { "id": "InternalMed_Harrison_21683", "title": "InternalMed_Harrison", "score": 0.009141378909429137, "content": "Imaging Studies The most useful imaging study is a renal ultrasound, which can verify the presence of two kidneys, determine if they are symmetric, provide an estimate of kidney size, and rule out renal masses and evidence of obstruction. Because it takes time for kidneys to shrink as a result of chronic disease, the finding of bilaterally small kidneys supports the diagnosis of CKD of long-standing duration, with an irreversible component of scarring. If the kidney size is normal, it is possible that the renal disease is acute or subacute. The exceptions are diabetic nephropathy (where kidney size is increased at the onset of diabetic nephropathy before CKD supervenes), amyloidosis, and HIV nephropathy, where kidney size may be normal in the face of CKD. Polycystic kidney disease that has reached some degree of renal failure will almost always present with enlarged kidneys with multiple cysts (Chap. 339). A discrepancy >1 cm in kidney length suggests either a unilateral developmental" }, { "id": "pubmed23n0983_25792", "title": "Refractory ascites and graft dysfunction in early renal transplantation.", "score": 0.00909090909090909, "content": "The occurrence of ascites after Renal Transplant (RT) is infrequent, and may be a consequence of surgical or medical complications. Case report: 61 year-old, male, history of arterial hypertension, tongue carcinoma and alcoholic habits 12-20g/day. He had chronic kidney disease secondary to autosomal dominant polycystic kidney disease, without hepatic polycystic disease. He underwent cadaver donor RT in September 2017. He had delayed graft function by surgically corrected renal artery stenosis. He was admitted in January 2018 for ascites de novo, with no response to diuretics. HE had visible abdominal collateral circulation. Graft dysfunction, adequate tacrolinemia, Innocent urinary sediment, mild anemia, without thrombocytopenia. Serum albumin 4.0g / dL. Normal hepatic biochemistry. Peritoneal fluid with transudate characteristics and serum albumin gradient &gt; 1.1. Ultrasound showed hepatomegaly, permeable vascular axes, without splenomegaly. Mycophenolate mofetil was suspended, with reduced remaining immunosuppression. He maintained refractory ascites: excluded infectious, metabolic, autoimmune and neoplastic etiologies. No nephrotic proteinuria and no heart failure. MRI: micronodules compatible with bile cysts. Upper Digestive Tract Endoscopy did not show gastroesophageal varicose veins. Normal abdominal lymphoscintigraphy. He underwent exploratory laparoscopy with liver biopsy: incomplete septal cirrhosis of probable vascular etiology some dilated bile ducts. He maintained progressive RT dysfunction and restarted hemodialysis. The proposed direct measurement of portal pressure was delayed by ascites resolution. There was further recovery of the graft function. Discussion: Incomplete septal cirrhosis is an uncommon cause of non-cirrhotic portal hypertension. Its definition is not well known, morphological and pathophysiological. We have not found published cases of post-RT ascites secondary to this pathology, described as possibly associated with drugs, immune alterations, infections, hypercoagulability and genetic predisposition." }, { "id": "wiki20220301en595_28332", "title": "Halide Pişkin", "score": 0.00909090909090909, "content": "She became well-known as \"Pişkin Teyze\" (\"Sophisticated Aunt\") in radio dramas she performed in addition to her acting on stage. She entered film world in 1933 with her performance in the movie Karım Beni Aldatırsa (\"If My Wife Cheats On Me\"). Later, she acted in the movies Aynaroz Kadısı (1938), Allah'ın Cenneti (1939), Tuzak (1948), Lüküs Hayat (1950), İncili Çavuş (1951), Kızımın Başına Gelenler (1958) and Kalpaklılar (1959). In 1958, she wrote the screenplay Kızımın Başına Gelenler (\"What Happened to My Daughter\"). Pişkin died at the age of 57 in Istanbul due to kidney failure on 1 November 1959. References and notes While some sources state her birth year as 1906, 1907 and 1910, in an interview at Milliyet on 28 Nov 1954, pg. 3, she states that she's born in 1320 Hijri, which is 1902. This seems consistent with her interviews on 1930s. 1902 births People from Shkodër Turkish stage actresses Turkish film actresses Turkish radio actresses 1959 deaths" }, { "id": "pubmed23n0728_17821", "title": "Incidental renal cell carcinoma presenting in a renal transplant recipient with autosomal dominant polycystic kidney disease: a case report.", "score": 0.009009009009009009, "content": "We report an instructive case of incidental renal cell carcinoma in a patient with autosomal dominant polycystic kidney disease who underwent simultaneous bilateral native nephrectomy and living donor renal transplantation. A 57-year-old Asian man with end-stage kidney disease due to autosomal dominant polycystic kidney disease received a living kidney graft from his brother. Because of recurrent infection, chronic pain and enlarged kidneys, he underwent a bilateral nephrectomy with concomitant renal transplantation. The total weight of the removed kidneys was 6kg; the maximal diameter of the larger kidney was 28cm. His left kidney had a 1cm diameter tumor. Pathology indicated papillary renal cell carcinoma. At the time of this report, the transplant kidney function was normal with no evidence of local recurrence or distant metastasis. This case shows and reinforces the importance of considering the possibility of an occult malignancy in the native kidneys of patients with autosomal dominant polycystic kidney disease. Simultaneous bilateral native nephrectomy should be considered in these renal transplant recipients not only for preventing the development of adverse symptoms but also for detecting an occult malignancy." }, { "id": "pubmed23n1068_1341", "title": "'I can assure you, there is nothing wrong with your kidney'.", "score": 0.009009009009009009, "content": "Normal baseline investigation results in a patient with common symptoms is often labelled as being due to a functional disorder, with all the pejorative connotations that go along with that term. When given the opportunity to see a patient for a second opinion, it is important to retain an open mind rather than assuming previous assessments are correct. Such an attitude helps with both attaining the definitive diagnosis but is also crucial to helping give hope to the patient. Understanding the patient's concerns about the meaning of their symptoms is critical in finding the balance between advanced investigation to identify a putative cause versus a decision to proceed with symptomatic control." }, { "id": "pubmed23n0752_23636", "title": "Diagnosis of autosomal dominant polycystic kidney disease.", "score": 0.008928571428571428, "content": "Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease and accounts for 5 - 10% of end stage renal disease. Mutations of two genes, PKD1 and PKD2, account for ∼ 85 and ∼ 15% of cases, respectively. This paper reviews the clinical features of ADPKD, highlights the current roles for image- and molecular-based diagnostics, and the potential for new innovations to improve the clinical diagnostics for ADPKD. This paper reviews the literature on the clinical features, differential diagnosis, and image- and molecular-based diagnostics for ADPKD. At present, presymptomatic diagnosis of ADPKD in subjects born with 50% risk is typically performed by renal ultrasonography. Renal MRI, with improved sensitivity for detecting smaller cysts, is a promising modality. There is also a clear role for molecular diagnostics, especially in patients with equivocal imaging results, in those with a negative family history and in younger at-risk subjects with a negative ultrasound study being evaluated as a living-related kidney donor. Also, several classes of promising disease-modifying drugs are being tested in clinical trials and, if proved effective, some of them will be used in early disease. Therefore, it is likely that there will be an increased demand for accurate and early diagnosis of ADPKD in the not so distant future." }, { "id": "wiki20220301en017_65336", "title": "Kidney cancer", "score": 0.008849557522123894, "content": "Computed tomography (CT) of the abdomen administered with and without IV contrast is the ideal imaging to diagnose and stage kidney cancer. There is tentative evidence that iodinated contrast agents may cause worsening of kidney function in people with chronic kidney disease (CKD) with a glomerular filtration rate (GFR) less than 45ml/min/1.73m2 and should therefore be given cautiously in this group. Abdominal magnetic resonance imaging (MRI) is an alternative imaging method that can be used to characterize and stage a kidney mass. It may be suggested if contrast material cannot be given. MRI can also evaluate the inferior vena cava if the mass is suspected to extend outside the kidney. Since the lungs are the most common organ for kidney cancer to spread to, a chest X-ray or CT scan may be ordered based on the person's risk for metastatic disease. Histopathologic classificationn" }, { "id": "wiki20220301en001_68236", "title": "Autosomal dominant polycystic kidney disease", "score": 0.008771929824561403, "content": "In 2014, Japan was the first country in the world to approve a pharmacological treatment for ADPKD followed by Canada and Europe, which approved the drug tolvaptan for ADPKD patients in the beginning of 2015. The USA FDA approved the use of tolvaptan in the treatment of ADPKD in 2018. Tolvaptan, an aquaretic drug, is a vasopressin receptor 2 (V2) antagonist. Pre-clinical studies had suggested that the molecule cAMP could be involved in the enlargement of ADPKD cysts, and studies on rodents confirmed the role of vasopressin in increasing the levels of cAMP in the kidney, which laid the basis for the conduction of clinical studies. Because data from the Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease (CRISP) led by Mayo Clinic showed that total kidney volume (TKV) predicted the risk of developing chronic kidney disease in patients with ADPKD, the TEMPO 3:4 trial, which enrolled patients from 129 sites worldwide from 2007 to 2009, evaluated TKV as a primary" }, { "id": "pubmed23n0071_20784", "title": "Heredity and origin of duplication of the pelvicalyceal collecting system.", "score": 0.008771929824561403, "content": "The present study was undertaken in an effort to prove the significance of genetic factors and their role in the origin of one of the most commonly occurring anomaly, i.e. the duplication of the pelvicalyceal collecting system. Our aim was to test foreign data on autosomal dominant inheritance of low penetrance in this anomaly and to try to find whether a preventive examination of the kidneys and urinary tract (sonography or intravenous urography) can be justified in 1st degree relatives. On intravenous urography made in 44.4% of 1st degree relatives a pathological finding was seen in 20%, one half of which having been estimated as serious requiring further examination and therapy. The above mentioned data in principle coincide with reports in literature abroad. Drawing on the results obtain the pediatrician or urologist can be advised to send the family, in which the pelvis et ureter duplex was discovered, to the genetic consulting centre. Here the 1st degree relatives could be recommended for the examination of their kidneys and urinary tracts on the evidence of the family tree and discussion with parents. The literature assumption that this anomaly is an autosomal dominant defect could not be quite confirmed. The fact that the defect was found in 10.7% of parents and 15% siblings indicates that it could represent the autosomal dominant trait type of low penetrance. An exact definition of the inheritance type is influenced by impossibility of examining the children' grandparents and by retrospective selection of the group. Although the type of heredity cannot be accurately stated yet, we believe the main contribution of our results to consist in the discovered importance of preventive examinations of the urinary tract in 1st degree relatives." }, { "id": "wiki20220301en498_7793", "title": "Polycystic kidney disease 3 (autosomal dominant)", "score": 0.008695652173913044, "content": "Polycystic kidney disease 3 (autosomal dominant) is a protein that in humans is encoded by the PKD3 gene. Polycystic kidney disease (ADPKD) is a life threatening hereditary disorder; it is characterized by the development of fluid-filled cyst formation and expansion of the kidney and other organs. It is an autosomal dominant disease, and it is the most common hereditary disorders with a rate of occurrence of approximately 1 in 1000. Characteristics ADPKD is an autosomal dominant disease, it contains 3 types of mutation: PKD1 (16 Chr), PKD2 (4 Chr) PKD3 (11 Chr, this gene). Mutations in the 3 different genes PKD1, PKD2 and PKD3 cause a very similar disorder of the autosomal dominant form of polycystic kidney disease (ADPKD). The PKD3 gene is located on chromosome number 11q12.3; the phenotype MIM number is 600666." }, { "id": "pubmed23n0656_7577", "title": "[Recent insights into polycystic kidney disease].", "score": 0.008695652173913044, "content": "Autosomal dominant polycystic kidney disease is one of the most prevalent genetic diseases and every general practitioner may have to counsel these patients. The follow-up of the patients carrying the trait has changed substantially lately and new treatments have been developed and are close to get approval. We review here the new ultrasound diagnostic criteria, the place of the renal volumetry by MRI in the follow-up, the place of the genetic molecular diagnosis and we discuss the pathogenesis and the future treatment that are in phase III clinical studies and will soon change completely the outcome of the disease." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 46, 588 ] ], "word_ranges": [ [ 9, 105 ] ], "text": "Most of the lesions identified as L-SIL are associated with HPV infection: for this reason, it is advisable to stop smoking, as this is a factor in the progression of the said infection. On the other hand, according to the latest studies, 70% of the cytologies reported as LSIL will remit, 15% will persist and another 15% will show a more severe cytology, without being able to differentiate whether it is a biological progression or a lesion hidden in the initial cytology. Because of this, it is best to return for a follow-up at 6 months." } }

{ "1": "Conization with diathermy loop.", "2": "Endocervical curettage with Kevorkian curettage.", "3": "Endometrial biopsy with Cornier cannula.", "4": "Hysterectomy without adnexectomy.", "5": "Advise her to stop smoking and contraceptives and to have a control in 6 months." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1071_16833", "title": "Endometriosis presenting as vaginal polyps: outpatient vaginoscopic treatment.", "score": 0.015176419022572867, "content": "To demonstrate an outpatient vaginoscopic technique for treating multiple vaginal polyps. Demonstration of surgical technique using slides, pictures, and video. Private hospital. Thirty-two-year-old nulligravid woman presenting to the gynecology clinic with one episode of intermenstrual bleeding, regular menstrual cycles with normal flow, and no history of dysmenorrhoea or dyspareunia. The genital local examination was normal, and speculum examination showed multiple vaginal lesions like polyps in the proximal posterior two-thirds and right lateral vaginal walls. Her transvaginal ultrasound read a normal uterus with a right ovarian simple cyst. The surgeon performed an outpatient operative vaginoscopy using a 5-mm continuous flow office hysteroscope with a 2.9-mm rod lens optical system and a 5F working channel. Distension of the vagina was achieved with a normal saline solution, and an intrauterine pressure of 50 to 60 mm Hg was maintained by an irrigation and aspiration electronic pump. An inspection of the vaginal walls, fornices, and the external cervical os (Fig. 1) revealed 10 vaginal lesions like polyps in the proximal two-thirds of the posterior and right lateral vaginal wall. The vaginal lesions (Fig. 2) varied in size from 0.5 cm to 4 cm. An excisional biopsy was performed and the sample sent for histopathologic evaluation. The vaginal lesions &lt;2 cm in length were excised by cutting the base with scissors or using a bipolar vaporization electrode, which was connected to an electrocautery unit by a bipolar high-frequency cord. Vaginal lesions &gt;2 cm were excised with the TruClear 5C Hysteroscopic Tissue Removal System (HTRS) with a zero-degree scope using the 2.9-mm incisor with a 5-mm cutting window at one end attached to a reusable handpiece with two connectors-one to the motor unit and second to the suction bottle with a collection bag. The overall diameter of TruClear 5C is 5.7 mm, and the optic size is 0.8 mm. The same irrigation pump is compatible with HTRS, and the pressure was increased to 150 mm Hg to maintain vaginal distension. Three factors influenced our decision to use the HTRS intraoperatively: the number and size of the vaginal lesions and the surgical time in the outpatient setting. A mechanical system that works on the principle of excising and aspirating tissue, the HTRS incisor has a rotatory action with the excising window placed against the most distal part of the vaginal lesions. The cutting action is controlled via a foot pedal attached to a motor control with 800 rotations per minute. The handpiece remains stationary while the polyp is excised and aspirated through the window into the collection bag. Minimal bleeding occurred and stopped spontaneously. The institutional ethics committee exempted this case report from review, and we obtained informed written consent from the patient. All vaginal lesions excised in an outpatient setting via vaginoscopy technique without anesthesia. The operative time with the Bettocchi hysteroscope was 14 minutes, and HTRS was 6 minutes. The patient did not complain of pain but did describe minimal discomfort, rated on the visual analog scale as 2 (where ≥5 is severe pain). She was discharged 1 hour later. The histopathology was reported as vaginal endometriosis (ectopic presentation of endometriosis is rare, accounting for 0.02% of cases). After surgery, she was started on cyclical oral contraceptive pills (OCP) in the combination of 30 mg of ethinyl estradiol + 2 mg of dienogest because she desired to delay pregnancy by 1 year. She remained asymptomatic for 6 months. These contraceptive hormones are available in the form of oral pills, vaginal rings, and transdermal patches, and a physician can provide OCP continuously or cyclically. Continuous OCP is more efficacious for control of dysmenorrhoea, but cyclical OCP is preferred because it is affordable, tolerable, effective, produces no unpredictable bleeding, and slows the progression of the disease. (A cohort study found the contraceptive vaginal ring to be more effective for symptom-control in rectovaginal endometriosis with higher patient satisfaction than the transdermal patch; vaginal rings or transdermal patches are not available in some countries.) CONCLUSION(S): Vaginoscopy allows a more in-depth visualization of the vagina with complete inspection and removal of all polyps. Vaginoscopy is feasible in the outpatient setting and allows a comfortable, ergonomic position for the surgeon. Vaginoscopy or no-touch technique avoids the use of a speculum or tenaculum and results in minimal pain during the outpatient procedure." }, { "id": "pubmed23n1137_3792", "title": "Superficial spreading cervical squamous cell carcinoma in situ involving the endometrium: a case report and review of the literature.", "score": 0.014810778680404198, "content": "The spread of cervical squamous cell carcinoma to the inner surface of the uterus with replacement of the endometrium is rare. Continuity of the lesion must be demonstrated to confirm superficial spread and rule out concomitant endometrial cancer. We present the case of a 66-year-old white woman with superficial spreading squamous cell carcinoma of the cervix that involved the endometrium. Her relevant past history included conization of the cervix to treat cervical intraepithelial neoplasia III with positive margins. She subsequently had three negative cervical vaginal cytology results, each with a positive high-risk human papillomavirus test. Transvaginal ultrasound showed occupation of the entire uterine cavity by dense material consistent with pyometra in addition to myometrial thinning due to tension and cervical dilation. The patient presented with greenish vaginal discharge of 3 months' duration. The cervix was not visible during speculum examination. Access for endometrial sampling was not possible, raising suspicion of post-conization cervical stenosis. The patient was treated with laparoscopic hysterectomy with double adnexectomy. Histologic examination showed superficial squamous cell carcinoma invading the cervix to a depth of 2.8 mm; superficial spreading squamous cell carcinoma in situ was also observed in the lower uterine segment and endometrium. The patient was free of symptoms 12 months after surgery. Squamous cell carcinoma of the cervix with superficial spread to the endometrium is not included in the 2020 (fifth edition) World Health Organization Classification of Female Genital Tract Tumors or the 2018 International Federation of Gynecology and Obstetrics cervical cancer staging system. More clinical cases are needed to identify other prognostic factors and inform clinical practice guidelines on the management of this disease." }, { "id": "pubmed23n0342_10010", "title": "Clinical evaluation of follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears.", "score": 0.014174972314507199, "content": "The aim of this study was to evaluate the efficacy of the follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears. From May 1991 to December 1996, we have performed 407, 451 cervicovaginal Pap smears, of which 326 patients were identified as AGUS. Of the 326 patients, 268 patients were followed by repeat Pap smears, colposcopy, cone biopsy, or endometrial curettage. The incidence of AGUS on Pap smears is approximately 0.08%. The mean age of the patients was 43 years (range 22-79 years). The most common complaint was abnormal vaginal bleeding. The gross findings of the cervix were normal to mild erosion. The following past histories of patients could affect the AGUS results on Pap smear: 30 had cone biopsy, 21 had Pap smears on pregnancy and within 8 weeks after delivery or evacuation, 3 were on hormonal replacement therapy, 2 had intrauterine devices for contraception, and 5 were undergoing follow-up after treatment of cervical cancer. The benign lesions detected during follow-up periods were 6 microglandular hyperplasia of the cervix, 5 atypical squamous metaplasia of the cervix, 2 cervical endometriosis, 2 tubal metaplasia, 10 cervical myoma, 11 cervical polyps, 9 endometrial polyps, 3 uterine myoma, 1 pelvic endometriosis, 1 ovarian endometriosis, and 4 uterine adenomyosis. The premalignant or malignant lesions of the cervix were 4 low-grade squamous intraepithelial lesions, 24 high-grade squamous intraepithelial lesions, 8 glandular atypia/dysplasia, 5 adenocarcinoma in situ, 3 microinvasive adenocarcinoma, and 4 invasive adenocarcinoma. The neoplastic lesions of the uterus were 6 endometrial hyperplasia, 11 endometrial adenocarcinoma, 1 malignant mixed Müllerian tumor, and 1 metastatic endometrial adenocarcinoma. Sixty-seven (25%) of 268 patients followed up were identified as having clinically significant lesions of the cervix or uterus. The detection rates of abnormal lesions were 3.1% with repeated Pap smears (3/98), 28.4% with colposcopic-directed biopsy (31/109), 63.6% with cone biopsy (35/55), and 29.7% with endometrial curettage (19/64). AGUS on Pap smears showed various benign and malignant lesions of the cervix or uterus. The clinicians must communicate with the pathologists regarding the patient's clinical information as well as the origin of the atypical glandular cells in Pap smears. We recommend that patients with AGUS on Pap smear should undergo immediate intensive diagnostic studies, including colposcopic-directed biopsy with endocervical curettage or cone biopsy, to detect cervical lesions and endometrial curettage to detect endometrial lesions." }, { "id": "pubmed23n0254_18725", "title": "Predictive factors from cold knife conization for residual cervical intraepithelial neoplasia in subsequent hysterectomy.", "score": 0.013988023952095809, "content": "The optimal management of cervical intraepithelial neoplasia after cold knife conization remains controversial. Reliable predictors of residual dysplasia in the cervix after cold knife conization have not been consistently identified. This study was initiated to examine the accuracy of the traditional factors used to predict residual dysplasia in hysterectomy specimens after cold knife conization. A retrospective 10-year chart review identified a cohort of 1272 patients who underwent cold knife conization, of whom 311 had a subsequent hysterectomy within 1 year of conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. All cone specimens were completely submitted for pathologic examination, and the following factors were analyzed for their predictive value: degree of dysplasia, margin involvement, endocervical gland involvement, and status of the endocervical curettage. The predictive value of age, race, gravidity, parity, socioeconomic status, cigarette smoking, and marital status were also examined. The chi 2 test, t test, and logistic regression were used for statistical analysis. Dysplasia or cancer were identified in 1066 (84%) of the 1272 patients who underwent cold knife conization. Of the 311 patients having a subsequent hysterectomy, 106 (34%) had residual disease in their hysterectomy specimen. By multivariate analysis only increasing age and degree of dysplasia were predictive of residual disease. The odds ratio of residual disease in the hysterectomy specimen for a 25-year-old woman was 2.7 (95% confidence interval 1.6 to 4.4) compared with a 40-year-old woman whose odds ratio was 4.9 (95% confidence interval 2.2 to 10.8). The presence of dysplasia in the cold knife conization specimen conferred an odds ratio of 12.1 (95% confidence interval 2.7 to 54.5) of identifying residual disease. Dysplasia involving the ectocervical margin, endocervical margin, and endocervical glands was not predictive of disease in the hysterectomy specimens. Endocervical curettage was not performed in 44% of the patients, preventing reliable statistical evaluation. Further analysis indicated that residual disease was found in 32% of the hysterectomy specimens with negative margins, in 31% with no endocervical gland involvement, and in 23% with a negative endocervical curettage sample. The presence or absence of dysplasia in the cold knife conization ectocervical margin, endocervical margin, and endocervical glands was not predictive of residual dysplasia in post-cold knife conization hysterectomy specimens. Increasing age and severity of disease in the cone specimen were the only factors that accurately predicted residual dysplasia. The traditional factors used to justify hysterectomy after cold knife conization may not be valid on the basis of these results." }, { "id": "pubmed23n0367_6706", "title": "The clinical importance of atypical glandular cells of undetermined significance on the cytologic smear.", "score": 0.012487512487512488, "content": "The objective of the study was to assess the prevalence of underlying cervical and endometrial lesions among patients with atypical glandular cells of undetermined significance (AGCUS) on the cytologic smear. Eighty-six patients with AGCUS, without evidence of squamous intraepithelial lesions, underwent coloposcopy and endocervical curettage (ECC) within 6 months of the initial finding. Endometrial samplings were performed in 25 patients. Coloposcopy, endocervical curettage, and endometrial biopsy results were reviewed. A significant lesion was defined as cervical intraepithelial neoplasia and/or any structural or histologic abnormality of the cervix or uterus (i.e., polyp). Statistical analyses were performed using the t test, chi-square, and Fisher's Exact tests comparing patients with underlying lesions to those without. A significant lesion(s) was identified in 21 (24.4%) patients, with 8 (9.3%) of the lesions being high-grade cervical neoplasias. An additional 14 (16.3%) patients, with negative initial work-ups, had underlying lesions or major cytologic abnormalities diagnosed on subsequent follow-up. All of the endometrial findings were benign. None of the following were statistically significant predictors of underlying pathology: age, gravidy, parity, medications, medical history, tobacco use, history of sexually transmitted diseases including human immunodeficiency virus, previous abnormal cytologic smear, concurrent diagnosis of atypical squamous cells of undetermined significance, or evidence of human papillomavirus. AGCUS is often associated with clinically important underlying lesions. Patients should therefore undergo colposcopy and ECC. Endometrial sampling and possible cervical conization should be performed when coloposcopic evaluation is nondiagnostic." }, { "id": "pubmed23n0302_21249", "title": "Predictive factors used to justify hysterectomy after loop conization: increasing age and severity of disease.", "score": 0.01185811865053223, "content": "To determine the interpretability and significance of the traditional factors used to predict residual dysplasia in hysterectomy specimens after loop conization. Loop electrosurgical cervical conization was performed on 372 patients. Ninety three women had a hysterectomy within 6 months of the loop conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. Of the 93 patients having a subsequent hysterectomy, 36 (38.7%) has residual disease in their hysterectomy specimen. The mean age of the patients with residual disease in the post loop conization hysterectomy specimen was 42.22. The mean age of those free of residual disease was 29.42. By multivariate analysis, dysplasia involving the ectocervical margin (p = 0.34) and the endocervical margin (p = 0.35) was not predictive of disease in the hysterectomy specimens. Endocervical curettage (p = 0.005), glandular involvement (p = 0.01), loop conization pathology findings (p &lt; 0.05) and cytological examination (p &lt; 0.001) were predictive of residual dysplasia. Cytological reports, increasing age, severity of disease, gland involvement and endocervical curettage were the only factors that accurately predicted residual dysplasia. The presence or absence of dysplasia in the loop conization, ectocervical margin and endocervical margin was not predictive of residual dysplasia in post loop conization hysterectomy specimens." }, { "id": "Gynecology_Novak_6915", "title": "Gynecology_Novak", "score": 0.011322566785452523, "content": "Patients with AIS who are treated with conization should undergo close clinical follow-up. Endocervical curettage, often used in surveillance, may miss residual or invasive disease, and false-negative rates as high as 50% were reported (34). In addition, skip lesions not resected at the time of conization may be present. For these reasons, hysterectomy should be considered the standard therapy for patients who have completed their childbearing. In two reports, patients with negative cone biopsy margins were followed conservatively, with few requiring repeat surgical procedures (35,36). Because cervical AIS tends to affect women during their reproductive years, a thorough discussion of risks and benefits should take place, and treatment should be individualized." }, { "id": "Gynecology_Novak_3044", "title": "Gynecology_Novak", "score": 0.01025132275132275, "content": "Cure rates are related to the grade of the lesion; CIN 3 has a greater chance of treatment failure (Table 19.4). Townsend showed that cures are related to the size of the lesion; those covering most of the ectocervix have failure rates as high as 42%, compared with a 7% failure rate for lesions less than 1 cm in diameter (99). Positive findings on endocervical curettage can reduce the cure rate significantly. Endocervical gland involvement is important because the failure rate Table 19.4 Results of Cryotherapy for Cervical Intraepithelial Neoplasia (CIN) Compared with Grade of CIN Table 19.5 Success Rate for Laser Vaporization Loop electrosurgical excision is a valuable tool for the diagnosis and treatment of CIN (106– 116). It offers the advantage of performing an operation that is simultaneously diagnostic and therapeutic during one outpatient visit (100–105,117–122)." }, { "id": "pubmed23n0354_22798", "title": "Clinical implication of atypical squamous cells of undetermined significance with or without favoring high-grade squamous intraepithelial lesion on cervical smears.", "score": 0.009900990099009901, "content": "The cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS) on a cervical smear usually makes clinicians unsure of how to manage the patient and follow-up on her condition. We attempted to define the clinical implication of qualifying the cytologic diagnosis of ASCUS as either favoring a high-grade squamous intraepithelial lesion (HSIL) or not in an effort to provide management guidelines. From January through May 1997, 65 of 5792 women who had cervical/vaginal smears taken at Kaohsiung Chang Gung Memorial Hospital were diagnosed as having ASCUS. Thirteen of the 65 cases of ASCUS favored an HSIL, based on nuclear abnormalities in atypical metaplastic and parakeratotic-type squamous cells. All these 65 patients were evaluated in our outpatient clinic by a second cervical smear, colposcopy, and colposcopically directed biopsies and/or endocervical curettage. The median length of the follow-up period was 19 months (range, 16 to 21 months). Of the 52 patients evaluated for ASCUS smears without favoring HSIL, 6 (11.5%) had a low-grade SIL (LSIL), 1 (1.9%) had cervical intraepithelial neoplasia grade II (CIN II), and 1 (1.9%) had invasive squamous carcinoma. Of the 13 patients with a cervical cytologic diagnosis of ASCUS favoring HSIL, 1 (7.6%) had immature metaplasia, 2 (15.4%) had LSIL, 2 (15.4%) had CIN II, 6 (46.2%) had CIN III, and 2 (15.4%) had invasive squamous carcinoma. For patients with a cytologic diagnosis of ASCUS favoring HSIL, more aggressive interventions, such as colposcopy-directed biopsy, endocervical curettage, or even conization, should be performed promptly. However, those without features favoring HSIL may be evaluated with regularly repeated smears." }, { "id": "pubmed23n0271_4576", "title": "[Electro-conization with the diathermic loop. Indications and results].", "score": 0.009900990099009901, "content": "The experiment of electro-conization with diathermic loop was effected on 185 patients. The indications are represented by: a) low grade lesions: 21 cases (11.3%) only when the squamo-columnar junction was into the endocervix; b) CIN 2: 44 cases (23.7%): c) CIN 3: 118 cases (63.7%); d) cyto-histologic discordance: 2 cases. After one year, the following results could be noted: 94.1% of the patients were cured, only 11 out of the 185 presented a recurrence (or persistence). It seemed interesting to us to study the factors which could influence the \"in sano\" (Free margin)/or not character of the resection. It appeared that the surface of the lesion did not seem to influence its histological result since we got: 83%, 96%, 94.5% and 92.3% of \"in sano\" conizations to be correlated with a lesion surface equal to 1/4, 2/4, 3/4, 4/4 of the cervical area. The second factor to be studied was the patients' age. So from 15 to 25 years (96%) of the resections were \"in sano\". There from 26 to 35 (92%), and from 36 to 45 (91.9%). Among post-menopausal women from 46 to 55 years old only 86.4% of electro-conizations were \"in sano\". Histologic alterations of the histologic specimen were noted in two cases (1%), the interpretation was easy and clear in the other cases. What about the complications? In 2 cases a moderate stenosis was to be noted; in 2 other cases: post-operative hemorragiae which were treated by a selective electro-coagulation.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "Gynecology_Novak_3051", "title": "Gynecology_Novak", "score": 0.009853819072401654, "content": "Percentage of patients undergoing conization who develop significant vaginal bleeding Table 19.8 Complications of Electrosurgical Excision Hysterectomy Hysterectomy is considered a treatment of last resort for recurrent high-grade CIN. In a study of 38 cases of invasive cancer occurring after hysterectomy among 8,998 women (0.4%), the incidence of significant bleeding, infection, and other complications, including death, is higher with hysterectomy than with other means of treating CIN (128). There are some situations in which hysterectomy remains a valid and appropriate (although not mandatory) method of treatment for CIN: 1. 2. CIN 3 at the endocervical limits of conization specimen in selected patients 3. Poor compliance with follow-up 4. Other gynecologic problems requiring hysterectomy, such as fibroids, prolapse, endometriosis, and pelvic inflammatory disease 5." }, { "id": "pubmed23n0854_25185", "title": "Escharotic Treatment for ECC-positive CIN3 in Childbearing Years: A Case Report.", "score": 0.00980392156862745, "content": "A persistent human papillomavirus (HPV) infection of a high-risk type is necessary for cervical cancer to develop. The severity of the diagnosis, together with colposcopy findings, determines the standard for treatment, and ablative or excisional options may be recommended. Escharotic treatment, together with an oral, anticarcinogenic HPV protocol and a vaginal-suppository protocol, is an alternative treatment, especially for those women of childbearing age who are concerned about the possibility of obstetrical complications associated with the use of loop electrosurgical excision (LEEP). The aim of the current case study was to observe the effect of an ablative escharotic treatment for a woman with severe dysplasia, cervical intraepithelial neoplasia grade 3 (CIN3). A 28-y-old female visited the National College of Natural Medicine clinic to obtain suggestions for alternative treatments following a satisfactory colposcopy and a biopsy revealing a high-risk HPV effect, severe dysplasia CIN3, and a positive endocervical curettage (ECC). She refused the recommended standard of care, a LEEP, because of concerns about the potential for future obstetrical complications. As an alternative, she elected to receive an escharotic treatment at a frequency of 2 treatments/wk for 5 wk. In addition to the escharotic treatment, she followed an oral protocol consisting of vitamins and botanical medicine for 1 y and she completed a 12-wk regime of vaginal suppositories following the escharotic. The authors followed her for 2 y. The woman's Papanicolaou (Pap) test at the 6-mo follow-up revealed negative cervical cytology for intraepithelial lesion or malignancy, and her follow-up ECC was negative. Liquid-based Pap results were normal, and HPV testing was negative at her 1-y follow-up. Her Pap continued to remain normal at her 2-y follow-up. For women with high-grade cervical neoplasias and positive ECCs, with satisfactory colposcopies, escharotic treatment, accompanied by oral supplementation, holds promise as an effective alternative to LEEP and other excisional procedures. " }, { "id": "pubmed23n0869_18526", "title": "See-and-Treat for High-Grade Cytology: Do Young Women Have Different Rates of High-Grade Histology?", "score": 0.00980392156862745, "content": "To compare rates of cervical intraepithelial neoplasia grade 3 or greater (CIN3+) between women aged 21 to 24 and women aged 25 or older undergoing a see-and-treat strategy for high-grade squamous intraepithelial lesion (HSIL) cytology. In this retrospective cohort study, women treated with a see-and-treat loop electrosurgical excisional procedure (LEEP) for HSIL cytology at our university-based colposcopy clinic between 2008 and 2013 were identified. Data collected included age, race, parity, smoking status, method of contraception, history of abnormal cytology, HIV status, and LEEP histology. Cohorts were compared using Pearson chi-squared test of association and Fisher exact test. Three hundred sixty-nine women were included in this analysis. The mean age was 30 (SD, 7.2; range, 21-56). Ninety-seven women (26.3%) were 21 to 24 years old. The rate of CIN3 in all women undergoing a see-and-treat LEEP for HSIL cytology was 65.9% (95% CI, 60.8-70.5). The rate of CIN 2 was 15.2% (95% CI, 11.9-19.2). Three women (1.1%) had invasive carcinoma. There was no difference in risk of CIN3+ in the young women compared with women aged 25 years or older (RR, 1.37; 95% CI, 0.92-2.02). Within this see-and-treat population, there was no correlation between presence of CIN3+ and race, smoking, contraception, or HIV status. Most women undergoing see-and-treat for HSIL cytology will have CIN3 on final histology. In this large cohort, women aged 21 to 24 did not have lower rates of CIN3 compared with women aged 25 and older, suggesting that see-and-treat is still a valid treatment option for the prevention of invasive disease in young women." }, { "id": "pubmed23n0077_10167", "title": "[Is consecutive curettage of the corpus uteri indicated in every conization case?].", "score": 0.009708737864077669, "content": "Endometrial curettage at the time of conisation is often performed as a routine procedure, even when indication for this treatment is rather unclear. 593 conisations including curettages were performed at the I. Department of Obstetrics and Gynaecology, of the University of Vienna and were evaluated retrospectively. Only 3 patients with a mild endometrial hyperplasia were found. Therefore, in our opinion, there is no indication for a curettage at the time of conisation, if a woman is under the age of 35 years and if there is no other specific indication for sampling the endometrium, based on high risk factors, physical examination, history or abnormal glandular cells found on cervical cytology. Such management would result in reducing the costs and the risk of infection in intrauterine operations." }, { "id": "pubmed23n0971_8158", "title": "Primary squamous cell carcinoma of the endometrium in a woman of perimenopausal age: A case report.", "score": 0.009615384615384616, "content": "Primary squamous cell carcinoma of the endometrium (PSCCE) is a rare entity, and only sporadic cases have been reported in the literature since the 1st report in 1892. This report describes a case of a perimenopausal woman with PSCCE. A 47-year-old, human papilloma virus type 16-positive, perimenopausal woman was admitted to our hospital with irregular vaginal bleeding for 6 months and secondary anemia. The patient was diagnosed with stage IIIc primary and moderately differentiated endometrial squamous cell carcinoma. The patient underwent diagnostic curettage twice and cold knife conization (CKC). Following this total abdominal hysterectomy combined with bilateral adnexectomy and pelvic lymph node, dissection was performed. After the surgery, the patient was treated with radiotherapy and chemotherapy. Tumor markers were followed up regularly after the operation to monitor tumor recurrence and therapeutic effect. Ninety-two days after the operation, there was tumor recurrence of the left pelvic cavity and the patient died after 11 months of follow-up. Intrauterine pathology after the 1st diagnostic curettage suggests that high-grade squamous intraepithelial lesion should make the clinician vigilant and investigate the origin of the lesion. Magnetic resonance imaging scans and tumor markers can be used to confirm the diagnosis as soon as possible and avoid unnecessary interventions like CKC." }, { "id": "pubmed23n0032_2279", "title": "[Intraepithelial carcinoma of the cervix uteri. 1) Cytologic detection in gynecologic practice. Our exerience with 15,000 smears].", "score": 0.009615384615384616, "content": "The best results in screening for subclinical cancer of the cervix are given by cytological studies. The authors in reviewing their experience in this method of screening studied the result of 15,000 smears which gave a diagnosis of 37 cases of intra-epithelial carcinoma of the cervix, which means 1 case of carcinoma in situ diagnosed in every 400 smears. Although the technique is very simple it has to be carried out according to strict criteria at the time of taking the smear, of fixing it immediately and of staining it. There is a group of patients who are at high risk about the age of forty, when there is a marked influence due to parity. But only a systematic policy will bring about diagnosis of pre-invasive carcinoma in cases where the cervix is clinically healthy. The cytology is usually characteristic, though the diagnosis may be difficult during pregnancy, or when hormone contraception is being used or when there is a trichomonas infection present. This explains why we find false positives in 0.03 per cent of cases in this study and false negatives in 0.03 per cent of cases. Their rarity means that the method is 99.94 per cent reliable. Finally, the cervical smear gives an opportunity for studying the vaginal microbial flora as well as the cyto-hormonal state." }, { "id": "pubmed23n0756_10901", "title": "Post-cervical conization outcomes in patients with high-grade intraepithelial lesions.", "score": 0.009523809523809525, "content": "To investigate the rates of residual, recurrent and invasive disease after cervical conization in patients diagnosed with cervical intraepithelial neoplasia (CIN) grades 2/3. A retrospective study was conducted with 274 patients undergoing cervical conization due to diagnosis of CIN 2/3. Cervical conization was done through the Loop Electrosurgical Excision Procedure (LEEP) and Cold Knife Conization. Data related to personal, familial, gynecological, and obstetric antecedents, as well as surgical specimens margins were collected from medical records. The outcome after conization was evaluated, including the time of follow-up and disease recurrence. The outcome after conization was not associated with age of menarche (p = 0.920), age of the first sexual intercourse (p = 0.533), number of parturition (p = 0.063), number of sexual partners (p = 0.328), immunosuppression (p = 0.225), smoking habit (p = 0.193), and conization type (p = 0.198). However, the outcome presented a significant association with age (p &lt; 0.001), pregnancy numbers (p = 0.009), use of hormonal contraception methods (p = 0.016), menopause (p = 0.007), type of margins (p = 0.011), and cone histological results (p = 0.030). The routine control of all patients who had undergone cervical conization is obligate, independently of surgical margins, due to the risk of disease recurrence; the older patients and those with CIN 3 should have a more rigorous follow-up." }, { "id": "pubmed23n0601_3853", "title": "[A falsely reassuring cervical smear in adenocarcinoma of the external os].", "score": 0.009433962264150943, "content": "3 women with only mild changes in cervical smears were later found to be suffering from cervical adenocarcinoma. The first patient was 53 years old. Her smears repeatedly showed Pap 3 with moderately atypical glandular cells. After 3 colposcopic examinations with biopsies and 2 loop electrosurgical excision procedures of the cervix which showed no histological signs of malignancy, diagnostic conization revealed an adenocarcinoma of the endocervix. She underwent a radical hysterectomy and chemoradiation because of positive pelvic nodes. The second patient was 30 years old and had persistent vaginal discharge and an enlarged cervix, but no cytological abnormalities. Colposcopy was unsatisfactory and the tissue obtained by loop electrosurgical excision was normal. Adenocarcinoma was diagnosed after conization. She was treated with radical hysterectomy and radiotherapy but died after one year. The third patient, aged 26, had a long history of slightly abnormal Pap smears and vulvar condylomata, and was referred with vaginal discharge. A severe abnormal smear with glandular atypia was followed by colposcopical biopsies and conization, which revealed an endocervical adenocarcinoma. She underwent radical hysterectomy. Adenocarcinoma is a rare type of cervical cancer: III cases out of 584 patients with cervical cancer in 2003 in the Netherlands. This neoplasm is more difficult to detect than cervical squamous cell carcinoma. Cervical cytology is not an effective tool for screening and diagnosis. Due to the localization, multifocality and diversity in its presentation, the assessment of cytology has a high false-negative percentage. Screening may be enhanced by combining cytology with testing for high-risk HPV types, notably type 18. If cervical cytology shows persistent atypical glandular cells with no conclusive histological result, then due to the endocervical localisation of the lesions adenocarcinoma can only be excluded by conization." }, { "id": "pubmed23n0132_4214", "title": "Endometrial curettage at the time of cervical conization.", "score": 0.009433962264150943, "content": "Endometrial curettage often is done as a routine procedure at the time of cervical conization, although the indications for this are unclear. Of 207 consecutive cone biopsies done recently at the Medical College of Pennsylvania, 199 (96%) included endometrial curettage. Two patients exhibited mild endometrial hyperplasia; the rest had no significant abnormality. Three uterine perforations (1.5%) occurred. Routine endometrial curettage is not necessary at the time of conization, and should be limited to patients with specific indications for sampling the endometrium, based on history, physical examination, and the finding of abnormal glandular cells on cytology. It is estimated that the elimination of routine curettage would result in a savings of over $100 per patient." }, { "id": "pubmed23n0829_8273", "title": "Predictive factors for positive or negative pathology in loop and laser conizations.", "score": 0.009345794392523364, "content": "The main purpose of this study is to predict positive-negative pathology in association with operative indications in laser and loop conizations. This retrospective study comprises two groups of women, the first group composed of 74 loop conizations, the second of 78 laser cones. Positive endocervical curettage, unsatisfactory colposcopy with no visible lesion or junction, discrepant cytology and biopsy, suspicion of invasion, or a glandular lesion were considered as indications for cones. All cones were performed under local intramucous anesthesia, and 15 mm of endocervical mucosa was removed. Loop and laser cone outcomes were comparable for age, parity, and pathology with negative or positive margins. Endocervical curettage of lesions of cervical intraepithelial neoplasia grades 2 and 3 (CIN2 and CIN3) predicted both higher cone pathology (p =.048) and high-grade squamous intraepithelial lesions, as evidenced by preoperative cytology (p =.000). Among 32 negative-margins cases, 2 (6.3%) had CIN persistence as compared to 6 patients (24%) of 25 positive margins. Laser and loop cones yield similar pathological results, and special care should be used for CIN1 endocervical curettage and low-grade squamous intraepithelial lesion cytology with conization indication, in regard to the high possibility of negative cone pathology." }, { "id": "pubmed23n0889_3207", "title": "Predictors of Positive Margins at Time of Loop Electrosurgical Excision Procedure.", "score": 0.009345794392523364, "content": "The aim of the study was to identify factors associated with the presence of high-grade squamous intraepithelial lesion (HSIL) at surgical margins of loop electrosurgical excision procedure (LEEP) pathology specimens. All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for all women who had a LEEP performed for indications within contemporary American Society of Colposcopy and Cervical Pathology guidelines between April 1, 2013, and April 30, 2015. Factors extracted from the database included demographics, contraception, weight, tobacco use, provider volume, resident participation, history of cervical procedure, and pathology features including preceding Pap test category. A positive margin was defined as HSIL on either the endocervical or ectocervical margin of the LEEP specimen or in endocervical curettage specimen after LEEP. We performed univariable statistics to identify factors associated with positive margins and then logistic regression modeling on significant factors for the outcome of positive margins. Two hundred sixty-nine women were identified. Seventy five (27.8%) of these women had positive margins. Only tobacco use, gravity, parity, and preceding Pap category were significant on univariable analysis. After multivariable analysis, smokers remained more likely to have positive margins (odds ratio = 2.01; CI = 1.12-3.6; p &lt; .01) as did those with preceding HSIL Pap tests (odds ratio = 1.96; CI = 1.13-3.41; p &lt; .01). In our population, of all the factors assessed, only tobacco use and preceding high-grade Pap tests were associated with positive margins at time of LEEP. This information may be helpful in preprocedural planning to optimize treatment." }, { "id": "pubmed23n1044_8627", "title": "Recurrent vaginal intraepithelial neoplasia successfully treated with topical imiquimod: A case report.", "score": 0.009259259259259259, "content": "Vaginal intraepithelial neoplasia (VAIN) is a rare disease associated with human papillomavirus infection. High-grade VAIN is typically treated with either excisional or ablative therapy. However, recurrent VAIN lesions are common and these treatments cause vaginal scarring. Recent studies have indicated that 5% imiquimod is an effective treatment for VAIN. The present report describes a case of a woman diagnosed with recurrent VAIN 3 who was treated with a 5% topical imiquimod cream and achieved a complete response after excision and CO<sub2</sub laser vaporization. A 53-year-old, gravida 5, para 2 postmenopausal woman who was diagnosed with papillary squamous cell carcinoma by biopsy underwent conization, total abdominal hysterectomy and bilateral salpingo-oophorectomy. A histological examination revealed grade 3 cervical intraepithelial neoplasia with free surgical margins. At 3 years after the hysterectomy, the vaginal smear revealed atypical squamous cells, leading to a pathological diagnosis of VAIN 3. Partial vaginectomy was performed, and VAIN 3 was detected in the lesion with positive margins. At 4 months into follow-up, the vaginal smear revealed a high-grade squamous intraepithelial lesion (HSIL), and subsequent biopsy during colposcopy revealed a pathological diagnosis of VAIN 3. At 3 months after CO<sub2</sub laser vaporization, the vaginal smear revealed HSIL with suspected recurrence and imiquimod treatment was initiated. One sachet of 5% imiquimod cream (0.25 g) was placed in the entire vagina three times per week for 14 weeks with no apparent complications. At 3 years after the treatment, there has been no recurrence. This case demonstrated that topical imiquimod with careful follow-up is an effective treatment for VAIN and is well-tolerated. Further clinical evidence of the effectiveness and safety of imiquimod in patients diagnosed with VAIN is required." }, { "id": "pubmed23n0786_25510", "title": "A case of adenosarcoma of the uterus.", "score": 0.009174311926605505, "content": "Adenosarcoma is a rare tumor which consists of benign glandular epithelium and malignant mesenchymal component. Here we report a case of adenosarcoma of the uterine corpus. Case Presentation. A 59-year-old woman presented with vaginal bleeding and visited a local clinic. She had a uterine tumor pointed out and was referred to our hospital. Ultrasound scans revealed a large heterogeneous mass occupying the whole uterine cavity. Cytological test of endometrium was performed but the result was negative. A fractional endometrial curettage revealed no malignancy. Magnetic resonance imaging (MRI) revealed a heterogeneous solid tumor of 77 × 76 mm. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was performed. On gross examination, the tumor was arising from the uterine body and occupied the whole uterine cavity. Histopathological examination revealed phyllodes-like architecture on low magnificationandperiglandular cuffing of tumor cells. The lesion was confined to the uterus. Histopathological final diagnosis was adenosarcoma. Her postoperative course was uneventful and she was discharged without postoperative treatment and remains alive without disease 6 months after the surgery. " }, { "id": "pubmed23n0391_17585", "title": "Five-year follow up of women randomised to medical management or transcervical resection of the endometrium for heavy menstrual loss: clinical and quality of life outcomes.", "score": 0.009174311926605505, "content": "To assess clinical status, changes in health related quality of life, and subsequent management five years after medical management or transcervical resection of the endometrium for treatment of heavy menstrual loss. Five year follow up using postal questionnaires and operative databank review. Gynaecology department of a large UK teaching hospital. Women referred to the gynaecologist for treatment of heavy menstrual loss. Eligible women, without a treatment preference, were randomised equally to either medical treatment or transcervical resection of the endometrium. Women's satisfaction with treatment, menstrual status, changes in health related quality of life, and additional treatments received at five years. One hundred and forty-four patients completed questionnaires, achieving 77% follow up (medical n = 71/94; transcervical resection of the endometrium n = 73/93). At five-year follow up, 7/71 (10%) of those randomised to the medical arm still used medical treatment, while 72/94 (77%) had undergone surgical treatment and 17/94 (18%) a hysterectomy. Twenty-five (27%) women allocated to transcervical resection of the endometrium had undergone further surgery, 18/93 (19%) a hysterectomy. At five years women initially randomised to medical treatment were significantly less likely to be totally satisfied (P &lt; 0.01, difference 21%, 95% CI -37% to -4%), or to recommend their allocated treatment to a friend (P &lt; 0.001, difference 59%, 95% CI -73% to -45%). Bleeding and pain scores were similar in both groups and highly significantly reduced. Significantly more women in the transcervical resection of the endometrium arm had no bleeding or very light bleeding (P &lt; 0.02, difference -22%, CI -31% to -4%), and they had significantly less days heavy bleeding (P &lt; 0.02). Short Form 36 health survey scores were significantly improved from baseline for all eight health scales in the transcervical resection of the endometrium arm, and four in the medical arm. A policy of immediate transcervical resection of the endometrium for women referred to a gynaecologist for treatment of heavy menstrual loss achieves higher levels of satisfaction, better menstrual status, and greater improvements in health related quality of life than medical treatment. In addition, transcervical resection of the endometrium is safe and does not lead to an increase in the number of hysterectomies. An effective endometrial ablative technique should be offered to all eligible women seeking treatment of their heavy menses from a gynaecologist." }, { "id": "pubmed23n1115_11924", "title": "Grade 3 endometrioid adenocarinoma of the lower uterine segment diagnosed 6 weeks after a term delivery: A case report and literature review.", "score": 0.00909090909090909, "content": "Endometrial cancer is the most common gynaecological malignancy in Australian women. Less than 5% of cases occur in women under 40 years of age and it is rarely associated with pregnancy. Most cases associated with pregnancy are diagnosed after first trimester loss. Only 14 cases of endometrial cancer diagnosed post-partum are reported in the literature. These cases were diagnosed up to 15 months post-partum. The histopathological classification was low grade in 12 patients and high grade in two patients. We describe a 37 year old woman, who presented after her second vaginal delivery (at 37 weeks of gestation) with suspected retained products of conception (RPOC). She had a dilation and curettage leading to the diagnosis of endometrial cancer six weeks post-partum. She underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and bilateral sentinel node biopsy. Histopathology confirmed a stage 1B grade 3 endometrioid adenocarcinoma located in the lower uterine segment with widespread lymph-vascular invasion and no other evidence of malignancy. She is planned to complete six cycles of adjuvant carboplatin/ paclitaxel chemotherapy, followed by pelvic external beam radiotherapy. We report the second case of a high-grade endometrial cancer diagnosed post-partum. The bulk of this tumour was in the lower segment of the uterus, which together with the fundal placenta, likely permitted the pregnancy progressing to term. Endometrial cancer should be considered a rare cause of abnormal post-partum bleeding. Curettage and histopathology examination is recommended in cases that do not resolve with conservative measures to exclude this rare complication." }, { "id": "pubmed23n1096_13004", "title": "Treatment Outcomes of Patients With Cervical Intraepithelial Neoplasia or Invasive Carcinoma Who Underwent Loop Electrosurgical Excision Procedure.", "score": 0.00909090909090909, "content": "This study aimed to evaluate the treatment outcomes of cervical intraepithelial neoplasia (CIN) or cancer patients who underwent loop electrosurgical excision procedure (LEEP) in terms of primary outcome and factors associated with persistence/recurrence. Patients with CIN or cancer who underwent LEEP from January 2007 to December 2015 were reviewed. Data collected were age, parity, menopausal status, human immunodeficiency virus (HIV) infection, smoking, cervical cytology, histopathology from cervical biopsy and LEEP including margin status, final histopathology, and follow-up data. The mean age of 385 patients was 41.9 ± 10.8 years (range 18 - 79 years). Majority were multiparous (81.6%) and premenopausal (78.2%). There were 15.3% of patients with HIV infection. The most common cervical cytology was high-grade squamous cell intraepithelial lesion (HSIL, 44.1%), followed by atypical squamous cells of undetermined significance (ACS-US, 21%). Minor complications of bleeding or infection from LEEP were encountered in 7.3%. Among 153 patients (39.7%) who had positive margin(s), 43 underwent second LEEP, whereas 76 had hysterectomy. From all patients, 47 had failure after treatment (12.2%), being either persistence (30 patients; 7.8%) or recurrence (17 patients; 4.4%). Factors associated with persistence or recurrence by multivariate analysis were age ≥ 55 years old, HIV infection, final diagnosis of invasive cancer, and positive endocervical margin or both ecto- and endo- cervical margins. LEEP had low rate of persistence/recurrence. Age ≥ 55 years old, HIV infection, final diagnosis of cancer, and positive endocervical or both endo- and ecto- surgical margin(s) were significantly associated with persistent or recurrent diseases." }, { "id": "pubmed23n0491_8545", "title": "Abnormal vaginal cytology in HIV-infected and at-risk women after hysterectomy.", "score": 0.009009009009009009, "content": "To determine the frequency of and risk factors for abnormal vaginal Papanicolaou smears in HIV-infected women after hysterectomy. Data were from the HIV Epidemiology Research (HER) study, a prospective multisite study of HIV-infected and uninfected women. Semiannual vaginal Papanicolaou smears and colposcopy data were obtained from 102 HIV-infected and 46 at-risk women who had hysterectomy either before or during the study. Analytic models used include Cox proportional hazards (women with hysterectomy during the study) and multiple logistic regressions, which corrected for repeated measures (all women). Among the HIV-infected women, evidence of cervical intraepithelial neoplasia before or at hysterectomy was associated with abnormal cytology during follow-up; 63% had squamous intraepithelial lesions (SIL) on vaginal Papanicolaou smears following hysterectomy. CD4 counts of &lt;200 cells/microL at hysterectomy and HIV viral load of &gt;10,000 copies/mL at hysterectomy were predictive of SIL vaginal cytology. Prevalent SIL vaginal cytology was associated with low CD4 count and human papillomavirus risk type. Of the 102 HIV-infected women, 16 (16%) had vaginal intraepithelial neoplasia on biopsy. The high rate of SIL on vaginal Papanicolaou smears and the presence of high-grade vaginal intraepithelial neoplasia among HIV-infected women after hysterectomy demonstrate the need for continued follow-up for lower genital tract lesions." }, { "id": "pubmed23n0788_6099", "title": "Factors associated with the persistence/recurrence of CIN2/3 in women submitted to loop electrosurgical excision procedure in a teaching hospital in northeastern Brazil: a case-control study.", "score": 0.009009009009009009, "content": "This study aimed to identify risk factors associated with the persistence/recurrence of cervical intraepithelial neoplasia (CIN) 2/3 in women submitted to loop electrosurgical excision procedure (LEEP) in a hospital in northeastern Brazil. A case-control study included 50 women with and 50 women without persistence/recurrence of CIN2/3 after LEEP at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between 2004 and 2011. Data were collected from June to December 2011. Inclusion criteria were diagnosis of CIN2/3 during follow-up (cases) and women free of CIN2/3 after a follow-up of 2 years or longer (controls). Exclusion criteria (cases/controls) were LEEP performed at another hospital, LEEP performed for persistent CIN1, invasive carcinoma in the cone specimen or at cytology, and/or histopathology within a 2-year follow-up period. Persistence was defined as residual disease detected in the first year after LEEP, and recurrence was defined as the reappearance of a lesion more than 1 year after surgery. Bivariate analysis was performed for biological, sociodemographic, sexual, reproductive, lifestyle, and clinical variables. Odds ratios (ORs) and their 95% confidence intervals (95% CIs) were calculated, and a multiple logistic regression analysis was performed to control for potential confounding factors. The study was approved by IMIP's internal review board. Multiple logistic regression analysis showed a significant association between persistence/recurrence of CIN2/3 and living outside the capital city (OR=3.11, 95% CI=1.14-8.41), smoking (OR=4.22, 95% CI=1.18-15.05), and positive endocervical margins (OR=6.58, 95% CI=2.37-18.28). Women with persistence/recurrence of CIN2/3 are more likely to live outside the state capital, be smokers, and have positive endocervical margins, so these women should be followed up more closely." }, { "id": "pubmed23n0636_2634", "title": "An alternative treatment for cervical intraepithelial neoplasia II, III.", "score": 0.008928571428571428, "content": "This report describes a case of a woman with progressive and recurrent cervical dysplasia 4 years after cervical conization for severe dysplasia. A 20-year-old female was referred for colposcopy and biopsy following results of moderate to severe atypia of cervical cells on her Papanicolaou (Pap) test. Her colposcopy was satisfactory and her biopsy revealed cervical intraepithelial neoplasia (CIN) II, III. She refused the conventional recommendation of loop electrosurgical excision procedure (LEEP) and, as an alternative, elected to receive escharotic treatment at a frequency of 2 treatments per week for 5 weeks. In addition to the escharotic treatment she followed an oral vitamin and botanical protocol. She was followed for 5 years. The patient's 4-month and 10-month follow-up Pap smears revealed negative cervical cytology for intraepithelial lesion or malignancy. Her 10-month colposcopy was satisfactory and no lesions were noted on the colposcopic exam. Liquid based Pap results continued to remain normal for 5 years after the initiation of treatment. Escharotic treatment of high-grade cervical neoplasias with satisfactory colposcopy holds promise as an effective and low-risk alternative therapy to LEEP and other excisional procedures." }, { "id": "pubmed23n0934_8176", "title": "HEALTH: laparoscopic supracervical hysterectomy versus second-generation endometrial ablation for the treatment of heavy menstrual bleeding: study protocol for a randomised controlled trial.", "score": 0.008928571428571428, "content": "Heavy menstrual bleeding (HMB) is a common problem affecting approximately 1.5 million women in England and Wales with a major impact on their physical, emotional, social and material quality of life. It is the fourth most common reason why women attend gynaecology outpatient clinics and accounts for one-fifth of all gynaecology outpatient referrals. Initial treatment in primary care is medical - either by means of oral or injected medication or the levonorgestrel-intrauterine system (Mirena®). If medical treatment fails then surgical treatment can be offered, either endometrial ablation (EA), which destroys the lining of the cavity of the uterus (endometrium), or hysterectomy, i.e. surgical removal of the uterus. While effective, conventional hysterectomy is invasive and carries a risk of complications due to injury to other pelvic structures. The procedure can be simplified and complications minimised by undertaking a 'supracervical' hysterectomy where the cervix is left in situ and only the body of the uterus removed. Recent advances in endoscopic technologies have facilitated increased use of laparoscopic supracervical hysterectomy (LASH) which can be performed as a day-case procedure and is relatively easy for the surgeon to learn. HEALTH (Hysterectomy or Endometrial AbLation Trial for Heavy menstrual bleeding) aims to address the question 'Is LASH superior to second generation EA for the treatment of HMB in terms of clinical and cost effectiveness?' Women aged &lt; 50 years, with HMB, in whom medical treatment has failed and who are eligible for EA will be considered for trial entry. We aim to recruit women from approximately 30 active secondary care centres in the UK NHS who carry out both surgical procedures. All women who consent will complete a diary of pain symptoms from day 1 to day 14 after surgery, postal questionnaires at six weeks and six months after surgery and 15 months post randomisation. Healthcare utilisation questions will also be completed at the six-week, six-month and 15-month time-points. Measuring the comparative effectiveness of LASH vs EA will provide the robust evidence required to determine whether the new technique should be adopted widely in the NHS. International Standard Randomised Controlled Trials, ISRCTN49013893 . Registered on 28 January 2014." }, { "id": "pubmed23n1094_17147", "title": "Seborrheic Keratosis-Like Lesion of the Cervix: First Report of the Cytological Features of a Low-Risk HPV 42-Associated Lesion.", "score": 0.008849557522123894, "content": "Seborrheic keratosis-like lesion of the cervix and vagina is a rare lesion and shows similar morphology to vulvar seborrheic keratosis; 3 of the 7 previously reported cases were associated with low-risk human papillomavirus (HPV) type 42. We report a case of seborrheic keratosis-like lesion of the cervix and provide the first description of the cytological features of this lesion. A woman in her late forties presented with postcoital bleeding. She had a cervical screening test following which she underwent cervical biopsy, endocervical and endometrial curettage, large loop excision of the transformation zone of the cervix, and hysterectomy. The liquid-based cytology preparation showed cohesive groups of mildly atypical squamoid cells with a spindle cell morphology, mildly increased nuclear to cytoplasmic ratio, prominent nucleoli, and occasional nuclear grooves. No koilocytes were identified. Molecular genotyping revealed positivity for HPV type 42. This represents the first description of the cytological features of a seborrheic keratosis-like lesion of the cervix, which are distinctive and unusual. Whilst the mild squamous atypia raised the possibility of a low-grade squamous intraepithelial lesion, no koilocytes were identified. The association in our case with a low-risk HPV type, HPV 42, provides further evidence for a role of this HPV type in the pathogenesis of these lesions." }, { "id": "pubmed23n0916_11936", "title": "See and treat strategy by LEEP conization in patients with abnormal cervical cytology.", "score": 0.008849557522123894, "content": "To determine the overtreatment and re-LEEP rates of see and treat strategy (S &amp; T) in women who underwent S &amp; T by LEEP and to identify the risk factors for overtreatment and surgical margin and/or endocervical curettage positivity. A total of 800 patients who underwent S &amp; T in Istanbul University Cerrahpasa Medical Faculty between June 2010 and June 2016 were retrospectively analyzed. Overtreatment rate was found to be 46.6%, decreasing with higher grade of cervical smear abnormalities. Age more than 45, low grade of cervical cytologic abnormality and absence of glandular involvement were associated with higher overtreatment rates. The more advanced the histopathology, the more increased risk of surgical margin on LEEP and ECC positivity (p &lt; 0.0001, for both). Glandular involvement was associated with both surgical margin and ECC positivity. S &amp; T can be used in patients with high grade cytologic anomaly with an acceptable overtreatment rate. In addition, bigger pieces of specimens may need to be removed during LEEP in patients who have suspicious images of higher grade of abnormalities on colposcopy to reduce surgical margin or ECC positivity. When high rate of ECC positivity in patients with HSIL cytology is considered, we suggest performing ECC to every patients with HSIL." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 183 ] ], "word_ranges": [ [ 0, 31 ] ], "text": "The endometrium is thickened for a menopausal woman (some guidelines put the limit at 5 and others at 3mm). And the first complementary test to perform would be an endometrial biopsy." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The endometrium is thickened and in view of the patient's symptoms, an endometrial biopsy is taken with a Cornier cannula.", "2": "The endometrium is not thickened so she is prescribed tranexamic acid and ambulatory follow-up.", "3": "Indications for diagnostic hysteroscopy without the need for endometrial biopsy.", "4": "The endometrium is not thickened, but since she has clinical signs of metrorrhagia, an endometrial biopsy is indicated.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0272_3318", "title": "Postmenopausal endometrial fluid collections revisited: look at the doughnut rather than the hole.", "score": 0.01770050125313283, "content": "To report 30 postmenopausal women and the thickness of the tissue surrounding an endometrial fluid collection seen on vaginal probe ultrasound. During routine ultrasound-enhanced bimanual examination, nine postmenopausal women with unremarkable palpatory findings and no history of bleeding were found to have endometrial fluid collections. The patients were 9-24 years postmenopausal. All underwent prompt endometrial sampling. Each woman had some degree of cervical stenosis as judged by the operator. At curettage, all had scant tissue, which was reported by the pathologist as \"inactive endometrium.\" Ultrasound scans on each patient were rereviewed, and it was found that the endometrium surrounding the fluid was uniformly 3 mm thick or less. Subsequently, 21 additional patients with small endometrial fluid collections have been seen. Eighteen of these had thin endometrium peripherally and were followed conservatively for 6-26 months. Six cases resolved and 12 remained unchanged. Three patients had a thickened heterogeneous endometrium peripheral to the fluid collection. In one, D&amp;C was unsuccessful in two attempts because of cervical stenosis, and hysterectomy was performed. A 15-mm endometrial polyp was found. Two other patients with thickened endometrium surrounding the fluid had D&amp;C, and hysteroscopy revealed simple hyperplasia without atypia. CONCLUSIONS. Normal atrophic postmenopausal endometrium in association with cervical stenosis can produce endometrial fluid collections, seen easily on vaginal probe ultrasound. If the endometrial tissue surrounding the fluid is thin (3 mm or less), the endometrium is invariably inactive and sampling is not necessary. If the peripheral endometrium is thicker than 3 mm, sampling is mandatory because the tissue cannot be expected to be invariably inactive and sampling is not necessary. If the peripheral endometrium is thicker than 3 mm, sampling is mandatory because the tissue cannot be expected to be inactive. Thus, the presence or amount of fluid is not as important as the thickness and character of the surrounding tissue." }, { "id": "pubmed23n0870_19261", "title": "Endometrial study in patients with postmenopausal metrorrhagia.", "score": 0.014932386571294313, "content": "The aim of the study was to devise a strategy to diagnose malign endometrial pathologies (adenocarcinoma or atypical hyperplasia) that minimizes the number of invasive tests done (hysteroscopy, aspiration biopsy or curettage) with no loss of its detection efficiency. We retrospectively studied the clinical histories of 779 postmenopausal women at the University Hospital Complex of Albacete, for whom an endometrial study had been done (hysteroscopy, aspiration biopsy or curettage) with a 1-year follow-up between 1 March 2006 and 31 March 2008. There were 77 cases of a malignant pathology (66 adenocarcinomas and 11 hyperplasias with atypia); 96.1% had metrorrhagia, and there were only 3 cases of asymptomatic patients (all 3 presented endometrial thickness of &gt; 5 mm: 10, 12 and 15 mm). The sensitivity and specificity of the transvaginal ultrasound, with a 5 mm cut-off point to diagnose a malignant pathology, were 98.4% and 30.1%, respectively; 89.1% and 99.6%, respectively, for aspiration biopsy; 83.9% and 99.1%, respectively, for hysteroscopy without biopsy; and both were 100% for biopsy. Statistical significance was considered at p &lt; 0.05 and confidence intervals were calculated at 95%. In postmenopausal women with metrorrhagia, the first action to take is to do a transvaginal ultrasound, followed by en endometrial study, but only if the endometrium is irregular or endometrial thickness is ≥ 5 mm; in asymptomatic women, the cut-off point should be set at 10 mm. The immediate method of choice is an ambulatory biopsy." }, { "id": "pubmed23n0480_1911", "title": "[Evaluation of endometrial biopsy in postmenopausal women before HRT].", "score": 0.01345250993138317, "content": "One of the reasons for not commencing or withdrawal of HRT in women is their fear for breast and endometrial cancers. Does ultrasonographic valuation guarantee sufficiently patient's safety? Most investigators do not recommend further endometrial diagnostics with endometrial thickness less than 4 mm. Endometrial biopsy is advised in cases of irregular uterine bleedings with normal endometrial image or when any endometrial pathology is suspected. In Poland the most frequently performed procedure of endometrial diagnostics is D&amp;C. Our proposition was to offer endometrial biopsies to all patients who were taken HRT for more than 5 years or, despite having strong climacteric ailments, refused to take it because of their cancerophobia. To evaluate the usefulness of aspiration endometrial biopsy in women after menopause qualified for HRT. In 84 females, being postmenopausal (amenorrhoeic for at least 12 months) and qualified for HRT, aspiration endometrial biopsies were performed in outpatient clinics. Age of women ranged 46-63 years, mean 57.3. Attained results were compared to ultrasonographic endometrial evaluation. Such factors as patient's age, menopausal age (years from last menstrual period) and previous administration of HRT were taken into our account (maintaining a 3-month wash-out interval). In 74% of women we have got a material being sufficient for histological evaluation. Form clinical point of view the most important for us was to exclude a proliferative or neoplastic process within endometrium. One of endometrial polyps was omitted in USG study, we were surprised also while detecting endometrial carcinoma cells in endometrium below 3.5 mm. In one postoperative slide the cells of endometrial ovarian carcinoma (with infiltrated Fallopian tube) were detected. Endometrial biopsy seems to be a useful, effective and cheap method of endometrial diagnostics also in women after menopause." }, { "id": "pubmed23n0824_2262", "title": "Does probability guided hysteroscopy reduce costs in women investigated for postmenopausal bleeding?", "score": 0.013315525335923587, "content": "To evaluate whether a model to predict a failed endometrial biopsy in women with postmenopausal bleeding (PMB) and a thickened endometrium can reduce costs without compromising diagnostic accuracy. Model based cost-minimization analysis. A decision analytic model was designed to compare two diagnostic strategies for women with PMB: (I) attempting office endometrial biopsy and performing outpatient hysteroscopy after failed biopsy and (II) predicted probability of a failed endometrial biopsy based on patient characteristics to guide the decision for endometrial biopsy or immediate hysteroscopy. Robustness of assumptions regarding costs was evaluated in sensitivity analyses. Costs for the different strategies. At different cut-offs for the predicted probability of failure of an endometrial biopsy, strategy I was generally less expensive than strategy II. The costs for strategy I were always € 460; the costs for strategy II varied between € 457 and € 475. At a 65% cut-off, a possible saving of € 3 per woman could be achieved. Individualizing the decision to perform an endometrial biopsy or immediate hysteroscopy in women presenting with postmenopausal bleeding based on patient characteristics does not increase the efficiency of the diagnostic work-up." }, { "id": "wiki20220301en043_17457", "title": "Vaginal bleeding", "score": 0.012539512526450535, "content": "Postmenopausal bleeding In postmenopausal vaginal bleeding, the primary goal of any diagnostic evaluations is to exclude endometrial hyperplasia and malignancy. Transvaginal ultrasonography and endometrial sampling are common methods for an initial evaluation. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend transvaginal ultrasonography as an appropriate first-line procedure to identify which patients are at higher risk of endometrial cancer. Endometrial sampling is indicated if having the following findings and/or symptoms: Endometrial thickness greater than 4 mm Diffuse or focal increased echogenicity (heterogeneity) Failure to visualize the endometrium Persistent or recurrent bleeding regardless of endometrial thickness Endometrial sampling can be obtained either by an endometrial biopsy using an endometrium sampling device such as a pipelle or by dilation and curettage (D&C) with or without a hysteroscopy. FIGO classification" }, { "id": "pubmed23n0566_19160", "title": "Ultrasound appearance of the uterus in women over 60 years of age on tibolone: is it a SERM?", "score": 0.012439792164447985, "content": "To evaluate the effects of long-term tibolone on the endometria of asymptomatic women over the age of 60 years. An observational study of the ultrasound appearance of the endometria of women aged 60 years or older taking long-term tibolone. Those found to have a double-layer endometrial thickness greater than 4 mm were offered endometrial biopsy. Seventeen asymptomatic patients with a mean age of 61 years (range 60-73 years) and an average duration of tibolone use of 5 years (range 3-12 years) were recruited. Seven patients (41%) showed a thickened endometrium of more than 4 mm. Three of these had an area of translucency in the subendometrial space. Of the ten women with an endometrial thickness of less than 4 mm, four showed the presence of subendometrial fluid. Hysteroscopy was performed in five out of the seven women, as two did not accept further investigations. In all five women, the endometrial cavity was reported as atrophic and the histology showed an inactive basal type. In two of the five cases examined histologically, there were additional changes suggesting endometrial polyp, although the samples were from macroscopically non-polypoid endometrium. Endometrial thickness is increased in 41% of elderly women on long-term treatment with tibolone. However, at hysteroscopy, the endometrium was uniformly atrophic. Similar finding have been described in women using selective estrogen receptor modulators and a similar mechanism of action of these drugs on the uterus should be considered." }, { "id": "wiki20220301en168_15945", "title": "Endometrial biopsy", "score": 0.012240056531395115, "content": "Medical uses There are a number of indications for obtaining an endometrial biopsy in a non-pregnant woman: Women with chronic anovulation such as the polycystic ovary syndrome are at increased risk for endometrial problems and an endometrial biopsy may be useful to assess their lining specifically to rule out endometrial hyperplasia or cancer. In women with abnormal vaginal bleeding the biopsy may indicate the presence of abnormal lining such as endometrial hyperplasia or cancer. In patients with suspected uterine cancer, the biopsy may discover the presence of cancer cells in the endometrium or cervix. In female infertility the assessment of the lining can determine, if properly timed, that the patient ovulated, however, the same information can be obtained by a blood test of the progesterone level." }, { "id": "pubmed23n0380_8864", "title": "[Ultrasound endometrium follow-up during tamoxifen treatment: Really not reliable or useful after all?].", "score": 0.01220591489047865, "content": "To investigate whether an examination of the endometrium of women treated with tamoxifen (TAM) is useful or not. 40 breast cancer patients who displayed a thickened endometrium of &gt; 8 mm and/or vaginal bleeding were included in the study. They received daily TAM adjuvantly. Histologic clarification by hysteroscopy and D&amp;C was recommended for patients with an endometrium of &gt; 8 mm or vaginal bleeding. In our collective, the mean endometrial thickness was 13.7 +/- 5.6 mm (SD). 32 patients underwent a histological examination. Most had a benign lesion; in 2 cases we merely found a cystic atrophy (11 mm, 18 mm), 2 displayed atypical tissue (13 mm, 25 mm) and 2 an endometrial cancer (19 mm, 33 mm). All patients with atypical tissue or cancer had an endometrial thickness markedly above the norm, but 3 of them were not bleeding. No linear correlation between thickness of the endometrium and duration of TAM intake was found. To detect early premalignant or malignant changes of the endometrium, we recommend histological examination by hysteroscopy and dilatation and curettage when the endometrium is &gt; 8 mm thick, even in the absence of symptoms. Therefore, these patients should have regular examinations by transvaginal ultrasound once or twice a year. Moreover, continuing regular screening of the endometrium for years after termination of tamoxifen-therapy is also to be recommended." }, { "id": "wiki20220301en017_58095", "title": "Endometrial cancer", "score": 0.012153725639138795, "content": "Dilation and curettage or an endometrial biopsy are used to obtain a tissue sample for histological examination. Endometrial biopsy is the less invasive option, but it may not give conclusive results every time. Hysteroscopy only shows the gross anatomy of the endometrium, which is often not indicative of cancer, and is therefore not used, unless in conjunction with a biopsy. Hysteroscopy can be used to confirm a diagnosis of cancer. New evidence shows that D&C has a higher false negative rate than endometrial biopsy. Before treatment is begun, several other investigations are recommended. These include a chest x-ray, liver function tests, kidney function tests, and a test for levels of CA-125, a tumor marker that can be elevated in endometrial cancer. Classification Endometrial cancers may be tumors derived from epithelial cells (carcinomas), mixed epithelial and mesenchymal tumors (carcinosarcomas), or mesenchymal tumors." }, { "id": "wiki20220301en047_30939", "title": "Endometrial polyp", "score": 0.011682049869127978, "content": "Cause No definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen. Risk factors include obesity, high blood pressure and a history of cervical polyps. Taking tamoxifen or hormone replacement therapy can also increase the risk of uterine polyps. The use of an intrauterine system containing levonorgestrel in women taking tamoxifen may reduce the incidence of polyps. Diagnosis Endometrial polyps can be detected by vaginal ultrasound (sonohysterography), hysteroscopy and dilation and curettage. Detection by ultrasonography can be difficult, particularly when there is endometrial hyperplasia (excessive thickening of the endometrium). Larger polyps may be missed by curettage." }, { "id": "wiki20220301en310_27546", "title": "Endometrosis", "score": 0.011434837092731829, "content": "Stages The following table shows the different degrees of endometrosis which is classified by KENNY u. DOIG (1986) and modified by SCHOON et al. (1992). Diagnosis Endometrosis is most often diagnosed in barren mares. For the diagnostic procedure the endometrium of mares are biopsied to examine the changes in the endometrium under microscope. Therefore a small piece of tissue is removed from the endometrium of the mare, which is subjected to conventional histopathology. The only contraindication for endometrial biopsy is pregnancy. Treatment As the changes in the endometrium are seen as irreversible there is no effective treatment available. But to prevent infection antibiotics are administered in the uterus" }, { "id": "article-21101_2", "title": "Endometrial Biopsy -- Introduction", "score": 0.011013431013431014, "content": "Endometrial biopsy is frequently used to evaluate abnormal uterine bleeding. It is a relatively quick and cost-effective way to sample the endometrium to allow for direct histological evaluation of the endometrium. It is an essential skill to have as endometrial cancer is the fourth most common cancer among women. The American Cancer Society estimates there will be 65,950 new uterine cancer cases and 12,550 related deaths in 2022 [American Cancer Society. Facts & Figures, 2022]. The patient does not need to undergo more invasive procedures as endometrial biopsies have a high sensitivity and specificity for detecting endometrial hyperplasia and endometrial malignancy, equal to the diagnostic accuracy of dilatation and curettage (D&C) procedure. [1]" }, { "id": "article-21104_24", "title": "Endometrial Hyperplasia -- Evaluation -- Endometrial Sampling", "score": 0.01076418915843612, "content": "The methods of obtaining tissue samples through dilatation and curettage (D&C) or suction curette have been shown to detect endometrial carcinoma with an equal rate in women with abnormal uterine bleeding. [32] However, these methods have their own side effects. Less than 50% of the uterine cavity was sampled in approximately 60% of these procedures. [30] The presence of a mass lesions in the uterus can deflect the flexible curette, which can curtail the proper sampling of the endometrium. As per the American College of Obstetricians and Gynecologists (ACOG) Committee opinion on tissue sampling methods, hysteroscopy with directed D&C can sample both focal pathology and background endometrium and may yield a higher detection rate. [33] However, if the treatment procedure is a hysterectomy, it makes the type of sampling procedure less important. This is because the chance of missing an invasion is far less in a uterine specimen on the final pathology result as compared to a tissue biopsy specimen. [32]" }, { "id": "article-21101_0", "title": "Endometrial Biopsy -- Continuing Education Activity", "score": 0.010041787480811871, "content": "Endometrial biopsy is a simple and effective office-based procedure that samples the endometrium to allow for direct histological evaluation. A clinician in the outpatient setting can perform this procedure independently. Endometrial biopsy is often used to evaluate abnormal uterine bleeding. It is a relatively quick and cost-effective way to sample the endometrium. It is an essential skill to have as endometrial cancer is a common cancer among women. This activity describes when and how to perform an endometrial biopsy and highlights interprofessional team members' role in collaborating to provide well-coordinated care and enhance outcomes for patients undergoing this procedure." }, { "id": "pubmed23n0405_16170", "title": "[Diagnostic hysteroscopy after D&amp;C in women with perimenopausal bleeding].", "score": 0.009900990099009901, "content": "Comparative estimation of D&amp;C and hysteroscopy as a method of receiving material to histological estimation in perimenopausal women. In 74 women (age 46-70) during the last year before this study, D&amp;C was performed. There were neither material nor pathologic changes in hystological estimation. Now we made hysteroscopy and again took the material to histological research. 29 endometrial polyps, 14 submucosus myomas, 2 endometrial hyperplasias and 2 endometrial cancers were detected. 1. Hysteroscopy with direct biopsy has superiority over curettage in detecting all types of intrauterine pathology, in particular focal changes. 2. Hysteroscopy should determine a method of choice for women with recurrent bleedings from the uterus, which pathological changes were not detected with curettage." }, { "id": "article-21104_23", "title": "Endometrial Hyperplasia -- Evaluation -- Endometrial Sampling", "score": 0.009838274932614556, "content": "The endometrial sample can be obtained through outpatient endometrial biopsy. A systematic review evaluating the efficacy of office endometrial biopsy has reported a pooled likelihood ratio (LR) of 12.0 (95% Confidence Interval (CI) 7.8-18.6) for a positive test. On the other side, a negative office biopsy test has a likelihood ratio of 0.2 (95% CI 0.1-0.3). [31] However, if the patient does not tolerate an office biopsy, has cervical stenosis, or the transvaginal ultrasound shows a polyp, an inpatient diagnostic hysteroscopy guided procedure has to be performed instead." }, { "id": "pubmed23n1165_18321", "title": "First-trimester miscarriage in the background of endometrial carcinoma.", "score": 0.00980392156862745, "content": "Endometrial cancer in young women (less than 40-year-old) is associated with anovulatory menses, polycystic ovarian syndrome (PCOS) and subfertility. Endometrial cancer occurring in a miscarriage is rare. We highlight a case of endometrial cancer occurring during miscarriage of a non-viable pregnancy, its management and the outcome. A 32-year-old woman, Gravida 1 Para 0, was referred to our center at 7 weeks gestation in 2018 for uncontrolled diabetes mellitus diagnosed during investigation for subfertility. Her poor compliance with the treatment is consistent with an HbA1c of 8%. During the assessment, she was already complaining of lower abdominal pain. Ultrasound showed irregular IUGS with no fetal echo. She had a miscarriage soon; however, due to ultrasound evidence of thickened and irregular endometrium (17 mm) with mixed echogenicity, dilatation and curettage (D + C) were commenced. The first and second tissues were reported as the product of conception (POC) and well differentiated endometrioid adenocarcinoma, respectively. The first hysteroscopy showed foci area of polypoidal growth at the right posterior endometrium, obscuring the right ostium, with similar histology report. She was commenced on high-dose progestogen with hysteroscopy surveillance 6 months later, which showed disease regression. After two normal hysteroscopies and endometrial biopsies with continuous progestogen therapy for 12 months, cyclical progestogen for 12 months and follow-up for another 6 months, she had spontaneous conception and is currently pregnant at 16 weeks gestation. Endometrial cancer should be suspected in high-risk patients with first-trimester miscarriage. Individualized treatment with high dose progestogen and follow-up with the proper patient and partner counselling and education has high successful regressionand later on, pregnancy rate." }, { "id": "pubmed23n0263_8195", "title": "Microhysteroscopy and endometrial biopsy results following failed diagnostic dilatation and curettage in women with postmenopausal bleeding.", "score": 0.00980392156862745, "content": "The aim of this study was twofold: firstly to evaluate and compare the diagnostic precision of the microhysteroscopy (MH) and endometrial biopsy in a group of menopausal women in whom D&amp;C had failed to obtain an adequate endometrial sample, and secondly to quantitate the value of a hysteroscopy in determining endometrial sampling in these patients. A Hamou type II CO2 microhysteroscope (MH) was used to evaluate the endocervical canal and the uterine cavity, followed by endometrial sampling. Thirty-nine women were assessed using MH and endometrial biopsy. Histopathology results were available for diagnosis in 29 of them (74.3%). In the remaining ten patients, the MH diagnosis was atrophic endometrium. Biopsy results corroborated with MH in 86.2% (25/29) of the patients with tissue samples. The analysis (r) of this concordance rate was statistically significant (r = 0.96). Sample results for patients with MH determined pathological and normal endometrium corroborated in 83% and 91%, respectively, inclusive of three cases of endometrial adenocarcinoma. The sensitivity, specificity and predictive values for MH alone were 93.7%, 76.9% and 83.3%, respectively. These significant results are indicative that this simplified endoscopic method surpasses all blind hospital or office endometrial sampling methods. Therefore, we suggest that MH and endometrial sampling should be the initial assessment tool for any type of indication requiring endometrial and uterine cavity assessment." }, { "id": "pubmed23n0589_5294", "title": "Follow-up of women after a first episode of postmenopausal bleeding and endometrial thickness greater than 4 millimeters.", "score": 0.009708737864077669, "content": "To estimate the incidence of recurrent postmenopausal bleeding among women who were diagnosed with an endometrial thickness greater than 4 mm. We designed a prospective cohort study and included consecutive women not using hormone replacement therapy, presenting with a first episode of postmenopausal bleeding. We evaluated patients who had an endometrial thickness greater than 4 mm at transvaginal ultrasonography and benign endometrial sampling; presence of carcinoma was ruled out by office endometrial sampling, hysteroscopy, and/or dilation and curettage. Time until recurrent bleeding was measured, and diagnosis at recurrent bleeding was recorded. Among 318 patients who had an endometrial thickness greater than 4 mm, 222 patients had benign histology results and were available for follow-up. During follow-up, 47 (21%, 95% confidence interval 16-27%) patients had recurrent bleeding, with a median time to recurrent bleeding of 49 weeks (interquartile range 18 to 86 weeks). There was no difference with respect to recurrence rate between patients with polyp removal, patients with a normal hysteroscopy, and patients with office endometrial sampling alone at the initial workup. Two patients were diagnosed with atypical endometrial hyperplasia upon recurrent bleeding. The recurrence rate of postmenopausal bleeding in women with endometrial thickness greater than 4 mm is 20%. This recurrence rate is not related to incorporation of hysteroscopy or polyp removal at the initial workup. II." }, { "id": "pubmed23n0408_5347", "title": "[Endometrial hyperplasia--hysteroscopy findings].", "score": 0.009615384615384616, "content": "Endometrial hyperplasia is considered to be a frequent cause of metrorrhagia. Traditionally diagnosis of this pathology was made on specimens obtained by uterine curettage or after hysterectomy performed for benign diseases. Recently, hysteroscopy has enabled to offer suggestive images of this pathology, in fact it allows to visualize directly the uterine cavity and to perform guided biopsies on the endometrial mucosa. The aim of this study is to evaluate the reliability of the hysteroscopy procedures in the diagnosis of the endometrial hyperplasia. 479 panoramic hysteroscopies were performed in a four-year period for different indications and we found endometrial hyperplasia in 129 patients. We compared the results with the histological findings. On the base be able the possible diagnose and the follow-up procedure for endometrial hyperplasia." }, { "id": "pubmed23n0788_5451", "title": "Asymptomatic thickened endometrium in postmenopausal women: malignancy risk.", "score": 0.009523809523809525, "content": "To assess the diagnostic findings and determine the frequency of malignancy in postmenopausal women evaluated by office hysteroscopy for a thickened endometrium without bleeding. Retrospective cohort (Canadian Task Force classification II-B). Academic medical center in the Midwestern United States. Over 3600 women underwent an office hysteroscopy between January 1, 2007, and October 20, 2011, for abnormal uterine bleeding or an abnormal ultrasound. Of these, 154 postmenopausal women had a thickened endometrium (&gt;4 mm) and no bleeding. Flexible office hysteroscopy using a 3.1-mm scope with saline as the distending media was performed for clinical reasons, and results were captured within a research database. For the 154 women, the range of endometrial measurements was 4.2 to 28 mm (mean = 10.0 mm). Hysteroscopy diagnoses included 93 patients with polyps, 19 with myomas or uterine synechiae, and 34 with benign-appearing endometrium. Nine hysteroscopies were inadequate because of poor visualization (n = 1), cervical stenosis (n = 6), or patient discomfort (n = 2). Endometrial biopsies (EMBs) were performed in 109 patients, and none were found to have cancer or an atypical endometrium. Six had simple hyperplasia without atypia, and their endometrial measurements were within the range of the patients in our study who had a benign endometrium (5-15 mm, mean = 10.3). Of the women with a polyp, 73 (78.4%) subsequently underwent polypectomy. On final pathology, 1 had cancer (endometrial measurement = 24 mm), and 1 had complex hyperplasia with atypia (endometrial measurement = 17 mm). EMBs performed in the office for these 2 patients showed an insufficient endometrium and inactive endometrium, respectively. Cancer and atypia can occur in asymptomatic women. Endometrial thickness was 17 mm or greater in 2 cases, and EMBs performed in the office were inconsistent with the final diagnosis. Hysteroscopy is important when ultrasound and EMB do not agree. Polypectomy may be indicated even in asymptomatic women, but further studies regarding an endometrial measurement threshold or polyp size are warranted." }, { "id": "pubmed23n0391_18175", "title": "Rebleeding and endometrial growth in women with postmenopausal bleeding and endometrial thickness &lt; 5 mm managed by dilatation and curettage or ultrasound follow-up: a randomized controlled study.", "score": 0.009523809523809525, "content": "To compare the frequency of rebleeding and endometrial growth during a 12-month follow-up period between women with postmenopausal bleeding and an endometrial thickness &lt; 5 mm managed by dilatation and curettage, and those managed by ultrasound follow-up. Consecutive women with postmenopausal bleeding and an endometrial thickness &lt; 5 mm were randomized to ultrasound follow-up after 3, 6, and 12 months (n = 48) or to primary dilatation and curettage with ultrasound follow-up at 12 months (n = 49). At all follow-up examinations, the endometrial thickness was measured and the women were asked about rebleeding. The endometrium was sampled at the 12-month examination, if sampling had not been performed previously because of rebleeding or endometrial growth. Rebleeding was reported by 33% (16/48) of the women in the ultrasound group and by 21% (10/48) of those in the dilatation and curettage group (P = 0.17). Endometrial growth to &gt;or= 5 mm was found in 21% (10/48) of the women in the ultrasound group and in 10% (5/48) of those in the dilatation and curettage group (P = 0.16). No endometrial pathology was found in women with isolated rebleeding. Endometrial pathology during follow-up was found more often in women with endometrial growth than in those without (33% vs. 4%; P = 0.008). Rebleeding and endometrial growth are common during a follow-up period of 12 months in women with postmenopausal bleeding and an endometrial thickness &lt; 5 mm, irrespective of whether or not dilatation and curettage is primarily carried out. If these women are managed by ultrasound follow-up, endometrial sampling should be performed if the endometrium grows, but not necessarily in the case of rebleeding without endometrial growth." }, { "id": "pubmed23n0371_9754", "title": "Disaccordance between estimation of endometrial thickness as measured by transvaginal ultrasound compared with hysteroscopy and directed biopsy in breast cancer patients treated with tamoxifen.", "score": 0.009433962264150943, "content": "To estimate endometrial thickness by transvaginal ultrasound technique (TVU) in patients treated with tamoxifen; and to compare the results with hysteroscopy and directed biopsy, and to relate the findings to curettage material. Fifty-four women, over 50 years of age at the time of their primary breast cancer operation and scheduled for adjuvant treatment of tamoxifen, were investigated. If the endometrium measured 8 mm or more (35 patients) hysteroscopy and directed biopsy was performed. In the 35 patients, hysteroscopy and curretage revealed polyps in 18 cases (51.4%), proliferation in 1 case (2.9%) and atrophy in 16 cases (45.7%). In 54.3% (19 cases) of the patients the histopathological finding was a polyp or benign proliferation of the endometrium in agreement with the thickened endometrium seen with TVU. In the remaining 45.7% (16 cases) of the patients a thickened endometrium by transvaginal ultrasound was false positive as the hysteroscopic and subsequent histopathological diagnosis only showed atrofia of the uterine endometrium. In almost half of the patients the TVU gave a misleading picture concerning the condition of the endometrium. Changes in the myometrium and related connective tissue could be misinterpreted by the ultrasound technique as changes in the endometrium. These results may confirm the theory that stimulation and changes by antiestrogenic treatment of the uterine tissue is not only restricted to the endometrium. In patients with thickened endometrium measured by TVU, a dilatation and curettage is not sufficient, as TVU has not the ability to differentiate between endometrial polyps and myometrial changes. A hysteroscopy and directed biopsy could therefore be performed." }, { "id": "pubmed23n0380_3037", "title": "Ultrasound, hysteroscopy and endometrial biopsy in the investigation of endometrial cancer.", "score": 0.009433962264150943, "content": "Over the course of the last two decades hysteroscopy with endometrial biopsy has begun to replace dilation and curettage as the method of choice for the diagnosis of endometrial carcinoma. In the majority of women this can be performed as an outpatient procedure with no loss in diagnostic accuracy. Transvaginal ultrasound measurement of endometrial thickness provides a highly sensitive and less invasive alternative means of assessing the endometrium but has a low positive predictive value for cancer, especially in women taking hormone replacement therapy. The cut-off value used to define normality needs to take into account patient age and ethnic origin. Ultrasound screening may not be suitable for women taking tamoxifen and those with recurrent or late-onset abnormal uterine bleeding." }, { "id": "pubmed23n0698_15379", "title": "Diagnosis of abnormal uterine bleeding with imaging.", "score": 0.009345794392523364, "content": "The major role of ultrasound in the evaluation of abnormal uterine bleeding, other than that occurring during pregnancy, is in postmenopausal women. Because postmenopausal bleeding can be the presenting symptom of endometrial cancer, any woman with this symptom should be evaluated to diagnose or exclude carcinoma. Over the last two decades, the role of ultrasound in the evaluation of postmenopausal bleeding has changed markedly, from little or no role in 1990 to a major role today. In the intervening years, numerous studies have shown that ultrasound is at least as sensitive as endometrial biopsy for endometrial cancer and that ultrasound can reliably exclude cancer without the need for biopsy in some women with postmenopausal bleeding. In particular, numerous studies have shown that women with an endometrial thickness of 4 mm or less have an extremely low likelihood of endometrial cancer and thus do not need to undergo endometrial biopsy. Ultrasound can also help in the selection of an appropriate biopsy technique. In a woman with postmenopausal bleeding and a thick endometrium, a sonohysterogram can determine whether the endometrium is diffusely thick or has focal areas of thickening. With diffuse thickening, a blind endometrial biopsy is appropriate. When there are one or more focal areas of thickening, hysteroscopic biopsy is likely to be the better choice. We present two clinical algorithms, either of which is an acceptable approach to the use of ultrasound and/or endometrial biopsy in women with postmenopausal bleeding: the \"ultrasound-first\" approach and the \"biopsy-first\" approach." }, { "id": "wiki20220301en560_9974", "title": "Pharmacokinetics of progesterone", "score": 0.009259259259259259, "content": "were assessed in three of the studies via endometrial biopsy and the results were mixed. In one study, there was no effect; in another, antiproliferative effects were observed; and in the last study, an atrophic state was observed but only in 28 of 40 (70%) of the women. Circulating progesterone levels were reported as less than 3.5 ng/mL in the first study, low and widely variable in the second study, and were not given in the third study. Moreover, the duration of the study in which no effect was observed was short at only 2 weeks, and a longer treatment period of 4 to 6 weeks is necessary to produce endometrial changes. It has also been suggested that the dosage of estrogen used may have been insufficient to allow for proper priming of the endometrium for progesterone to act. Taken together, further studies are required to adequately establish a protective effect of transdermal progesterone on the endometrium." }, { "id": "pubmed23n0563_24744", "title": "Ten-year follow-up of endometrial ablation.", "score": 0.009259259259259259, "content": "This paper presents a ten-year follow-up of a randomized, controlled trial which gives the long-term hysterectomy rate and patient satisfaction rate of transcervical hysteroscopic endometrial ablation in the treatment of heavy dysfunctional bleeding. There were 120 women enrolled in the study, from June 10, 1993 to August 31, 1995, all requiring endometrial ablation for the treatment of heavy dysfunctional bleeding. All patients were offered a clinical examination two years postoperatively. Long-term outcome was assessed by completion of a questionnaire five and ten years after initial treatment. Any new symptomatology and need for further treatment or a hysterectomy was registered. A bleeding index and the patients' satisfaction rate and acceptability of the treatment method were stated. Sixty-one patients were treated by endometrial coagulation, and 59 by endometrial resection. No significant difference in the number of hysterectomies or satisfaction rate between the two groups was observed. At a ten-year follow-up, 63% of patients only had one ablation, 11% were treated twice, and 22% had a hysterectomy. Only 3% were lost to follow-up. For the group of patients above 40 years of age, only 17% had a hysterectomy. Since the two-year follow-up only six patients with one hysteroscopic treatment have had further intervention. Ninety-four percent of the women would recommend the treatment to their best female friend. The long-term results show that an ablation for heavy dysfunctional bleeding is an excellent treatment. Overall 22% of patients had a hysterectomy. If the patient had no further intervention at the two-year clinical control, there was only a 6% risk of hysterectomy after a period of at least ten years." }, { "id": "wiki20220301en168_15948", "title": "Endometrial biopsy", "score": 0.009181952993276048, "content": "Pain Endometrial biopsy pain is quite common. The reason that doctors spray the lidocain is to help to deal with some of the pain from the procedure. The lidocain spray can burn when it is sprayed into the area. The clamp that is put onto the cervix may be another cause of pain and the procedure itself, with the doctor procuring a piece of the lining with the tube potentially being painful. Most of the time, this will only be required once, but sometimes the procedure can entail two or three instances of procuring a piece of the endometrium. Procedure Generally, an endometrial biopsy follows this process:" }, { "id": "pubmed23n0478_14031", "title": "Sonohysterography compared with endometrial biopsy for evaluation of the endometrium in tamoxifen-treated women.", "score": 0.009174311926605505, "content": "This study was performed to compare endometrial biopsy and sonohysterography for evaluation of the endometrium in tamoxifen-treated women. Medical records were retrospectively reviewed to identify 51 consecutive tamoxifen-treated women who had sonohysterography and correlative endometrial biopsy for evaluation of postmenopausal bleeding or thickened endometrium of greater than 8 mm. Endometrial biopsy and sonohysterographic results were compared in all women, and for 27 (53%) women who had hysteroscopy with dilation and curettage, endometrial biopsy and sonohysterographic findings also were compared with surgical pathologic findings. Thirty-two (63%) of 51 sonohysterograms revealed endometrial polyps; 4 (8%) showed endometrium of greater than 5 mm; 14 (27%) showed endometrium of less than 5 mm; and 1 (2%) was inadequate. Endometrial biopsy findings were benign endometrium in 42 (82%), polyps in 4 (8%), and insufficient samples in 5 (10%). Among the adequate sonohysterograms, 64% (32 of 50) resulted in a diagnosis of polyps (95% confidence interval, 49%-77%) whereas the corresponding proportion for endometrial biopsy was 9% (4 of 46; 95% confidence interval, 2%-21%). For the group with hysteroscopy, 24 (92%) of 26 polyps were confirmed histopathologically; 1 polyp had complex hyperplasia. Polyps were present in 23 (89%) of 26 women with benign endometrium or insufficient samples by endometrial biopsy, and only 1 confirmed polyp was identified by endometrial biopsy. The sensitivity of sonohysterography for diagnosis of endometrial polyps (100%) was significantly higher than for endometrial biopsy (4%; P &lt; .01). In tamoxifen-treated women, sonohysterography provides a significant improvement in sensitivity for diagnosis of endometrial polyps compared with endometrial biopsy." }, { "id": "pubmed23n0379_7942", "title": "Endometrial biopsy during outpatient hysteroscopy: evaluation and comparison of two devices.", "score": 0.009174311926605505, "content": "Association of office hysteroscopy with outpatient endometrial biopsy is interesting to evaluate correctly endometrium. Purpose of this study was to evaluate and compare two endometrial biopsy devices during outpatient hysteroscopy, based on effectiveness and tolerance of the procedure. A single blind, randomised prospective study. 200 patients were randomised into two groups following outpatient hysteroscopy: 100 were biopsied with Vacurette and 100 biopsed with Pipelle. Pipelle was less painful compared to Vacurette (1.1+0.2 versus 1.6+0.3; P&lt;0.001), no matter hormonal status (1+0.3 versus 2+0.6; P&lt;0.001 in premenopausal subgroup and 1+0.3 versus 1.4+0.3; P&lt;0.001 in postmenopausal subgroup). Vacurette was more effective than Pipelle (64/100 versus 48/100; P=0.02), in case of normal or hypertrophic endometrium (56/72 (77%) versus 40/65 (61%); P=0.04) but not in case of atrophic endometrium (8/28 (29%) versus 8/35 (23%); P=0.6). Among the 112 patients with adequate sample, histologic results were normal, except for three cases of endometrial hyperplasia. Among the 88 patients with inadequate sample, 47 (53%) presented an atrophic endometrial aspect at hysteroscopy, whereas 41 (47%) were considered as normal. Vacurette was more effective though more painful than Pipelle. Both instruments were, however, well tolerated. Both instruments were not very effective in case of atrophic endometrium. Outpatient hysteroscopy combined with endometrial biopsy may help avoid further investigations." }, { "id": "pubmed23n0987_1621", "title": "Brain Metastasis in Papillary Serous Adenocarcinoma of the Endometrium.", "score": 0.00909090909090909, "content": " Most endometrial cancers (75%) are diagnosed in early stages (stages I and II), in which abnormal uterine bleeding is the most frequent clinical sign. When the diagnosis is performed in stage IV, the most common sites of metastasis are the lungs, liver and bones. Central nervous system (CNS) metastasis is a rare condition. The aim of this study is to describe a case of uterine papillary serous adenocarcinoma of the endometrium that progressed to brain and bone metastases.  We present the case of a 56-year-old woman with abnormal uterine bleeding and endometrial thickened echo (1.8 cm). A hysteroscopy with biopsy was performed, which identified poor differentiated serous adenocarcinoma of the endometrium. A total abdominal hysterectomy, with pelvic and para-aortic lymphadenectomy, was performed. Analysis of the surgical specimen revealed a grade III uterine papillary serous adenocarcinoma. Adjuvant radio/chemotherapy (carboplatin and paclitaxel-six cycles) was indicated. Sixteen months after the surgery, the patient began to complain of headaches. Brain magnetic resonance imaging demonstrated an expansile mass in the right parietal lobe, suggesting a secondary hematogenous implant subsequently confirmed by biopsy. She underwent surgery for treatment of brain metastasis, followed by radiotherapy. She died 12 months after the brain metastasis diagnosis due to disease progression.  Uterine papillary serous adenocarcinoma of the endometrium has a low propensity to metastasize to the brain. To the best of our knowledge, this is the fifth documented case of uterine papillary serous adenocarcinoma of the endometrium with metastasis to the CNS." }, { "id": "article-21104_28", "title": "Endometrial Hyperplasia -- Treatment / Management -- Treatment duration and follow up:", "score": 0.00909090909090909, "content": "In order to induce the regression of the hyperplasia, treatment should be for at least six months. Endometrial surveillance with office endometrial biopsy is recommended at six-monthly intervals. Before discharging the patient, two consecutive 6 – monthly negative biopsies should be obtained. Women who have a BMI of more than 35 and who were treated with oral progestogens are at a higher risk of relapse and should be advised annual follow -up. All women should be advised to come for a follow -up if they experience the symptoms of abnormal uterine bleeding.[2]" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 45, 179 ] ], "word_ranges": [ [ 7, 28 ] ], "text": "child with otalgia, but without fever or acute inflammatory signs: it is neither 1 (recurrent acute otitis media) nor 5 (mastoiditis)." }, "2": { "exist": true, "char_ranges": [ [ 389, 458 ] ], "word_ranges": [ [ 63, 73 ] ], "text": "Otoscopy is characteristic of serous otitis media (answer 2 correct)." }, "3": { "exist": true, "char_ranges": [ [ 312, 388 ] ], "word_ranges": [ [ 50, 63 ] ], "text": "nor perforations or adhesions, so it is not 3 (simple chronic otitis media)." }, "4": { "exist": true, "char_ranges": [ [ 180, 311 ] ], "word_ranges": [ [ 28, 50 ] ], "text": "On otoscopy, a pinkish and amber eardrum is observed: there are no scales, so it is not 4 (cholesteatomatous chronic otitis media);" }, "5": { "exist": true, "char_ranges": [ [ 45, 179 ] ], "word_ranges": [ [ 7, 28 ] ], "text": "child with otalgia, but without fever or acute inflammatory signs: it is neither 1 (recurrent acute otitis media) nor 5 (mastoiditis)." } }

{ "1": "Recurrent acute otitis media.", "2": "Serous otitis media.", "3": "Simple chronic otitis media.", "4": "Chronic cholesteatomatous otitis media.", "5": "Mastoiditis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0293_22349", "title": "Management of otitis media with effusion.", "score": 0.017475875693336373, "content": "Timmy, a two-year-old, has received two antibiotic courses (ampicillin, cefaclor) for acute otitis media during the past year. Today, his mom visits your pharmacy and mentions that they have just returned from an appointment with the boy's doctor. Timmy was diagnosed with otitis media with effusion, which the doctor described as fluid in the ears unaccompanied by fever or any signs of pain or discomfort. She is puzzled that the doctor did not prescribe any antibiotics this time. Worried about her son's recurrent ear problems, she asks your advice. Your review of Timmy's history reveals that he is otherwise healthy except for the two previous episodes of acute otitis media. Further discussion with Timmy's mom also reveals that his father is a heavy smoker." }, { "id": "pubmed23n0586_21307", "title": "Diagnosis and treatment of otitis media.", "score": 0.016636998493769685, "content": "Diagnostic criteria for acute otitis media include rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. Fever, otalgia, headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are common, but nonspecific symptoms. Detection of middle ear effusion by pneumatic otoscopy is key in establishing the diagnosis. Observation is an acceptable option in healthy children with mild symptoms. Antibiotics are recommended in all children younger than six months, in those between six months and two years if the diagnosis is certain, and in children with severe infection. High-dosage amoxicillin (80 to 90 mg per kg per day) is recommended as first-line therapy. Macrolide antibiotics, clindamycin, and cephalosporins are alternatives in penicillin-sensitive children and in those with resistant infections. Patients who do not respond to treatment should be reassessed. Hearing and language testing is recommended in children with suspected hearing loss or persistent effusion for at least three months, and in those with developmental problems." }, { "id": "pubmed23n0824_14050", "title": "Acute otitis media: a simple diagnosis, a simple treatment.", "score": 0.016628206868467492, "content": "To assess the symptoms and signs of acute otitis media and efficiency of simple antibiotics like amoxicillin in its treatment in the primary health care setup. This is a prospective longitudinal study including 204 patients from different institutions. Patients were diagnosed as suffering from acute otitis media when presented with earache, fever, fullness and or otorrhea. Patients were divided into two equal groups on basis of the treatment they received, Group A received only symptomatic treatment while Group B were given Amoxicillin (40 mg/kg/day) for 7 days. Acute otitis media was common in children under 15 years (64.7%). Patients presented with earache (100%), aural fullness (90.68%), fever (76.47%) associated with recent onset of upper respiratory tract infections (88.23%). In group A, improvement was noticed in 28.43% in 3 days while 35.29% in 7 days. In group B, improvement was noticed in 48.03% in day 3 while 86.27% in day 7. In countries where medical care is scarce, patients lost to follow up, it is wise to treat with simple antibiotics like amoxicillin in adequate dose than to treat only symptomatically. It prevents chronicity, early hearing impairments and reduces antibiotic resistance." }, { "id": "wiki20220301en011_35273", "title": "Otitis media", "score": 0.016581719334012913, "content": "Epidemiology Acute otitis media is very common in childhood. It is the most common condition for which medical care is provided in children under five years of age in the US. Acute otitis media affects 11% of people each year (709 million cases) with half occurring in those below five years. Chronic suppurative otitis media affects about 5% or 31 million of these cases with 22.6% of cases occurring annually under the age of five years. Otitis media resulted in 2,400 deaths in 2013—down from 4,900 deaths in 1990. Etymology The term otitis media is composed of otitis, Ancient Greek for \"inflammation of the ear\", and media, Latin for \"middle\". References External links Otitis Diseases of middle ear and mastoid Pediatrics Audiology Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate fr:Otite" }, { "id": "wiki20220301en048_65108", "title": "Ear pain", "score": 0.015826564739608216, "content": "Epidemiology 2/3 of people presenting with ear pain were diagnosed with some sort of primary otalgia and 1/3 were diagnosed with some sort secondary otalgia. A common cause of primary otalgia is ear infection called otitis media, meaning an infection behind the eardrum. The peak age for children to get acute otitis media is ages 6–24 months. One review paper wrote that 83% of children had at least one episode of acute otitis media by 3 years of age. Worldwide, there are 709 millions cases of acute otitis media every year. Hearing loss globally due to ear infection is estimated to be 30 people in every 10,000. Around the world there is around 21,000 to 28,000 deaths due to complications from ear infections. These complications include brain abscesses and meningitis. Otitis externae peaks at age 7–12 years of age and around 10% of people has had it at least once in their lives." }, { "id": "wiki20220301en048_65094", "title": "Ear pain", "score": 0.01563920712856883, "content": "Middle and inner ear Acute otitis media Acute otitis media is an infection of the middle ear. More than 80% of children experience at least one episode of otitis media by age 3 years. Acute otitis media is also most common in these first 3 years of life, though older children may also experience it. The most common causative bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Otitis media often occurs with or following cold symptoms. The diagnosis is made by the combination of symptoms and examination of the tympanic membrane for redness, bulging, and/or a middle ear effusion (collection of fluid within the middle ear)." }, { "id": "wiki20220301en011_35252", "title": "Otitis media", "score": 0.015407061569886197, "content": "Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum. To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum. It is important to attempt to differentiate between acute otitis media and otitis media with effusion (OME), as antibiotics are not recommended for OME. It has been suggested that bulging of the tympanic membrane is the best sign to differentiate AOM from OME, with a bulging of the membrane suggesting AOM rather than OME. Viral otitis may result in blisters on the external side of the tympanic membrane, which is called bullous myringitis (myringa being Latin for \"eardrum\")." }, { "id": "pubmed23n0772_19030", "title": "Otitis media: diagnosis and treatment.", "score": 0.015219907407407408, "content": "Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. Management of acute otitis media should begin with adequate analgesia. Antibiotic therapy can be deferred in children two years or older with mild symptoms. High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin. Children with persistent symptoms despite 48 to 72 hours of antibiotic therapy should be reexamined, and a second-line agent, such as amoxicillin/clavulanate, should be used if appropriate. Otitis media with effusion is defined as middle ear effusion in the absence of acute symptoms. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. Children with evidence of anatomic damage, hearing loss, or language delay should be referred to an otolaryngologist. " }, { "id": "pubmed23n0420_6893", "title": "Acute otitis media in adults: many unknowns.", "score": 0.015050167224080268, "content": "(1) Acute otitis media is likely in adults with recent-onset otalgia, fever, and a bulging eardrum on otoscopy. Management is similar to that in children: no antibiotics in the first instance, then amoxicillin later if antibiotic therapy is needed. (2) Otitis media with a perforated eardrum, and evidence of pus must be distinguished from external otitis. In patients with otitis media and a perforated eardrum, the commonest bacterial isolates are staphylococci, pseudomonas and pneumococci. (3) If antibiotics are prescribed the choice of agent is based on individual clinical findings and underlying health status." }, { "id": "pubmed23n0731_14529", "title": "[Consensus document on the aetiology, diagnosis and treatment of acute otitis media].", "score": 0.014981483559645382, "content": "This is the consensus document on acute otitis media (AOM) of the Sociedad Española de Infectología Pediatrica (SEIP), Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Sociedad Española de Urgencias Pediátricas (SEUP) and Asociación Española de Pediatría de Atención Primaria (AEPAP). It discusses the aetiology of the disease and its potential changes after the introduction of the pneumococcal 7-valent, 10-valent and 13-valent vaccines. A proposal is made based on diagnostic classification of otitis media as either confirmed or likely. AOM is considered confirmed if 3 criteria are fulfilled: acute onset, signs of occupation of the middle ear (or otorrhea) and inflammatory signs or symptoms, such as otalgia or severe tympanic hyperaemia. Oral amoxicillin is the antibiotic treatment of choice (80mg/kg/day divided every 8hours). Amoxicillin-clavulanate (80mg/kg/day) is indicated in the following cases: when the child is under 6 months, in infants with severe clinical manifestations (fever&gt;39°C or severe pain), there is family history of AOM sequels, and after amoxiciline treatment failure." }, { "id": "pubmed23n0512_1210", "title": "A randomized, double-blind, placebo-controlled noninferiority trial of amoxicillin for clinically diagnosed acute otitis media in children 6 months to 5 years of age.", "score": 0.014961389961389961, "content": "Debate continues with respect to a \"watch and wait\" approach versus immediate antibiotic treatment for the initial treatment of acute otitis media. In this double-blind noninferiority trial, we compared clinical improvement rates at 14 days for children (6 months to 5 years of age) with acute otitis media who were randomly assigned to receive amoxicillin or placebo. We enrolled healthy children who presented to clinics or the emergency department with a new episode of acute otitis media during the fall and winter months in Ottawa (from December 1999 to the end of March 2002). The children were randomly assigned to receive amoxicillin (60 mg/kg daily) or placebo for 10 days. Telephone follow-up was performed on each of days 1, 2 and 3 and once between day 10 and day 14. The primary outcome was clinical resolution of symptoms, defined as absence of receipt of an antimicrobial (other than the amoxicillin in the treatment group) at any time during the 14-day period. Secondary outcomes were the presence of pain and fever and the activity level in the first 3 days, recurrence rates, and the presence of middle ear effusion at 1 and 3 months. According to clinical scoring, 415 of the 512 children who could be evaluated had moderate disease. At 14 days 84.2% of the children receiving placebo and 92.8% of those receiving amoxicillin had clinical resolution of symptoms (absolute difference -8.6%, 95% confidence interval -14.4% to -3.0%). Children who received placebo had more pain and fever in the first 2 days. There were no statistical differences in adverse events between the 2 groups, nor were there any significant differences in recurrence rates or middle ear effusion at 1 and 3 months. Our results did not support the hypothesis that placebo was noninferior to amoxicillin (i.e., that the 14-day cure rates among children with clinically diagnosed acute otitis media would not be substantially worse in the placebo group than the treatment group). Nevertheless, delaying treatment was associated with resolution of clinical signs and symptoms in most of the children." }, { "id": "wiki20220301en011_35244", "title": "Otitis media", "score": 0.01475924291458272, "content": "Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media (AOM), an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. The other main type is otitis media with effusion (OME), typically not associated with symptoms, although occasionally a feeling of fullness is described; it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. Chronic suppurative otitis media (CSOM) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. It may be a complication of acute otitis media. Pain is rarely present. All three types of otitis media may be associated with hearing loss. If children with hearing loss due to OME do not" }, { "id": "pubmed23n0912_20846", "title": "Acute Otitis Media in Children.", "score": 0.01460046384145056, "content": "Acute otitis media is a common childhood infection. Prompt diagnosis and appropriate treatment are very important. To review in depth the epidemiology, pathophysiology, clinical manifestations, diagnosis, complications and particularly treatment of acute otitis media in children. A PubMed search was completed in Clinical Queries using the key term \"acute otitis media\". Patents were searched using the key term \"acute otitis media\" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com. Acute otitis media affects over 80% of children before their third birthday and 30 to 45% of these children have suffered two or more episodes. Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis are the most frequently isolated middle-ear pathogens. The diagnosis is based on acute onset of symptoms such as otalgia and fever, middle ear inflammation such as erythema of the tympanic membrane, and middle ear effusion. The choice of treatment method depends on the age of the child, laterality, and the severity of the disease. Recent patents related to the management of acute otitis media are also retrieved and discussed. Antimicrobial treatment is recommended for all children less than two years of age, as well as in children ≥ two years of age who have a temperature ≥ 39oC; are toxic looking; have otalgia &gt; 48 hours; have bilateral otitis media or otorrhea; have craniofacial abnormalities; are immunocompromised; or have uncertain access to follow-up. Amoxicillin is the drug of choice. Observation without antibiotic is an option in immunocompetent children ≥ two years of age who have an acute uncomplicated otitis media and non-severe illness if appropriate follow-up can be arranged." }, { "id": "wiki20220301en011_35253", "title": "Otitis media", "score": 0.01435897435897436, "content": "Viral otitis may result in blisters on the external side of the tympanic membrane, which is called bullous myringitis (myringa being Latin for \"eardrum\"). However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small. If wax in the ear canal obscures a clear view of the eardrum it should be removed using a blunt cerumen curette or a wire loop. Also, an upset young child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media. Acute otitis media The most common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus." }, { "id": "pubmed23n0296_2358", "title": "Acute otitis media in children.", "score": 0.014197151105011595, "content": "Acute otitis media (AOM) is the most common reason parents bring children into the primary care physician's office. It is diagnosed by clinical symptoms of otalgia and often fever and irritability and by clinical otoscopy. Organisms common to the nasopharynx usually cause AOM. Many episodes of AOM resolve spontaneously. Because it is uncertain how many and which children will resolve without therapy, it is reasonable to treat all children with AOM with antibiotics. The first choice of antibiotics is amoxicillin. Other choices rest on a variety of factors." }, { "id": "wiki20220301en011_35249", "title": "Otitis media", "score": 0.013524178504807003, "content": "Signs and symptoms The primary symptom of acute otitis media is ear pain; other possible symptoms include fever, reduced hearing during periods of illness, tenderness on touch of the skin above the ear, purulent discharge from the ears, irritability, ear blocking sensation and diarrhea (in infants). Since an episode of otitis media is usually precipitated by an upper respiratory tract infection (URTI), there are often accompanying symptoms like a cough and nasal discharge. One might also experience a feeling of fullness in the ear. Discharge from the ear can be caused by acute otitis media with perforation of the eardrum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to cerebrospinal fluid otorrhea (discharge of CSF from the ear) due to cerebral spinal drainage from the brain and its covering (meninges)." }, { "id": "pubmed23n1004_11062", "title": "Otitis Media: Rapid Evidence Review.", "score": 0.013413547237076648, "content": "Acute otitis media (AOM) is the most common diagnosis in childhood acute sick visits. By three years of age, 50% to 85% of children will have at least one episode of AOM. Symptoms may include ear pain (rubbing, tugging, or holding the ear may be a sign of pain), fever, irritability, otorrhea, anorexia, and sometimes vomiting or lethargy. AOM is diagnosed in symptomatic children with moderate to severe bulging of the tympanic membrane or new-onset otorrhea not caused by acute otitis externa, and in children with mild bulging and either recent-onset ear pain (less than 48 hours) or intense erythema of the tympanic membrane. Treatment includes pain management plus observation or antibiotics, depending on the patient's age, severity of symptoms, and whether the AOM is unilateral or bilateral. When antibiotics are used, high-dose amoxicillin (80 to 90 mg per kg per day in two divided doses) is first-line therapy unless the patient has taken amoxicillin for AOM in the previous 30 days or has concomitant purulent conjunctivitis; amoxicillin/clavulanate is typically used in this case. Cefdinir or azithromycin should be the first-line antibiotic in those with penicillin allergy based on risk of cephalosporin allergy. Tympanostomy tubes should be considered in children with three or more episodes of AOM within six months or four episodes within one year with one episode in the preceding six months. Pneumococcal and influenza vaccines and exclusive breastfeeding until at least six months of age can reduce the risk of AOM." }, { "id": "wiki20220301en000_37899", "title": "Amoxicillin", "score": 0.013137665967854647, "content": "Acute otitis media Children with acute otitis media who are younger than 6 months of age are generally treated with amoxicillin or other antibiotics. Although most children with acute otitis media who are older than two years old do not benefit from treatment with amoxicillin or other antibiotics, such treatment may be helpful in children younger than two years old with acute otitis media that is bilateral or accompanied by ear drainage. In the past, amoxicillin was dosed three times daily when used to treat acute otitis media, which resulted in missed doses in routine ambulatory practice. There is now evidence that two times daily dosing or once daily dosing has similar effectiveness." }, { "id": "pubmed23n0131_6151", "title": "Acute otitis media: clinical course among children who received a short course of high dose antibiotic.", "score": 0.012562427967729543, "content": "A prospective study was carried out in 274 children aged 3 to 10 years with acute otitis media. They were randomly allocated to one of two treatment regimens: (a) a seven day course of amoxycillin 125 mg three times a day, and (b) a two day course of amoxycillin 750 mg twice a day. They were followed up by symptom diaries and clinical examination. The findings in the 243 children who completed the trial showed that the short course of treatment was as effective as the seven day course in the speed of resolution of symptoms and signs, irrespective of previous history of otitis media or of episodes in which bulging of the eardrums was observed at presentation. A subgroup of 185 children was followed up for one year after entry to the trial. During this period no appreciable differences emerged between the two antibiotic regimens, either in recurrence rate of otitis media or in the frequency of hearing loss at one month and six months after entry to the study. Side effects of treatment were few, and those that could be attributed to antibiotic use occurred with equal frequency in the two treatment groups." }, { "id": "article-17163_12", "title": "Acute Otitis Media -- History and Physical", "score": 0.01247457627118644, "content": "Although one of the best indicators for otitis media is otalgia, many children with otitis media can present with non-specific signs and symptoms, which can make the diagnosis challenging. These symptoms include pulling or tugging at the ears, irritability, headache, disturbed or restless sleep, poor feeding, anorexia, vomiting, or diarrhea. Approximately two-thirds of the patients present with fever, which is typically low-grade." }, { "id": "article-24772_11", "title": "Mastoiditis -- History and Physical", "score": 0.012332798287854468, "content": "The otoscopic examination will reveal a bulging of the posterosuperior wall of the external auditory canal and bulging of and pus behind the tympanic membrane. Often the tympanic membrane can be ruptured and draining pus. Some important considerations include the following. A normal tympanic membrane usually, but not always, excludes acute mastoiditis. Also, although a history of recent or concurrent otitis media is common, it is not required to make the diagnosis of acute mastoiditis as some cases may take place rapidly during the onset of acute otitis media. [5]" }, { "id": "wiki20220301en011_35263", "title": "Otitis media", "score": 0.012330648685771366, "content": "Antibiotics It is important to weigh the benefits and harms before using antibiotics for acute otitis media. As over 82% of acute episodes settle without treatment, about 20 children must be treated to prevent one case of ear pain, 33 children to prevent one perforation, and 11 children to prevent one opposite-side ear infection. For every 14 children treated with antibiotics, one child has an episode of either vomiting, diarrhea or a rash. If pain is present, pain medications may be used. For people requiring surgery to treat otitis media with effusion, preventative antibiotics may not help reduce the risk of post-surgical complications. For bilateral acute otitis media in infants younger than 24 months of age, there is evidence that the benefits of antibiotics outweigh the harms. A 2015 Cochrane review concluded that watchful waiting is the preferred approach for children over six months with non severe acute otitis media." }, { "id": "wiki20220301en011_35251", "title": "Otitis media", "score": 0.012149377593360995, "content": "Diagnosis As its typical symptoms overlap with other conditions, such as acute external otitis, symptoms alone are not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the tympanic membrane. Examiners may use a pneumatic otoscope with a rubber bulb attached to assess the mobility of the tympanic membrane. Other methods to diagnose otitis media is with a tympanometry, reflectometry or hearing test. In more severe cases, such as those with associated hearing loss or high fever, audiometry, tympanogram, temporal bone CT and MRI can be used to assess for associated complications, such as mastoid effusion, subperiosteal abscess formation, bony destruction, venous thrombosis or meningitis." }, { "id": "wiki20220301en581_2254", "title": "List of ICD-9 codes 320–389: diseases of the nervous system and sense organs", "score": 0.011963748782450346, "content": "Diseases of the ear and mastoid process (380–389) Disorders of external ear Perichondritis of pinna Infective otitis externa Other otitis externa Noninfective disorders of pinna Impacted cerumen Acquired stenosis of external ear canal Other disorders of external ear Unspecified Nonsuppurative otitis media and Eustachian tube disorders Acute nonsuppurative otitis media Chronic serous otitis media Chronic mucoid otitis media Other and unspecified chronic nonsuppurative otitis media Nonsuppurative otitis media, not specified as acute or chronic Eustachian salpingitis Obstruction of Eustachian tube Patulous Eustachian tube Other disorders of Eustachian tube Unspecified Eustachian tube disorder Suppurative and unspecified otitis media Acute suppurative otitis media Chronic tubotympanic suppurative otitis media Chronic atticoantral suppurative otitis media Unspecified chronic suppurative otitis media Unspecified suppurative otitis media" }, { "id": "pubmed23n0206_11340", "title": "Treatment of otitis media with effusion.", "score": 0.01184994582881907, "content": "Otitis media is the most common disease of children who seek medical care. It is estimated that over 30 million visits to physicians are made per year, and that over one billion dollars are spent annually in the United States for the treatment of otitis media. More prescriptions are written for oral antimicrobial agents for otitis media than any other disease. Antimicrobial therapy is still the mainstay of treatment for children with acute otitis media. Myringotomy (and tympanocentesis) should also be performed when acute otitis media is associated with: severe otalgia, when otalgia or fever persists or recurs in spite of antimicrobial therapy, in the very young or immunocompromised host and when a suppurative intratemporal or intracranial complication is impending or present. Antimicrobial agents should be selected according to the incidence of bacteria prevalent in the community and should be altered depending upon the results of cultures obtained from middle ear aspirates in children who are not responding to the usual antimicrobial agents. Children who experience frequently recurrent acute otitis media (without a middle ear effusion between attacks) should be considered candidates for prophylactic antimicrobial therapy or tympanostomy tube insertion, or both. A middle ear effusion that has persisted for three months or longer should be considered chronic and active treatment should be instituted. A course of antimicrobial therapy should be tried, and if not effective, then a myringotomy with aspiration of the effusion is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en581_2255", "title": "List of ICD-9 codes 320–389: diseases of the nervous system and sense organs", "score": 0.011656005685856433, "content": "Chronic tubotympanic suppurative otitis media Chronic atticoantral suppurative otitis media Unspecified chronic suppurative otitis media Unspecified suppurative otitis media Unspecified otitis media Mastoiditis and related conditions Acute mastoiditis Chronic mastoiditis Petrositis Complications following mastoidectomy Other Unspecified mastoiditis Other disorders of tympanic membrane Acute myringitis without mention of otitis media Chronic myringitis without mention of otitis media Perforation of tympanic membrane Other Unspecified Other disorders of middle ear and mastoid Tympanosclerosis Adhesive middle ear disease Other acquired abnormality of ear ossicles Cholesteatoma of middle ear and mastoid Other Unspecified Vertiginolls syndromes and other disorders of vestibular system Ménière's disease Other and unspecified peripheral vertigo Vertigo of central origin Labyrinthitis Labyrinthine fistula Labyrinthine dysfunction" }, { "id": "InternalMed_Harrison_11652", "title": "InternalMed_Harrison", "score": 0.011586721946129981, "content": "Amoxicillin (80–90 mg/kg per day) is recommended for children with acute otitis media except in situations where observation and symptom-based treatment without antibiotics are advocated. These situations include nonsevere illness and an uncertain diagnosis in children 6 months to 2 years of age and nonsevere illness (even if the diagnosis seems certain) in children >2 years of age. Although the optimal duration of therapy has not been conclusively established, a 10-day course is recommended for younger children and for children with severe disease at any age. For children >6 years old who have mild or moderate disease, a course of 5–7 days is considered adequate. Patients whose illness fails to respond should be reassessed at 48–72 h. If acute otitis media is confirmed and antibiotic treatment has not been started, administration of amoxicillin should be commenced. If antibiotic therapy fails, a change is indicated. Failure to respond to second-line antibiotics as well indicates that" }, { "id": "wiki20220301en011_35256", "title": "Otitis media", "score": 0.011247639056896075, "content": "Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity that is characterised by discharge from the middle ear through a perforated tympanic membrane for at least 6 weeks. CSOM occurs following an upper respiratory tract infection that has led to acute otitis media. This progresses to a prolonged inflammatory response causing mucosal (middle ear) oedema, ulceration and perforation. The middle ear attempts to resolve this ulceration by production of granulation tissue and polyp formation. This can lead to increased discharge and failure to arrest the inflammation, and to development of CSOM, which is also often associated with cholesteatoma. There may be enough pus that it drains to the outside of the ear (otorrhea), or the pus may be minimal enough to be seen only on examination with an otoscope or binocular microscope. Hearing impairment often accompanies this disease. People are at increased risk of developing CSOM when they have poor" }, { "id": "Surgery_Schwartz_4191", "title": "Surgery_Schwartz", "score": 0.011063218390804597, "content": "the absence of these factors, the child with OME should be reexamined at 3to 6-month intervals until the effusion is no longer present or until significant hear-ing loss is identified or structural abnormalities of the eardrum or middle ear are suspected. When hearing, speech, or structural concerns exist, myringotomy with tympanostomy tube place-ment is indicated.Signs and symptoms of infectious otitis media occurring for <3 weeks denote AOM. In this phase, otalgia and fever are the most common symptoms and physical exam reveals a bulging, opaque tympanic membrane (Fig. 18-1). If the process lasts 3 to 8 weeks, it is deemed subacute. Chronic otitis media, lasting more than 8 weeks, usually results from an unresolved acute otitis media. The most common organisms responsible are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.In order to minimize antibiotic resistance and obviate complications of antimicrobial therapy such as allergic reaction and diarrhea," }, { "id": "article-18247_7", "title": "Bezold Abscess -- History and Physical", "score": 0.010833086565985589, "content": "Bezold's abscess may occur in both children and adults with well-developed mastoid bones. Both may have had a history of recurrent otitis media or chronic otitis media with tympanic membrane perforation and a draining ear. Prior mastoid surgery for cholesteatoma normally causes further thinning of the mastoid walls making it easier for infection to spread in this way. An important early clinical sign of a coalescent mastoiditis on physical examination is sagging of the posterior superior external auditory canal. Other common clinical signs include the following: neck pain swelling in the lateral neck postauricular tenderness over the affected mastoid bone otalgia otorrhea hearing loss" }, { "id": "article-17163_13", "title": "Acute Otitis Media -- History and Physical", "score": 0.010675914592683258, "content": "The diagnosis of otitis media is primarily based on clinical findings combined with supporting signs and symptoms as described above. No lab test or imaging is needed. According to guidelines set forth by the American Academy of Pediatrics, evidence of moderate to severe bulging of the tympanic membrane or new onset of otorrhea not caused by otitis externa or mild tympanic membrane (TM) bulging with recent onset of ear pain or erythema is required for the diagnosis of acute otitis media. These criteria are intended only to aid primary care clinicians in the diagnosis and proper clinical decision-making but not to replace clinical judgment. [19]" }, { "id": "pubmed23n0683_19326", "title": "Treatment of acute otitis media in children under 2 years of age.", "score": 0.01063169768753525, "content": "Recommendations vary regarding immediate antimicrobial treatment versus watchful waiting for children younger than 2 years of age with acute otitis media. We randomly assigned 291 children 6 to 23 months of age, with acute otitis media diagnosed with the use of stringent criteria, to receive amoxicillin-clavulanate or placebo for 10 days. We measured symptomatic response and rates of clinical failure. Among the children who received amoxicillin-clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7; among children who received placebo, 28% had initial resolution of symptoms by day 2, 54% by day 4, and 74% by day 7 (P=0.14 for the overall comparison). For sustained resolution of symptoms, the corresponding values were 20%, 41%, and 67% with amoxicillin-clavulanate, as compared with 14%, 36%, and 53% with placebo (P=0.04 for the overall comparison). Mean symptom scores over the first 7 days were lower for the children treated with amoxicillin-clavulanate than for those who received placebo (P=0.02). The rate of clinical failure--defined as the persistence of signs of acute infection on otoscopic examination--was also lower among the children treated with amoxicillin-clavulanate than among those who received placebo: 4% versus 23% at or before the visit on day 4 or 5 (P&lt;0.001) and 16% versus 51% at or before the visit on day 10 to 12 (P&lt;0.001). Mastoiditis developed in one child who received placebo. Diarrhea and diaper-area dermatitis were more common among children who received amoxicillin-clavulanate. There were no significant changes in either group in the rates of nasopharyngeal colonization with nonsusceptible Streptococcus pneumoniae. Among children 6 to 23 months of age with acute otitis media, treatment with amoxicillin-clavulanate for 10 days tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00377260.)." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 23, 177 ] ], "word_ranges": [ [ 4, 34 ] ], "text": "Lung cancer is the most frequent cause of brain metastases and in 20-30% of cases it is as a result of them that the primary tumor is diagnosed (as here)." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Head and neck cancer.", "2": "Lung cancer.", "3": "Urinary bladder cancer.", "4": "Colon cancer.", "5": "Pancreatic cancer." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0665_22925", "title": "Clinical characteristics of patients with lung cancer and metachronous or synchronous tumours with other locations.", "score": 0.015756302521008403, "content": "Lung cancer is the leading form of cancer death worldwide. Cancer patients are at a high risk of developing a second cancer. The present study attempts to determine the characteristics of a population with lung cancer diagnosed with another cancer. We analysed records of patients from the Department of Lung Oncology of our hospital from 2000 to 2007 who were identified as having two or more tumours. We found 4.2% (n=44) multiple cancers among the registered cases (n=1046), 88.6% males, (high) mean age 70.1+/-10 years old. About 86% (n=38) of the patients were smokers or ex -smokers. From the patients with record of family history, 65.4% (n=17) had relevant family history of cancer. The majority of the first malignancy diagnosed was prostate, colon, head and neck and bladder. Lung cancer was essentially the second malignancy. The mean time lag between the two diagnoses was 62.9+/-64.9 months (max. 240, min. 0), with the second cancer usually detected at an advanced stage. The mean survival of patients who had a second primary lung cancer was 8.6+/-8.24 months (max. 32, min. 1), with four patients still surviving. Our results suggest that extended follow -up is needed in these patients, using screening strategies which follow international recommendations, and with control of carcinogenic risk factors such as smoking. We suggest a tailored risk algorithm and a further study to assess if there are particular molecular markers in these patients." }, { "id": "pubmed23n1063_24066", "title": "Unusual Case of Pancreatic Adenocarcinoma with Bladder Metastasis.", "score": 0.014381914381914381, "content": "<iBackground</i: The pancreas can be the site of neoplasms of several histogenetic origins; in most cases, tumors derive from the exocrine component, and ductal adenocarcinoma certainly prevails over the others. This tumor displays remarkably aggressive behavior, and it is often diagnosed at a late stage of disease. <iCase presentation</i: We discuss the rare case of a 76-year-old male with locally advanced pancreatic head adenocarcinoma who developed uncommon metastatic disease. The bladder constitutes a very rare site of metastases, mostly deriving from melanoma, gastric, lung and breast cancers. The bladder's secondary involvement in pancreatic malignancies represents an extremely unusual occurrence, and there are very few cases described in the literature to date. <iConclusions:</i The finding of pancreatic adenocarcinoma metastases leads to a poor prognosis, and patients who are diagnosed at this stage constitute 53% of cases, with a 5-year survival of 3%. Although rare, therefore, the diagnostic hypothesis of pancreatic ductal adenocarcinoma (DAC) metastases to the bladder must, in some cases, be considered, especially if accompanied by a clinical picture that may suggest it." }, { "id": "pubmed23n0563_18969", "title": "Carcinoma of sigmoid colon after ureterosigmoidostomy.", "score": 0.013459879206212253, "content": "An unusual case of adenocarcinoma of the colon in a 49-year-old man is described. The patient underwent ureterosigmoidostomy at the age of 3 years after a traffic accident. At the age of 49 years, he was admitted to a Department of Urology for treating urinary lithiasis. A chest x-ray and thoracic computed tomography (CT) showed some nodules in both pulmonary fields, while an abdominal CT was normal. The previous patient's history was ignored, the patient underwent thoracoctomy and a nodule was removed. The histology revealed a metastatic, moderately differentiated mucinous adenocarcinoma, probably of the bowel. A sunsequent colonoscopy was non-disclosing and the patient was thought to suffer from a carcinoma of unknown origin and received 6 cycles of chemotherapy with carboplatin and 5-fluorouracil. Five months after the end of chemotherapy he presented with an uncerated mass in the lower abdominal wall. A new CT scan revealed a solid mass in the pelvis with infiltration of the suprapubic region while a repeat colonoscopy showed an infiltrating mass in the sigmoid. Biopsies were obtained from both lesions and the histology was similar with that of the pulmonary nodule." }, { "id": "pubmed23n0083_3966", "title": "[Clinicopathological study on multiple primary malignant neoplasms, related to the oral-maxillofacial region].", "score": 0.011976474781678844, "content": "The present study consists of a clinical and histopathological analysis of those cases which were diagnosed as multiple primary malignant neoplasms of the oral-maxillofacial region and the other organs. 9 patients of those multiple primary malignant neoplasms out of 261 patients of malignant neoplasms in the oral-maxillofacial region, who visited in out department from 1975 to 1986, were detected. 3.4% of the incidence rate was calculated. All the cases were male, and these included each 1 case of triple and quadruple. 7 cases were detected prior in the oral-maxillofacial region to the other organs. There seemed to be a preponderance to early detection of a neoplasm in the oral-maxillofacial region. Therefore, the possibility of multiple primary malignant neoplasms should be kept in mind in the routine clinical activities. 2 cases were synchronous, 6 months or less interval between the first and the second neoplasms, the others were metachronous, averaged 5-year interval. The primary sites in the oral-maxillofacial region were tongue (3 cases), floor of the mouth (2), buccal mucosa (2), lower gingiva (1), maxillary sinus (1), all of them were diagnosed as squamous cell carcinomas, histopathologically. The other organs were esophagus (3 cases), stomach (2), colon (2), lung (2), liver (1), urinary bladder (1), hypopharynx (1). Histopathological diagnoses of them were squamous cell carcinomas (3 cases of esophagus, each 1 case of lung, urinary bladder, and hypopharynx), adenocarcinomas (2 cases of stomach and colon, and 1 case of lung), and a hepatoma. It's necessary to differentiate the multiple primary malignant neoplasms from metastases when each of them were diagnosed as squamous cell carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "First_Aid_Step1_790", "title": "First_Aid_Step1", "score": 0.010884893354486162, "content": "Natural history of lobar pneumonia Lung cancer Leading cause of cancer death. Presentation: cough, hemoptysis, bronchial obstruction, wheezing, pneumonic “coin” lesion on CXR or noncalcified nodule on CT. Sites of metastases from lung cancer: Liver (jaundice, hepatomegaly), Adrenals, Bone (pathologic fracture), Brain; “Lung ‘mets’ Love Affective Boneheads and Brainiacs.” In the lung, metastases (usually multiple lesions) are more common than 1° neoplasms. Most often from breast, colon, prostate, and bladder cancer. SPHERE of complications: Superior vena cava/thoracic outlet syndromes Pancoast tumor Horner syndrome Endocrine (paraneoplastic) Recurrent laryngeal nerve compression Risk factors include smoking, secondhand smoke, radon, asbestos, family history. Squamous and Small cell carcinomas are Sentral (central) and often caused by Smoking." }, { "id": "pubmed23n0378_1075", "title": "[Small cell carcinoma of the urinary bladder with synchronous esophageal cancer and incidental lung cancer: a case report].", "score": 0.010668322420410927, "content": "We present a case of triple primary cancers occurring synchronously in the urinary bladder, esophagus, and incidentally in the lung. A 65-year-old man with a chief complaint of gross hematuria was admitted to our hospital. Cystoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a non-papillary broad-based bladder tumor. Histological diagnosis was transitional cell carcinoma of the urinary bladder and he underwent one course of neoadjuvant chemotherapy (M-VAC) with the preoperative diagnosis of T3bN0M0. After one course of chemotherapy, chest CT, lymph node biopsy and esophagoscopy revealed squamous cell carcinoma of the esophagus. He first underwent radiochemotherapy (total 70 Gy, CDDP 5 mg x 41, 5-FU 250 mg x 24) for esophageal cancer and achieved complete remission. Then, he underwent radiotherapy for a total of 60 Gy for bladder cancer. However, his general condition gradually became worse and he died from metastatic cancer. The autopsy proved that he died from multiple metastases of small cell carcinoma of the urinary bladder and incidentally squamous cell carcinoma of the lung was identified." }, { "id": "wiki20220301en295_38604", "title": "Brain metastasis", "score": 0.009900990099009901, "content": "Causes The most common sources of brain metastases in a case series of 2,700 patients undergoing treatment at the Memorial Sloan–Kettering Cancer Center were: Lung cancer, 48% Breast cancer, 15% Genitourinary tract cancers, 11% Osteosarcoma, 10% Melanoma, 9% Head and neck cancer, 6% Neuroblastoma, 5% Gastrointestinal cancers, especially colorectal and pancreatic carcinoma, 3% Lymphoma, 1% Lung cancer and melanoma are most likely to present with multiple metastasis, whereas breast, colon, and renal cancers are more likely to present with a single metastasis. Diagnosis Brain imaging (neuroimaging such as CT or MRI) is needed to determine the presence of brain metastases. In particular, contrast-enhanced MRI is the best method of diagnosing brain metastases, though detection is primarily done by CT. Biopsy is often recommended to confirm diagnosis." }, { "id": "pubmed23n0090_10587", "title": "[Carcinoma of unknown origin. Diagnostic study of 48 cases and its clinical yield].", "score": 0.009900990099009901, "content": "Forty-eight patients fulfilling the criteria for carcinoma of unknown origin (CUO) between April 1983 and December 1987 were retrospectively analyzed. Mean age was 62 (33-83). Twenty-seven were males (56%) and 21 females (44%). The most common site of metastasis was the bone (35%), followed by the liver (19%) and lymph nodes (19%). 58% of cases were adenocarcinomas. Overall 274 studies for the detection of the primary tumor were carried out, the diagnosis being achieved in 10 cases (3.65%) which corresponded to lung neoplasms (5 cases), prostatic adenocarcinoma with negative markers (2 cases), bile duct neoplasms (2 cases) and pancreatic carcinoma (1 case). In our series, the most useful studies were computed tomography (CT) and fibrobronchoscopy. The necropsy, carried out in 11 patients, yielded 8 additional diagnoses: pulmonary neoplasm (one case), gastric adenocarcinoma (2 cases), malignant melanoma (2 cases), small intestine neoplasm (one case), parotid cancer (one case) and hepatocarcinoma (one case). Thirty-five patients were treated with chemotherapy and/or radiation; 12 objective responses (3 complete and 9 partial) were achieved, with a median duration of the response of 10 months (range 0.2-78 +). In view of the low diagnostic yield of the studies in patients with CUO we feel that the diagnostic study may be limited to CT scan with evaluation of the possible usefulness of bronchoscopy in individual patients. Regarding therapy, it is to be noted that there was a tendency for a longer survival in patients who responded." }, { "id": "pubmed23n0920_8965", "title": "Post-traumatic seizure with an unexpected finding.", "score": 0.00980392156862745, "content": "A 5-year-old boy of non-consanguineous Indian descent presented to the emergency department (ED) following a prolonged seizure, preceded by a minor head injury from a low-level unwitnessed fall. The seizure was described as focal with head and neck version to the right. There was urinary and faecal incontinence and foaming at the mouth. The seizure lasted for 30 min, following which the child made a rapid recovery and had no neurological deficit when examined in the ED. His initial observations were unremarkable, with him being afebrile, normotensive and having a blood sugar of 4.6 mmol/L. QUESTION 1: Which imaging modality, if any, should be performed? QUESTION 2: Initial imaging showed two parenchymal lesions, one within the left frontal lobe and the other in the right parietal lobe with possible areas of blood or calcification. MRI (figure 1A,B) was urgently undertaken and reported as likely to be either haemorrhage into cavernomatous malformations, haemorrhagic metastases or haemorrhage within infected lesions such as tuberculomas.What would be the most useful next step in view of the differential diagnosis?CT chest and abdomenPerform a C-reactive proteinPerform a Mantoux testRefer to neurosurgeryTake a detailed family history QUESTION 3: As the patient remained stable on the ward, with no signs of focal neurology and no mass effects on MRI, a lumbar puncture was performed the following day to exclude tuberculosis (TB) (table 1). What cell appearance would indicate TB infection? QUESTION 4: A review of the mother's medical records and MRI scans revealed her to have multiple discrete cerebral cavernous malformations (CCMs) (figure 2).In view of this new information, what is the next step in investigating this child?" }, { "id": "pubmed23n0369_9389", "title": "Metastatic spread and common symptoms. Part six: Advanced cancer of the pancreas, prostate, stomach, and uterus.", "score": 0.00980392156862745, "content": "This is the last article in a six-part series on metastatic spread and natural history of the 18 most lethal tumors. The articles summarize symptom/problem anticipation, cancer metastasis, and the 18 tumors that each cause more than 6000 deaths/year in the United States. Bladder and brain cancer were discussed, with information given on tumor types, metastatic spread and invasion, and common symptoms. Parts II, III, IV, and V charted the natural histories, problems, and assessment parameters of advanced cancers of the breast, colon and rectum, esophagus, kidney, liver, and lung; and leukemia, melanoma, multiple myeloma, non-Hodgkin's lymphoma, and cancers of the oral cavity (and pharynx) and ovary. Part VI finishes the series with discussions of cancers of the pancreas, prostate, stomach, and uterus. Each of these cancers is presented separately, with information given on mortality rates, the most common tumor types, sites of metastases, common problems, and common oncology emergencies. Sites of spread, resulting problems (including site-specific symptoms), and assessment parameters are presented as tables. Material is presented so that clinicians are able to anticipate the spread of these cancers and can thus identify problems early in their development so that the problems are more easily managed." }, { "id": "pubmed23n0721_10860", "title": "Pancreatic metastasis arising from a BRAF(V600E)-positive papillary thyroid cancer: the role of endoscopic ultrasound-guided biopsy and response to sorafenib therapy.", "score": 0.009708737864077669, "content": "Lungs and bones are the most common sites for distant metastases from papillary thyroid cancer (PTC). Metastases to the pancreas are extremely rare. Here we present a man with pancreatic metastases from PTC, report our experience with sorafenib therapy, and discuss the role of endoscopic ultrasound (EUS)-guided biopsy in its diagnosis. A 56-year-old man underwent total thyroidectomy, right-modified neck dissection, and radioactive iodine (RAI) remnant ablation for PTC at age 47 years (in 2002). Between 2002 and 2007, he had three more neck surgeries, two RAI therapies, and external beam radiotherapy for persistent and subsequently metastatic PTC. In 2008, a computed tomography/positron emission tomography (CT/PET) scan showed an 18F-fluorodeoxyglucose (FDG)-avid pancreatic focus. Magnetic resonance imaging (MRI) revealed a pancreatic nodule at the same location. An EUS-guided biopsy confirmed the diagnosis of pancreatic metastasis from PTC, and molecular studies showed positive BRAF(V600E) mutation. He was treated with sorafenib for 6 months. Although a lung CT scan done 2 months after initiation of sorafenib suggested stability of the disease, MRI studies done at 3 and 6 months showed clear progression with an increase in the size of the lung and pancreatic metastases. Subsequently, he developed liver, bone, and omental metastases. He died in July 2011, 9 years and 8 months after the initial diagnosis of PTC and 20 months after discovery of the pancreatic metastasis. A middle-aged man with PTC developed lung metastases despite multiple surgeries and RAI therapies. Seven years after the initial diagnosis, a pancreatic metastasis was accidentally discovered. Both the metastasis and the primary thyroid tumor are positive for BRAF(V600E) mutation. The lung and pancreatic metastases progressed while the patient was receiving sorafenib for 6 months, and the patient died 20 months after diagnosis of pancreatic metastasis. PTC rarely metastasizes to the pancreas. In this patient, an FDG PET scan and EUS-guided biopsy played important roles in the diagnosis. PTC metastases to the pancreas usually occur in otherwise advanced disease. In the patient presented here, sorafenib may have slowed disease progression but the overall utility of tyrosine kinase inhibitors in pancreatic metastases from PTC is not clear." }, { "id": "pubmed23n0492_19209", "title": "Familial and personal history of cancer in bronchogenic carcinoma--frequency and clinical implications.", "score": 0.009708737864077669, "content": "A familial and personal history of cancer might be associated with a more aggressive cancerous disease. This study was carried out on 1277 consecutive lung cancer (LC) patients, seen from January 1989 to October 2002 in a single institution. A set of 31 clinical laboratory, radiological and pathological variables was recorded prospectively for all patients. In addition, both the number of first-degree blood-relatives with cancer (lung and non-lung cancers) and the personal history of previously cured cancers were noted. There were 368 patients (28.8% of the sample) who had one first-degree relative with cancer (112, 8.7% of the sample with LC), 100 (7.8%) had two first-degree relatives (six with LC) and 31 (2.4%) had three or more relatives affected (four with LC). In total, 1142 patients (89.4% of the sample) have never been treated for another cancer; the remaining 135 patients (10.6%) had already been diagnosed with a variety of tumours, including head and neck cancer (36 patients, 2.8%), bladder cancer (33 patients, 2.6%), colorectal cancer (24 patients, 1.9%), breast cancer (seven patients, 0.6%), melanoma (five patients, 0.4%), skin (five patients, 0.4%) and prostate cancer (five patients, 0.4%). Among the variables studied, none was found to be significantly associated with a personal and/or family history of cancer. Survival expectancy was similar among patients with or without a familial or personal history of cancer. A familial and a personal history of cancer are common features in LC, but are not of clinical significance." }, { "id": "Surgery_Schwartz_4581", "title": "Surgery_Schwartz", "score": 0.009623392245766632, "content": "carcinoids, and tumors <1 cm in diameter), as well as false-positive results (because of confusion with other infectious or inflammatory processes).Metastatic Lesions to the LungThe cause of a new pulmonary nodule(s) in a patient with a previous malignancy can be difficult to discern.29 Features sug-gestive of metastatic disease are multiplicity; smooth, round borders on CT scan; and temporal proximity to the original pri-mary lesion. One must always entertain the possibility that a single new lesion is a primary lung cancer. The probability of a new primary cancer vs. metastasis in patients presenting with solitary lesions depends on the type of initial neoplasm. The highest likelihood of a new primary lung cancer is in patients with a history of uterine (74%), bladder (89%), lung (92%), and head and neck (94%) carcinomas.Surgical resection of pulmonary metastases has a role in properly selected patients.30 The best data regarding outcomes of resection of pulmonary metastases come" }, { "id": "pubmed23n0735_3743", "title": "Cardiac metastasis of head and neck squamous cell carcinoma.", "score": 0.009615384615384616, "content": "Two patients with cardiac metastasis from head and neck cancer are reported. Cardiac metastasis located in the left atrium was detected on a follow-up computed tomography (CT) scan 15 months after partial glossectomy for a tongue carcinoma in a 60-year-old man. The diagnosis was confirmed as cardiac metastasis of squamous cell carcinoma (SCC) by surgical excision of the cardiac lesion. The patient died 3 weeks after surgery. In a 69-year-old man with a partial maxillectomy for primary soft palate cancer, a follow-up CT scan 5 months after surgery revealed a mass in the right atrium and ventricle, and multiple lung metastases. He died of heart failure 3 weeks after the diagnosis of cardiac metastasis. Information on these cases should add to knowledge about rarely encountered cardiac metastasis." }, { "id": "pubmed23n0515_21390", "title": "The value of postmortem examination in cases of metastasis of unknown origin-20-year retrospective data from a tertiary care center.", "score": 0.009615384615384616, "content": "Metastasis of unknown origin (MUO) is a diagnostic challenge in clinical practice even with the state of current advanced diagnostic technology. To evaluate the value of autopsy in determining the primary site of MUO, this study reviewed the Hamilton experience-over the last 20 years-with patients autopsied with clinical diagnosis of MUO. All autopsy diagnoses from cases performed at the Hamilton Health Sciences Center and St Joseph's Healthcare from 1980 to 2000 were reviewed. Fifty-three cases of MUO were identified (MUO was defined as a patient with pathological and/or radiological diagnosis of a metastatic tumor for which the primary site of malignancy was unknown). The clinical history and gross and microscopic diagnoses for these cases were reviewed. There were 31 men (58.5%) and 22 women (41.5%) in the study. Their mean age was 66 years. Pathological diagnoses at autopsy were adenocarcinoma (n = 37), small cell carcinoma (n = 6), anaplastic carcinoma (n = 3), and undifferentiated carcinoma (n = 3). Primary tumors were identified in 27 patients (51%), most commonly in the lung (n = 8), large bowel (n = 6), and pancreas (n = 4). Histochemical and immunohistochemical stains were helpful in reaching the diagnosis of a primary tumor in 4 of 27 cases. The following were observed: (1) in this series, autopsy was helpful in establishing the diagnosis of a primary tumor in 51% of the cases, reaffirming the value of postmortem examination in these instances; (2) adenocarcinoma was the most frequent tumor presenting as MUO; (3) the lung and the large bowel were the most frequent sites for primary tumors; and (4) careful gross and histological examinations remain the most important tools in identifying the primary site." }, { "id": "pubmed23n1040_24189", "title": "Desmoplastic Melanoma as a Diagnostic Pitfall.", "score": 0.009523809523809525, "content": "Dear Editor, Desmoplastic melanoma (DM) is a rare histological subtype of melanoma, usually presenting as a slowly-growing, amelanotic, discoid, and/or firm lesion composed of spindle cells with abundant collagen (1). It is more common on sun-exposed areas, especially on head and neck in elderly patients (2). Regional lymph node involvement is reported to be less frequent than in other cutaneous melanomas (3). Desmoplastic melanoma can clinically mimic a wide spectrum of benign and malignant lesions, including Bowen's disease, desmoplastic nevus, basal cell carcinoma, squamous cell carcinoma, lentigo maligna, dermatofibrosarcoma protuberans, peripheral nerve sheath tumors, cysts, or hypertrophic/keloid scars (4). Regarding its appearance, at the time of diagnosis DM frequently presents as advanced lesions with deep infiltration. A 60-year-old man presented with an one-year history of an asymptomatic, erythematous, well-defined plaque in the right lumbar region (Figure 1). Dermatological examination revealed a 5×5 cm, pink/red infiltrated plaque accompanied by a 6 mm dark-brown melanocytic lesion. Dermoscopically, atypical vascular structures in the form of linear, irregular, and dotted vessels, milky-red areas, and atypical pigment network, and streaks were observed near the melanocytic lesion (Figure 2). A 4 mm punch biopsy was performed on the erythematous plaque next to the melanocytic lesion, and a dermal-based, paucicellular proliferation of atypical spindle cells without melanin in a sclerotic stroma was found histologically (Figure 3, a). Immunohistochemically, dermal spindle cells were stained with S-100 and HMB45 antibodies (Figure 3, b). The patient was histologically diagnosed with melanoma, of the desmoplastic subtype. The lesion was totally excised with 2 cm clear margins. A diagnosis of nonulcerated nodular melanoma with a Breslow thickness of 4 mm and a mitotic index 1/mm2 was established. Sentinel lymph node biopsy revealed no metastases. No systemic metastases were detected in PET-CT scanning and cranial magnetic resonance imaging. The patient remained under follow-up and has been free of any local recurrence or primary or systemic metastasis for 3 years. Dermoscopic characteristics of DM are not well known, probably due to it not being considered a melanocytic lesion. Debarbieux et al. first reported the dermoscopic features of desmoplastic melanoma in six cases (5). They found that only half of the cases presented one classical feature of a melanocytic lesion, whereas the other cases were diagnosed based on the presence of figures of regression such as white scar-like and \"peppering\", multiple (&gt;4) color, and melanoma-related vascular patterns (five out of six) such as linear-irregular vessels and milky-red areas (5). In the largest DM case series, Jaime et al. reported that all DM featured at least 1 melanoma-specific structure, with atypical vascular structures being the most common (6). Similarly, in our patient dermoscopy showed an atypical pigment network and streaks, atypical vascular structures, and milky-red areas, which is predictive for melanoma. We reported this case to serve as a reminder to consider desmoplastic melanoma in the differential diagnosis of pink tumoral lesions despite its rarity and atypical localization." }, { "id": "pubmed23n0282_9930", "title": "[Prevalence, rate of correct clinical diagnosis and mortality of cancer in 4,894 elderly autopsy cases].", "score": 0.009523809523809525, "content": "The prevalence, rate of correct clinical diagnosis and mortality of cancer were analyzed in 4,894 consecutive autopsies at the Tokyo Metropolitan Geriatric Hospital from 1972 to 1990. average age and standard deviation of patients was 78.1 +/- 9.1 years. Cancer was found in 45.5% of patients of 60 years and over, and in 49.1% in men and 41.9% in women (p &lt; 0.001). Cancer prevalence decreased with advance in age; 50.0% in the sixties, 47.9% in the seventies, 43.2% in the eighties and 39.3% in the nineties and over. Multiple cancer was found in approximately 12% of patients of 70 years and over. The top three cancer incidences were gastric cancer, 15.0%, lung cancer, 10.7% and colon cancer, 5.9% in both genders. In men, prostate cancer was next common, followed in orderly hepatic cancer, esophageal cancer, gall bladder-bile duct cancer, pancreas cancer, renal cancer and urinary bladder cancer. In women, the following order of frequency was gall bladder-bile duct cancer, uterus cancer, pancreas cancer, hepatic cancer, breast cancer, thyroid cancer, esophageal cancer, renal cancer and urinary bladder cancer. The prevalence of gastric cancer, lung cancer, hepatic cancer and esophageal cancer was significantly higher in men, while that of gall bladder-bile duct cancer was higher in women. The age-related tendencies varied among cancers of different organs. Gastric cancer increased up to the sixties in men and up to the seventies in women and leveled off after those ages. Lung cancer revealed peak prevalence in the sixties and seventies and decreased after the age of eighty.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0884_24795", "title": "[A Case of Synchronous Multiple Metastases in which the Origin Could Not Be Identified by Routine Examination].", "score": 0.009433962264150943, "content": "A 67-year-old man presented at our hospital with severe edema on the left side of his neck, chest and brachial regions. He had a history of right radical nephrectomy due to renal cell carcinoma (RCC, clear cell subtype, stage II) 15 years earlier. Thereafter, metastases to the pancreatic tail and right lung, and left lung metastasis were removed at 8 years and 11 years, respectively, after the nephrectomy. Four years earlier, he had also undergone total gastrectomy for gastric carcinoma (poorly differentiated adenocarcinoma, stage IV) and subsequent maintenance chemotherapy for gastric carcinoma. Follow-up computed tomography (CT) disclosed bilateral lung metastases and a pancreatic head metastasis. Cytology of pleural effusion on admission suggested pleuritis carcinomatosa from RCC. Clinical diagnosis was bilateral lung and pancreatic head metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to RCC metastasis. Maintenance chemotherapy for gastric carcinoma was replaced by Sunitinib 50 mg for RCC but he died of progressive disease 20 days later. Immunohistochemical study of the tissue from autopsy revealed lung metastasis and pancreatic head metastasis from both RCC and gastric carcinoma as well as multiple visceral metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to gastric carcinoma. Cause of death was acute respiratory failure due to pulmonary tumor embolism and pulmonary edema. Immunohistochemical study from autopsy was able to reveal the exact diagnosis, and immunohistochemical studies may be helpful in diagnosing the exact origin of metastasis and selecting appropriate treatmentsin patientswith multiple cancers." }, { "id": "pubmed23n1109_2249", "title": "A case report of primary signet ring cell carcinoma of the lung: imaging study and literature review.", "score": 0.009433962264150943, "content": "Signet ring cell carcinoma (SRCC) is a subtype of adenocarcinoma with characteristics of strong invasion and a poor prognosis. While it can occur in various organs, including the stomach, colon, esophagus, bladder, prostate, pancreas, and breast, primary lung SRCC is rare, and most SRCC found there are from gastrointestinal metastasis. Reports on primary lung SRCC are few and the aim of this study is to describe the imaging, histopathological, and immunohistochemical characteristics of a case of primary lung SRCC in our hospital. A 68-year-old female with no smoking history was admitted with recurrent cough, chest pain, and dyspnea of 2 months duration. Computed tomographic (CT) chest showed multiple solids nodules of different sizes and mass in the left upper lobe, lower lobe, and subpleural region. Multiple enlarged lymph nodes were seen in the mediastinum and left hilum. The aim of this paper is to improve the understanding of this tumor. A literature review identified 15 cases of primary lung SRCC with available CT imaging. Except for two patients with multiple ground glass nodules and multiple small nodules, the rest were solid, and ranged in size from 1.0 to 8 cm. Only one patient had a cavity in the solid lesion. Immunohistochemical stains for thyroid transcription factor-1 (TTF-1) (13/13) and CK7 (12/12) showed positive reaction in all cases evaluated, and napsin A (3/4) were also positive, while all cases including CK20 (12/12) and CDX2 (6/6) were negative." }, { "id": "pubmed23n1054_3878", "title": "Multiple polypoid colonic metastases from rectal adenocarcinoma with signet ring cells features: a case report.", "score": 0.009345794392523364, "content": "Multiple polypoid colonic metastases are very rare which mainly originated from gastric carcinoma or melanoma. For rectal cancers, liver, lung and peritoneum are the most common metastatic sites. Here we present an unusual case with rectal adenocarcinoma and metachronous multiple colonic polypoid metastases. A 53-year-old man who underwent radical resection for rectal cancer 2 years ago was admitted to our department for an elevation of CEA level of 18.4 ng/ml. Colonoscopy revealed ten ivory rubbery colonic polypoid lesions (about 5 mm in diameters) in the large bowel which were confirmed as signet ring cell carcinomas (SRCC) by biopsy, but full-body contrast enhanced CT and PET-CT showed no other suspicious lesion. Seven weeks later, a laparoscopic total colectomy was performed and more than 50 polypoid lesions were observed throughout the mucosal surface of the large intestine which were confirmed as metastatic SRCC by postoperative pathological examination. All the 34 paracolic lymph nodes retrieved were involved. After 4 months, diffuse abdominopelvic and multiple bone metastases were identified by CT and the patient died of the disease 1 month later. Here we present an unusual case of multiple colonic polypoid metastases of rectal adenocarcinoma. For SRCC that is prone to have disseminated micrometastases, colonic 'polyps' may be the early noticeable sign of undetectable and extensive tumor spread. Instead of surgical resection of 'the confined disease in colon', systemic treatment maybe a more appropriate choice." }, { "id": "pubmed23n0280_5824", "title": "Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy.", "score": 0.009345794392523364, "content": "We carried out a prospective study of the effectiveness of a diagnostic strategy in forty consecutively seen patients who had skeletal metastases of unknown origin. The diagnostic strategy consisted of the recording of a medical history; physical examination; routine laboratory analysis; plain radiography of the involved bone and the chest; whole-body technetium-99m-phosphonate bone scintigraphy; and computed tomography of the chest, abdomen, and pelvis. After this evaluation, a biopsy of the most accessible osseous lesion was done. The laboratory values were non-specific in all patients. The history and physical examination revealed the occult primary site of the malignant tumor in three patients (8 per cent): one patient who had carcinoma of the breast; one, of the kidney; and one, of the bladder. Plain radiographs of the chest established the diagnosis of carcinoma of the lung in seventeen patients (43 per cent). Computed tomography of the chest identified an additional six primary carcinomas of the lung (15 per cent). Computed tomography of the abdomen and pelvis established the diagnosis in five patients (13 per cent): three patients who had carcinoma of the kidney; one, carcinoma of the liver; and one, carcinoma of the colon. Examination of the biopsy tissue established the diagnosis in only three additional patients (8 per cent) and confirmed it in eleven others. On the basis of the biopsy alone, we were unable to identify the primary site of the malignant tumor in twenty-six (65 per cent) of the patients. In thirty-four (85 per cent) of the forty patients, the primary site was identified with the use of the diagnostic strategy described here, and only two additional occult malignant tumors were found on follow-up studies. Our diagnostic strategy was simple and highly successful for the identification of the site of an occult malignant tumor before biopsy in patients who had skeletal metastases of unknown origin." }, { "id": "pubmed23n1162_13547", "title": "Assessment of Cost-Effectiveness of Computerized Cranial Tomography in Children with Mild Head Trauma.", "score": 0.009259259259259259, "content": "Pediatric head traumas constitute the majority of admissions to emergency departments (ED) due to trauma. This study aims to draw attention to the use of cranial computerized tomography (CT) scans in the evaluation of children with head trauma under the age of 18, and to determine CT scans' usefulness in terms of cost-effectiveness. Age, gender, mechanism of trauma and Glasgow Coma Scale (GCS), diagnosis, time of admission to hospital, hospitalization and operation, cranial computerized tomography and hospitalization costs of all cases were retrospectively analyzed. A total of 26,412 patients younger than 18 years old who were admitted to the emergency department due to head trauma and who had a cranial tomography were analyzed. They had a mean age of 7.74 ± 5.66 years. In total, 26,363 (99.8%) of these patients had a GCS greater than 14. Out of these patients, only 402 (1.5%) had brain injury revealed by cranial CT, 41 (0.2%) of these patients were operated and 3 of the patients lost their lives. The total cost of patients admitted to the emergency department with a head injury amounts to USD 583,317. Furthermore, 75.78% of this cost comes from negative cranial CTs. A cost analysis according to different age groups did not show a meaningful difference between 0-2 years and 3-5 years (<ip</i = 1.000), but there was a meaningful difference for all the other age groups. Our findings show that applying algorithms to predict traumatic brain injury in children with mild head injury rather than scanning all patients with cranial CT will enable more reliable and cost-effective patient care. Current practices should be reviewed to avoid unnecessary radiation exposure and expense in the ED. It is also necessary to inform and educate parents about the risk/benefit ratio of cranial CT scans." }, { "id": "pubmed23n0788_19256", "title": "Characteristics of lung cancer after a previous malignancy.", "score": 0.009259259259259259, "content": "In the era of improving overall survival rates of malignant diseases, the impact of a previous malignancy (PM) on treatment and outcome of lung cancer (LC) remains unclear. We reviewed all LC patients from our institution that were treated from 2004 to 2006 for the occurrence of LC with PM excluding patients with multiple primary LC. A total of 444 and 2698 LC patients with and without a history of a PM were identified (prevalence of 14.1%). PM were most often located in breast (15.5%), prostate (14.9%), bladder (9.0%) and kidney (8.8%). Compared to never smokers, patients with nicotine consumption had more often a cancer history of prostate, gastrointestinal, and the head-neck region. The median interval until diagnosis of LC was 72.2 months (range 0-537 months) with most LC diagnosed 5 years after PM diagnosis. With a similar distribution of histology, stage and localization compared to controls, NSCLC patients with PM and stage IV disease showed a favorable overall survival (p &lt; 0.0001). In contrast, SCLC patients had similar survival curves (n.s.). A considerable subgroup of LC patients has a history of PM that may indicate a favorable prognostic factor. However, these patients should be treated similar to other LC patients." }, { "id": "pubmed23n0551_9237", "title": "Sister Mary Joseph's nodule as a presenting sign of internal malignancy.", "score": 0.009174311926605505, "content": "CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I." }, { "id": "pubmed23n0008_7816", "title": "[Bronchopulmonary adenocarcinomas of apparently primary origin. A retrospective study of sixty-six patients (author's transl)].", "score": 0.009174311926605505, "content": "A retrospective study of sixty-six case-reports confirmed the traditional factors described in this histological type of cancer, particularly the age, a slight predominence of males, and the very poor prognosis. A selection was made of 42 cases in which extensive investigations had been carried out to search for a possible extrapulmonary primary adenocarcinoma, but only one case of renal cancer and one of thyroid cancer were demonstrated. Autopsy had revealed the presence of 3 prostatic lesions and their relation to the pulmonary affection is discussed. Thyroid cancer had been found in 2 cases, which emphasizes the value of scintigraphy for this organ, whereas the authors felt that other investigations were of no value in the absence of clinically oriented signs." }, { "id": "pubmed23n0974_14720", "title": "Inflammatory myofibroblastic tumor of urinary bladder with severe hematuria: A Case report and literature review.", "score": 0.00909090909090909, "content": "Inflammatory myofibroblastic tumor (IMT) is a rare intermediate soft tissue tumor. Rarely occurring in the urinary bladder, MTs is composed of myofibroblast differentiated spindle cells and accompanied by numerous inflammatory cells, plasma cells and/or Lymphocytes. A 28-year-old female, with history of 2 cesarean sections 8 years ago and 2 years ago, was admitted to the emergency department for a 7-day ongoing gross hematuria with clots. A cystoscopy showed a tumor near the bladder neck, computed tomography (CT) showed a mass and massive blood clots in the bladder. Finally, postoperative pathological examination confirmed a diagnosis of inflammatory myofibroblastic tumor of bladder. The patient was given rehydration and blood transfusion to improve the general condition. Then, emergency transurethral resection of the bladder tumor was performed. No metastases to lymph nodes and other organs were found, and no tumor progression was revealed during 3-months of follow-up. IMTs rarely occur in the urinary bladder. Due to the lack of specificity in clinical symptoms, it's difficult to arrive at a definite diagnosis before operation. Therefore, usually, the final diagnosis depends on histomorphological features and the immunohistochemical profile. Further case studies are required to study the biological behavior of this condition." }, { "id": "pubmed23n0809_2908", "title": "Prostate sarcoma: report of 2 cases and bibliographic review.", "score": 0.009009009009009009, "content": "To report two cases of prostate sarcoma and perform a review of the published literature. The first case is a 21 year old patient who presented acute urine retention and lung metastases on diagnosis. He was diagnosed by TURP of rhabdomyosarcoma of the prostate dying 1 month after surgery. The second case was a 33 years old male who presented to the emergency room with anal pain, urinary symptoms, hematochezia and loss of 20 kg over the past 3 months. Abdominal CT scan showed an 11 x 10 x 9 cm mass in the lower pelvis that infiltrated the bladder and rectum, being unable to define its origin. CA 19.9, CEA and PSA were normal. The suspected diagnosis was a prostate sarcoma infiltrating rectum and bladder. A pelvic exenteration was performed with a wet colostomy. The pathologic diagnosis was a high grade sarcoma not clearly identified of the prostate. He was treated with adriamycin as adjuvant chemotherapy, having local recurrence, nodal involvement and multiple pulmonary metastases after 3 months of follow up Prostate sarcomas are rare tumors. This makes difficult to know their natural history. Their rapid progression and systemic spread, despite multimodal treatment, gives a mean survival of 24 months. Main survival factors are grade, a complete resection of the tumor and a low local stage. There is a need to find new chemotherapy protocols to increase survival rates as it has been shown in extremities sarcomas." }, { "id": "pubmed23n0643_15499", "title": "Are patients with non-muscle-invasive bladder cancer a suitable population for a lung cancer screening trial?", "score": 0.009009009009009009, "content": "Prognosis (case series) Level of Evidence 4. To estimate the relative risk of developing a second primary neoplasm, in particular lung cancer, after having non-muscle-invasive bladder cancer (NMIBC). Patients were included in the study if they had developed NMIBC between 1995 and 2003. All clinical data were extracted from the medical records of our institution's database. The interval between neoplasms, smoking habits, histological subtypes and survival were also analysed. Patient follow-up was &gt;or=5 years. We found 231 patients with NMIBC, 39 of which had a second primary neoplasm: 10 lung cancer, one pancreas, one gastric, one pharynx, one liver, one parathyroid, one oesophageal, five basal cell carcinoma, three larynx, two colon, three rectal and 10 prostate. In patients with lung cancer, NMIBC was the first primary tumour. Overall, the median (range) interval between occurrence of NMIBC and lung cancer was 54.2 (8-168) months. For the relationship between the observed and expected cases of lung cancer, after normalizing our frequencies to the sex ratio and age of our group of patients, the risk of lung cancer was 10.27-fold higher in patients with NMIBC as compared with the general population of Catalonia (95% confidence interval 4.92-18.88). We consider that an annual examination for the detection and prevention of lung cancer must be included in clinical guides for patients with NMIBC. This proposal is reinforced by the finding that death in our group of patients with both tumours was always derived from lung cancer and not from bladder cancer." }, { "id": "pubmed23n1099_7052", "title": "A Rare Case of Thyroid Metastasis Secondary to Hidden Undiagnosed Lung Adenocarcinoma.", "score": 0.008928571428571428, "content": "The majority of thyroid lesions are primary in origin while secondary metastases to thyroid are considered a rare incidence. However, presentation of such cases with no signs of lung cancer can be extremely challenging to diagnose. Here, we present a 64-year-old man, an ex-smoker of 70 pack-years, who presented with a complaint of hoarseness of voice with associated dyspnea, choking episodes, weight loss, and hemoptysis. With no investigation abnormalities indicating lung adenocarcinoma, he was transferred to the Otolaryngology Department as being suspicious of thyroid cancer. A laryngoscopy demonstrated an immobile right vocal cord and pooling of secretions while a computed tomography (CT) scan showed a right thyroid lobe nodule, upper mediastinal lymphadenopathy, and pleural effusion. The patient underwent a total thyroidectomy. Biopsies from the lymph nodes and lung were obtained, and all demonstrated lung adenocarcinoma. Thus, a diagnosis of primary lung adenocarcinoma with thyroid and mediastinal lymph nodes metastases was established. Despite being a rare clinical presentation, thyroid metastasis should be considered and evaluated for a primary origin according to the associated clinical history and presentation." }, { "id": "pubmed23n0025_7236", "title": "[Adenocarcinomas of unknown origin. Study of 17 autopsies (author's transl)].", "score": 0.008928571428571428, "content": "This article reports on the autopsy results of 17 patients with adenocarcinomas from occult primary tumours: 10 are of bronchial origin, 3 of renal origin, 1 of hepatic origin, 1 of ovarian origin, and 1 of pancreatic or bronchial origin. In one case no primary tumour was found. Factors which can lead the clinicians toward further investigations are the location or nature of the first clinical signs (neurological and respiratory for bronchial cancers, subdiaphragmatic for primary abdominal tumours) and smoking habit (bronchial carcinoma in smokers)." }, { "id": "pubmed23n0979_5787", "title": "Stroke Mimic Caused by Acetazolamide.", "score": 0.008849557522123894, "content": "To describe a case of a stroke mimic caused by iatrogenic ataxia due to acetazolamide. An 86-year-old man with a history of gout and glaucoma, presented to the emergency department with progressive confusion, dizziness, disequilibrium and slurred speech, 3 days after he had started acetazolamide following ocular surgery. Physical examination showed he was hypertensive and had dysarthria; it was not possible to observe his gait due to pain in the right foot presumed to be due to a gout crisis. A stroke was thought to be the cause of these neurological deficits so a head CT scan was performed but did not show any alterations. During a stay in the stroke unit the neurological deficits remained unchanged and so, after review of the history, neurological side effects due to acetazolamide were suspected and the drug was suspended. A head MRI was performed to rule out stroke and the patient gradually improved. In the meanwhile, the patient was observed by an ophthalmologist and repeat surgery was proposed because of increased intraocular pressure. Neurological deficits with a normal head CT scan in the emergency department pose many difficulties and require extensive knowledge of brain vascular anatomy and the differential diagnoses for stroke. Not all focal neurological deficits are strokes.The need to diagnose stroke very quickly in order that effective treatment can be started can obscure the actual diagnosis so the differential diagnoses should always be carefully considered.Even though the sudden onset of focal neurological deficits suggests a stroke, a careful history should indicate the correct diagnosis." }, { "id": "pubmed23n0596_17239", "title": "Multiple and incidentally found cancers detected by 18F-FDG positron emission tomography/CT at one examination.", "score": 0.008849557522123894, "content": "During the initial 8 months period of 18F-FDG PET/CT examination in our institution eleven cases of double cancers were detected. Eight cases were simultaneous second cancers and 3 cases are consecutive cancers. All cases are clinical ones and were referred from both outside hospitals and our own hospital. 18F-FDG PET/CT examination were utilized either to determine the extent of tumor or to stage the cancer or to detect recurrent tumors during the follow-up period. During the 8-months period 964 cases were studied. Therefore, the detection rates of simultaneous and consecutive cancers are 0.83% and 0.31% respectively. All together the detection rate of double cancer was 1.14%. To gain the general conception of double cancers the authors reviewed the autopsy registry of Japanese Society of Pathology during the four years from 2000 through 2003, and tabulated the combination of primary and second cancers. Frequently found combination of cancers were cancers of the thyroid, lung, stomach, liver, biliary tract, colon, rectum, and prostate. 18F-FDG PET/CT examination seems to be very useful in the management of cancer patients in terms of whole patient care." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 587, 930 ] ], "word_ranges": [ [ 93, 140 ] ], "text": "In this particular case, since the patient was previously treated with propranolol, this indicates that the correct answer is 4, which includes the administration of glucagon, which is administered because patients taking beta-blockers can be resistant to treatment with adrenaline and develop refractory hypotension and prolonged bradycardia." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Adrenaline.", "2": "Adrenaline and dexchlorpheniramine.", "3": "Adrenaline, dexchlorpheniramine and methylprednisolone.", "4": "Adrenaline, dexchlorpheniramine and glucagon.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1114_22265", "title": "Successful treatment of severe adrenaline-resistant anaphylactic shock with glucagon in a patient taking a beta-blocker: a case report.", "score": 0.018000642880102863, "content": "The efficacy of glucagon for adrenaline-resistant anaphylactic shock in patients taking β-blockers is controversial. However, understanding the efficacy of glucagon is important because adrenaline-resistant anaphylactic shock is fatal. We present a case of severe adrenaline-resistant anaphylactic shock in a patient taking a β-blocker, and glucagon was effective in improving hemodynamics. An 88-year-old woman with severe aortic stenosis and taking a selective β-1 blocker underwent transcatheter aortic valve implantation under general anesthesia. Postoperatively, she received 100 mg sugammadex, but 2 min later developed severe hypotension and bronchospasm. Suspecting anaphylactic shock, we intervened by administering adrenaline, fluid loading, and an increased noradrenaline dose. Consequently, the bronchospasm improved, but her blood pressure only increased minimally. Therefore, we administered 1 mg glucagon intravenously, and the hypotension resolved immediately. Glucagon may improve hemodynamics in adrenaline-resistant anaphylactic shock patients taking β-blockers; however, its efficacy must be further evaluated in more cases." }, { "id": "pubmed23n1150_25196", "title": "An unusual presentation of anaphylaxis with severe hypertension: a case report.", "score": 0.017170228445099484, "content": "Low blood pressure and associated postural symptoms are well-recognized manifestations of anaphylaxis. Nonetheless, anaphylaxis can present with high blood pressure and is rarely reported in the literature. We report an unusual presentation of anaphylaxis with severe supine hypertension and orthostatic intolerance. A 43-year-old Asian female presented to the emergency department with generalized itching, hives, and postural dizziness after taking a slow-release diclofenac sodium 100 mg tablet. On admission, the patient was tachycardic with a supine blood pressure of 200/100 mmHg. She had urticaria and bilateral rhonchi. A clinical diagnosis of anaphylaxis was made. She was treated with intravenous hydrocortisone and chlorpheniramine, but intramuscular adrenaline was withheld owing to her high blood pressure. She was kept in the supine position, and her vital parameters were closely monitored. Although the respiratory and cutaneous symptoms improved with treatment, her blood pressure remained elevated. Forty minutes later, the postural dizziness recurred as she sat up on the bed and her blood pressure plummeted from 198/100 mmHg to 80/60 mmHg. She was put back in the supine position immediately, and the blood pressure was restored with three doses of intramuscular adrenaline and a fluid bolus. Her postural symptoms completely resolved after adrenaline, but her blood pressure remained elevated. Two weeks after the initial presentation, a diagnosis of essential hypertension was made, which probably had been undetected. In anaphylaxis, where the cardiovascular system is involved, a blood pressure reduction from baseline is expected in patients with preexisting hypertension. Despite cardiovascular involvement, our patients' blood pressure on presentation to the emergency department was much higher than her pretreatment ambulatory blood pressure, thus making this presentation unusual. Diagnosis and treatment of anaphylaxis can be delayed in patients presenting with high blood pressure. Postural symptoms should alert the clinician to cardiovascular involvement despite elevated supine blood pressure. Early treatment with adrenaline should be considered in these patients with extreme caution." }, { "id": "pubmed23n0868_3615", "title": "[Morphine-induced Anaphylaxis before Induction of Anesthesia].", "score": 0.016016016016016016, "content": "We describe a case of anaphylaxia that occurred in a 67-year-old man. He was planned to have an operation on mitral valve prolapse (MVP) for mitral regurgitation (MR). Morphine 5 mg was injected intramusculaly 45 min before operation. Since then, he felt itchy sensation around his inguinal region. After he came to the operating room, he felt itchy sensation all over the body. Initially, his vatal signs were stable. We started to give extracellular fluid including ulinastatin 300,000 U, methylprednisolone 2 g, and ranitidine 50 mg. A few minutes later, he had nettle rash all over the body and his blood pressure decreased to 40/20 mmHg, and the heart rate increased to 120 beats x min(-1). Soon after, he had pulseless electric activity (PEA). We started chest compression and tracheal intubation. We injected adrenaline 1 mg. After doing the continuous chest compression for 2 min, he revived. He had continuous medications including dopamine 5 μg x kg(-1) x min(-1), dobutamine 5 μg x kg(-1) x min(-1), noradrenaline 0.05 μg x kg(-1) x min(-1). We cancelled the operation, and he was transfered to the high care unit (HCU), where his blood pressure was 120/65 mmHg, and heart rate 120 beats x min(-1). After 24 hours, we extubated his trachea. In this case, morphine was considered to be the most likely cause for anaphylaxis." }, { "id": "pubmed23n1140_838", "title": "Hypertensive Anaphylaxis After Moderna COVID-19 Vaccination: A Case Report.", "score": 0.01574894331538417, "content": "Hypotension after exposure to an allergen is a well-known indicator of an anaphylactic reaction. However, hypertensive anaphylaxis often goes unrecognized. Increased blood pressure can present as an anaphylactic reaction, which is called hypertensive anaphylaxis. A 48-year-old woman complained of a tickle sensation in the throat and dyspnea 30 minutes after being administered the first dose of the Moderna coronavirus disease 2019 (COVID-19) vaccine. The patient had no history of hypertension, anxiety, or panic disorder. Forty-five minutes after the vaccination, stridor was noted, and the patient developed severe hypertension with a blood pressure of 197/153 mmHg. The patient also had tachycardia, cervical angioedema, and nausea, which occurred in a short period of time, indicating type I hypersensitivity reaction, that is, an anaphylactic reaction. The patient was diagnosed with Brighton classification Level 1 anaphylaxis caused by COVID-19 vaccination. For managing the patient, two intramuscular adrenaline injections, famotidine, chlorpheniramine, metoclopramide, and methylprednisolone were administered via intravenous infusion. After the administration of medications, all symptoms resolved, and the blood pressure was reduced. Other differential diagnoses for increased blood pressure after vaccination were excluded; therefore, we concluded that this phenomenon of increased blood pressure was hypertensive anaphylaxis. Not only hypotension but also the acute onset of increased blood pressure after vaccination may occur as a premonitory symptom of anaphylaxis. In hypertensive anaphylaxis, both anaphylaxis and increased blood pressure can be treated with intramuscular adrenaline injection. Clinicians should be aware of the occurrence of hypertensive anaphylaxis." }, { "id": "pubmed23n0682_20102", "title": "Allergic shock and death associated with protamine administration in a diabetic patient.", "score": 0.01571294559099437, "content": "Insulin is used to treat patients with both type 1 and type 2 diabetes mellitus. Allergic reactions to insulin might be triggered by insulin itself or inactive ingredients in the insulin formulation, including proteins such as protamine in neutral protamine Hagedorn (NPH) insulin. The use of highly purified animal insulin and human recombinant insulin has reduced the incidence of anaphylactic reactions to insulin from ~30% to &lt;1%. We report a case of fatal allergic shock after the administration of protamine in a patient with a history of allergy to fish and a protamine-containing insulin. A 72-year-old Chinese male patient (height, 175 cm; weight, 80 kg) with a history of diabetes and progressive limb weakness was diagnosed with spinal vascular malformations after admission to the Xuan Wu Hospital of Capital Medical University, Beijing, People's Republic of China. He underwent epidural spinal cord arteriovenous fistula embolization with a liquid embolic agent (ethylene vinyl alcohol copolymer) after spinal cord angiography. During the operation, heparin was infused every hour with 6250, 2500, 2500, and 1250 IU, respectively. The last dose of heparin was administered ~10 minutes before the operation was completed. This was followed by the administration of protamine to neutralize the remaining heparin in the patient's body. Blurry vision and dizziness 5 minutes after protamine administration were followed by pruritus and hives over his neck and face. Oxygen was administered and 10 mg of dexamethasone with 2 mg of epinephrine was injected. The patient's heart rate dropped, his blood pressure decreased, and his arterial oxygen saturation (SaO₂) declined progressively. About 10 minutes after the administration of protamine sulfate, the patient developed bradycardic arrest. Cardiopulmonary resuscitation efforts were undertaken and the patient was administered epinephrine 2 mg IV, atropine 0.5 mg IV, and subsequently, intravenous dopamine (50 mg/h). Ten minutes later, the patient's heart rate gradually increased, but blood pressure fluctuated, and SaO₂ ranged from 90% to 100%. Despite the initial response, the patient lost consciousness and heart rate declined progressively within 5 hours. Vasoactive agents including dopamine, norepinephrine, and adrenaline were administered. After all these measures proved ineffectual, the patient died. It was later determined that the patient had a history of allergic reactions to fish as well as to a premixed insulin that contained soluble human insulin 30% and low-protein intensive insulin zinc 70% (NPH). The Naranjo adverse drug reaction probability scale score for the association of protamine with the allergic reaction was 4, suggesting a possible relationship. This case report highlights a preventable fatal allergic reaction possibly associated with protamine administration in a patient with a history of allergy to a protamine-containing insulin." }, { "id": "pubmed23n0910_17574", "title": "Thyrotoxic and pheochromocytoma multisystem crisis: a case report.", "score": 0.012241689128481581, "content": "Thyrotoxic crisis and pheochromocytoma multisystem crisis are rare, life-threatening, emergency endocrine diseases with various clinical manifestations. Here we report a case of a patient who simultaneously developed thyrotoxic crisis and pheochromocytoma multisystem crisis and required intensive cardiovascular management. A 60-year-old Asian man experienced nausea and vomiting, and subsequently developed dyspnea and cold sweats while farming. His serum free thyroxine, free triiodothyronine, and thyrotropin receptor antibody levels were elevated at 2.9 ng/dL, 7.2 pg/dL, and 4.7 IU/L, respectively. Serum thyrotropin levels were suppressed at less than 0.01 μIU/mL. Thyroid echography demonstrated no thyroid swelling (23 × 43 mm). A whole body computed tomography was performed for systemic evaluation. This revealed exophthalmos and a mass of size 57 × 64 mm in the anterior pararenal space. Based on these findings, we made an initial diagnosis of thyrotoxic crisis secondary to exacerbation of Grave's hyperthyroidism. Treatment was begun with an iodine agent at a dose of 36 mg/day, thiamazole at a dose of 30 mg/day, and hydrocortisone at a dose of 300 mg daily for 3 consecutive days. To control tachycardia, continuous intravenously administered propranolol and diltiazem infusions were given. At the same time, small doses of doxazosin and carvedilol were used for both alpha and beta adrenergic blockade. On hospital day 5, his blood pressure and serum catecholamine concentrations (adrenalin 42,365 pg/mL, dopamine 6409 pg/mL, noradrenalin 72,212 pg/mL) were still high despite higher beta blocker and calcium channel blocker doses. These findings contributed to the diagnosis of pheochromocytoma multisystem crisis with simultaneous thyrotoxic crisis. We increased the doses of doxazosin and carvedilol, which stabilized his hemodynamic status. On hospital day 16, metaiodobenzylguanidine scintigraphy showed high accumulation in the right adrenal gland tumor. After retroperitoneal laparoscopic adrenalectomy on hospital day 33, his condition stabilized. He was discharged on hospital day 58. Since he required more intensive cardiovascular management for thyrotoxic crisis, beta blockade was increased under intensive care unit monitoring even though initial alpha blockade is recommended in pheochromocytoma. When these crises occur simultaneously, cardiovascular management can be very challenging." }, { "id": "article-17372_30", "title": "Allergy -- Treatment / Management", "score": 0.012163433537923929, "content": "Anaphylaxis treatment begins with triage and the removal from exposure, which can involve decontamination if topical agents are involved or clothing is contaminated. Removal of the patient's clothing and standard precautions by staff such as masks, gloves, and gown should take place. Hand washing by staff who may have used latex gloves or eaten peanuts may be necessary. ABC’s (airway, breathing, and circulation) of emergency care should have priority.  Patients should have oxygen and intravenous administration of fluids. The patient should receive epinephrine intramuscularly (IM) (1 to 1000 dilution {1 mg/1ml} 0.3cc) 0.3 to 0.5 mg which can be repeated every 5 to 15 minutes as needed. Most patients should respond to 1 to 3 doses if symptoms persist, progress or the patient becomes hypotensive IV epinephrine should be started at 0.1 mcg/kg/minute by infusion device and titrated to maintain perfusion of body organs. Patients on beta-blockers should be given glucagon 1 to 5 mg over 5 minutes. Antiemetics should be given to treat vomiting often associated with glucagon administration. Histamine type 2 receptor blockers such as famotidine 20 mg IV or ranitidine at  50 mg IV should be administered. The glucocorticoid, methylprednisolone 125 mg, should be given. [26]" }, { "id": "pubmed23n0298_22077", "title": "The incidence, aetiology and management of anaphylaxis presenting to an accident and emergency department.", "score": 0.00980392156862745, "content": "We retrospectively studied anaphylaxis in an A&amp;E department from computerized records. In 1993 (Study A), of 55,000 patients seen in casualty, nine had severe anaphylaxis (ANA) with loss of consciousness (LOC) or fainting (about 1: 6000). Fifteen had generalized allergic reactions (GR) without LOC or fainting, but including dyspnoea due to laryngeal oedema or asthma, angioedema and/or urticaria. Thus there were 24 (about 1:2300) generalized reactions involving hypotension and/or respiratory difficulty. A further case diagnosed as hyperventilation syndrome was probably a wasp sting GR. Six cases of urticaria and/or angioedema were also identified. Of the nine with ANA, a possible cause was identified in eight (3 stings; 2 drugs; 3 foods). There was delay in arrival in A&amp;E: hypotension was noted in three and had resolved spontaneously in six. Only 3/9 were related with adrenaline: i.v. hydrocortisone and chlorpheniramine was the mainstay of treatment. No investigation was recommended nor advice given on future management. Four patients were later referred to our allergy clinic by their GPs. In study B (aug-Oct 1994), nine cases of ANA were identified (1:1500), eight due to bee or wasp stings. The increased incidence was probably related to more detailed history-taking. Only three were treated with adrenaline. The use of adrenaline for future anaphylaxis was discussed with six patients, and five were referred to our allergy clinic. A reaction to the same allergen had occurred previously in 24%. Improved awareness of anaphylaxis and its management is necessary." }, { "id": "pubmed23n0119_16676", "title": "Systemic absorption of adrenaline after aerosol, eye-drop and subcutaneous administration to healthy volunteers.", "score": 0.009708737864077669, "content": "Adrenaline is the drug of choice for management of the anaphylactic reaction. The objective of this study was to compare systemic absorption of adrenaline after administration by different routes to healthy volunteers. Ten puffs (1.5 mg as adrenaline base) with 10-15 s intervals between them followed 2 h later by 20 puffs (3 mg) of adrenaline from a pressurized aerosol (Medihaler-Epi, 3M Riker, 14.0 mg/ml adrenaline acid tartrate) were sprayed into the cheek pouch or inhaled through the mouth or the nostrils. Adrenaline was also administered to the eyes by giving 2 drops (1 mg) of Isopto-Epinal (Alcon, 10 mg X ml-1). Finally, 0.5 ml (0.5 mg) of adrenaline was given subcutaneously in the upper arm of the same individuals. The systemic absorption was determined by measuring plasma adrenaline levels and effects on blood pressure, heart rate and finger tremor before and 5, 15, 30, 60, 90, and 120 min after adrenaline administration. Adrenaline given as eye-drops did not have any significant effect on these parameters. Subcutaneously administered adrenaline caused within 5 min a significant increase of plasma adrenaline level (from 1.0 +/- 0.2 to peak of 6.5 +/- 1.2 nM) which gradually decreased during 2 h. This mode of adrenaline administration increased the systolic blood pressure by a maximum of 11 +/- 3.5 mmHg, heart rate by 9 +/- 2.2 beats X min-1, tremor ratio by 4 +/- 0.6 and reduced the diastolic blood pressure by 18 +/- 4.7 mmHg. The cardiovascular effects were approximately maximum 15 min after administration and lasted almost 90 min.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "article-40870_22", "title": "Case Study: 60-Year-Old Female Presenting With Shortness of Breath -- Management -- Endocrine", "score": 0.009708737864077669, "content": "Considering the primary diagnosis of myxedema coma, early supplementation with thyroid hormone is essential. Healthcare providers followed the American Thyroid Association recommendations, which recommend giving combined T3 and T4 supplementation; however, T4 alone may also be used. T3 therapy is given as a bolus of 5 to 20 micrograms intravenously and continued at 2.5 to 10 micrograms every 8 hours. An intravenous loading dose of 300 to 600 micrograms of T4 is followed by a daily intravenous dose of 50 to 100 micrograms. Repeated monitoring of TSH and T4 should be performed every 1 to 2 days to evaluate the effect and to titrate the dose of medication. The goal is to improve mental function. Until coexistent adrenal insufficiency is ruled out using a random serum cortisol measurement, 50 to 100 mg every 8 hours of hydrocortisone should be administered. In this case, clinicians used hydrocortisone 100 mg IV every 8 hours. Dexamethasone 2 to 4 mg every 12 hours is an alternative therapy." }, { "id": "pubmed23n0477_9849", "title": "Endobronchial adrenaline: should it be reconsidered? Dose response and haemodynamic effect in dogs.", "score": 0.009615384615384616, "content": "Tracheal drug administration is a route for drug delivery during cardiopulmonary resuscitation when intravenous access is not immediately available. However, tracheal adrenaline (epinephrine) injection has been recently shown to be associated with detrimental decrease in blood pressure. This was attributed to exaggerated early beta2 mediated effects unopposed by alpha-adrenergic vasoconstriction. We hypothesized that endobronchial adrenaline administration is associated with better drug absorption, which may abolish the deleterious drop of blood pressure associated with tracheal drug administration. To determine haemodynamic variables after endobronchial adrenaline administration in a non-arrest canine model. Prospective, randomized, laboratory study. Adrenaline (0.02, 0.05, 0.1 mg/kg) diluted with normal saline was injected into the bronchial tree of five anaesthetized dogs. Injection of 10-ml saline served as control. Heart rate, blood pressure and arterial blood gases were monitored for 60 min after drug instillation. The protocol was repeated after 1 week. Adrenaline at a dose of 0.02 mg/kg produced only a minor initial decrease in diastolic (from 90 +/- 5 to 78 +/- 3 mmHg, P=0.05), and mean blood pressure (from 107 +/- 4 to 100 +/- 3 mmHg, P=0.05), in all dogs. This effect lasted less then 30 s following the drug administration. In contrast, higher adrenaline doses (0.05 and 0.1 mg/kg) produced an immediate increase in diastolic (from 90 +/- 5 to 120 +/- 7 mmHg; and from 90 +/- 5 to 170 +/- 6 mmHg, respectively), and mean blood pressure (from 107 +/- 4 to 155 +/- 10 mmHg; and from 107 +/- 4 to 219 +/- 6 mmHg, respectively). All adrenaline doses resulted in an immediate increase in systolic blood pressure and pulse. Endobronchial administration of saline (control) affected none of the haemodynamic variables. In a non-arrest model, endobronchial adrenaline administration, as opposed to the effect of tracheal adrenaline, produced only a minor decrease in diastolic and mean blood pressure. We suggest that endobronchial adrenaline administration should be investigated further in a CPR low-flow model when maintaining adequate diastolic pressure may be crucial for survival." }, { "id": "pubmed23n0124_10297", "title": "Adrenaline and stress-induced increases in blood pressure in rats.", "score": 0.009523809523809525, "content": "Stress was induced by immobilizing the hind limbs of rats for 12 days and housing the rats in individual cages. Control rats were housed in groups without immobilization. Blood pressure and heart rate were measured through an indwelling carotid cannula. After 10 and 12 days of immobilization and isolation, the stressed rats had significantly higher blood pressures (ca. 10 mmHg) and higher cardiac adrenaline levels (ca. 90%). After adrenal medullectomy cardiac adrenaline levels were markedly reduced in both stressed and control rats. Furthermore, the stressing procedure did not cause a rise in blood pressure in adrenal-medullectomized rats. Desipramine HCl (2 mg/kg per day), administered orally to block the neuronal uptake of adrenaline, prevented the elevation in blood pressures and cardiac adrenaline levels. Propranolol HCl (2.8 mg/kg per day), orally, also prevented the rise in blood pressure. The results are consistent with the hypothesis that activation of facilitatory prejunctional beta-adrenoceptors on sympathetic nerves by neuronally-released adrenaline may be responsible for the raised blood pressure." }, { "id": "pubmed23n0853_17890", "title": "Angiotensin Converting Enzyme Inhibitor-related Angioedema: A Case of an Unexpected Death.", "score": 0.009523809523809525, "content": "Angioedema is an asymmetric non-pitting oedema on face, lips, tongue and mucous membranes; any delay in diagnosis and treatment can be fatal. Treatment with lisinopril as an angiotensin converting enzyme (ACE) inhibitor, can be a reason of angioedema. Here we report a case who developed oral-facial edema four years after using lisinopril/hydrochlorothiazide. Laryngeal oedema is a main cause of death in angioedema. The treatment of choice in angioedema including fresh frozen plasma, C1 inhibitor concentrations and BRK-2 antagonists (bradykinin B2 receptor antagonists) were used. In this case; a 77 years old female patient suffering from hypertension was considered. This patient was suffering two days from swelling on her face and neck. Non- allergic angioedema was distinguished in five major forms; acquired (AAO), hereditary (HAE), renin-angiotensin-aldosterone system (RAAS) blocker-dependent, pseudoallergic angioedema (PAS) and an idiopathic angioedema (IAO). She was admitted to our clinic with the diagnosis of hereditary angioedema. Patient had skin edema and life threatening laryngeal edema. In emergency department treatment was started using intravenous methylprednisolone, diphenydramine as well as inhaled and subcutaneous epinephrine simultaneously. Despite the initial treatment, the patient died due to the insufficient respiration and cardiac arrest. The patient has no history of kidney disease. " }, { "id": "pubmed23n0873_9370", "title": "Current real-life use of vasopressors and inotropes in cardiogenic shock - adrenaline use is associated with excess organ injury and mortality.", "score": 0.009433962264150943, "content": "Vasopressors and inotropes remain a cornerstone in stabilization of the severely impaired hemodynamics and cardiac output in cardiogenic shock (CS). The aim of this study was to analyze current real-life use of these medications, and their impact on outcome and on changes in cardiac and renal biomarkers over time in CS. The multinational CardShock study prospectively enrolled 219 patients with CS. The use of vasopressors and inotropes was analyzed in relation to the primary outcome, i.e., 90-day mortality, with propensity score methods in 216 patients with follow-up data available. Changes in cardiac and renal biomarkers over time until 96 hours from baseline were analyzed with linear mixed modeling. Patients were 67 (SD 12) years old, 26 % were women, and 28 % had been resuscitated from cardiac arrest prior to inclusion. On average, systolic blood pressure was 78 (14) and mean arterial pressure 57 (11) mmHg at detection of shock. 90-day mortality was 41 %. Vasopressors and/or inotropes were administered to 94 % of patients and initiated principally within the first 24 hours. Noradrenaline and adrenaline were given to 75 % and 21 % of patients, and 30 % received several vasopressors. In multivariable logistic regression, only adrenaline (21 %) was independently associated with increased 90-day mortality (OR 5.2, 95 % CI 1.88, 14.7, p = 0.002). The result was independent of prior cardiac arrest (39 % of patients treated with adrenaline), and the association remained in propensity-score-adjusted analysis among vasopressor-treated patients (OR 3.0, 95 % CI 1.3, 7.2, p = 0.013); this was further confirmed by propensity-score-matched analysis. Adrenaline was also associated, independent of prior cardiac arrest, with marked worsening of cardiac and renal biomarkers during the first days. Dobutamine and levosimendan were the most commonly used inotropes (49 % and 24 %). There were no differences in mortality, whether noradrenaline was combined with dobutamine or levosimendan. Among vasopressors and inotropes, adrenaline was independently associated with 90-day mortality in CS. Moreover, adrenaline use was associated with marked worsening in cardiac and renal biomarkers. The combined use of noradrenaline with either dobutamine or levosimendan appeared prognostically similar." }, { "id": "pubmed23n0548_24338", "title": "Pharmacological prevention of serious anaphylactic reactions due to iodinated contrast media: systematic review.", "score": 0.009433962264150943, "content": "To review the efficacy of pharmacological prevention of serious reactions to iodinated contrast media. Systematic review. Systematic search (multiple databases, bibliographies, all languages, to October 2005) for randomised comparisons of pretreatment with placebo or no treatment (control) in patients receiving iodinated contrast media. Review methods Trial quality was assessed by all investigators. Information on trial design, population, interventions, and outcomes was abstracted by one investigator and cross checked by the others. Data were combined by using Peto odds ratios with 95% confidence intervals. Nine trials (1975-96, 10 011 adults) tested H1 antihistamines, corticosteroids, and an H1-H2 combination. No trial included exclusively patients with a history of allergic reactions. Many outcomes were not allergy related, and only a few were potentially life threatening. No reports on death, cardiopulmonary resuscitation, irreversible neurological deficit, or prolonged hospital stays were found. In two trials, 3/778 (0.4%) patients who received oral methylprednisolone 2x32 mg or intravenous prednisolone 250 mg had laryngeal oedema compared with 11/769 (1.4%) controls (odds ratio 0.31, 95% confidence interval 0.11 to 0.88). In two trials, 7/3093 (0.2%) patients who received oral methylprednisolone 2x32 mg had a composite outcome (including shock, bronchospasm, and laryngospasm) compared with 20/2178 (0.9%) controls (odds ratio 0.28, 0.13 to 0.60). In one trial, 1/196 (0.5%) patients who received intravenous clemastine 0.03 mg/kg and cimetidine 2-5 mg/kg had angio-oedema compared with 8/194 (4.1%) controls (odds ratio 0.20, 0.05 to 0.76). Life threatening anaphylactic reactions due to iodinated contrast media are rare. In unselected patients, the usefulness of premedication is doubtful, as a large number of patients need to receive premedication to prevent one potentially serious reaction. Data supporting the use of premedication in patients with a history of allergic reactions are lacking. Physicians who are dealing with these patients should not rely on the efficacy of premedication." }, { "id": "pubmed23n0729_15168", "title": "[Vasoplegic syndrome after cardiac surgery with cardiopulmonary bypass].", "score": 0.009345794392523364, "content": "A 71-year-old valvular patient with cardiac arrhythmia, low ejection fraction, administered angiotensin converting enzyme inhibitor underwent aortic and mitral valvular replacement. Starting during normothermic cardiopulmonary bypass (CPB), hypotension occurred, refractory to phenylephrine, noradrenaline, terlipressin, hydrocortisone and dexchlorpheniramine. After 3 hr of CPB biventricular hyperkinesia, severe hypotension and metabolic acidosis persisted despite volume loading, sodium bicarbonate, adrenaline infusion and intraaortic conterpulsation. Refractory asystole occurred 5 hr postoperatively. The responsability of sepsis and anaphylaxis were ruled out and post-CPB vasoplegic syndrome appeared to be involved. Moderate and severe vasoplegic syndromes are discussed with regards to risk factors, physiology and treatment, including prophylaxis with vasopressin and methylene blue." }, { "id": "pubmed23n1123_8234", "title": "Anaphylactic Shock as a Rare Side Effect of Intravenous Amiodarone.", "score": 0.009345794392523364, "content": "Amiodarone is a very commonly used antiarrhythmic agent. However, it has a wide variety of systemic side effects as well as many hypersensitivity and allergic reactions, ranging from angioedema to anaphylactic shock in patients who have iodine allergies. We present a rare and unique case of an 86-year-old female who developed anaphylactic shock from intravenous (IV) amiodarone. She had no reported allergies to iodine or iodinated contrast. She had a history of chronic persistent atrial fibrillation and was being maintained on oral amiodarone as an outpatient. She was admitted with shortness of breath and was found to have atrial fibrillation with rapid ventricular response. She was started on an IV amiodarone bolus. Immediately after a few milliliters of infusion, she complained of shortness of breath, with facial flushing and generalized blanching erythema, followed by severe hypotension and cardiopulmonary arrest. IV amiodarone infusion was suspected to be the culprit and was discontinued immediately. IV epinephrine 0.3 mg was administered, followed by the advanced cardiovascular life support (ACLS) protocol for cardiopulmonary arrest. She did not respond to the standard ACLS protocol and continued to remain in cardiopulmonary arrest. A spot diagnosis of anaphylactic reaction to IV amiodarone was made, and she was started on IV epinephrine infusion 0.1 µg/kg/minute, and immediate return of spontaneous circulation was achieved. She was started on IV methylprednisolone 125 mg, IV famotidine 20 mg, and IV diphenhydramine 25 mg. She was intubated and required mechanical ventilation. She was successfully extubated later and safely discharged, receiving oral metoprolol 25 mg for rate control and PO rivaroxaban 20 mg once daily. Anaphylactic shock from IV amiodarone administration is a potentially fatal complication observed in patients with prior reported allergies to iodine or iodinated contrast media. It has rarely been reported in the absence of prior allergy to iodine or iodinated contrast media. Prompt recognition by clinicians is prudent for early diagnosis and appropriate treatment." }, { "id": "pubmed23n0123_2348", "title": "An immediate generalized reaction to iopamidol.", "score": 0.009259259259259259, "content": "Intravascularly administered lower-osmolality contrast media cause fewer adverse effects than do higher-osmolality media. Immediate generalized reactions such as acute urticaria or bronchospasm have been documented occasionally in patients receiving lower-osmolality contrast media. To our knowledge, this is the first reported case of an immediate generalized reaction to a lower-osmolality contrast medium in which significant hypotension also occurred. During cardiac catheterization, in a patient who had never been exposed to a contrast medium, a 69-year old man developed chest tightness, periorbital and facial edema, slight uvular edema, and a decline in blood pressure from 150/71 to 97/67 mm Hg. Epinephrine hydrochloride, diphenhydramine hydrochloride, and hydrocortisone were administered. The lack of absolute safety of lower-osmolality contrast media emphasizes the need for clinical awareness and availability of emergency therapy when these agents are utilized." }, { "id": "pubmed23n0775_22188", "title": "Addition of glucagon to adrenaline improves hemodynamics in a porcine model of prolonged ventricular fibrillation.", "score": 0.009174311926605505, "content": "Cardiac arrest is a daunting medical emergency. The aim of the present study was to assess whether the combination of adrenaline and glucagon would improve initial resuscitation success, 48-hour survival, and neurologic outcome compared with adrenaline alone in a porcine model of ventricular fibrillation. Ventricular fibrillation was induced in 20 healthy Landrace/Large White piglets, which were subsequently left untreated for 8 minutes. The animals were randomized to receive adrenaline alone (n = 10, group C) and adrenaline plus glucagon (n = 10, group G). All animals were resuscitated according to the 2010 European Resuscitation Council guidelines. Hemodynamic variables were measured before arrest, during arrest and resuscitation, and during the first 60 minutes after return of spontaneous circulation. Survival and a neurologic alertness score were measured at 48 hours after return of spontaneous circulation. Return of spontaneous circulation was achieved in 8 animals (80%) from group C and 10 animals (100%) from group G (P = .198). A significant gradual increase in coronary perfusion pressure and diastolic aortic pressure over time, which started 1 minute after the onset of cardiopulmonary resuscitation, was observed. Three animals (30%) from group C and 9 animals (90%) from group G survived after 48 hours (P = .006), whereas neurologic examination was significantly better in the animals of group G (P &lt; .001). In this porcine model of prolonged ventricular fibrillation, the addition of glucagon to adrenaline improves hemodynamics during resuscitation and early postresuscitation period and may increase survival." }, { "id": "InternalMed_Harrison_32267", "title": "InternalMed_Harrison", "score": 0.009174311926605505, "content": "Therapy is directed at reversing the histamine effect with antihistamines, either H-1 or H-2. If bronchospasm is severe, an inhaled bronchodilator—or in rare, extremely severe circumstances, injected epinephrine—may be used. Glucocorticoids are of no proven benefit. Protracted nausea and vomiting, which may empty the stomach of toxin, may be controlled with a specific antiemetic, such as ondansetron or prochlorperazine. The persistent headache of scombroid poisoning may respond to cimetidine or a similar antihistamine if standard analgesics are not effective." }, { "id": "pubmed23n0566_11126", "title": "Interventions for pityriasis rosea.", "score": 0.00909090909090909, "content": "Pityriasis rosea is a scaly rash that mainly affects young adults. It can be very itchy but most people recover within 2 to 12 weeks. To assess the effects of interventions for pityriasis rosea. We searched the Cochrane Skin Group Specialised Register (December 2004), the Cochrane Central Register of Controlled Clinical Trials in The Cochrane Library (Issue 4, 2004), MEDLINE (1966 to January 2005), EMBASE (1976 to January 2005), LILACS (1982 to January 2005), BIOSIS Preview (1980 to June 2002), and ongoing trials databases. We scanned bibliographies of published studies, abstracts from dermatology conference proceedings, corresponded with trialists and contacted the pharmaceutical industry. Randomised controlled trials evaluating interventions for pityriasis rosea. Two authors independently assessed trial quality and extracted data. We contacted study authors to retrieve missing data. Three trials involving 148 people were included. One poor quality trial (23 people), compared intravenous glycyrrhizin and intravenous procaine. It found no significant difference between the two interventions for treating symptoms and rash. One fair quality trial (85 people), compared the oral antihistamine dexchlorpheniramine (4 mg), the oral steroid betamethasone (500 mcg), and a combination of betamethasone (250 mcg) and dexchlorpheniramine (2 mg). It found no significant difference in itch resolution at two weeks, as rated by the participants, between dexchlorpheniramine and betamethasone, and the combination of dexchlorpheniramine and betamethasone. However, both dexchlorpheniramine and betamethasone alone seem to be better at clearing rash than the combination of dexchlorpheniramine and betamethasone. These interventions were not compared with placebo. The small good quality trial (40 people) that compared oral erythromycin and placebo found that erythromycin was more effective than placebo in terms of rash improvement, as rated by the trialists, after two weeks (RR 13.00; 95% CI 1.91 to 88.64). It was also more effective in decreasing the itch score (difference of 3.95 points, 95% CI 3.37 to 4.53). No serious adverse effects were reported for the interventions. Two out of 17 people on oral erythromycin and 1 out of 17 on placebo reported minor gastrointestinal upset. We found inadequate evidence for efficacy for most treatments for pityriasis rosea. Oral erythromycin may be effective in treating the rash and decreasing the itch. However, this result should be treated with caution since it comes from only one small RCT. More research is necessary to evaluate the efficacy of erythromycin and other treatments." }, { "id": "pubmed23n0624_14752", "title": "Celecoxib-associated anaphylaxis.", "score": 0.00909090909090909, "content": "To report and discuss a case of anaphylaxis in a young, healthy white male taking celecoxib for intermittent lower back pain. A healthy 27-year-old man with a documented history of anaphylaxis to penicillins and macrolides presented to the emergency department (ED) in anaphylactic shock after ingesting a 200-mg capsule of celecoxib and a cup of orange juice. The patient had been taking celecoxib over the past 6 months, for 1-2 weeks at a time, for low back pain secondary to a pilonidal cyst and an L5/S1 bulging disc. The day of admission was the seventh day of the most recent course of twice-daily celecoxib. The patient initially self-treated the reaction with diphenhydramine and subcutaneous epinephrine that he had at home due to his history of drug- and bee sting-induced anaphylaxis; neither intervention improved his symptoms. He became profoundly diaphoretic and developed systemic swelling, shortness of breath, bradycardia, and hypotension. Emergency medical services transported the patient to the ED, where he was treated appropriately and the symptoms resolved. However, 4 hours later, at time of discharge from the ED, the symptoms recurred. He was admitted to the intensive care unit and monitored for 3 days. Supportive care, steroids, and histamine blockade provided resolution of the symptoms. Cardiac workup was initiated because of the recurrence and severity of bradycardia and hypotension; results of the workup were unremarkable. The patient was discharged in stable condition. This case demonstrates rare anaphylaxis to celecoxib in a patient who had previously taken the drug and who had documented tolerance to sulfonamide antibiotics. Despite this history, our patient developed type V immunoglobulin E-mediated anaphylaxis secondary to the sulfonamide component of celecoxib. This reaction was considered probable according to the Naranjo probability scale. A review of published case reports and related allergy literature for celecoxib allergenicity revealed that such reactions are rare. This is the first case report with great detail of a patient with anaphylaxis to celecoxib after having previously tolerated the medication. Celecoxib can produce an anaphylactic reaction in patients who have previously tolerated sulfonamide antibiotics and who have previously tolerated celecoxib. This case also reviews the potentially biphasic presentation of anaphylaxis. Clinicians need to be aware of this biphasic anaphylactic response to ensure optimal duration of evaluation." }, { "id": "pubmed23n0602_14213", "title": "Hypersensitivity to administered adrenaline in tetraplegia.", "score": 0.009009009009009009, "content": "Case report. To describe two clinical examples of denervation hypersensitivity, an enhanced response to catecholamines demonstrated experimentally in tetraplegic patients. USA. A 63-year-old man with chronic paralysis at C4 ASIA Impairment Scale (AIS) A with partial preservation to T6, and a history of coronary artery and pulmonary disease, developed bradycardia leading to cardiac arrest. He was treated with intravenous atropine 0.4 mg and adrenaline 1 mg. He regained consciousness and blood pressure within 30 s, but developed supraventricular tachycardia leading to ventricular fibrillation and death within minutes. The dose of adrenaline was routine for a cardiac arrest.A 60-year-old man with chronic paralysis at C6, AIS A, presented with fever to 106 degrees F and a renal stone. Thirty minutes after treatment with intravenous fluids, antibiotics, and 1 g aspirin orally, he became afebrile, then suddenly lost consciousness and palpable pulse. He recovered with equal rapidity after an intravenous injection of 0.1 mg adrenaline. The dose of adrenaline was a tenth the usual dose for cardiac arrest. Because of denervation hypersensitivity, effective treatment of a cardiac arrest in tetraplegic patients may require a reduced dose of adrenaline." }, { "id": "pubmed23n0543_16955", "title": "[A case of anaphylactic shock in an elderly man following protamine sulfate administration during emergent off-pump coronary artery bypass grafting].", "score": 0.009009009009009009, "content": "An 80-year-old diabetic man undergoing emergent off-pump coronary artery bypass grafting for acute myocardial infarction developed anaphylactic shock immediately following administering a small dose of protamine sulfate. Preoperative examination revealed atrial fibrillation, severe three-vessel coronary artery disease and impaired left ventricular function with ejection fraction of 40% and severe septal as well as apical hypokinesis and akinesis. After successful completion of coronary bypass grafting, a total of 40 mg of protamine sulfate was given through the central venous line. Three minutes after protamine administration, profound hypotension occurred. Pulmonary artery pressure was low and the left ventricle was almost empty by transesophageal echocardiography. Hypotension was refractory to rapid administration of 2 l of crystalloid and albumin, and repeated administrations of phenylephrine. Blood pressure finally returned towards baseline after infusion of norepinephrine 0.2 microg x kg(-1) x min(-1) and epinephrine 0.1 microg x kg(-1) x min(-1). Hemoconcentration and impaired oxygenation were also noted. The situation suggested anaphylactic shock due to protamine. He had diabetes mellitus for 20 years and been treated by protamine containing insulin. Postoperative interview revealed that the patient had experienced urticaria over the abdominal area with neutral protamine hagedorn (NPH) insulin administration. This history suggested that the patient had been sensitized by protamine before surgery. Although it is rare to experience anaphylactic shock due to protamine, it is important to elicit the detailed allergic history to insulin in diabetic patients. Because anaphylactic shock still carries high mortality even in a patient without cardiac disease, we were lucky to save this elderly patient with acute myocardial infarction and compromised left ventricular function." }, { "id": "pubmed23n1038_18042", "title": "Efficacy of Intravenous, Endotracheal, or Nasal Adrenaline Administration During Resuscitation of Near-Term Asphyxiated Lambs.", "score": 0.008928571428571428, "content": "<bObjectives:</b Neonatal resuscitation guidelines recommend administering intravenous (IV) adrenaline if bradycardia persists despite adequate ventilation and chest compressions (CC). Rapid IV access is challenging, but little evidence exists for other routes of administration. We compared IV, endotracheal (ET), and intranasal routes for adrenaline administration during resuscitation of asphyxiated newborn lambs. <bStudy design:</b Near-term lambs (<in</i = 22) were delivered by caesarean section. Severe asphyxia was induced by clamping the umbilical cord while delaying ET ventilation until blood flow in the carotid artery ceased. Following a 30 s sustained inflation and ventilation for 30 s, we commenced uncoordinated CC at 90/min. We randomized four groups receiving repeated treatment doses (Tds) every 3rd min of (i) IV-Adrenaline (50 μg), (ii) ET-Adrenaline (500 μg), (iii) Nasal-Adrenaline via an atomizer (500 μg), and (iv) IV-saline. If return of spontaneous circulation (ROSC) was not achieved after three Tds by the assigned route, up to two rescue doses (Rds) of IV adrenaline were administered. Main outcome measures were achievement of ROSC and time from start of CC to ROSC, defined as heart rate &gt;100/min, and mean carotid arterial pressure &gt;30 mmHg. <bResults:</b In the IV-Adrenaline group, 5/6 lambs achieved ROSC after the first Td, whereas 1 lamb required two Tds before achieving ROSC. In the ET-Adrenaline group, 1/5 lambs required one Td, 1 lamb required three Tds, 2 lambs required 2 Rds, and 1 did not achieve ROSC. In the Nasal-Adrenaline group, 1/6 lambs required one Td, 2 required two Tds, whereas 3 lambs required either one (2 lambs) or two (1 lamb) Rds of adrenaline to achieve ROSC. In the IV-saline group, no lambs achieved ROSC until adrenaline Rds; 4/5 lambs required one Rd and 1 lamb required two Rds. Time to ROSC was shorter using IV-Adrenaline (2.4 ± 0.4 min) compared with ET-Adrenaline (10.3 ± 2.4 min), Nasal-Adrenaline (9.2 ± 2.2 min), and IV-saline (11.2 ± 1.2 min). <bConclusion:</b IV adrenaline had superior efficacy compared with nasal or ET administration. Nasal administration had a similar effect as ET administration and is an easier route for early application. Nasal high-dose adrenaline administration for neonatal resuscitation merits further investigation." }, { "id": "pubmed23n0088_7585", "title": "Drug-induced hypoglycemia. A review of 1418 cases.", "score": 0.008928571428571428, "content": "The present review catalogues 1418 reported cases of drug-induced hypoglycemia. The main findings are that sulfonylureas (especially chlorpropamide and glyburide), either alone or with a second hypoglycemic or potentiating agent, still account for 63% of all cases; that alcohol, propranolol, and salicylate, either singly or with another hypoglycemic drug, are the next most frequent offenders (19% of the total); and that one older drug (quinine) and three new ones (pentamidine, ritodrine, and disopyramide) have caused an additional 7% of all episodes of severe hypoglycemia. The clinical factors that set the stage for drug-induced hypoglycemia are still restricted food intake, age, hepatic disease, and renal disease, both individually and even more so in combination. Drug-induced hypoglycemia continues to be so common that virtually every unconscious patient should be considered hypoglycemic until immediate estimation of the blood sugar level rules it in or out. If ruled in, the clinician should promptly start 10% intravenous glucose and plan to maintain it uninterruptedly for 1 or more days, with added glucagon, hydrocortisone, and diazoxide administration if necessary, until sustained hyperglycemia guarantees that all drug effects have worn off." }, { "id": "pubmed23n0253_21666", "title": "Haemodynamic effects of tracheally administered adrenaline in anaesthetised patients.", "score": 0.008849557522123894, "content": "Ten patients undergoing arterial surgery in the leg received a combined general anaesthetic, which included muscle relaxation and intubation of the trachea, and a regional anaesthetic using a lumbar extradural catheter. The radial arterial pressure was measured. Adrenaline 0.1 micrograms.kg-1 was administered intravenously and the heart rate, arterial pressure and oxygen saturation were recorded every 15 s for 10 min. Adrenaline in 5 ml of saline was given into the trachea at 10 min intervals. The first was saline only, and successive injections contained 0.5 micrograms.kg-1, 1 microgram.kg-1, 2 micrograms.kg-1, and 3 micrograms.kg-1 of adrenaline. The mean maximum rise in systolic arterial pressure after adrenaline given intravenously was 30 (SD 11) mmHg, and 15 (SD 16) mmHg after the maximum dose of adrenaline given into the trachea (p &lt; 0.05). The mean systolic arterial pressure was significantly increased between 45 s and 4.5 min after the adrenaline given intravenously, and 2 min after adrenaline given into the trachea. Of seven patients who received adrenaline 3 micrograms.kg-1 into the trachea, six had no noticeable effect and in the other patient, the increase in arterial pressure was less than 90% of the maximum rise after the adrenaline. We conclude that adrenaline given into the trachea is unreliable in humans with very large doses necessary in some patients to produce a clinically useful haemodynamic effect." }, { "id": "pubmed23n0261_11702", "title": "[A fatal case of hereditary angioedema].", "score": 0.008849557522123894, "content": "A 27 year old woman suffered from recurrent attacks of laryngeal oedema due to C1-inhibitor deficiency, and was treated with danazol and tranexamic acid. The trachea was intubated with great difficulty, twice on one occasion. Two and a half years later she was admitted to the Intensive Care Unit with dyspnoea and dysphagia. Tranexamic acid, corticosteroids, adrenaline (also inhalated), were administered intravenously, but dyspnoea progressed. During preparation for tracheostomy the patient suffered from sudden airway collapse. Attempts to ventilate by mask, puncture of the cricothyroid membrane and intubation were unsuccessful. A small tube was eventually inserted into the trachea after four minutes. The patient was then severely cyanotic with a pulse of thirty, and had dilated pupils. The next morning convulsions ensued and a CT scan showed cerebral oedema. In spite of treatment with pentothal, mannitol and hyperventilation she died. The authors advocate the use of intravenous infusion of C1-inhibitor concentrate, since traditional treatment is inadequate. Persons with hereditary angio-oedema should have a personal supply of C1-inhibitor at hand." }, { "id": "pubmed23n0773_23157", "title": "Experimental cardiac arrest treatment with adrenaline, vasopressin, or placebo.", "score": 0.008771929824561403, "content": "The effect of vasoconstrictors in prolonged cardiopulmonary resuscitation (CPR) has not been fully clarified. To evaluate adrenaline and vasopressin pressure effect, and observe the return of spontaneous circulation (ROSC). A prospective, randomized, blinded, and placebo-controlled study. After seven minutes of untreated ventricular fibrillation, pigs received two minutes cycles of CPR. Defibrillation was attempted (4 J/kg) once at 9 minutes, and after every cycle if a shockable rhythm was present, after what CPR was immediately resumed. At 9 minutes and every five minutes intervals, 0.02 mg/kg (n = 12 pigs) adrenaline, or 0.4 U/kg (n = 12) vasopressin, or 0.2 mL/kg (n = 8) 0.9% saline solution was administered. CPR continued for 30 minutes or until the ROSC. Coronary perfusion pressure increased to about 20 mmHg in the three groups. Following vasoconstrictors doses, pressure level reached 35 mmHg versus 15 mmHg with placebo (p &lt; 0.001). Vasopressin effect remained at 15-20 mmHg after three doses versus zero with adrenaline or placebo. ROSC rate differed (p = 0.031) among adrenaline (10/12), vasopressin (6/12), and placebo (2/8). Time-to-ROSC did not differ (16 minutes), nor the number of doses previously received (one or two). There was no difference between vasoconstrictors, but against placebo, only adrenaline significantly increased the ROSC rate (p = 0.019). The vasoconstrictors initial pressure effect was equivalent and vasopressin maintained a late effect at prolonged resuscitation. Nevertheless, when compared with placebo, only adrenaline significantly increased the ROSC rate." }, { "id": "article-17372_31", "title": "Allergy -- Treatment / Management", "score": 0.008771929824561403, "content": "Weight-base dosing is recommended for pediatric patient populations. IM epinephrine is dosed at 0.01mg/kg and injected in the outer thigh. The maximum dose for children over 50 kg is 0.5 mg; this is done every 5 to 15 minutes for up to three doses if needed until obtaining an adequate response. After three doses, IV administration should begin 0.1 to 1 mcg/kg/minute titrated to effect. IV fluids should be 10 to 20 ml/kg infusion for hypotension and fluid replacement. H1 histamine blockers should be dosed at 1 mg/kg for diphenhydramine up to a maximum of 40 mg. H2 histamine blockers ranitidine is 1 mg/kg up to 50 mg and famotidine at 0.25 mg /kg iv not to exceed 40mg/day for patients 1 to 16 years of age. (If labs show renal dysfunction, consultation with the pharmacy is recommended for dosing based on creatinine clearance in both pediatrics and adults). Glucocorticoid administration methylprednisolone is 1 mg/kg up to a max of 125 mg. [1] [26]" }, { "id": "pubmed23n0815_16668", "title": "Hemodynamic changes by drug interaction of adrenaline with chlorpromazine.", "score": 0.008695652173913044, "content": "Adrenaline (epinephrine) is included in dental local anesthesia for the purpose of vasoconstriction. In Japan, adrenaline is contraindicated for use in patients receiving antipsychotic therapy, because the combination of adrenaline and an antipsychotic is considered to cause severe hypotension; however, there is insufficient evidence supporting this claim. The purpose of the present study was to clarify the changes in hemodynamics caused by drug interaction between adrenaline and an antipsychotic and to evaluate the safety of the combined use of adrenaline and an antipsychotic in an animal study. Male Sprague-Dawley rats were anesthetized with sodium pentobarbital. A catheter was inserted into the femoral artery to measure blood pressure and pulse rate. Rats were pretreated by intraperitoneal injection of chlorpromazine or chlorpromazine and propranolol, and after 20 minutes, saline or 1 of 3 different doses of adrenaline was administered by intraperitoneal injection. Changes in the ratio of mean arterial blood pressure and pulse rate were measured after the injection of adrenaline. Significant hypotension and tachycardia were observed after the injection of adrenaline in the chlorpromazine-pretreated rats. These effects were in a dose-dependent manner, and 100 μg/kg adrenaline induced significant hemodynamic changes. Furthermore, in the chlorpromazine and propranolol-pretreated rats, modest hypertension was induced by adrenaline, but hypotension and tachycardia were not significantly shown. Hypotension was caused by a drug interaction between adrenaline and chlorpromazine through the activation of the β-adrenergic receptor and showed a dose-dependent effect. Low-dose adrenaline similar to what might be used in human dental treatment did not result in a significant homodynamic change." }, { "id": "pubmed23n0544_14083", "title": "Case report: acute unintentional carbachol intoxication.", "score": 0.008620689655172414, "content": "Intoxications with carbachol, a muscarinic cholinergic receptor agonist are rare. We report an interesting case investigating a (near) fatal poisoning. The son of an 84-year-old male discovered a newspaper report stating clinical success with plant extracts in Alzheimer's disease. The mode of action was said to be comparable to that of the synthetic compound 'carbamylcholin'; that is, carbachol. He bought 25 g of carbachol as pure substance in a pharmacy, and the father was administered 400 to 500 mg. Carbachol concentrations in serum and urine on day 1 and 2 of hospital admission were analysed by HPLC-mass spectrometry. Minutes after oral administration, the patient developed nausea, sweating and hypotension, and finally collapsed. Bradycardia, cholinergic symptoms and asystole occurred. Initial cardiopulmonary resuscitation and immediate treatment with adrenaline (epinephrine), atropine and furosemide was successful. On hospital admission, blood pressure of the intubated, bradyarrhythmic patient was 100/65 mmHg. Further signs were hyperhidrosis, hypersalivation, bronchorrhoea, and severe miosis; the electrocardiographic finding was atrio-ventricular dissociation. High doses of atropine (up to 50 mg per 24 hours), adrenaline and dopamine were necessary. The patient was extubated 1 week later. However, increased dyspnoea and bronchospasm necessitated reintubation. Respiratory insufficiency was further worsened by Proteus mirabilis infection and severe bronchoconstriction. One week later, the patient was again extubated and 3 days later was transferred to a peripheral ward. On the next day he died, probably as a result of heart failure. Serum samples from the first and second days contained 3.6 and 1.9 mg/l carbachol, respectively. The corresponding urine concentrations amounted to 374 and 554 mg/l. This case started with a media report in a popular newspaper, initiated by published, peer-reviewed research on herbals, and involved human failure in a case history, medical examination and clinical treatment. For the first time, an analytical method for the determination of carbachol in plasma and urine has been developed. The analysed carbachol concentration exceeded the supposed serum level resulting from a therapeutic dose by a factor of 130 to 260. Especially in old patients, intensivists should consider intoxications (with cholinergics) as a cause of acute cardiovascular failure." } ] } } }

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{ "1": "A probable cause is an arterioarterial embolism due to detachment of a carotid plaque.", "2": "Doppler ultrasound of supra-aortic trunks is not very useful for diagnosis.", "3": "A cranial CT scan is necessary to assess the impact on the brain parenchyma.", "4": "Surgical treatment is indicated if imaging tests reveal carotid stenosis >70%.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en023_84320", "title": "Stroke", "score": 0.014040163376446563, "content": "When a stroke has been diagnosed, various other studies may be performed to determine the underlying cause. With the current treatment and diagnosis options available, it is of particular importance to determine whether there is a peripheral source of emboli. Test selection may vary since the cause of stroke varies with age, comorbidity and the clinical presentation. The following are commonly used techniques: an ultrasound/doppler study of the carotid arteries (to detect carotid stenosis) or dissection of the precerebral arteries; an electrocardiogram (ECG) and echocardiogram (to identify arrhythmias and resultant clots in the heart which may spread to the brain vessels through the bloodstream); a Holter monitor study to identify intermittent abnormal heart rhythms; an angiogram of the cerebral vasculature (if a bleed is thought to have originated from an aneurysm or arteriovenous malformation);" }, { "id": "wiki20220301en301_1862", "title": "Carotid ultrasonography", "score": 0.013071895424836603, "content": "Doppler ultrasound allows for assessment of carotid arterial blood flow. Blood flow velocity is increased in areas of stenosis compared to normal. Therefore doppler imaging substantially aids in the diagnosis of carotid artery stenosis by ultrasound. Internal carotid artery (ICA) is located posterolateral, and larger when compared to the external carotid artery (ECA). ICA has low resistive pattern (difference between the blood velocities during heart systole and diastole) when compared to ECA. Besides, ECA can be differentiated from the ICA by tapping superficial temporal artery of the same side. This will generate a saw-like appearance on ECA doppler. Temporary reversal of the direction of flow during early diastole in ECA is normal. ICA peak systolic velocity more than 125m/sec and diastolic velocity more than 40 m/sec signifies stenosis. Vertebral artery also has low resistive pattern similar to ICA." }, { "id": "wiki20220301en243_24587", "title": "Syncope (medicine)", "score": 0.012483530961791832, "content": "Imaging Echocardiography and ischemia testing may be recommended for cases where initial evaluation and ECG testing is nondiagnostic. For people with uncomplicated syncope (without seizures and a normal neurological exam) computed tomography or MRI is not generally needed. Likewise, using carotid ultrasonography on the premise of identifying carotid artery disease as a cause of syncope also is not indicated. Although sometimes investigated as a cause of syncope, carotid artery problems are unlikely to cause that condition. Additionally an electroencephalogram (EEG) is generally not recommended. A bedside ultrasound may be performed to rule out abdominal aortic aneurysm in people with concerning history or presentation." }, { "id": "wiki20220301en001_181803", "title": "Transient ischemic attack", "score": 0.011907810499359794, "content": "Surgery If the TIA affects an area that is supplied by the carotid arteries, a carotid ultrasound scan may demonstrate stenosis, or narrowing, of the carotid artery. For people with extra-cranial carotid stenosis, if 70-99% of the carotid artery is clogged, carotid endarterectomy can decrease the five-year risk of ischemic stroke by approximately half. For those with extra-cranial stenosis between 50-69%, carotid endarterectomy decreases the 5-year risk of ischemic stroke by about 16%. For those with extra-cranial stenosis less than 50%, carotid endarterectomy does not reduce stroke risk and may, in some cases, increase it. The effectiveness of carotid endarterectomy or carotid artery stenting in reducing stroke risk in people with intra-cranial carotid artery stenosis is currently unknown." }, { "id": "wiki20220301en001_181791", "title": "Transient ischemic attack", "score": 0.011563724678478778, "content": "Vessels in the head and neck may also be evaluated to look for atherosclerotic lesions that may benefit from interventions, such as carotid endarterectomy. The vasculature can be evaluated through the following imaging modalities: magnetic resonance angiography (MRA), CT angiography (CTA), and carotid ultrasonography/transcranial doppler ultrasonography. Carotid ultrasonography is often used to screen for carotid artery stenosis, as it is more readily available, is noninvasive, and does not expose the person being evaluated to radiation. However, all of the above imaging methods have variable sensitivities and specificities, making it important to supplement one of the imaging methods with another to help confirm the diagnosis (for example: screen for the disease with ultrasonography, and confirm with CTA). Confirming a diagnosis of carotid artery stenosis is important because the treatment for this condition, carotid endarterectomy, can pose significant risk to the patient, including" }, { "id": "wiki20220301en067_28793", "title": "Carotid artery stenosis", "score": 0.011534261534261535, "content": "The common carotid artery is the large vertical artery in red. The blood supply to the carotid artery starts at the arch of the aorta (bottom). The carotid artery divides into the internal carotid artery and the external carotid artery. The internal carotid artery supplies the brain. Plaque often builds up at that division and causes a narrowing (stenosis). Pieces of plaque can break off and block the small arteries above in the brain, which causes a stroke. Plaque can also build up at the origin of the carotid artery at the aorta. Diagnosis Carotid artery stenosis is usually diagnosed by color flow duplex ultrasound scan of the carotid arteries in the neck. This involves no radiation, no needles and no contrast agents that may cause allergic reactions. This test has good sensitivity and specificity." }, { "id": "pubmed23n0573_5922", "title": "[Diagnosis of brain death by multislice CT scan: angioCT scan and brain perfusion].", "score": 0.010133156809328615, "content": "BD was diagnosed by clinical examination, electroencephalogram (EEG), Transcranial Doppler (TCD) and multislice CT of 64 detectors. Initially, a brain perfusion study was performed. This was followed by supra-aortic trunk and brain artery angiography with acquisition of images using 0.5 mm slices, from the origin of the aortic root to the vertex. In all the patients, BD diagnosis was verified by clinical examination, EEG and TCD. Brain perfusion never detected brain blood flow. The angioCT through internal carotid arteries and vertebral arteries demonstrated complete absence of intracranial circulation, observing circulation of the external carotid artery branches. Sensitivity and specificity of the method compared with clinical examination was 100%. These findings demonstrate that the study of brain perfusion and brain angiography by multislice CT scan is a rapid and minimally invasive technique, that is easily available and that shows the absence of brain blood flow through the four vascular trunks. This technique makes it possible to made the diagnosis of BD with high diagnostic safety. Its use has special interest in patients with clinical diagnostic difficulty due to treatment with sedative drugs and serious metabolic alterations." }, { "id": "pubmed23n0418_10641", "title": "[Transient paraparesis as a manifestation of left carotid stenosis].", "score": 0.009900990099009901, "content": "Paraparesis caused by a cerebrovascular disorder is infrequent, although it is seen in infraction of both anterior cerebral arteries (ACA), in vertebrobasilar insufficiency syndromes or in infarction of the border zones of the anterior circulation. Male aged 52 years, right handed, with a history of high blood pressure, who visited because of two episodes of transient paraparesis that lasted 5 minutes and 15 hours. During the last episode the presence of paraparesis and left Babinski sign were observed. Complementary explorations conducted to test for medullar pathology were negative. Cranial MRI showed only bilateral lacunar infarctions in deep territories. Four months later, the patient presented an episode of motor aphasia and paresthesia of the right lower limb, which remitted spontaneously in 10 minutes. Echo Doppler exploration of the supra aortic trunks showed significant stenosis of the left internal carotid artery (LICA) and occlusion of the right artery (RICA). Arteriography of the supra aortic trunks revealed a 99% stenosis of the RICA and 95% of the LICA, with vascularisation of both ACA dependent on the LICA. A left carotid endarterectomy was performed and the patient has remained asymptomatic to date. In our patient, both ACA depended on the flow from the LICA. We therefore consider that the symptoms of transient paraparesis were secondary to the left carotid stenosis, either due to a haemodynamic or an artery to artery embolic mechanism." }, { "id": "pubmed23n0277_4277", "title": "[Syncope in a general population: etiologic diagnosis and follow-up. Results of a prospective study].", "score": 0.009900990099009901, "content": "Syncope is a common clinical problem in a general population. A prospective study was performed, in our hospital, to evaluate the incidence of the disease and to standardize the diagnostic and clinical management. 194 patients aged 10-92 years were recruited during one year. The diagnostic produce followed the three standard stages: First stage clinical evaluation (a complete history, physical and neurological examination, a base-line laboratory evaluation, a 12-lead electrocardiogram, carotid sinus stimulation); Second stage non invasive investigation (echocardiogram, 24-hour electrocardiographic monitoring, electroencephalography, Doppler echocardiography of epiaortic vessels, head-up tilt test, head CT scan); third stage invasive investigation (electrophysiologic study). Diagnosis was, sometimes, difficult because of the sporadic and transitory nature of the syncope. The etiological diagnosis were the following: cardiovascular causes 68.55% (cardiac 31.95%, reflex syncope 36.59%). Non-cardiovascular causes 10.82% (metabolic 5.15%, neurologic 3.5%, different 2.06%). Unknown cause 20.61%. Diagnosis was determined at the following stages: ist stage 63.40% (complete history and physical examination alone 4072%), 2nd stage 14.43%, 3rd stage 1.54%. The mean follow-up period was 21.71 +/- 6.22 months. Over this period 17 (8.76) patients died; all aged (&gt; 65 years) end in this aged the incidence is 18.08%. If we look at patients with correct diagnosis of syncope (183 patients) the mortality rate is 8.19% (if we consider those aged &gt; 65 the rate is 17.44%). The mortality rate of cardiac syncope of unknown (28.88% for aged &gt; 65 years). 2 deaths among syncope of unknown cause. 17.48% had 1 or more episodes of recurrent syncope during this follow-up period with little prevalence for patients with syncope of unknown origin. Other major cardiovascular events was 18.03% in all patients with little prevalence for cardiac cause of syncope. 1) Frequently an accurate history, a physical examination and a standard ECG are enough to formulate a correct diagnosis. 2) Head-up tilt test must be considered in patients with a unknown diagnosis, before starting invasive investigation. 3) Prognosis is dependent on the specific cause. Since cardiac syncope has a serious prognosis, when it is not treated correctly, it can even lead to sudden death." }, { "id": "wiki20220301en026_42545", "title": "Amaurosis fugax", "score": 0.00980392156862745, "content": "If laboratory tests are abnormal, a systemic disease process is likely, and, if the ophthalmologic examination is abnormal, ocular disease is likely. However, in the event that both of these routes of investigation yield normal findings or an inadequate explanation, noninvasive duplex ultrasound studies are recommended to identify carotid artery disease. Most episodes of amaurosis fugax are the result of stenosis of the ipsilateral carotid artery. With that being the case, researchers investigated how best to evaluate these episodes of vision loss, and concluded that for patients ranging from 36 to 74 years old, \"...carotid artery duplex scanning should be performed...as this investigation is more likely to provide useful information than an extensive cardiac screening (ECG, Holter 24-hour monitoring, and precordial echocardiography).\" Additionally, concomitant head CT or MRI imaging is also recommended to investigate the presence of a “clinically silent cerebral embolism.”" }, { "id": "pubmed23n0389_20553", "title": "[Clinical diagnostic of brain death and transcranial Doppler, looking for middle cerebral arteries and intracranial vertebral arteries. Agreement with scintigraphic techniques].", "score": 0.00980392156862745, "content": "The Real Ordinance 2070/1999 meant an important modification in the legislation, when including transcranial Doppler (TCD) in explorations to confirm the clinical diagnosis of brain death (BD). Habitually for their employment in the diagnosis of BD, we look for blood flow signal from the middle cerebral arteries (MCA) and the basilar artery (BA). To check the effectiveness of the TCD like test of BD, looking for both middle cerebral arteries (MCA) and both intracranial vertebral arteries (VA), instead of the BA, and taking as Gold Standard cerebral scintigraphic techniques. . We present 25 patients diagnosed clinically with BD; on these TCD was carried out to confirm BD. Later on we proceeded to carry out cerebral scintigraphic techniques in all these cases. As statistical tool the test of c2 is used with confidence interval of 95%. In 24 of the 25 cases, the TCD was effective in confirming the diagnosis of BD. In the remaining patient, a false positive result was obtained, since the TCD didn't reveal flow in the infratentorial compartment, as contrary to the cerebral scintigraphic techniques which showed the presence of residual flow at this level; this residual flow disappeared in 36 hours. This patient was hemodynamically unstable during TCD exploration. In our results the TCD obtains a reliability of 100% when confirming the absence of blood flow in the supratentorial compartment; nevertheless the false positive result obtained at the infratentorial level, warns us to be cautious in accepting the flow from the VA as a test of absence of flow at the infratentorial compartment, especially in those patients with hemodynamic instability." }, { "id": "pubmed23n0711_13073", "title": "Brugada syndrome (BS) and syncope: a complex therapeutic issue.", "score": 0.009708737864077669, "content": "A 66 year-old man was brought to the emergency room (ER) for syncope and sphincter incontinence; syncope duration was about 15 min. Similar short duration episodes had been referred by his relatives during the last months, following small traumas; no seizures had been registered. Patient told he was affected with BS, having already been diagnosed 5 years before, after performing an electrocardiogram (ECG) highly suggestive for it. He had performed an electrophysiologic study, which had not shown any sustained ventricular arrhythmias after scheduled stimulation. This finding together to the lack of symptoms had suggested a conservative treatment, notwithstanding that familiar history documented his father's sudden death. Patient was also affected with hypertension and gastroesophageal reflux disease. Clinical examination did not suggest any significant findings. Laboratory tests, supra aortic Doppler ultrasound, electroencephalogram (EEG) and brain CT were normal. ECG showed sinus rhythm with a heart frequency of 82 bpm, QRS axis was normal, as well as atrioventricular conduction. ST coved-type elevation with right bundle branch block pattern and repolarization abnormalities were found. Holter ECG and Doppler echocardiography were also performed. The onset of syncope in presence of BS suggested the evaluation of this case report together with electrophysiolgists and neurologists. Therefore, an implantable cardioverter defibrillator (ICD) was implanted through left subclavian vein. He was discharged eight days after hospitalization, diagnosis was \"Syncope in patient affected with BS, hypertension\". Arrhythmogenic risk stratification is necessary; the indication for implanting this device is obvious in symptomatic patients, whereas it is controversial in patients presenting only ECG patterns of BS. In conclusion, the above mentioned case report rises remarkable diagnostic and therapeutic issues. The finding of BS in a patient with syncope indicates the opportunity of implanting a defibrillator and only clinical experience and common opinions may help doctors in taking the most appropriated, often difficult, decisions." }, { "id": "pubmed23n0944_14036", "title": "[Ultrasonographic control of cerebral blood flow in patients with stenosis of brachiocephalic arteries before and after carotid endarterectomy].", "score": 0.009708737864077669, "content": "The authors studied the parameters of arterial and venous blood flow in patients presenting with haemodynamically significant atherosclerosis of the carotid arteries before and after carotid endarterectomy, as well as while carrying out functional tests. Comparing the indices of arterial blood flow in the Study Group consisting of 52 patients and the Control Group comprising 15 apparently healthy volunteers at rest prior to the operation revealed statistically significant differences of volumetric parameters of blood flow in the internal carotid artery. The obtained results showed that the breath-holding test was accompanied and followed by increased velocity of blood flow in the middle cerebral artery (MCA) on the side contralateral to stenosis, with the reactivity index (RI) amounting to 0.98±0.20, which statistically significantly differed from the RI in the Control Group patients (1.28±0.13). The forced respiration test demonstrated a decrease in the volumetric indices of blood flow in the MCA on the side of stenosis, as well as an increase of the maximum end-diastolic velocity of blood flow on the side contralateral to stenosis. The test with sublingual administration of nitroglycerin appeared to result in reduced blood flow in the MCA. The supratrochlear test demonstrated decreased velocity of blood flow in the supratrochlear artery. Studying the venous link of cerebral vessels after the operation showed that statistically significant differences were revealed only on the side contralateral to stenosis as compared with the values prior to revascularization. An increase of blood flow in the internal jugular veins after the operation on the side contralateral to the operation was apparently suggestive of an adequate distribution of blood flow through the main vessels of the brain." }, { "id": "pubmed23n0025_4606", "title": "[The Doppler test: its practical importance in the study of lesions of the supra-aortic trunks].", "score": 0.009615384615384616, "content": "Ultrasonography by the Doppler effect is of indisputable use in the investigation of lesions of the supra-aortic trunks leading to the brain. It allows a direct study of the extracranial carotidian and vertebral axes, and gives an idea of the intracerebral circulation. It detects the main lesions affecting them, provided that such lesions have hemodynamic repercussions. The Doppler does not replace arteriography, but is a complementary exam making it possible to decide on or to dismiss the need for it. Its harmlessness and simplicity make it a standard exam in cerebral vascular pathology." }, { "id": "wiki20220301en243_24556", "title": "Syncope (medicine)", "score": 0.009523809523809525, "content": "A medical history, physical examination, and electrocardiogram (ECG) are the most effective ways to determine the underlying cause. The ECG is useful to detect an abnormal heart rhythm, poor blood flow to the heart muscle and other electrical issues, such as long QT syndrome and Brugada syndrome. Heart related causes also often have little history of a prodrome. Low blood pressure and a fast heart rate after the event may indicate blood loss or dehydration, while low blood oxygen levels may be seen following the event in those with pulmonary embolism. More specific tests such as implantable loop recorders, tilt table testing or carotid sinus massage may be useful in uncertain cases. Computed tomography (CT) is generally not required unless specific concerns are present. Other causes of similar symptoms that should be considered include seizure, stroke, concussion, low blood oxygen, low blood sugar, drug intoxication and some psychiatric disorders among others. Treatment depends on the" }, { "id": "pubmed23n0294_23018", "title": "[Carotid endarterectomy without angiography].", "score": 0.009523809523809525, "content": "Duplex scanning has emerged as an accurate noninvasive method of evaluating patients with extracranial cerebrovascular disease; it has research, clinical and economic implications. The risks associated with cerebral angiography are numerous and well-known. During 1990-1995, 227 carotid endarterectomies (CEA) were performed without preoperative arteriography in 192 patients. 91% were performed under local anesthesia. Indications for surgery without angiography were: renal insufficiency (in 5), allergy to contrast material (11), and need for urgent surgery (25). In 81% CEA was performed due to the preference of both the neurologist and surgeon. In only 2 cases there was a discrepancy in duplex evaluation. 3 patients had postoperative strokes (total stroke rate 1.56%), only 1 of which was disabling (0.52%). 2 died during the immediate postoperative period (mortality 1.04%): 1 on the 2nd postoperative day due to asphyxia caused by a huge neck hematoma which appeared suddenly after discharge (related death, 0.52%); the other died several days after coronary surgery which followed CEA (unrelated death). Our study confirms that patients with well-defined symptoms, appropriate physical findings, and concurrent CT and duplex scans, can safely undergo CEA without preoperative angiography. It is extremely important however, that the duplex scan be a reliable study from a laboratory which has validated its results by sequential comparison of previous duplex and angiographic data. Angiography remains appropriate in patients with atypical symptoms; with conflicting findings between history, physical and duplex data; when there is proximal disease; or in an asymptomatic patient when the duplex scan suggests total occlusion." }, { "id": "wiki20220301en554_13646", "title": "Embolic stroke of undetermined source", "score": 0.009459924320605436, "content": "Diagnosis ESUS is a diagnosis of exclusion based on radiological and cardiological examinations. For exclusion of haemorrhagic or lacunar strokes CT or MRI imaging is needed. Both procedures also allow detection of embolic pattern of ischemic lesions. 12-lead ECG and cardiac monitoring for at least 24 h with automated rhythm detection are mandated to exclude atrial fibrillation; echocardiography (TTE and/or TEE) is used to detect other major-risk cardioembolic sources (e.g., intracardiac thrombi, or ejection fraction <30%). For imaging of both the extracranial and intracranial arteries supplying the area of brain ischaemia, examination methods like catheter, MR/CT angiography or cervical duplex plus transcranial Doppler ultrasonography are required. They allow an exclusion of large vessel stenosis (≥ 50%)." }, { "id": "pubmed23n0899_18455", "title": "Evaluation by Magnetic Resonance Imaging of Silent Brain Infarcts in Preoperative and Postoperative Asymptomatic Carotid Surgery.", "score": 0.009433962264150943, "content": "To report the prevalence of silent brain infarcts (SBI) at magnetic resonance imaging (MRI) before and after surgery for asymptomatic high grade carotid stenosis. This is a single center retrospective observational study. Asymptomatic patients who underwent carotid endarterectomy between October 2012 and October 2014 were included. The preoperative assessment included a Doppler and a computed tomographic (CT) scan dating less than 3 months. A neurological examination was performed during the anesthesia consultation and in the 15 days before surgery. An MRI angiography was performed the day before and 3 days after surgery and was analyzed by an independent neuroradiologist. Preoperative analysis focused on the presence of ischemic events at MRI. The type of plaque, the supra aortic trunk lesions, and the quality of the circle of Willis were analyzed using Doppler and CT scanning. Postoperatively, we searched for signs of postoperative ischemic events at MRI. Forty-one patients were included (85.4% of men), and the mean age was 72.4 ± 8.3 years. We noted 7 (17.1%) contralateral stenoses (&gt;50%) and 2 (4.9%) contralateral thromboses, 6 (14.6%) vertebral stenoses, and 7 (17.1%) abnormalities of the circle of Willis. The morphological analysis described 6 unstable plaques including 4 ulcerated, 1 pseudodissection, and 1 intraplaque hemorrhage. Preoperatively, we noted the presence of 21 (51.2%) ischemic lesions including 9 (21.9%) multiple lacunar ischemic events and 12 (29.3%) silent arterial territory infarcts. Eversion was performed for all patients except for 6 (14.6%), for whom a bypass was necessary. No deaths or major complications were observed in the 30 postoperative days. Postoperatively, MRI showed 3 (7.3%) asymptomatic recent ischemic strokes, 1 ipsilateral middle cerebral artery (MCA) stroke, and 2 contralateral (cerebellar and MCA) strokes. Patients with asymptomatic significant carotid stenosis show many preoperative SBI indicating a significant embolic risk. It is difficult to conclude about intraoperative embolic risk, but we hope that more data could demonstrate the importance of MRI for the preoperative evaluation of carotid plaques and brain parenchyma, to identify high-risk embolic patients." }, { "id": "pubmed23n0273_2546", "title": "[Common carotid artery thrombosis--clinical and radiological evaluation].", "score": 0.009433962264150943, "content": "Common carotid artery thrombosis (CCAT) is not common. We studied 4 patients with CCAT to clarify the clinical and radiological features of this disorder. Case 1 had only episodes of TIA. Case 2 was diagnosed by chance as having CCAT at the time of admission due to cerebellar infarction. On the contrary, Cases 3 and 4 were admitted because of disturbance of consciousness and hemiparesis. Case 4 died soon after his stroke because of complications. We evaluated cases 1, 2 and 3 using head CT, head MRI, neck MRI, MR angiography, SPECT and cerebral angiography. Case 4, who was evaluated with head CT and cerebral angiography, was autopsied to confirm the occlusion of the common carotid artery. The clinical severity of CCAT varies from asymptomatic to severe, because each differs in the time taken for complete occlusion of the common carotid artery; the development of collateral circulation; and hemodynamics of the brain. As for the collaterals their contribution is variable; for example, the thyrocervical and other arteries function as the bypass. We can diagnose CCAT easily and noninvasively using MR angiography and neck MRI based on disappearance of the flow void in the common carotid artery or internal carotid artery. On physical examination, it is important to detect faded pulsation of the superficial temporal artery that is ipsilateral to the occluded common carotid artery." }, { "id": "pubmed23n0291_15991", "title": "[A case report of thoracic aortic and common carotid artery dissecting aneurysm diagnosed by duplex ultrasound examination].", "score": 0.009345794392523364, "content": "A 61-year-old man was admitted to our hospital because of sudden consciousness disturbance, aphasia and right-side hemiparesis. On admission his blood pressure was 124/74mmHg, and his pulse was a regular rate of 46 beats per minute. Electrocardiogram was normal. Thirty minutes after the onset brain computed tomographic (CT) scan showed no abnormality. Fifty minutes after the onset cervical ultrasound examination with color-coded Doppler demonstrated a subintimal dissection with a false channel of the left common carotid artery. Eighty minutes after the onset thoracic CT scan demonstrated the false lumen in ascending and descending thoracic aortic artery. Cervical CT scan showed a dissection with a false channel of the left common carotid artery. We could diagnose him as cerebral infarction due to thoracic aortic and common carotid artery dissection by means of ultrasound examination within 80 minutes after the onset. He spontaneously and fully recovered three days later. We emphasize the usefulness of noninvasive technique such as cervical ultrasound examination with color-coded Doppler in the diagnosis and follow-up of common carotid artery dissection." }, { "id": "pubmed23n0281_5606", "title": "[What studies should be done in syncope?].", "score": 0.009345794392523364, "content": "Fainting (short loss of consciousness) is a frequent reason for a consultation in a general practitioner's or cardiologist's office. Four main causes are recognized commonly: cardial with auriculo-ventricular block and arrhythmias, vascular in particular vaso-vagal syncopes, neurologic and other causes. In 38 to 47% of the patients no etiology is found: these are syncopal attacks of unknown origin. The first diagnostic step comprises noninvasive investigations. A 24-hour recording of the ECG or a 'long strip' improve the diagnostic rate by 10%. They are particularly useful for sick sinus syndromes. The head-up tilt-test has been developed recently. It is very useful for detection of vagovasal syncope and permits to understand the pathophysiology and the therapeutic consequences of these disorders. This test plays a particular role for the diagnosis of syncopes of unknown causes and shows in 24 to 75% of the cases pathologic results. Patients at high risk for ventricular arrhythmia can be recognized by ECG with high amplification. Doppler investigation of the neck vessels, however, seems to be of low diagnostic value in syncopes. Invasive measures are the last line resort. Electrophysiologic studies provide criteria that are well defined. They are useful for detection of ventricular dysrhythmias and conduction disorders. This latter approach is reserved to patients with negative noninvasive tests and in particular with cardiopathy. The approach to syncope and the power of noninvasive and invasive tests is thus well established. However, in a certain number of patients the cause for fainting is not disclosed. Fortunately mortality is low in this particular group." }, { "id": "wiki20220301en087_31620", "title": "Carotid bruit", "score": 0.009270911321025217, "content": "A carotid bruit is a vascular murmur sound (bruit) heard over the carotid artery area on auscultation during systole. Associated conditions It may occur as the result of carotid artery stenosis (though some disagree); however, most carotid bruits, particularly those found in younger or asymptomatic patients, are not related to any disease and are termed \"innocent carotid bruits\". A carotid bruit is unlikely to be heard if the stenosis occludes less than 40% of the diameter of the artery. Likewise, a stenosis of greater than 90% may not be heard, as the flow may be too low. Many carotid bruits are discovered incidentally in an otherwise asymptomatic patient. The presence of a carotid bruit alone does not necessarily indicate the presence of stenosis, and the physical examination cannot be used to estimate the degree of stenosis, if present; therefore, any bruit must be evaluated by ultrasound or imaging." }, { "id": "wiki20220301en027_45808", "title": "Aortic aneurysm", "score": 0.009259259259259259, "content": "The diagnosis of an abdominal aortic aneurysm can be confirmed at the bedside by the use of ultrasound. Rupture may be indicated by the presence of free fluid in the abdomen. A contrast-enhanced abdominal CT scan is the best test to diagnose an AAA and guide treatment options. Only 10–25% of patients survive rupture due to large pre-and postoperative mortality. Annual mortality from ruptured aneurysms in the United States is about 15,000. Most are due to abdominal aneurysms, with thoracic and thoracoabdominal aneurysms making up 1% to 4% of the total. Aortic rupture An aortic aneurysm can rupture from wall weakness. Aortic rupture is a surgical emergency and has a high mortality even with prompt treatment. Weekend admission for a ruptured aortic aneurysm is associated with increased mortality compared with admission on a weekday, and this is likely due to several factors including a delay in prompt surgical intervention." }, { "id": "pubmed23n0301_16625", "title": "[History of neurovascular ultrasonography].", "score": 0.009259259259259259, "content": "History of diagnostic ultrasound begins with the Austrian physicist Christian Doppler, who described in 1842 the Doppler principle. 40 years later, the Curies discovered the reverse piezoelectric effect that produces ultrasound. The first ultrasonic devices were designed at the beginning of the 20th century and were used among other things for detection of submarines. Development during World War II permitted the construction of the first transcranial (1940) and extracranial (1949) ultrasound imaging units. Continuous-wave Doppler sonography was introduced in clinical practice 20 to 30 years later. Due to its high validity, this technique has become the standard method for evaluation of extracranial occlusive cerebrovascular disease. Further ultrasonic developments like duplex and color duplex sonography have increased the diagnostic possibilities but did not replace continuous-wave sonography in many European ultrasound laboratories. Transcranial ultrasound studies are performed by means of pulsed-wave Doppler or color duplex sonography. It is likely that power Doppler and transpulmonary contrast agents will further increase diagnostic confidence in neurovascular ultrasound. The search for a source of arterio-arterial embolism in case of ocular and cerebral ischemia remains the main indication for neurovascular ultrasonography. Additional indications are repetitive studies in dissection, vasospasm, endovascularly treated vascular malformations and stenoses, intracranial pressure monitoring, examination of cerebrovascular reactivity in suspicion of hemodynamic ischemia, and diagnostic work-up of cough syncope, pulsatile tinnitus and cardiac right-left shunt." }, { "id": "pubmed23n0872_22194", "title": "Innominate Artery Stenosis Presenting With Migratory Digital Ischemia.", "score": 0.009174311926605505, "content": "Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative-endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events. An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits. Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients." }, { "id": "pubmed23n0351_2507", "title": "Outcome for patients with carotid stenosis undergoing carotid endarterectomy, the cerebral condition followed by extra/intracranial ultrasound examinations.", "score": 0.009174311926605505, "content": "Seventy-six patients undergoing carotid endarterectomy were studied to estimate the effect of operation, evaluate the accessible methods of examination and disclose the complications owing to the operation. In addition, the hypothesis that the pulsatility index in MCA measured by the Doppler method could disclose severe ischemia and risk of complications during endarterectomy was tested. The study was a prospective study of patients operated at the University Hospital in Odense in the years 1991-1996. Data collected included demographics, operative indications, complications, follow-up extra/transcranial Doppler examinations, cerebrovascular reactivity investigations, recurrent symptoms and deaths. Concerning the carotid stenosis, a fairly good correlation was found between the results of extracranial Doppler examinations, Duplex and carotid angiography. Serious complications after surgery were few. One patient, who had a coronary by-pass operation consecutive to the endarterectomy, died 3 weeks after the operation, owing to a hematothorax. Five patients (7%) suffered a stroke. Only 2 patients needed rehabilitation, and they came out with minor disturbances in the use of a hand. Recurrent stenosis in excess of 69% emerged in 3% of the patients. All were hemodynamically insignificant. One patient had a new TIA during the observation time of 3-60 months. After the operation she had a thrombosis in the operated carotid artery. Thus our results, a perioperative stroke rate of 7% and a mortality rate of 1%, are in line with the average results in multicenter trials. In addition a PI below 0.60 in the MCA seemed to be a warning of the risk of postoperative cerebral hyperemia." }, { "id": "pubmed23n0104_5966", "title": "[Value of the carotid compression test for the diagnosis of cerebrovascular disorders].", "score": 0.00909090909090909, "content": "The carotid compression tests have been performed in 1940 outpatients and 233 hospitalized patients with clinical signs and symptoms of cerebrovascular disturbances. The frequency of EEG slowing, positivity of the compression tests and carotis sinus hypersensitivity was in patients with local neurological signs: 36%, 22.5%, and 24.8%, while the corresponding numbers for patients without neurological signs were: 24.6%, 21.8%, 14.7%. On the basis of the carotis angiography the following groups of the patients could be formed: Thrombosis of the internal carotid artery (A), thrombosis of the anterior or medial cerebral artery (B), carotis stenosis (C), other vascular pathological signs of the arteries (D), normal angiography (E). They were compared with the control group of patients with vertebrobasilar insufficiency (F). The frequency of EEG slowing (A = 92%, B = 72%, C = 58.9%, D = 57%, E = 40%, F = 22.5%). The percentage of the positivity of carotid compression tests (A = 54%, B = 32%, C = 46%, D = 26%, E = 12%) and occurrence of carotis sinus hypersensitivity (A = 26.8%, B = 16%, C = 17.7%, D = 10.8%, E = 11.3%, F = 6.9%) were proportionate to the pathological morphological signs. The results of the compression tests may give indication for detailed clinical investigation, and are helpful in the estimation of the functional capacity of the carotid arteries in the cerebral circulation." }, { "id": "pubmed23n0052_18987", "title": "[A case with cerebral embolism due to the recurrence of thrombotic valve five years after the reoperation].", "score": 0.009009009009009009, "content": "Between April 1972 and May 1990, a total of 300 patients in our institution underwent insertion of a Björk-Shiley aortic valve prosthesis, and development of a thrombosed valve was observed only in 4 female cases. It was considered that the thrombosed valves in all 4 cases were caused by inadequacy of the anticoagulant agents. As reoperative procedures, thrombectomy, resection of the excessive granulation under the valve, and a method of turning the opening direction of the valve 180 degrees were used. These procedures were reported previously. One case died late in the day after the operation, while the remaining 3 cases progressed favorably. Although control of one of these three cases was favorably maintained after reoperation, a restriction of 43.2 degrees of the opening angle of the valve was again observed by valve-fluoroscopy performed in the 3rd postoperative year. However, progress of this patient was observed on an outpatient basis because flow velocity at the position of aortic valve was also within normal range. This was shown Doppler's test using ultrasonic waves and the patient showed no symptoms. However, this patient was admitted to our institute due to sudden right hemiplegia on May 1990 in the 5th year after reoperation. The cerebral embolism due to the recurrent thrombosed valve was diagnosed because a low density in the middle cerebral area was observed by CT, and increase of the opening angle of the valve (compared with that at ambulation) was also noted by valve-fluoroscopy. The hemiplegia remained even though this patient was saved from death. (ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en008_112444", "title": "Radiology", "score": 0.008928571428571428, "content": "Because ultrasound imaging techniques do not employ ionizing radiation to generate images (unlike radiography, and CT scans), they are generally considered safer and are therefore more common in obstetrical imaging. The progression of pregnancies can be thoroughly evaluated with less concern about damage from the techniques employed, allowing early detection and diagnosis of many fetal anomalies. Growth can be assessed over time, important in patients with chronic disease or pregnancy-induced disease, and in multiple pregnancies (twins, triplets, etc.). Color-flow Doppler ultrasound measures the severity of peripheral vascular disease and is used by cardiologists for dynamic evaluation of the heart, heart valves and major vessels. Stenosis, for example, of the carotid arteries may be a warning sign for an impending stroke. A clot, embedded deep in one of the inner veins of the legs, can be found via ultrasound before it dislodges and travels to the lungs, resulting in a potentially" }, { "id": "pubmed23n0297_8122", "title": "[Ultrasonic diagnosis in the area of the carotid and vertebrobasilar circulation].", "score": 0.008928571428571428, "content": "At present the duplex ultrasonic method is the best non-invasive examination method of the carotid and vertebrobasilar circulation. It was developed by a combination of the Doppler method with two-dimensional imaging in real time. It makes it possible to evaluate all stages of the stenotic process, the size and surface of plaques, the lumen of the vessels, occlusions. It provides a comprehensive picture of the morphology and function of vessels. The introduction of transcranial Doppler ultrasonography by R. Aaslid in 1982 made it possible to examine also basal intracranial arteries. Examination by ultrasound makes it possible to diagnose vascular changes in still asymptomatic patients; it helps to establish the correct diagnosis, offers the possibility to evaluate the therapeutic effect as well as terminal conditions-cerebral death." }, { "id": "pubmed23n0314_1466", "title": "[A 62-year-old man with an acute onset of consciousness disturbances].", "score": 0.008849557522123894, "content": "We report a 62-year-old man who developed coma and died in a fulminant course. The patient was well until May 1, 1996 when he noted chillness, tenderness in his shoulders, and he went to bed without having his lunch and dinner. In the early morning of May 2, his families found him unresponsive and snoring; he was brought into the ER of our hospital. He had histories of hypertension, gout, and hyperlipidemia since 42 years of the age. On admission, his blood pressure was 120/70, heart rate 102 and regular, and body temperature 36.3 degrees C. His respiration was regular and he was not cyanotic. Low pitch rhonchi was heard in his right lower lung field. Otherwise general physical examination was unremarkable. Neurologic examination revealed that he was somnolent and he was only able to respond to simple questions such as opening eyes and grasping the examiner's hand, but he was unable to respond verbally. The optic discs were flat; the right pupil was slightly larger than the left, but both reacted to light. He showed ptosis on the left side, conjugate deviation of eyes to the left, and right facial paresis. The oculocephalic response and the corneal reflex were present. His right extremities were paralyzed and did not respond to pain Deep tendon reflexes were exaggerated on the right side and the plantar response was extensor on the right. No meningeal signs were present. Laboratory examination revealed the following abnormalities; WBC 18,400/ml, GOT 131 IU/l GPT 50 IU/l, CK616 IU/l, BUN 30 mg/dl, Cr 2.1 mg/ dl, glucose 339 mg/dl, and CRP 27.4 mg/dl. ECG showed sinus tachycardia and ST elevation in II, III and a VF leads and abnormal q waves in I, V5, and V6 leads. Chest X-ray revealed cardiac enlargement but the lung fields were clear. Cranial CT scan revealed low density areas in the left middle cerebral and left posterior cerebral artery territories. The patient was treated with intravenous glycerol infusion and other supportive measures. At 2: 10 AM on May 3, he developed sudden hypotension and cardiopulmonary arrest. He was pronounced dead at 3:45 AM. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that the patient had acute myocardial infarction involving the inferior and the true posterior walls and left internal carotid embolism from a mural thrombus. Post mortem examination revealed occlusion of the circumflex branch of the left coronary artery due to atherom plaque rupture and myocardial infarction involving the posterior and the lateral wall with a rupture in the postero-lateral wall. Marked atheromatous changes were seen in the left internal carotid, the middle cerebral and the basilar arteries; the left internal carotid and the middle cerebral arteries were almost occluded by thrombi and blood coagulate. The territories of the left middle cerebral and the occipital arteries were infarcted; but the left thalamic area was spared. The neuropathologist concluded that the infarction was thrombotic origin not an embolic one as the atherosclerotic changes were severe. Cardiac rupture appeared to be the cause of terminal sudden hypotension and cardiopulmonary arrest. It appears likely that a vegetation which had been attached to the aortic valve induced thromboembolic occlusion of the left internal carotid artery which had already been markedly sclerotic by atherosclerosis. It is also possible that the vegetations in the aortic valve came from mural thrombi at the site of acute myocardial infarction, as no bacteria were found in those vegetations." }, { "id": "pubmed23n1075_9318", "title": "[Internal carotid artery dissection in the neurologist's practice - a case study].", "score": 0.008849557522123894, "content": "Dissection of the interior carotid artery is rare in the general population. It can however be a potentially life-threatening condition. In the group of patients below 45 years of age, it constitutes a fairly common cause of cerebral stroke. The study describes the case of a patient with the right interior carotid artery dissection, sustained most probably in the course of work. The patient was admitted to hospital for a severe headache of a few days' duration accompanied by Horner's syndrome on the right side. Promptly undertaken diagnostic procedures allowed for immediate diagnosis and application of the right treatment. The check-up examinations performed showed a healed artery and withdrawal of the neurological syndrome. The case emphasizes the role of prompt diagnosis and treatment in preventing the development of more serious complications. The article refers also to the standards of treating the dissection of the interior carotid artery which still arouse controversies." } ] } } }

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{ "1": "He cannot eat any fish, crustaceans, mollusks or cephalopods.", "2": "He can eat fresh fish cooked on the grill.", "3": "May eat commercially flash-frozen fish.", "4": "You can eat fresh marinated or cold smoked fish.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0378_20158", "title": "Freezing protects against allergy to Anisakis simplex.", "score": 0.01752123786407767, "content": "Allergic reactions to Anisakis simplex have been described following ingestion of fish and were thought to be possible even if seafood is frozen or well-cooked. This study aimed to confirm, by challenge test, that dead A. simplex larvae are not able to trigger allergic reactions in patients with proven hypersensitivity to this parasite. Simple-blind, placebo-controlled, oral challenge tests with frozen A. simplex larvae were performed in 12 patients who had suffered severe anaphylactic reactions after ingestion of seafood and diagnosed of A. simplex hypersensitivity by skin prick test and specific IgE. If no reaction appeared, they were told to eat frozen seafood. 63 patients who had suffered urticaria or urticaria/angioedema by demonstratred hypersensitivity to A. simplex were also advised to eat frozen seafood. All of them were reevaluated 6 months later. All patients tolerated the dead larvae challenge test. After eating previously frozen seafood at least two times per week, all patients, including those who had suffered anaphylactic reactions and those who had only presented cutaneous manifestations, remained asymptomatic. Anisakis simplex-allergic patients tolerate ingestion of dead larvae. It is probable that these patients can eat frozen fish and that a seafood-free diet is not necessary." }, { "id": "pubmed23n0973_24434", "title": "Occupational disease due to Anisakis simplex in fish handlers.", "score": 0.016842847075405214, "content": "Anisakis is a marine nematode. Its larvae can be found encysted in several species, both in the abdominal cavity and in the adjacent musculature. The most commonly affected commercial species are hake, whiting, cod, and mackerel. The prevalence in fish varies according to the fishing area and the size of the host. Until now only three species have been confirmed to be involved in human anisakiasis, the most common ones being A. simplex sensu stricto (s.s.) and A. pegreffii, and anecdotally, A. physeteris. Infestation in humans occurs when they eat raw or undercooked parasitized fish or cephalopods (pickled, cold-smoked, salted, semi-preserved, prepared in certain Asian styles like sushi or sashimi, ceviche). The majority of anisakiasis cases have been described by Japanese authors. However, over the last few years there has been an increase in the number of cases reported in other countries including Italy and Spain. It is estimated that its incidence in the European Union is 0.32/100,000, and in the Basque Country (Spain), this parasite is responsible for 10% of anaphylaxis cases and 32% of urticaria cases in adults aged 40-60 years, around 300 cases/year. Anisakis-related disease in the work environment (occupational disease) is less common. We present three cases of the occupational disease in Spain due to a type I hypersensitivity to Anisakis simplex in individuals who handle fish (one fishmonger, one supermarket employee, and one chef)." }, { "id": "wiki20220301en064_1925", "title": "Fish as food", "score": 0.016394496592516395, "content": "Parasite infection by raw fish is rare in the developed world (fewer than 40 cases per year in the United States), and involves mainly three kinds of parasites: Clonorchis sinensis (a trematode/fluke), Anisakis (a nematode/roundworm) and Diphyllobothrium (a cestode/tapeworm). Infection risk of Anisakis is particularly higher in fishes which may have lived in a river or estuary, such as salmon (sa ke in Japanese cuisine) or mackerel (sa ba in Japanese cuisine). Such parasite infections can generally be avoided by boiling, grilling, preserving in salt or vinegar, or deep-freezing. In Japan, it is common to eat raw salmon and ikura (roe), but these foods are frozen overnight prior to eating to prevent infections from parasites, particularly Anisakis. Vegetarianism Since fish is animal flesh, the Vegetarian Society has stated that vegetarian diets cannot contain fish." }, { "id": "pubmed23n1130_11786", "title": "[Human diseases caused by Anisakis simplex].", "score": 0.016285153695225638, "content": "Anisakis simplex is a parasitic worm. It infects marine mammals that feed on fish and cephalopods, its intermediary hosts. Human disease is caused by accidental ingestion of Anisakis larvae. Upon consumption of contaminated fish, cuttlefish or squid, human may develop two distinct clinical pictures: Anisakiasis is provoked by living larvae penetrating the digestive mucosa. Allergy is caused by IgE-mediate hypersensitivity to living or dead larvae in a previously sensitized individual. Anisakiasis may manifests with violent epi gastric pain, acute abdomen or eosinophilic gastroenteritis. The larvae may be visualized by endoscopy or histology. The main Anisakis allergens are not denaturated by heat or cold and resist to digestion. Allergy diagnosis relies on careful history and detection of specific IgE." }, { "id": "pubmed23n0448_2220", "title": "[Allergy to Anisakis simplex].", "score": 0.016255534471853256, "content": "Anisakis simplex is a parasite, belonging to the Anisakidae family. The life cycle of the parasite can include one or more intermediary hosts, their final hosts being marine mammals or large fish, in which the larvae develop until the adult stage is reached. Man is an accidental host who acquires the larvae by eating raw or undercooked fish. Since the mid-50s, when the first case studies were published in Holland and Japan, new cases have been emerging in different countries including Spain. Parasitization of man by the living larva is known as anisakiasis, principally giving rise to digestive symptomology, with other rare cases described of invasion of other organs such as the lung, the liver, the spleen, the pancreas, etc. Clinical pictures of allergy to IgE mediated anisakis simplex have also been described: reactions by thermostable antigens of the parasite that develop in spite of the fish being cooked or frozen, and an acute digestive parasitization with allergic symptoms called gastro-allergic anisakiasis. In the diagnosis of anisakiasis and/or allergy to Anisakis, the antecedent of the prior ingestion of fish as well as the clinical accompaniment can form basic data of considerable orientational value, and endoscopy can reveal the presence of the larvae and make possible their extraction. Besides, in cases of allergy the detection test for specific IgE facing Anisakis simplex, and cutaneous tests with fish should be carried out. The best treatment for avoiding this parasitization is prophylactic, avoiding the consumption of raw or undercooked fish, while a fish free diet is necessary in cases of true allergy to the thermostable proteins of the parasite." }, { "id": "pubmed23n1046_25484", "title": "Investigation of Anisakis larvae in different products of ready-to-eat fish meat and imported frozen fish in Turkey.", "score": 0.016009695114172728, "content": "Globalization opens new market areas and affects food consumption habits, resulting in rapid and remarkable cultural change. Food habits such as consumption of raw fish meat have become popular, resulting in increased risk of emerging infectious diseases. Anisakis simplex sensu stricto (s.s) and A. pegreffii are the most common and important fish-borne zoonotic nematodes responsible for human anisakiasis, which occurs through the consumption of raw or undercooked fish as well as cooked fish due to their heat-stable allergens. Here, we investigated the prevalence, intensity, and abundance of Anisakis larvae in imported fish and ready-to-eat local fish products in Turkey. A total of 205 ready-to-eat fish products, 100 imported frozen Atlantic salmon (Salmo salar) fillets, and 100 imported frozen whole Atlantic mackerel (Scomber scombrus) were sampled from supermarkets, sushi restaurants, and fish markets. All samples were individually examined using a pepsin digestion technique. In total, 602 Anisakis type I larvae were recovered from 98/100 mackerel. No larvae were found in ready-to-eat products or frozen Atlantic salmon fillets. Overall, 8.8% of the larvae were found in the muscle tissue. The overall mean intensity and abundance of infection in mackerel were 6.14 and 6.02, respectively. The larvae were molecularly identified and their phylogenetic relationships with the relevant Anisakis sequences in GenBank were investigated. For this purpose, a subsample of randomly selected 100 Anisakis larvae were analyzed with PCR-RFLP of the ITS region. The larvae were identified as A. simplex (s.s.) (n = 87) and hybrids (n = 13). ITS and cox2 gene regions of all hybrids and randomly selected 50 A. simplex (s.s.) larvae were sequenced for species confirmation and phylogenetic analyses. No intraspecific nucleotide variation was found among the ITS sequences of either species. Seven and three haplotypes, respectively, were identified for A. simplex (s.s.) and hybrid species according to DNA polymorphism of the cox2 gene. Hybrids in our study clustered within the common A. simplex (s.s.) clade in the cox2 phylogenetic tree indicating the dominance of A. simplex (s.s) in the catching area of Atlantic mackerel. Consequently, our study indicates high occurrence of A. simplex (s.s.) larvae with an overall 98.0% prevalence in imported Atlantic mackerel, and highlights the importance of these fish as potential reservoirs for human allergic anisakiasis in Turkey and possibly in other countries." }, { "id": "pubmed23n0369_455", "title": "[Eosinophilic esophagitis associated with recurrent urticaria: is the worm Anisakis simplex involved?].", "score": 0.015826564739608216, "content": "Anisakis simplex, a fish parasite of the nematode family, typically infects marine mammals such as whales, dolphins and seals. Human anisakiasis, which is acquired by eating raw or insufficiently heated fish or squid, has gained world-wide importance. Infestation with living larvae caused by eating parasitised fish results in acute upper abdominal pain, nausea and vomiting and may be confused with acute abdomen due to appendicitis and other inflammatory abdominal disorders. Extraintestinal organ manifestations are rare. Endoscopically, inflammation, oedema, erosions and ulcerations may be found. The parasite can been found in up to 50% of patients. Histologically, an eosinophilic inflammation is typical. Acute anisakiasis may be prevented by thorough cooking or deep-freezing the parasitised fish for at least 48 h. IgG-antibodies specific for Anisakis simplex are thought to represent an immunological host reaction against parasitic antigens. More recently, allergic reactions to Anisakis ingestion or exposure, such as urticaria, anaphylaxis and even occupational asthma, have been reported. These allergic reactions may also occur when the fish has been properly cooked, and hence these allergens are thought to be heat-stable. Such cases may be diagnosed by skin tests and the determination of specific Anisakis-IgE. However, the specificity of IgE is low, since they may also be present in exposed asymptomatic individuals. Since the eliciting allergens are temperature-stable, prophylactic dietetic measures are indicated. We report a case from Switzerland acquired during a holiday in Portugal. The patient suffered from recurrent dysphagia and urticaria, and histologically eosinophilic oesophagitis was found. IgG-antibodies and a positive skin prick test to Anisakis simplex support its aetiologic role for the symptoms." }, { "id": "wiki20220301en219_4581", "title": "List of raw fish dishes", "score": 0.01555104800540906, "content": "Parasite infection by raw fish is rare in the developed world (fewer than 40 cases per year in the U.S.), and involves mainly three kinds of parasites: Clonorchis sinensis (a trematode/fluke), Anisakis (a nematode/roundworm) and Diphyllobothrium (a cestode/tapeworm). Infection risk of anisakis is particularly higher in fishes which may live in a river such as salmon (sake) in Salmonidae or mackerel (saba). Such parasite infections can generally be avoided by boiling, burning, preserving in salt or vinegar, or freezing overnight. In Japan it is common to eat raw salmon and ikura, but these foods are frozen overnight prior to eating to prevent infections from parasites, particularly anisakis. See also Eating live seafood Lomi salmon List of fish dishes List of seafood dishes References Fish, Raw" }, { "id": "wiki20220301en044_43344", "title": "Anisakis", "score": 0.014610995574041486, "content": "Raising consumer and producer awareness about the existence of anisakid worms in fish is a critical and effective prevention strategy. Anisakiasis can be easily prevented by adequate cooking at temperatures greater than 60 °C or freezing. The FDA recommends all shellfish and fish intended for raw consumption be blast frozen to −35 °C or below for 15 hours or be regularly frozen to −20 °C or below for seven days. Salting and marinating will not necessarily kill the parasites, as in Italy where two-thirds of cases were attributed to anchovies marinated in lemon or vinegar. Humans are thought to be more at risk of anisakiasis from eating wild fish rather than farmed fish. Many countries require all types of fish with potential risk intended for raw consumption to be previously frozen to kill parasites. The mandate to freeze herring in the Netherlands has virtually eliminated human anisakiasis." }, { "id": "wiki20220301en044_43341", "title": "Anisakis", "score": 0.014581396486764202, "content": "Anisakiasis is a human parasitic infection of the gastrointestinal tract caused by the consumption of raw or undercooked seafood containing larvae of the nematode Anisakis simplex. The first case of human infection by a member of the family Anisakidae was reported in the Netherlands by Van Thiel, who described the presence of a marine nematode in a patient suffering from acute abdominal pain. It is frequently reported in areas of the world where fish is consumed raw, lightly pickled, or salted. The areas of highest prevalence are Scandinavia (from cod livers), Japan (after eating sashimi), the Netherlands (by eating infected fermented herrings (maatjes)), Spain (from eating anchovies and other fish marinated in escabeche), and along the Pacific coast of South America (from eating ceviche). The frequency in the United States is unknown, because the disease is not reportable and can go undetected or be mistaken for other illnesses. Anisakiasis was first recognized in the 1960s." }, { "id": "pubmed23n0408_23427", "title": "Dietary recommendations for patients allergic to Anisakis simplex.", "score": 0.01420975430876421, "content": "Anisakis simplex, a fish parasite, causes allergic urticaria, angioedema and anaphylactic shock through an IgE-mediated hypersensitivity mechanism. Consensus on the dietary recommendations that should be given to allergic patients is lacking. Our objective was to evaluate the usefulness of different types of diets in preventing further reactions in patients allergic to A. simplex. Twenty-eight adult patients, who had suffered an allergic episode caused by A. simplex were asked to follow one of the following three diets for a mean period of 13.16 months: a fish-free diet (diet 1; n = 19), a diet including fish frozen for more than 48 hours (diet 2; n = 9) and a diet with fresh fish (diet 3; n = 12). In all patients raw fish was excluded. Relapse rates and changes in total serum IgE and specific IgE to A. simplex were studied during the follow up. During the 13-month follow-up none of the patients developed anaphylaxis. Urticaria symptoms were present in 5.8 %, 11.1 % (n.s) and 33.3 % (p = 0.016) of patients following diets 1, 2 and 3, respectively. Total IgE decreased by 64 % (p &lt; 0.05), 48 % (p &lt; 0.05) and 39.4 % (p &lt; 0.05), respectively. Specific IgE to A. simplex decreased by 50.7 % (p &lt; 0.05), 54.1 % (p &lt; 0.05) and 23.6 % (p &lt; 0.05) after diets 1, 2 and 3, respectively. No statistically significant differences were found among the groups in variations in total and specific IgE. Patients allergic to A. simplex can eat fish that has been frozen at -20 C for 48 hours without risk of a severe allergic reaction. Long term decreases in specific and total IgE may not be good markers of eventual contact with A. simplex." }, { "id": "wiki20220301en219_4579", "title": "List of raw fish dishes", "score": 0.013852672750977835, "content": "This article is about raw fish or shellfish. It includes marinated raw fish (soaked in a seasoned liquid) and raw fish which is lightly cured such as gravlax, but not fish which is fully cured (fermented, pickled, smoked or otherwise preserved). Raw fish dishes Health concerns Parasites in fish are a natural occurrence and common. Though not a health concern in thoroughly cooked fish, parasites are a concern when consumers eat raw or lightly preserved fish such as sashimi, sushi, ceviche, and gravlax. The popularity of such raw fish dishes makes it important for consumers to be aware of this risk. Raw fish should be frozen to an internal temperature of −20 °C (−4 °F) for at least 7 days to kill parasites. It is important to be aware that home freezers may not be cold enough to kill parasites." }, { "id": "wiki20220301en278_867", "title": "Fish disease and parasites", "score": 0.013450026521179055, "content": "Eating raw fish Though not a health concern in thoroughly cooked fish, parasites are a concern when human consumers eat raw or lightly preserved fish such as sashimi, sushi, ceviche, and gravlax. The popularity of such raw fish dishes makes it important for consumers to be aware of this risk. Raw fish should be frozen to an internal temperature of −20 °C (−4 °F) for at least 7 days to kill parasites. It is important to be aware that home freezers may not be cold enough to kill parasites." }, { "id": "pubmed23n0572_15968", "title": "[New data on anisakiasis].", "score": 0.013289183222958058, "content": "Acute anisakiasis is generally due to the third-stage larvae of Anisakis simplex, and occasionally to other anisakidae. Human infection occurs through consumption of raw seafish, and especially herring, hake, black plaice and cod. Patients sensitized by prior consumption of parasitized fish develop, within a few hours, violent abdominal pain and an allergic reaction. Anisakis-induced urticaria is seen in about one in five cases. Preventive measures have reduced the number of cases. In France for example, the number of cases fell four-fold between 1977-1991 and 1992-2005. In 1990 Kasuya [1] reported chronic anisakiasis related to consumption of cooked parasitized fish. Seafish-induced urticaria might be an allergic response to Anisakis larval antigens rather than to the fish itself. Indeed, 11 patients with mackerel-related urticaria all had a positive reaction to Anisakis simplex larval antigen, while none reacted to mackerel antigen. A low-molecular-weight thermostable A. simplex allergen causes chronic urticaria, angioedema and even anaphylactoid reactions. Victims have a genetic predisposition (HLA class II alleles) that is uncommon in France and Germany but frequent in Japan. A number of cases have been observed in Spain, where fish is particularly popular. Immunoblotting shows cross-reactions between antigens of A. simplex and Toxocara canis, nematodes belonging to the same superfamily. At present, the only way to avoid contracting anisakiasis is not to eat raw or even cooked parasitized seafish." }, { "id": "pubmed23n0740_8440", "title": "Anisakis simplex: current knowledge.", "score": 0.013175675675675676, "content": "Anisakiasis, firstly described in 1960s in the Netherlands, is a fish-borne parasitic disease caused by the consumption of raw or undercooked fish or cephalopods contaminated by third stage (13) larvae of the Anisakidae family, in particular Anisakis simplex (As), A. pegreffii and Pseudoterranova decipiens. Every year, approximately 20,000 cases of anisakiasis were reported worldwide, over 90% are from Japan and most others in Spain, the Netherlands and Germany, depending on the habits of fish consuming. Live As larvae can elicit i) a parasitic infection of the digestive tract or, occasionally, other organs, causing erosive and/or haemorrhagic lesions, ascites, perforations until granulomas and masses, if larva is not removed, and ii) allergic reactions, as anaphylaxis, acute/chronic urticaria and angioedema. Like other parasite infestations, As larva induces an immune adaptive response characterised by T-lymphocyte proliferation with polyclonal and monoclonal (responsible for As allergic symptoms) IgE production, eosinophilia and mastocytosis. Several As allergens, many of which thermostable, were described In particular the major allergen Ani s 1 and Ani s 7 could characterized a past or a recent infection. There is a general agreement that an active infection is required to initiate allergic sensitivity to Anisakis. Until now, the only effective treatment for anisakiasis is the endoscopic removal of live larvae and the best protection against anisakiasis is to educate consumers about the dangers of eating raw fish and to recommend avoiding the consumption of raw or inadequately thermally treated marine fish or cephalopods." }, { "id": "pubmed23n0928_13142", "title": "A Multicenter Study of IgE Sensitization to <i>Anisakis simplex</i> and Diet Recommendations.", "score": 0.01294881588999236, "content": "Allergy to Anisakis simplex (s.) is spreading due to the increased consumption of raw, smoked or marinated fish. In man, Anisakis s. can directly attack the gastrointestinal mucosa, provoking a parasitosis known as anisakiasis, or giving rise to the formation of IgE and, finally, inducing IgE-mediated reactions like urticaria, angioedema and anaphylactic shock. During recent years, a dietary approach to Anisakis s. infestation has also been addressed. A total of 620 patients with urticaria, angioedema, or both and a history of anaphylaxis following consumption of raw, smoked or marinated fish were recruited, evaluated for specific IgE levels to Anisakis s. and subjected to Skin Prick test. Following 18 month fish-free diet, patients were reevaluated at 6, 12 and 18 months, respectively. Patients undergoing diet were selected among those who had a clinical history with multiple accesses to first aid. After 6-month fish-free diet, we recorded an improvement of symptoms and a remarkable reduction of specific IgE levels. The extension of the diet over 6 months in some cases resulted in a further reduction of specific IgE levels. Data obtained confirm the importance of a fish-free diet in patients with severe symptoms since a new antigenic exposure coincides with a relapse of symptoms and increased IgE levels. This last point should be kept in mind and carefully evaluated in patients at risk for anaphylaxis or angioedema." }, { "id": "wiki20220301en580_29237", "title": "Sermon of Saint Anthony to the Fish", "score": 0.012867647058823529, "content": "The greatest thing Vieira finds reprehensible about fish is that they eat one another (\"So foreign a thing it is, not only to reason but to nature itself, that you live by eating one another, all you being created in the same element, all of you citizens of the same homeland, and all of you, finally, brothers\"), noting on how big fish eating small fish is particularly perverse because the big ones cannot satisfy their hunger by eating the little ones one by one. He also remarks on how easily fish are tempted by just any old piece of cloth passing for bait dangling on a hook (Vieira here makes reference to the habits of the Portuguese orders of chivalry, overtly attacking the social elites). He then chastises specific fish on their particular vices:" }, { "id": "pubmed23n0841_13551", "title": "Tolerability to dogfish in children with fish allergy.", "score": 0.012349397590361445, "content": "Fish is a potent food allergen. The aim of this work is to demonstrate that dogfish, a small shark, has low allergenicity in both its clinical tolerance as well as its molecular structure. We present a study of 34 paediatric patients with IgE-mediated immediate reactions after eating fish. The diagnosis of several fish allergies was demonstrated by skin prick techniques and determination of specific IgE, in all the cases excluding sensitisation to Anisakis simplex. Open oral challenge test was checked with dogfish. Analysis was by SDS-PAGE of dogfish and other fish (megrim, shark, hake, sole, cod, anchovy and tuna) and Western-blot with \"pool\" of patients polysensitised sera against extracts of dogfish and other fish, and ELISA - inhibition with the \"pool\" sera. The prick-prick with raw dogfish was slightly positive in six patients, however cooked was negative in 34 cases. The specific IgE showed in the 34 cases class ≥2 for megrim, hake, sole, cod and anchovy, class 0 for tuna in 26 patients, class 0 for emperor in 18 patients and class 0 to Anisakis simplex in all cases. The IgE binding capacity for proteins of allergenic extracts of tested fish revealed, in immunoblotting, the absence of IgE-mediated recognition abstract dogfish by the \"pool\" of polysensitised patient sera. Testing in vivo and in vitro demonstrated the low allergenicity of dogfish. Dogfish brings an alternative to eating fish in polysensitised patients." }, { "id": "pubmed23n0344_15160", "title": "Dietary assessment in five cases of allergic reactions due to gastroallergic anisakiasis.", "score": 0.01222040370976541, "content": "Anisakis simplex can cause allergic reactions in sensitized patients. Some of these reactions are related to acute parasitism, as is shown in gastroallergic anisakiasis (anisakiasis with digestive and predominantly allergic symptoms). At present, a nonseafood diet is recommended for all patients with any kind of A. simplex allergy. We wished to confirm the clinical suspicion that patients with allergic symptoms after ingestion of raw or undercooked seafood who are sensitized to A. simplex, and diagnosed with gastroallergic anisakiasis, can tolerate the ingestion of seafood when the parasites are dead and noninfective. We included patients diagnosed with gastroallergic anisakiasis (positive skin prick test or/and serum specific IgE to A. simplex, with one or more parasites found by gastroscopy in the stomach). Patients included in the study gave written, informed consent. Specimens of A. simplex about 2 cm long were selected, placed in capsules, and frozen at -20 degrees C for more than 48 h to make them noninfective. We administered 11 specimens to every patient at the hospital. If they tolerated the larvae, they were told to eat well-frozen seafood (-20 degrees C at least 48 h). After 6 months, the patients were re-evaluated. Five patients accepted the challenge with noninfective A. simplex larvae. All tolerated the noninfective larvae. After eating deep-frozen seafood for 6 months, no patient suffered a reaction. In gastroallergic anisakiasis, the antigens of the live parasite probably cause the allergic symptoms. Patients with this disease can tolerate deep-frozen seafood, in which the parasites are dead." }, { "id": "wiki20220301en617_1933", "title": "Shellfish allergy", "score": 0.01212709192335678, "content": "Shellfish parasite The food-borne parasite Anisakis is a genus of nematodes known to be present in squid. Anisakis are directly infective to humans whenever infected squid (or marine fish) are consumed raw or slightly processed, causing a condition called anisakiasis. Symptoms from consuming live nematodes include severe abdominal pain, nausea, and vomiting. In addition, there can be an allergic reaction to Anisakis proteins, even if the food in question was frozen or cooked before being consumed, killing the nematodes, as some of the nematode proteins are resistant to cold and heat. Allergic reactions can include hives, asthma and true anaphylactic reactions." }, { "id": "pubmed23n0309_10070", "title": "Allergic reactions to anisakis simplex parasitizing seafood.", "score": 0.012084684574435539, "content": "The ingestion of Anisakidae ssp larvae parasitized fish can cause anisakiasis. Allergic reactions after ingestion of safely cooked but parasitized fish have been reported. Twenty-three patients who suffered allergic reactions after seafood ingestion, with negative skin tests were studied. Anisakis simplex sensitization was assessed by skin prick test and/or specific serum Immunoglobulin E (IgE). Total serum IgE and specific IgE against the implicated seafood and Ascaris lumbricoides were also determined. Manifestations of Anisakis simplex allergy were urticaria/angioedema (18/23) patients and anaphylaxis (5/23). Gastric symptoms were also observed (3/23). Sea fish and shellfish were implicated. Raw and cooked seafood ingestion caused reactions. Total serum IgE ranged from 13 to 7200 KU/L. Specific IgE to Anisakis simplex was positive (&gt; 0.35 KU/L) in all patients, and skin tests were positive in 20. Serum-specific IgE and skin tests to the involved seafoods were negative in every patient. Serum-specific IgE to Ascaris lumbricoides was negative in 13 patients. No association between total IgE and the eosinophil count (r &lt; 0.1) was observed, but there was some association between total IgE and specific IgE to Anisakis simplex (r = 0.58). Anisakis simplex sensitization is the cause of allergic reactions after seafood ingestion. It is important to pay attention to this new \"food allergy\" to diagnose correctly the etiology of adverse food reactions." }, { "id": "pubmed23n0306_1573", "title": "Anisakis simplex, a relevant etiologic factor in acute urticaria.", "score": 0.011970306217135789, "content": "Anisakis simplex, a parasite of fish and cephalopods, can induce IgE-mediated reactions. This study aimed to determine the etiologic role of A. simplex in patients affected by urticaria/angioedema (AE) or anaphylaxis. We studied 100 adult subjects suffering acute episodes of urticaria/AE, by anamnesis, prick tests with A. simplex and fish-mix extracts, and total and specific IgE to both A. simplex and cod. The following criteria of A. simplex allergy were considered: 1) urticaria/AE within 6 h after fish ingestion; 2) specific IgE to A. simplex; 3) positive prick test to A. simplex extract; 4) exclusion of other suspected causes. Double-blind, placebo-controlled food challenge was not carried out because ethical considerations forbid challenge with a parasite. Specific IgE to A. simplex (&gt; 0.7 kU/l) was found in 22 subjects, but only eight were diagnosed as having A. simplex allergy. Other allergens were involved in 37 patients, and 55 cases were considered idiopathic. Specific IgE to fish (&gt; 0.7 kU/l) was found in two patients, but only one was diagnosed as having fish allergy. We concluded that A. simplex is an important etiologic factor in acute urticaria. We suggest that it should be considered in cases of urticaria/AE or anaphylaxis, especially after fish ingestion." }, { "id": "wiki20220301en471_16105", "title": "Anisakis simplex", "score": 0.011963357943669675, "content": "The allergic symptoms caused by A. simplex can be alleviated by anti-histamines, or other treatments that are commonly used for allergies. Prevention The elimination of raw or semi-cooked seafood is the most effective prevention method. According to FDA guidelines, seafood should be cooked at a temperature of at least 63° C, and fish should be stored at a maximum temperature of -20°C for 7 days or -35°C for 15 hours for safe consumption. However, the allergens in A. simplex cannot be removed by heating or freezing processes. See also List of parasites of humans References Further reading Parasitic nematodes of humans Parasitic nematodes of fish Parasitic nematodes of mammals Marine mammals Zoonoses Ascaridida Nematodes described in 1809 Taxa named by Karl Rudolphi" }, { "id": "pubmed23n0377_6866", "title": "[Anisakiasis: a borderline disorder].", "score": 0.011853226138940425, "content": "Anisakis simplex is a nematode which can parasitize many different kinds of fish or cephalopods (codfish, salmon, tuna, mackerel, hake, etc). Anisakis simplex can cause different diseases in humans. The human being acquires the larvae by eating raw or undercooked seafood. Acute anisakiasis is probably caused by an inflammatory and/or allergic response in the digestive tract mucosa with abdominal pain. It can also induce IgE-mediated reactions with several clinical manifestations ranging from urticaria/angioedema to anaphylaxis. Chronic anisakiasis results from abscesses or eosinophilic granulomas caused by parasite invasion. This later form can mimic appendicitis, duodenal ulcer, inflammatory bowel diseases and intestinal obstruction. An early gastroduodenoscopy can confirm the diagnosis and prevent the complications. Serodiagnosis of anisakiasis is difficult since many Anisakis antigens show cross-reativity complications. In fact many people have high IgE titles in the absence of obvious allergic reactions to seafoods. As preventive measures heating for 10 min over 65 degrees C or freezing (minus 20 degrees for 24 h) destroys the infectivity of the larval stage but not always prevent allergic reactions." }, { "id": "pubmed23n1025_24460", "title": "Anisakis spp. as etiological agent of zoonotic disease and allergy in European region – an overview", "score": 0.011795166858457998, "content": "Nematodes of the genus Anisakis are worldwide distributed marine species parasitized many fish and cephalopod species as larvae and sea mammals as adult form. Anisakiosis as food-borne disease is an important public health problem worldwide. Human become infected by eating raw or undercooked fish or squids. Well documented are gastrointestinal response to infection but increasingly allergic symptoms were observed also after eating well cooked fish. This is because some of allergens of Anisakis are thermostable and resistant to pepsin treatment. Due to a significant increase in human mobility and global transport of fresh products like fish on ice, food-borne diseases require educational campaigns that pay attention to threats in various parts of the world." }, { "id": "pubmed23n0875_18943", "title": "Changes over Time in IgE Sensitization to Allergens of the Fish Parasite Anisakis spp.", "score": 0.01170076726342711, "content": "Sensitization to Anisakis spp. can produce allergic reactions after eating raw or undercooked parasitized fish. Specific IgE is detected long after the onset of symptoms, but the changes in specific IgE levels over a long follow-up period are unknown; furthermore, the influence of Anisakis spp. allergen exposure through consumption of fishery products is also unknown. To analyse the changes in IgE sensitization to Anisakis spp. allergens over several years of follow-up and the influence of the consumption of fishery products in IgE sensitization. Total IgE, Anisakis spp.-specific IgE, anti-Ani s 1 and anti-Ani s 4 IgE were repeatedly measured over a median follow-up duration of 49 months in 17 sensitized patients. Anisakis spp.-specific IgE was detected in 16/17 patients throughout the follow-up period. The comparison between baseline and last visit measurements showed significant decreases in both total IgE and specific IgE. The specific IgE values had an exponential or polynomial decay trend in 13/17 patients. In 4/17 patients, an increase in specific IgE level with the introduction of fish to the diet was observed. Three patients reported symptoms after eating aquaculture or previously frozen fish, and in two of those patients, symptom presentation was coincident with an increase in specific IgE level. IgE sensitization to Anisakis spp. allergens lasts for many years since specific IgE was detectable in some patients after more than 8 years from the allergic episode. Specific IgE monitoring showed that specific IgE titres increase in some allergic patients and that allergen contamination of fishery products can account for the observed increase in Anisakis spp.-specific IgE level. Following sensitization to Anisakis spp. allergens, the absence of additional exposure to those allergens does not result in the loss of IgE sensitization. Exposure to Anisakis spp. allergens in fishery products can increase the specific IgE level in some sensitized patients." }, { "id": "pubmed23n0570_10172", "title": "Sensitization to the fish parasite Anisakis simplex: clinical and laboratory aspects.", "score": 0.0115777194517352, "content": "Hypersensitivity to Anisakis simplex is a worldwide medical problem. The parasite larvae die after freezing or cooking, but the tolerance of sensitized subjects to eating frozen fish remains a matter of controversy with contradictory findings. The aim of this study was to test if intolerance to properly cooked/frozen fish was due to the recognition of a particular allergen. Sixty-four patients with Anisakis simplex sensitization were studied by an IgE multiblot using simultaneously five different antigenic extracts. The antigens tested were a crude extract, excretory/secretory allergens, a heated extract, and two gradient ethanol precipitates of the crude extract. Intolerance was reported by 20% of the patients and was not related to the detection of any special allergen, nor to total or specific IgE levels. Intolerant patients only reported a higher frequency of digestive symptoms than the patients who tolerated fish ingestion. The most sensitive immunoblot antigen source was the 50-66% ethanol fraction of a crude extract (10x concentrated) that was found to be positive in 100% of the samples. Interestingly, 95% sensitivity in the IgE-immunoblot assay could be achieved using only two allergens, Ani s 1 and Ani s 4. Allergens from the dead larvae remain a problem for 20% of the sensitized subjects. The use of a fractionated and concentrated crude extract improved the sensitivity of the immunoblot assay." }, { "id": "pubmed23n0416_21524", "title": "Anisakiasis of the colon presenting as bowel obstruction.", "score": 0.011382344592676697, "content": "Anisakiasis is a disease caused by human infection by the Anisakis larvae, a marine nematode found in raw or undercooked fish. With the increased popularity of eating sushi and raw fish (sashimi) in the United States infection with anisakis is expected to rise. We present the first reported case in the United States of intestinal anisakiasis presenting as a bowel obstruction. A 25-year-old healthy woman with no prior history of surgery presented to the emergency room with bowel obstruction by history and CT. CT also showed a mass in the right lower quadrant. She had eaten seviche, a raw fish appetizer, 2 days earlier and sashimi 3 weeks before admission. She was taken to the operating room for an exploratory laparotomy and was found to have an obstruction, the 2-cm mass in the mesentery, and diffuse mesenteric adenopathy. She had an ileocolectomy. Pathology showed a degenerating fish worm, anisakiasis. She also had a serologic test for immunoglobulin E specific to anisakiasis and it was highly positive. Human infections, as mentioned before, are principally the result of ingestion of the Anisakis larvae. These larvae are usually found in herring, mackerel, salmon, cod, halibut, rockfish, sardine, and squid. Most human infections have been reported from Japan and The Netherlands and involve the stomach. Invasion of the gastric or intestinal wall one to 5 days after eating raw fish may be characterized by the abrupt onset of abdominal pain, nausea and/or vomiting, diarrhea, or an ileus. For transient anisakiasis, supportive measures and reassurance are all that is needed. If the larvae have invaded the intestine or the stomach wall diagnosis and cure occur with endoscopic or surgical removal if evidence of obstruction or perforation is found. The incidence of anisakiasis in the United States is unknown but will likely continue to increase with the popularity of eating sashimi. This case is meant to demonstrate another possible cause for bowel obstruction in the patient who has just eaten raw or undercooked fish." }, { "id": "pubmed23n0650_8950", "title": "[A case of an allergic reaction due to Anisakis simplex after the ingestion of salted fish guts made of Sagittated calamari: allergen analysis with recombinant and purified Anisakis simplex allergens].", "score": 0.011326957561267184, "content": "A 75-year-old man ingested salted fish guts made of Sagittated calamari which he caught in the daytime, with alcohol and then dozed. Five hours later, he woke up due to itching over his entire body and noticed generalized urticaria and a swollen tongue, which was too large for him to close his mouth. Serum total IgE was 456 IU/ml and ImmunoCAP was positive for anisakis, but negative for squid, shrimp, and ascaris. A skin prick test (SPT) was positive for anisakis extract (10 mg/ml) and house dust mites, but negative for squid and shrimp. He was diagnosed with IgE-mediated allergy due to Anisakis simplex after the ingestion of salted fish guts made of Sagittated calamari, which had been parasitized by Anisakis simplex. Furthermore, we performed SPT with six extracts of purified or recombinant allergens (Ani s 1, 3, 4, 5, 6, and 8) to identify the causative allergens in this case. Only Ani s 3 (tropomyosin) was positive, indicating that Ani s 3 was the causative allergen in this case. Third stage larvae of the nematode Anisakis simplex often parasitize not only marine fish but also invertebrates, including squid. It is necessary to consider Anisakis simplex allergy for urticarial reactions that develop after the ingestion of squid." }, { "id": "pubmed23n0476_19913", "title": "Gingivostomatitis after eating fish parasitized by Anisakis simplex: a case report.", "score": 0.011159659896079357, "content": "Anisakis simplex (AS) is a nematode that may be encountered as a parasite in various kinds of seafood. Human beings may accidentally acquire AS larvae by eating raw or undercooked seafood. In addition to human parasitization (anisakiasis), this nematode can induce allergic reactions. AS-related diseases are frequent, especially in those countries with a high level of fish consumption and with traditions of eating raw or undercooked seafood. To our knowledge, this is the first report of gingivostomatitis secondary to the ingestion of fish with AS parasites." }, { "id": "pubmed23n0480_2593", "title": "[Anisakis and anisakiosis].", "score": 0.011072685353719209, "content": "The nematode Anisakis simplex (AS) is a world wide distributed parasite that infects consumers of raw or undercoocked parasitized fish. The clinical manifestation of Anisakiosis depend on the site in the digestive tract in which larva lodges. The symptoms develops as a result of the inflammation when the larvae penetrates the gastric mucous. Most of asymptomatic subjects show high levels of specific IgE to AS. Diagnosis of AS allergy is not simple, due to cross-reactivity with other allergens. In childhood is more difficult to make a right diagnosis than in adult population. Most of positive prick test to AS correspond to children with positive prick tests to other allergens. Cross-reactivity between this parasite and other parasites with a higher prevalence in childhood, is the cause of a false diagnosis. The secretor-excretory antigen shows a better specificity, recognizing the true parasitized patients. This antigen could be used as indicator of parasitization. To follow prevention rules AS, avoid consumption of raw fish unless frozen for 48 hours or ingestion of fresh fish always cooked for more than 20 minutes at least at 60 C." }, { "id": "pubmed23n1021_7587", "title": "First case of human anisakiasis in Poland.", "score": 0.01103061335657479, "content": "Consumption of raw or inadequately processed marine fish may result in anisakidosis - a zoonotic disease caused by larvae of the parasitic nematodes of the family Anisakidae (anisakiasis when caused by members of the genus Anisakis (Nematoda: Anisakidae)), commonly found in a variety of marine fish species all over the world. Most cases of anisakidosis have been detected in the residents of Japan and South Korea, which results from the tradition of eating raw and semi-raw fish dishes. However, the disease is now increasingly often diagnosed in other parts of the world, including Europe (mainly in Spain and Italy). In Poland, no cases of human infection with anisakid nematodes have been detected so far. In this study, we report the first case of gastric anisakiasis in Poland, in a 59-year-old female patient, after eating raw Atlantic salmon (Salmo salar). The parasite was identified as the third-stage larva of Anisakis simplex sensu stricto on the basis of morphology and molecular analysis. The larva was still alive and causing pain until it was removed, which occurred more than 5 weeks after infection. The described case prove that anisakiasis should be considered as a potential cause of gastrointestinal tract ailments following the consumption of seafood in countries where no cases of this zoonosis have been reported to date." } ] } } }

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{ "1": "Urgent surgical treatment.", "2": "Biliary drainage by percutaneous cholecystostomy.", "3": "Replace piperacillin-tazobactam with metronidazole-cefotaxime.", "4": "Replace piperacillin-tazobactam with amikacin-clindamycin.", "5": "Add an aminoglycoside such as gentamicin to the treatment." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en059_34174", "title": "Piperacillin", "score": 0.009900990099009901, "content": "Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis. Piperacillin is used to treat patients diagnosed with various internal infections such as abdominal, bacteremia, gynecological, respiratory, and urinary, mainly caused by Pseudomonas aeruginosa and other infectious bacteria. They are primarily used in current and former neutropenic patients, and patients with biliary tract infections. Other uses include applications in surgical infection prophylaxis; in biliary surgery, a single dose of piperacillin is administered intravenously to inhibit the development of acute cholangitis and prevent wound infections. The combination of piperacillin and an aminoglycoside is commonly used to treat severe infections, but due to the incompatibilities in drug interaction, they are administered separately." }, { "id": "wiki20220301en109_29982", "title": "Spanish conquest of the Aztec Empire", "score": 0.009900990099009901, "content": "1520" }, { "id": "InternalMed_Harrison_10725", "title": "InternalMed_Harrison", "score": 0.009862346818868557, "content": "for 14 days) also is effective for treatment of acute uncomplicated pyelonephritis if the uropathogen is known to be susceptible. If the pathogen’s susceptibility is not known and TMPSMX is used, an initial IV 1-g dose of ceftriaxone is recommended. Oral β-lactam agents are less effective than the fluoroquinolones and should be used with caution and close follow-up. Options for parenteral therapy for uncomplicated pyelonephritis include fluoroquinolones, an extended-spectrum cephalosporin with or without an aminoglycoside, or a carbapenem. Combinations of a β-lactam and a β-lactamase inhibitor (e.g., ampicillin-sulbactam, ticarcillinclavulanate, piperacillin-tazobactam) or imipenem-cilastatin can be used in patients with more complicated histories, previous episodes of pyelonephritis, or recent urinary tract manipulations; in general, the treatment of such patients should be guided by urine culture results. Once the patient has responded clinically, oral therapy should be substituted" }, { "id": "wiki20220301en059_34175", "title": "Piperacillin", "score": 0.00980392156862745, "content": "Pneumonia The piperacillin-tazobactam (piptaz) antibiotic commonly used with an aminoglycoside retains similar levels of drug safety and efficacy as other antibiotic combinations such as ceftazidime with the aminoglycoside tobramycin in the treatment of patients with hospital acquired pneumonia. In a clinical comparison primarily targeting patients not initially placed in intensive care units, piperacillin-tazobactam was found to produce higher clinical and microbiological rates of success. By contrast, the drug efficacy of ceftazidime and piperacillin-tazobactam resulted in similar response rates (61.5% and 63.9 respectively) when tobramycin was added into both groups. Identical evaluations are shown when compared to the imipenem and tobramycin combination, where the administration of piperacillin-tazobactam on patients (especially those under mechanical ventilation) was only consisted of a slightly higher response rate." }, { "id": "wiki20220301en109_29985", "title": "Spanish conquest of the Aztec Empire", "score": 0.00980392156862745, "content": "1521" }, { "id": "wiki20220301en166_44924", "title": "WHO Model List of Essential Medicines", "score": 0.009708737864077669, "content": "Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquineα Cysticidal medicines Albendazoleα Mebendazoleα Praziquantelα Antibacterials Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Spectinomycin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Trimethoprim Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidimeα Meropenemα Vancomycinα" }, { "id": "pubmed23n0026_3569", "title": "[Comparative clinical studies of the effectiveness of the most frequently used antibiotics in the period of 1961-1970].", "score": 0.009708737864077669, "content": "The results from the treatment of 1086 patients, treated at the Therapeutic Clinic, HMI- Sofia were followed up for the period 1961-1970 incld. Acute bacterial and vuris-bacterial pneumonias were found in 318 patients, 475 of the patients were with exacerbated chronic bronchitis and bronchiectasis, with exacerbated chronic pyelo-nephritis -216 patients and with exacerbated chronic cholecystitis and cholangiohepatitis --92 patients. The effect of the treatment was determined according to a three-stage scale \"good\" with complete clinical healing (in acute pneumonia), with \"improvement\"--with complete clinical remission (in chronic infections) and \"without effect\". Clinical and paraclinical indices were used as criteria in the determination of the effectiveness. The data are statistically processed according to the method of variation analysis. In patients with acute pneumonia the- best effectiveness was manifested by tetraolean (88,7 per cent), tetracylins (77,8 per cent), chloramphenicol (76,8 per cent), penicillin (72,5 per cent), the combination penicillin-streptomycin (71,9 per cent); in patients with exacerbated chronic bronchitis--tetraolean (88,0 per cent), chloramphenicol (73,2 per cent), tetracylins (65,3 per cent); in patients with exacerbated chronic pyelonephritis - chloramphenicol (65,5 per cent); in patients with exacerbated chronic cholecystitis and cholecysto-cholangiohepatitis-tetraolean (70,7 per cent), tetracyclins (66,7 per cent), chloramphenicol (66,1 per cent)." }, { "id": "wiki20220301en059_34208", "title": "Piperacillin/tazobactam", "score": 0.009615384615384616, "content": "Piperacillin/tazobactam was approved for medical use in the United States in 1993. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. Medical uses Its main uses are in intensive care medicine (pneumonia, peritonitis), some diabetes-related foot infections, and empirical therapy in febrile neutropenia (e.g., after chemotherapy). The drug is administered intravenously every 6 or 8 hr, typically over 3–30 min. It may also be administered by continuous infusion over four hours. Prolonged infusions are thought to maximize the time that serum concentrations are above the minimum inhibitory concentration (MIC) of the bacteria implicated in infection. Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as first-line therapy for the treatment of bloodstream infections in neutropenic cancer patients." }, { "id": "InternalMed_Harrison_11649", "title": "InternalMed_Harrison", "score": 0.009615384615384616, "content": "For outpatient management, amoxicillin (1 g every 8 h) provides effective treatment for virtually all cases of pneumococcal pneumonia. Neither cephalosporins nor quinolones, which are far more expensive, offer any advantage over amoxicillin. Levofloxacin (500–750 mg/d as a single dose) and moxifloxacin (400 mg/d as a single dose) also are highly likely to be effective in the United States except in patients who come from closed populations where these drugs are used widely or who have themselves been treated recently with a quinolone. Clindamycin (600–1200 mg/d every 6 h) is effective in 90% of cases and azithromycin (500 mg on day 1 followed by 250–500 mg/d) or clarithromycin (500–750 mg/d as a single dose) in 80% of cases. Treatment failure resulting in bacteremic disease due to macrolide-resistant isolates has been amply documented in patients given azithromycin empirically. As noted above, rates of resistance to all these antibiotics are relatively low in some countries and much" }, { "id": "wiki20220301en521_16277", "title": "WHO Model List of Essential Medicines for Children", "score": 0.009523809523809525, "content": "Antifilarials Albendazole Diethylcarbamazine Ivermectin Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquine Antibiotics Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidime Meropenem Vancomycin Reserve group antibiotics Ceftazidime/avibactam (ceftazidime + avibactam) Colistin Fosfomycin Linezolid Polymyxin B Antileprosy medicines Clofazimine Dapsone Rifampicin" }, { "id": "pubmed23n0387_20620", "title": "[Objectives for antibiotic therapy in acute exacerbations of chronic bronchitis].", "score": 0.009523809523809525, "content": "ANTIBIOTIC EFFICACY: According to early studies, antibiotics have moderate efficacy in acute exacerbation of chronic bronchitis. The lack of efficacy is particularly clear for patent exacerbation with marked alteration of respiratory function. Recent studies have shown that newer compounds exhibit an efficacy similar (no proven superiority) to comparison compounds (75 to 95% favorable outcome with treatment). The recommendations of the IVth Consensus Conference on Anti-infectious Therapy thus propose first line antibiotic therapy for patients with a forced expiratory volume in 1 second (FEV1) between 80 and 35% and broader spectrum and new antibiotics in case of failure of the first line treatment for patients with severe obstruction or frequently recurrent exacerbation. Using exacerbation-free interval, reduction in the number of exacerbations, duration of treatment and/or hospital stay as evaluation criteria, interesting results are obtained with amoxicillin/clavulanic acid, azithromycin, and ciprofloxacin. Independent factors predictive of therapeutic failure are, according to one study, FEV1 less than 35%, ambulatory administration of oxygen, more than 4 acute exacerbations within 24 months, history of pneumonia or sinusitis, and requirement for long-term corticosteroid therapy. Factors predictive of recurrence are, according to another study, dependence on oxygen therapy, prolonged corticosteroid therapy, smoking, and/or heart disease. Cost effectiveness is particularly interesting with ciprofloxacin, especially in more severe patients. It is important to target antibiotic therapy for acute exacerbation of chronic bronchitis specifically for patients who will truly benefit, adapting the prescribed compound to the bacterial target." }, { "id": "wiki20220301en059_34180", "title": "Piperacillin", "score": 0.009433962264150943, "content": "Following two studies conducted in 1986 and 2006, piperacillin was found to inhibit the removal of methotrexate in animal kidneys. Furthermore, in the presence of piperacillin-tazobactam, the decay time for methotrexate triples in comparison to the normal half-life, leaving the patient exposed to cytotoxic effects produced by the chemical agent. While penicillin antibiotics generally work synergistically with aminoglycosides by enhancing their penetration of bacterial membranes, they can also work adversely by inactivating them. A reformulation of ethylenediaminetetraacetic acid and piperacillin-tazobactam has produced results showing an increase in their affinity with amikacin and gentamicin in vitro, enabling the process of simultaneous Y-site infusion to occur. However, tobramycin was found to be incompatible as a combination through Y-site infusion." }, { "id": "wiki20220301en633_21607", "title": "History of the Later Roman Empire", "score": 0.009433962264150943, "content": "Divided empire" }, { "id": "wiki20220301en084_10424", "title": "Chorioamnionitis", "score": 0.009345794392523364, "content": "Treatment The American College of Obstetricians and Gynecologists' Committee Opinion proposes the use of antibiotic treatment in intrapartum mothers with suspected or confirmed chorioamnionitis and maternal fever without an identifiable cause. Intrapartum antibiotic treatment consists of: Standard Ampicillin + gentamicin Alternative Ampicillin/sulbactam Ticarcillin/clavulanate Cefoxitine Cefotetan Piperacillin/tazobactam Ertapenem Cesarean delivery Ampicillin and gentamicin plus either clindamycin or metronidazole Penicillin-allergy Vancomycin + gentamicin Gentamicin + clindamycin" }, { "id": "wiki20220301en052_964", "title": "Age of Empires", "score": 0.009345794392523364, "content": "Historical elements" }, { "id": "wiki20220301en195_22213", "title": "Febrile neutropenia", "score": 0.009259259259259259, "content": "In 2010, updated guidelines were issued by the Infectious Diseases Society of America, recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), or piperacillin/tazobactam for high-risk patients and amoxicillin-clavulanic acid and ciprofloxacin for low-risk patients. Patients who do not strictly fulfill the criteria of low-risk patients should be admitted to the hospital and treated as high-risk patients. Research to compare antibiotic treatments currently recommended in consensus guidelines identified 44 studies comparing different antibiotics. Significantly higher mortality was reported for cefepime compared to all other antibiotics combined. Piperacillin/tazobactam resulted in lower mortality than other antibiotics. Piperacillin/tazobactam might be the preferred antibiotic for the treatment of cancer patients with fever and neutropenia, while cefepime should not be used." }, { "id": "wiki20220301en062_67208", "title": "Aztec Empire", "score": 0.009259259259259259, "content": "Goddesses" }, { "id": "wiki20220301en337_7076", "title": "Anaerobic infection", "score": 0.009174311926605505, "content": "Empiric antibiotic therapy for health care-associated intra-abdominal should be driven by local microbiologic results. Empiric coverage of likely pathogens may require multidrug regimens that include agents with expanded spectra of activity against gram-negative aerobic and facultative bacilli. These include meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. Aminoglycosides or colistin may be required. Antimicrobial regimens for children include an aminoglycoside-based regimen, a carbapenem (imipenem, meropenem, or ertapenem), a beta-lactam/beta-lactamase-inhibitor combination (piperacillin-tazobactam or ticarcillin-clavulanate), or an advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole." }, { "id": "wiki20220301en109_30079", "title": "Spanish conquest of the Aztec Empire", "score": 0.009174311926605505, "content": "Secondary sources" }, { "id": "wiki20220301en059_34173", "title": "Piperacillin", "score": 0.00909090909090909, "content": "Medical uses Piperacillin is used almost exclusively in combination with the beta lactamase inhibitor tazobactam for the treatment of serious, hospital-acquired infections. This combination is among the most widely used drug therapies in United States non-federal hospitals, accounting for $388M in spending in spite of being a low-cost generic drug. Piperacillin-tazobactam is recommended as part of a three-drug regimen for the treatment of hospital-acquired pneumonia suspected as being due to infection by multi-drug resistant pathogens. It is also one of several antibacterial drugs recommended for the treatment of infections known to be caused by anaerobic Gram-negative rods. Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis." }, { "id": "pubmed23n0001_1508", "title": "[Proceedings: Long-term therapy with antibiotics in chronic bronchitis].", "score": 0.00909090909090909, "content": "Longterm therapy of chronic bacterial bronchitis assumes two forms: (a) therapy of acute exacerbations, and (b) continuous longterm prophylaxis, chiefly during the 4-7 winter months. Longterm prophylaxis should be confined exclusively to patients with two or more severe annual exacerbations. The commonest pathogens, Haemophilus influenzae and pneumococci, are usually sensitive to ampicillin and amoxycillin, cotrimoxazole (Bactrim or Eusaprim) and tetracyclines." }, { "id": "pubmed23n0545_11961", "title": "[Controlled, open, parallel-group study of the clinical and microbiological efficacy of piperacillin-tazobactam versus metronidazole + gentamicin in urgent colorectal surgery].", "score": 0.009009009009009009, "content": "Antibiotic treatment is an important element in infection control after urgent abdominal surgery. The aim of this study was to determine the therapeutic efficacy of piperacillin-tazobactam versus a combination of 2 antibiotics (metronidazole and gentamicin) in patients undergoing urgent appendicular and/or colorectal surgery. The study period comprised December 1998 to December 2002. A total of 183 patients who required urgent surgery for colon disease and/or severe acute appendicitis were prospectively and randomly included. Patients were randomly distributed in 2 groups. Group A received piperacillin-tazobactam (4/0.5/8 h/i.v.) and group B received metronidazole (500 mg/i.v./8 h) plus gentamicin (5 mg/kg/i.v./24 h). Treatment was started between 30 and 60 minutes prior to surgery and was continued for at least 3 days. The incidence of wound infection in patients who underwent surgery for colon disease and acute appendicitis was lower when they were treated with piperacillin-tazobactam (P&lt; .05). The incidence of intraperitoneal abscess in the group of patients who underwent surgery for severe acute appendicitis was lower when they were treated with piperacillin-tazobactam. Microbiological analyses revealed that there was a predominance of infection due to Escherichia coli. The association of piperacillin-tazobactam was more effective than that of metronidazole and gentamicin in the prevention and treatment of local infection in the treated groups. Therapeutic failure was mainly related to the presence of gram-negative bacteria." }, { "id": "wiki20220301en140_52527", "title": "Gajapati Empire", "score": 0.009009009009009009, "content": "History" }, { "id": "pubmed23n0251_18812", "title": "Piperacillin/tazobactam in comparison with clindamycin plus gentamicin in the treatment of intra-abdominal infections.", "score": 0.008928571428571428, "content": "Concerned about the inactivation of piperacillin by beta-lactamase and the risk of aminoglycoside-induced nephrotoxicity and clindamycin-induced enterocolitis, we conducted the following phase III clinical trial. Between November 1991 and March 1993, 77 surgical patients with intraabdominal infections were enrolled and randomly assigned in a 3:2 ratio to receive either piperacillin/tazobactam or clindamycin plus gentamicin to compare safety, tolerance and efficacy between both two treatment groups. There were 76 clinically and 50 bacteriologically evaluable patients with 80 isolated pathogens. The demographic data were comparable in both groups. There was no statistically significant difference of clinical response at any time-point of treatment, with 97.8% favorable clinical response rate in piperacillin tazobactam group and 96.6% in clindamycin plus gentamicin group at endpoint. The bacteriological eradication rates were similar, with 97.7% in piperacillin/tazobactam group and 94.4% in clindamycin plus gentamicin group at pathogen level, and 96.7% in piperacillin/tazobactam group and 95.0% in clindamycin plus gentamicin group at patient level. By susceptibility tests, only 3 (4%) isolated pathogens were resistant to piperacillin/tazobactam, which was much superior to the use of piperacillin, clindamycin or gentamicin alone in antimicrobial activity. The piperacillin tazobactam-related adverse experiences included 1 (2.1%) urticaria and 2 (4.3%) diarrhea. However, there were no significant differences in the adverse experiences between these two groups. This study has demonstrated that piperacillin/tazobactam is comparable with clindamycin plus gentamicin in efficacy, safety and tolerance in the treatment of surgical patients with intra-abdominal infections. The combination of piperacillin/tazobactam could potentially be the treatment of choice in adjunt to surgical management in intra-abdominal infection." }, { "id": "wiki20220301en093_44301", "title": "History of penicillin", "score": 0.008928571428571428, "content": "Early scientific evidence" }, { "id": "InternalMed_Harrison_12423", "title": "InternalMed_Harrison", "score": 0.008910960834037756, "content": "treatment of patients who are colonized but not infected (e.g., who have a positive sputum culture without evidence of pneumonia). At present, the most reliably active agents against enteric GNB are the carbapenems (e.g., imipenem), the aminoglycoside amikacin, the fourth-generation cephalosporin cefepime, the β-lactam/β-lactamase inhibitor combination piperacillin-tazobactam, and the polymyxins (e.g., colistin or polymyxin B). The number of antimicrobials effective against certain Enterobacteriaceae is shrinking. Truly pan-resistant GNB exist, and it is unlikely that new agents will come to market in the short term. Accordingly, the presently available antimicrobials must be used judiciously." }, { "id": "pubmed23n0250_20393", "title": "Results of the North American trial of piperacillin/tazobactam compared with clindamycin and gentamicin in the treatment of severe intra-abdominal infections. Investigators of the Piperacillin/Tazobactam Intra-abdominal Infection Study Group.", "score": 0.008849557522123894, "content": "A total of 192 men and 139 women aged 15 to 89 years with diagnosed intra-abdominal infection were randomised in a 2:1 ratio to treatment with either intravenous piperacillin/tazobactam (3 g/375 mg every six hours) or clindamycin (600 mg every six hours) plus gentamicin (2.5 mg to 5.0 mg/kg every eight to 12 hours) in a multicentre trial. Of 147 evaluable patients with microbiologically confirmed infections, 104 were treated with piperacillin/tazobactam and 43 with clindamycin plus gentamicin. The diagnoses of perforated appendicitis (n = 79), other peritonitis (n = 32), cholecystitis/cholangitis (n = 18), intraabdominal abscess (n = 14), and diverticulitis (n = 3), were distributed proportionately between the two therapeutic groups. Ninety one of 104 patients (88%) in the piperacillin/tazobactam group and 33 of 43 patients (77%) in the clindamycin plus gentamicin group were considered cured or improved (p = 0.13). In the piperacillin/tazobactam group, 80 of 88 (91%) Bacteroides fragilis group organisms and 68 of 74 (92%) E coli isolates were eradicated; in the clindamycin plus gentamicin group, 21 of 25 (84%) Bacteroides fragilis group isolates and 23 of 30 (76%) E coli isolates were eradicated. Eleven evaluable patients in the piperacillin/tazobactam group had beta-lactamase-producing organisms that were resistant to piperacillin but susceptible to piperacillin/tazobactam; in 10 of these patients (91%) bacteria were eradicated. We conclude that piperacillin/tazobactam is an effective antimicrobial drug for monotherapy of intra-abdominal infections, with efficacy similar to or better than standard aminoglycoside/anti-anaerobe combinations." }, { "id": "wiki20220301en071_59838", "title": "Empiric therapy", "score": 0.008849557522123894, "content": "See also Broad-spectrum antibiotic References Therapy" }, { "id": "wiki20220301en059_34178", "title": "Piperacillin", "score": 0.008771929824561403, "content": "Adverse effects Common side effects associated with the administration of piperacillin-tazobactam include: Gastrointestinal: constipation, diarrhea, nausea, vomiting Dermatologic: erythema, pain, phlebitis, rash Neurologic: headaches, insomnia Prolonged periods of piperacillin-tazobactam therapy have been associated with the potential development of hematologic adversities such as leukopenia (16.3%), neutropenia (10%), and eosinophilia (10%) in adult patients. The combination of piperacillin-tazobactam with other antibiotics was found to be a major risk factor for leukopenia as well. Additionally, the chances of developing these illnesses increases in younger patients suffering from fewer conditions, prolonging their time to recover." }, { "id": "wiki20220301en109_29981", "title": "Spanish conquest of the Aztec Empire", "score": 0.008771929824561403, "content": "8 November 1519 – Meeting of Cortés and Moctezuma November 1519" }, { "id": "wiki20220301en071_56095", "title": "Ventilator-associated pneumonia", "score": 0.008695652173913044, "content": "Risk factors for infection with an MDR strain include ventilation for more than five days, recent hospitalization (last 90 days), residence in a nursing home, treatment in a hemodialysis clinic, and prior antibiotic use (last 90 days). Possible empirical therapy combinations include (but are not limited to): vancomycin/linezolid and ciprofloxacin, cefepime and gentamicin/amikacin/tobramycin vancomycin/linezolid and ceftazidime Ureidopenicillin plus β-lactamase inhibitor such as piperacillin/tazobactam or ticarcillin/clavulanate a carbapenem (e.g., imipenem or meropenem) Therapy is typically changed once the causative bacteria are known and continued until symptoms resolve (often 7 to 14 days). For patients with VAP not caused by nonfermenting Gram-negative bacilli (like Acinetobacter, Pseudomonas aeruginosa) the available evidence seems to support the use of short-course antimicrobial treatments (< or =10 days)." }, { "id": "pubmed23n0327_6217", "title": "[Our experience in introducing current antibiotic prophylaxis into abdominal surgery--the initial results].", "score": 0.008695652173913044, "content": "Over a one-year period (Nov. 1996-Nov. 1997), a total of 154 patients are admitted on an emergency basis, with deferred emergency and for routine treatment in the Clinic of Emergency Surgery. They are distributed in three groups, as follows: patients not requiring perioperative antibiotic prophylaxis and postoperative antibiotic therapy--27, patients subjected to perioperative parenteral antibiotic prophylaxis under adequate hospital conditions--121, and patients undergoing antibiotic prophylaxis in conditions inappropriate for its application--six. The drug schemes elaborated are in conformity with worldwide and Bulgarian experience along this line, and with the concrete hospital and economical conditions in this country. In all patient indicated for antibiotic prophylaxis the listed below antibacterial agents (presented as drug schemes) are administered i.v. a single time prior to anesthesia induction: in operations on the gastrointestinal tract except for interventions in acute appendicitis: cephalotin/cefazolin 2.0 g and metronidazole 0.5 g i.v.; in operations for acute appendicitis: amoxicillin/clavulanate 1.2 g and petronidazole 0.5 f i.v.; biliary surgery free of extrahepatic cholestasis: cephalotin/cefazolin 2.0 g i.v.; biliary surgery with present or preceding extrahepatic cholestasis: cefotetan 2 g i.v.; contaminated liver cysts (parasitic and nonparasitic): cefotetan 2 g i.v.; abdominal trauma without perforation of a hollow organ: cefotetan 2 g i.v.; in plastic repair of the anterior abdominal wall (congenital defects, postoperative eventration) and in poor risk patients (local and general status: cephalotin/cefazolin 2.0 g i.v. In 135 patients the postoperative period runs a course free of complications worthy of notice. Complications directly linked to introduction of the method proposed are recorded in ten cases: operative wound suppuration (4) and hospital infection (6). Complications not related directly to the procedure are observed in nine cases: urinary tract infection (4), bronchopneumonia (2), fever with unknown source of infection (including negative hemoculture) necessitating additional antibiotic therapy (2) and secondary infection (within a week of intervention) necessitating further therapy with antibiotics. The specific features of antibiotic prophylaxis used in the various types of operative interventions are discussed from microbiological, clinical and pharmacotherapeutic viewpoints. The obtained results are compared with pertinent literature data on the issue with a special reference to the clinical efficacy attained. They mirror the approach against the background of the concrete hospital conditions in this country. The method developed is fully consistent with the level of surgical expertise in Bulgaria. All efforts should be aimed at intrahospital environment improvement by means of meticulous asepsis and antisepsis." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 221, 344 ] ], "word_ranges": [ [ 34, 49 ] ], "text": "Characteristic of Epstein-Barr infectious mononucleosis is the appearance of macular rash after treatment with amoxicillin." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 90, 220 ] ], "word_ranges": [ [ 15, 34 ] ], "text": "Although a similar picture may occur in acute toxoplasmosis, less than 1% of acute toxoplasma infections present as mononucleosis." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "It is a typical picture of infectious mononucleosis.", "2": "Varicella zoster infection.", "3": "Acute toxoplasmosis.", "4": "Lyme disease.", "5": "Infection by herpes virus 8." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0559_10414", "title": "Screening tests for diagnosis of cervical lymphadenopathy presenting as prolonged fever.", "score": 0.016335978835978836, "content": "During a two years period, 16 cases having cervical lymphadenopathy presenting as prolonged fever were studied in Abbassia fever hospital, Cairo, Egypt. Patients were subjected to careful history, thorough clinical examination, complete blood picture, tuberculin test, chest x-ray, Monospot test, indirect fluorescent antibody test for toxoplasmosis, detection of cytomegalovirus antibodies and lymph node biopsy with histopathological examination. Ten within normal subjects were taken as controls. The patients were grouped on histopathological basis into 5 groups: (1) One (6%) of the cases was non-specific lymphadenitis diagnosed by clinical examination of the scalp and leucocytosis with polymorphonuclear predominance. (2) Reactive lymphadenitis included 6 (38%) of the cases. Infectious mononucleosis cases were diagnosed by clinical triad of fever, pharyngitis and cervical lymphadenopathy, relative lymphocytosis, monocytosis and positive monospot test. Cytomegalovirus case was diagnosed by lymphocytosis, monocytosis and negative monospot test. Toxoplasmosis cases were diagnosed by monocytosis, negative tuberculin test and positive indirect fluorescent antibody test. (3) Granulomatous lymphadenitis comprised 6 (3%) of the cases. Tuberculous cases were diagnosed by high ESR and highly positive tuberculin test. Sarcoidosis cases were diagnosed by negative tuberculin test and presence of hilar lymphadenopathy. (4) Non-Hodgkin lymphoma case (6%) was diagnosed by clinical deterioration and total lymph node biopsy. 15) Systemic infections were diagnosed by clinical examination, blood culture for salmonellae and brucellae, Widal and Brucella agglutination tests. It is concluded from this study that screening tests are important aids in the diagnosis of cases of cervical lymphadenopathy presenting by prolonged fever especially if lymph node biopsy and histopathological examination are not available or contraindicated. Tub" }, { "id": "pubmed23n0083_1756", "title": "[Acute infection associated with HIV: clinical and laboratory picture].", "score": 0.016059757236227826, "content": "Very few case reports evaluate clinical and laboratory parameters of acute HIV infection. This paper describes seven such cases, four being mononucleosis like disease and one lymphocytic meningitis. Clinical manifestations were fever (7/7), lymphadenopathy (7/7), enlarged liver size (7/7) pharyngitis (6/7), malaise (4/7) and anorexia (4/7). Inversion of the normal T4/T8 ratio was present in 3/5 patients, all with normal absolute values for T4 cells. Moderate transaminase increases were found in 5/6; 5/7 had atypical lymphocytes in blood smear and 5/5 had abnormal mucoprotein levels. All patients had a total remission of clinical symptoms within two weeks. However, the abnormal lymph nodes and the enlarged liver persisted. Follow-up for ten months showed 4/7 patients with all abnormalities resolved and 3/7 still with persistent enlarged lymph nodes." }, { "id": "pubmed23n0476_2513", "title": "Acute human immunodeficiency virus syndrome in an adolescent.", "score": 0.01542585197746294, "content": "Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient's only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors." }, { "id": "pubmed23n0498_10724", "title": "Infectious disease capsules: a pox on your house.", "score": 0.014909997831273043, "content": "A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a \"rash.\" His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with \"chickenpox\" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy." }, { "id": "pubmed23n0379_13456", "title": "Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus.", "score": 0.014708918249380677, "content": "Knowledge regarding the clinical characteristics and natural history of acute infectious mononucleosis is based largely on older, often retrospective, studies without systematic follow-up. Differences in diagnosis, methodology, or treatment between historical and current practice might affect an understanding of this illness. Using a prospective case series design, we enrolled 150 persons with an acute illness serologically confirmed as Epstein-Barr virus infection. The goal of the study was to assess symptoms, physical examination findings, laboratory tests, and functional status measures during the acute presentation and 1, 2, and 6 months later. Acutely, infectious mononucleosis was characterized by the symptoms of sore throat and fatigue and substantial functional impairment. Objective physical and laboratory examination findings included pharyngitis and cervical lymphadenopathy, a moderate absolute and atypical lymphocytosis, and mildly elevated transaminase levels. The traditional signs of fever and splenomegaly were relatively uncommon. By 1 month, most symptoms and signs and all laboratory tests had returned to normal. Fatigue, cervical lymphadenopathy, pharyngitis, and functional health status improved more slowly. In contemporary practice most of the classical illness features of infectious mononucleosis are observed. Symptoms, signs, and poor functioning might be protracted in some patients." }, { "id": "wiki20220301en005_4079", "title": "Infectious mononucleosis", "score": 0.01470873786407767, "content": "Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis. People with infectious mononucleosis are sometimes misdiagnosed with a streptococcal pharyngitis (because of the symptoms of fever, pharyngitis and adenopathy) and are given antibiotics such as ampicillin or amoxicillin as treatment. Other conditions from which to distinguish infectious mononucleosis include leukemia, tonsillitis, diphtheria, common cold and influenza (flu)." }, { "id": "pubmed23n0357_20887", "title": "[A case with infectious mononucleosis-like syndrome caused by human herpes virus-6 infection].", "score": 0.014663511010495987, "content": "A 26-year-old female was admitted because of multiple fractures in lower extremities. While in the hospital, she developed a high fever and generalized skin eruption. Physical examination revealed bilateral cervical lymphadenopathy and mild hepatosplenomegaly. The white cell count was 11,200 with 11% atypical lymphocytes. Serum GOT, GPT, LDH were markedly elevated. Infectious mononucleosis was suspected, but the serological test for EB virus did not show evidence of acute EB virus infection. Anti-HSV, CMV, hepatitis A virus antibody titers also did not show significant change during the coarse. The serological test for HHV-6 only showed increased titer of IgM and IgG antibodies. Rapidly elevated IgG antibody titer was indicative of reactivation of HHV-6. So, she was diagnosed as mononucleosis-like syndrome caused by HHV-6, probably reactivated infection. Her symptoms gradually disappeared during a month." }, { "id": "pubmed23n0717_2208", "title": "Infectious mononucleosis-like syndrome probably attributable to Coxsackie A virus infection.", "score": 0.01360062893081761, "content": "Infectious mononucleosis (IM) is a clinical syndrome most often attributable to Epstein-Barr virus (EBV). Characteristic clinical features of EBV IM include bilateral upper lid edema, exudative or nonexudative pharyngitis, bilateral posterior cervical adenopathy, and splenomegaly ± maculopapular rash. Laboratory features of EBV IM include atypical lymphocytes and elevated levels of serum transaminases. Leukopenia and thrombocytopenia are not uncommon. The syndrome of IM may also be attributable to other infectious diseases, eg, cytomegalovirus (CMV), human herpes virus-6 (HHV-6), or Toxoplasma gondii. Less commonly, viral hepatitis, leptospirosis, brucellosis, or parvovirus B(19) may present as an IM-like infection. To the best of our knowledge, only 2 cases of IM-like infections attributable to Coxsackie B viruses (B(3) and B(4)) have been reported. We present the first reported case of an IM-like syndrome with sore throat, fatigue, atypical lymphocytes, and elevated levels of serum transaminases likely due to Coxsackie A in an immunocompetent adult." }, { "id": "wiki20220301en005_4078", "title": "Infectious mononucleosis", "score": 0.013401043870785724, "content": "Differential diagnosis About 10% of people who present a clinical picture of infectious mononucleosis do not have an acute Epstein–Barr-virus infection. A differential diagnosis of acute infectious mononucleosis needs to take into consideration acute cytomegalovirus infection and Toxoplasma gondii infections. Because their management is much the same, it is not always helpful, or possible, to distinguish between Epstein–Barr-virus mononucleosis and cytomegalovirus infection. However, in pregnant women, differentiation of mononucleosis from toxoplasmosis is important, since it is associated with significant consequences for the fetus. Acute HIV infection can mimic signs similar to those of infectious mononucleosis, and tests should be performed for pregnant women for the same reason as toxoplasmosis." }, { "id": "wiki20220301en032_60070", "title": "Lymphadenopathy", "score": 0.013148953519978256, "content": "Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include: Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis, cat-scratch disease). The most distinctive sign of bubonic plague is extreme swelling of one or more lymph nodes that bulge out of the skin as \"buboes.\" The buboes often become necrotic and may even rupture. Infectious mononucleosis is an acute viral infection usually caused by Epstein-Barr virus and may be characterized by a marked enlargement of the cervical lymph nodes. It is also a sign of cutaneous anthrax and Human African trypanosomiasis Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy). Plasma cell variant of Castleman's disease - associated with HHV-8 infection and HIV infection" }, { "id": "pubmed23n0412_7921", "title": "[Febrile respiratory infection and erythema in a 25-year-old man].", "score": 0.012781244091510683, "content": "A 26-year-old man fell acutely ill with fever (39 degrees C), rigor, dry cough, headache and pain in the neck and limbs. Ambulant treatment with amoxycillin, later cefuroximaxetil, worsened his general condition. At admission to hospital he had, over his trunk and limbs, cocarde-like, erythematous efflorescences up to 2 cm in diameter with central elevations and blisters. Additional acute bronchitis, pharyngitis, stomatitis, tonsillitis, conjunctivitis and urethritis indicated extensive mucosal involvement. Significant findings were: 9900/microl WBC, ESR 57 mm at one hour, C-reactive protein 160 mg/l, capillary pO2 6.4 kPa, pCO2 4.2 kPa. Mycoplasma serology (days 1, 8, 15) took a typical course. Chest radiogram showed an interstitial infiltrate on day 5. Respiratory Mycoplasma infection with interstitial pneumonia and exudative erythema multiforme. Because infection with an atypical pathogen was suspected, antibiotic treatment was changed to erythromycin and, at the suggestion of the dermatologist and ophthalmologist, local treatment (erythromycin, dexamethasone and dexpanthenol) was begun. Mycoplasma serology was first positive on day 3. The fever had disappeared on day 6 and the rash had regressed. Blood gases and blood picture were normal by day 8. The patient was discharged on day 18, after marked improvement of the skin and mucosal changes. The occurrence of a rare dermatological complication of a relatively common respiratory Mycoplasma infection can, when the erythema precedes positive Mycoplasma serology, aid in the differential diagnosis." }, { "id": "wiki20220301en257_9056", "title": "Herpes labialis", "score": 0.012725848856072048, "content": "Signs and symptoms Herpes infections usually show no symptoms; when symptoms do appear they typically resolve within two weeks. The main symptom of oral infection is inflammation of the mucosa of the cheek and gums—known as acute herpetic gingivostomatitis—which occurs within 5–10 days of infection. Other symptoms may also develop, including headache, nausea, dizziness and painful ulcers—sometimes confused with canker sores—fever, and sore throat. Primary HSV infection in adolescents frequently manifests as severe pharyngitis with lesions developing on the cheek and gums. Some individuals develop difficulty in swallowing (dysphagia) and swollen lymph nodes (lymphadenopathy). Primary HSV infections in adults often results in pharyngitis similar to that observed in glandular fever (infectious mononucleosis), but gingivostomatitis is less likely." }, { "id": "Pediatrics_Nelson_2203", "title": "Pediatrics_Nelson", "score": 0.012591575091575092, "content": "Initial laboratory tests of regional lymphadenopathy include a complete blood count and inflammatory markers. Infectious mononucleosis is characterized by lymphocytosis with atypical lymphocytes; thrombocytopenia and elevated hepatic enzymes are common. Cultures of infected skin lesions and tonsillar exudates should be obtained. Isolation of group A streptococci from the oropharynx suggests, but does not confirm, streptococcal cervical lymphadenitis. A blood culture should be obtained from children with systemic signs and symptoms of bacteremia. Serologic testing for EBV and for B. henselae should be obtained if there are appropriate findings. The most reliable test for diagnosis of acute EBV infection is the IgM antiviral capsid antigen (Fig. 99-1). Heterophil antibody is also diagnostic but is not reliably positive in children younger than 4 years with infectious mononucleosis." }, { "id": "pubmed23n0565_20506", "title": "[Retrospective evaluation of patients who were diagnosed as infectious mononucleosis between 1984-2005].", "score": 0.012418597607148266, "content": "In this study, the clinical and laboratory features of 26 infectious mononucleosis (IMN) cases who have been diagnosed between the years of 1984-2005 were evaluated retrospectively. The mean age of the patients was 26+/-11 years, the rate of being hospitalized was 65%, and mean hospitalization period was 9.2+/-6 days. Fever (81%), weakness (50%), sore throat (50%), headache (50%) and swollen neck (35%) were the most common symptoms, while in the physical examination cervical lymphadenopathy (81%), splenomegaly (69%), hyperemic pharynx (65%), hepatomegaly (54%) and tonsillitis (50%) were observed. Laboratory results yielded leukocytosis in 21%, leucopenia in 12%, anemia in 44%, thrombocytopenia in 5% and elevated transaminase levels in 84% of the patients. Of the patients 15 (57.7%) had the history of using antibiotics before the diagnosis. Serological diagnosis was performed by Paul-Bunnel test and/or IgM positivity against Epstein-Barr virus (EBV) viral capsid antigen (VCA). Tonsillo-pharyngitis secondary to edema and respiratory distress due to lymphadenopathy pressure were detected in four patients, whereas pancytopenia was established only in one patient, as complications. This study emphasized that, although IMN is a self-limited infection, the diagnostic difficulties may arise when the clinical course is atypical, and rarely seen life-threatening complications may also develop during IMN course." }, { "id": "pubmed23n0985_25692", "title": "[THE FEATURES OF THE COURSE OF INFECTIOUS MONONUKLEOSIS OF DIFFERENT ETIOLOGY IN CHILDREN].", "score": 0.011777845466544826, "content": "Aim - to study the effect of different pathogens (EBV, CMV, HHV-6, and MIXT) on the severity of clinical-paraclinical manifestations of infectious mononucleosis in children. The clinical and laboratory study performed for 410 children aged from 10 months up to 12 years with infectious mononucleosis. The association of herpes viruses, mainly EBV, CMV and HHV type 6, takes part in the formation of the clinical picture of IM in (52,9%) of cases. The sole participation of EBV in the development of IM was observed only in (34,1%), CMV (9,02%) and HHV-6 in (3,17%) patients. The etiology of infectious mononucleosis in children affects the acuity, severity, and intensity of the clinical and paraclinical signs of the disease. Infectious mononucleosis VEB etiology is manifested by acute onset (79,5%), intoxication (70,5%), subfebrile and febrile fever up to 7 days (61,03%), lacunar tonsillitis (85,8%), hepatomegaly ( 88,2%), splenomegaly (63,8%), mostly moderate (81,7%) with lymphocytosis (62,9%) and monocytosis (20,5%). For CMV mononucleosis - acute onset (89,9%), severe course (29,8%), febrile and high fever for up to 7 (56,7%) or more days, neutrophilic leukocytosis (73,55) with atypical mononuclear cells (64,7%) and anemia (29,7%). Severe (33,3%), with prolonged high fever (50%), exanthema syndrome (33,3%), pharyngitis without tonsillitis (66,7%), leukocytosis (66,7%) with accelerated ESR (66,7%) and monocytosis (33,3%) are characteristic of HHV-6 infection. For MIXT - acute onset (78,3%), intoxication (79,7%), lacunar tonsillitis (92,9%), hepatomegaly (84,1%) and splenomegaly (67%), low-grade and febrile fever from 3- x (27,1%) up to 7 days (35,05%), lymphocytosis (55,3%) with neutropenia (57,4%), atypical mononuclear cells (48,2%) and hypochromic anemia (17,29 %)." }, { "id": "pubmed23n0678_6418", "title": "Acute hepatitis: a rare complication of Epstein-Barr virus (EBV) infection.", "score": 0.011673813899666463, "content": "Infectious Mononucleosis (IM), a benign lymphoproliferative disease, is the best known clinical syndrome caused by Epstein-Barr Virus (EBV). It usually resolves over a period of weeks or months without sequelae but may occasionally be complicated by a wide variety of neurologic, hematologic, hepatic, respiratory, and psychological complications. In this report we describe a patient with acute hepatitis following EBV-IM in a previously healthy woman. A 26-year-old woman who presented with fever, generalized weakness, nausea, sore throat, yellowing of skin, and a generalized skin rash was admitted to our clinic. Tonsillar enlargement, pharyngeal erythema, palatal petechiae, lymphadenopathy, and jaundice were noted. Significant atypical lymphocytes ( &gt; 10%) were seen on the peripheral blood smear. Liver function tests such as ALT: 303 U/L, AST: 172 U/L, ALP: 193 U/L and total bilirubin: 7.3 mg/dl were elevated. Serological tests for EBV infection were consistent with acute infection (EBV virus capsid antigen was reactive with IgM and IgG antibodies). The Monospot test was also positive. On the seventh day, liver function tests and bilirubin had risen to peak level and platelets were decreased. The patient was managed supportively and her critical condition improved and was finally stabilized. Although the prognosis for IM is very favorable, a variety of acute complications may occur." }, { "id": "wiki20220301en004_55583", "title": "Streptococcal pharyngitis", "score": 0.011605359031613586, "content": "Differential diagnosis As the symptoms of streptococcal pharyngitis overlap with other conditions, it can be difficult to make the diagnosis clinically. Coughing, nasal discharge, diarrhea, and red, irritated eyes in addition to fever and sore throat are more indicative of a viral sore throat than of strep throat. The presence of marked lymph node enlargement along with sore throat, fever, and tonsillar enlargement may also occur in infectious mononucleosis. Other conditions that may present similarly include epiglottitis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, and retropharyngeal abscess." }, { "id": "pubmed23n0324_10987", "title": "[Agranulocytosis as a complication of acute infectious mononucleosis].", "score": 0.011596703086064787, "content": "Acute infections mononucleosis is the most common clinical manifestation of primary Epstein-Barr virus (EBV) infection occurring during adolescence. It is a benign lymphoproliferative, usually self-limiting disease. Complications are relatively rare, but they may occur, especially hematological. Most common are autoimmune hematolytic anemia and thrombocytopenia, and they respond to corticoid therapy. Deuteration of white blood cells is rather rare, whereas mild neutropenia is a normal finding during the course of acute disease. On the other hand, agranulocytosis is extremely rate, and almost every case has been reported in the literature. Filgrastim--the recombinant human granulocyte colony-stimulating factor (G-CSF) stimulates the activation, proliferation and maturation of progenitor granulocyte cells. This drug is usually applied in treatment of iatrogenic neutropenia, during chemotherapy of malignancies and in some idiopathic and cyclic neutopenias. A female patient, 18 years of age, has been hospitalized at the Clinic of Infectious Diseases in Novi Sad on two occasions. First because of severe acute infectious mononucleosis with acute hepatitis and jaundice 10 days after onset of symptoms. Physical examination revealed severe intoxication, dehydration, icteric skin, mucosis and massive hepatosplenomegaly. The diagnosis was confirmed by ELISA IgM, EBV VCA positive and ELISA IgG EBV VCA and IgG EBVNA negative results. The patient was discharged from hospital after 24 days without complaints and with normal physical and laboratory findings. For several days she felt well, but gradually severe fatigue and malaise occurred and she became febrile again. That was the reason why she was hospitalized again, two weeks later. This time she was febrile, extremely intoxicated with general lymphadenopathy, catarrhal gingivostomatitis and massive splenomegaly. The first laboratory findings showed severe neutropenia (absolute count of granulocytes was 0.156 x 10/l, with only 12% segmented neutrophils). Mild anemia--3.05 x 10/l was also registered, while the platelet count was normal. Other biochemical analyses were normal, the Coombs' test negative, while the serological response was also normal. Bone marrow puncture was performed and normocellular bone marrow was registered, somewhere hypercellular due to hyperplasia of granulocyte progenitor cells from promyelocytes to normal maturated cells. Anemia showed megaloblastoid proliferation, while megakaryocytes were normal. High doses of corticosteroids were applied (dexamethasone 160 mg daily) and filgrastim 5 micrograms every other day. From the very beginning of therapy the patient felt better, whereas granulocytes responded with elevation as soon as 48 hours after initiation of therapy. On the sixth day the treatment was stopped because the level of granulocytes was normal and the patient has completely recovered. She was discharged from hospital 4 weeks later with mild meteorism, but normal physical and laboratory findings and mild splenomegaly registered only by ultrasonography. During the last 10 years only several cases of severe leukopenia with acute infectious mononucleosis had been reported in literature. In all cases it was associated with some other hematological complications and it occurred in young adults without previously registered immunodeficiency. We have no knowledge about application of filgrastim in treatment of EBV-induced agranulocytosis, but the International Association for Studying Agranulocytosis and Aplastic Anemia reported that in 4% of patients Epstein-Barr virus can cause agranulocytosis even a year after the occurrence of acute disease." }, { "id": "wiki20220301en013_144073", "title": "Roseola", "score": 0.010671099552242807, "content": "Other symptoms A small percentage of children acquire HHV-6 with few signs or symptoms of the disease. Children with HHV-6 infection can also present with myringitis (inflammation of the tympanic membranes), upper respiratory symptoms, diarrhea, and a bulging fontanelle. In addition, children can experience pharyngitis with lymphoid hyperplasia seen on the soft palate and swelling of the eyelids. These symptoms usually present during the febrile phase of roseola. Cervical and postocciptal lymphadenopathy can also be seen, but this generally presents 2–4 days after the onset of the febrile phase. In rare cases, HHV-6 can become active in an adult previously infected during childhood and can show signs of mononucleosis. Cause" }, { "id": "wiki20220301en002_219423", "title": "Erysipelas", "score": 0.010642644114883361, "content": "The rash is due to an exotoxin, not the Streptococcus bacteria, and is found in areas where no symptoms are present; e.g., the infection may be in the nasopharynx, but the rash is found usually on the epidermis and superficial lymphatics. Diagnosis Erysipelas is usually diagnosed by the clinician looking at the characteristic well-demarcated rash following a history of injury or recognition of one of the risk factors. Tests, if performed, may show a high white cell count, raised CRP or positive blood culture identifying the organism. Erysipelas must be differentiated from herpes zoster, angioedema, contact dermatitis, erythema chronicum migrans of early Lyme disease, gout, septic arthritis, septic bursitis, vasculitis, allergic reaction to an insect bite, acute drug reaction, deep venous thrombosis and diffuse inflammatory carcinoma of the breast." }, { "id": "Pediatrics_Nelson_2200", "title": "Pediatrics_Nelson", "score": 0.010568635947806828, "content": "The characteristic triad of EBV infectious mononucleosis is fever, pharyngitis, and lymphadenopathy. The pharynx shows enlarged tonsils and exudate and, sometimes, anenanthem with pharyngeal petechiae. Lymphadenopathy ismost prominent in the anterior and posterior cervical andsubmandibular lymph nodes and less commonly involvesaxillary and inguinal lymph nodes. Other findings includesplenomegaly in 50% of cases, hepatomegaly in 10% to 20%, and maculopapular or urticarial rash in 5% to 15%. A diffuse,erythematous rash develops in approximately 80% of mononucleosis patients treated with amoxicillin. Compared with EBV infection, infectious mononucleosis-like illness caused by CMV has minimal pharyngitis and often more prominentsplenomegaly; it often presents with fever only. The mostcommon manifestation of toxoplasmosis is asymptomaticcervical lymphadenopathy, but approximately 10% of casesof acquired toxoplasmosis develop chronic posterior cervical lymphadenopathy and fatigue, usually" }, { "id": "wiki20220301en381_16630", "title": "Signs and symptoms of HIV/AIDS", "score": 0.01033804893460175, "content": "During this period (usually days to weeks post-exposure) fifty to ninety percent of infected individuals develop an influenza or mononucleosis-like illness called acute HIV infection (or HIV prodrome), the most common symptoms of which may include fever, lymphadenopathy, pharyngitis, rash, myalgia, malaise, mouth and esophageal sores, and may also include, but less commonly, headache, nausea and vomiting, fatigue, ulcers in the mouth or on the genitals, enlarged liver/spleen, weight loss, thrush, night sweats and diarrhea and neurological symptoms. Infected individuals may experience all, some, or none of these symptoms. The duration of symptoms varies, averaging 28 days and usually lasts at least a week." }, { "id": "wiki20220301en503_18576", "title": "Eosinophilic myocarditis", "score": 0.010267573696145125, "content": "The DRESS syndrome is a severe immunological drug reaction. It differs from other drug reactions in that it: a) is caused by a particular set of drugs; b) typically occurs after a delay of 2 to 8 weeks following intake of an offending drug; c) presents with a specific set of signs and symptoms (i.e. modest or extreme elevations in blood eosinophil and atypical lymphocyte counts; acute onset of a skin rash; lymphadenopathy; fever; neuralgia; and involvement of at least one internal organ such as the liver, lung, or heart; d) develops in individuals with particular genetic predispositions; and e) involves reactivation of latent viruses, most commonly human herpesvirus 6 or more rarely human herpes virus 5 (i.e. human cytomegalovirus), human herpesvirus 7, and human herpesvirus 4 (i.e. Epstein–Barr virus). These viruses usually become dormant after infecting humans but under special circumstances, such as drug intake, are reactivated and may contribute to serious diseases such as the" }, { "id": "article-27104_8", "title": "Pharyngitis -- History and Physical", "score": 0.010068015034902452, "content": "If viral in etiology, associated symptoms often include coughing, rhinorrhea, conjunctivitis, headache, and a rash. Group A beta-hemolytic streptococcal pharyngitis typically has an acute onset, lacks signs of a viral upper respiratory infection such as a cough or rhinorrhea, and is associated with fever, tonsillar exudates, and cervical adenopathy. Pharyngitis due to the Epstein-Barr virus, otherwise known as infectious mononucleosis,  can cause headaches, fever, tonsillar hypertrophy, lymphocytosis, and atypical lymphocytes. Myalgia and fatigue are commonly reported symptoms. Infectious mononucleosis can have both anterior and posterior cervical lymphadenopathy. Patients can have persistent lymphadenopathy and fatigue for up to 3 weeks. It is important to assess for hepatomegaly or splenomegaly. If a morbilliform rash develops after amoxicillin for presumed Group A beta-hemolytic streptococci, infectious mononucleosis should be suspected." }, { "id": "pubmed23n1129_1788", "title": "An Unusual Presentation of Glandular Fever.", "score": 0.010036130068245684, "content": "Epstein-Barr virus (EBV) is an ubiquitous DNA herpesvirus with &gt;90% of adults &gt;40 years of age showing a serological response. While in their youth, primary EBV infection may pass unnoticed, young adults have a high incidence of infectious mononucleosis (IM). This is characterized by a triad of pharyngitis, cervical lymphadenopathy, and fever because of a self-limiting lymphoproliferative disease. Common complications include but are not limited to hepatitis, splenomegaly, encephalitis, and haemophagocytic lymphohistiocytosis (HLH) with evidence that Caucasian males and smokers are more likely to suffer severe disease. Here we present a 21-year-old male who presented with a 2-week history of fever, dry cough, and a 4-week history of pharyngitis. He had no exposure to unwell contacts and denied any new sexual partners. Examination revealed general pallor with tender bilateral cervical lymphadenopathy and pharyngeal erythema. Admission bloods revealed pancytopenia (WCC 1.5 × 10<sup9</sup/L, Plt 84 × 10<sup9</sup/L, and Hb 82 g/L) with normal reticulocyte count and raised mean corpuscular volume (114 fL). Serum vitamin B12 and folate were low with serum ferritin raised (1027 <iµ</ig/L) suggesting a proinflammatory state. Admission liver function tests, coeliac serology, autoimmune panel (ANA, ANCA, and anti-dsDNA), hepatitic (hepatitis A, B, and E), human immunodeficiency virus (HIV), toxoplasmosis, parvovirus, and CMV serology were normal. The monospot test on day 1 of the presentation was negative. Ultrasound (US) of the abdomen on day 3 of the presentation revealed isolated splenomegaly (16.8 cm). Day 4 EBV serology (VCA IgM, VCA IgG, and EBNA IgG) was negative as such haematological investigations including JAK2, serum free light chains, and BCR-ABL were undertaken alongside cervical lymph node core biopsy. Repeat Monospot testing on day 7 came back positive. Repeat EBV serology now showed equivocal EBV VCA IgG (0.77 OD) and positive VCA IgM (9.04 OD) with concurrent new hepatitis. Histopathology of the core biopsy revealed Sternberg-reed cells and a mixed immunoblastic reaction in keeping with resolving IM. This case highlights the need for physicians to have a strong clinical suspicion of IM and understand the multiple ways in which IM may be present as well as the time lag to positivity in serological testing." }, { "id": "wiki20220301en005_4077", "title": "Infectious mononucleosis", "score": 0.009997543601080815, "content": "Other tests Epstein–Barr nuclear antigen detection. While it is not normally recognizable until several weeks into the disease and is useful for distinguishing between a recent-onset of infectious mononucleosis and symptoms caused by a previous infection. Elevated hepatic transaminase levels are highly suggestive of infectious mononucleosis, occurring in up to 50% of people. By blood film, one diagnostic criterion for infectious mononucleosis is the presence of 50% lymphocytes with at least 10% atypical lymphocytes (large, irregular nuclei), while the person also has fever, pharyngitis, and swollen lymph nodes. The atypical lymphocytes resembled monocytes when they were first discovered, thus the term \"mononucleosis\" was coined. A fibrin ring granuloma may be present." }, { "id": "pubmed23n0279_19449", "title": "Atypical exanthema in a patient with infectious mononucleosis.", "score": 0.00980392156862745, "content": "A 19-year-old male with a sore throat developed numerous, indistinct, erythematous, maculopapular lesions on the trunk. The eruptions, which mimicked secondary syphilis, continued for seven weeks and faded away without pigmentation or scarring. The laboratory examinations revealed lymphocytosis with atypical lymphocytes, seroconversion of Epstein-Barr virus titers, and elevation of transaminase in liver function." }, { "id": "pubmed23n0377_8012", "title": "Diagnosis of atypical cases of infectious mononucleosis.", "score": 0.009708737864077669, "content": "The variable manifestations of infectious mononucleosis rarely cause clinicians to suspect primary Epstein-Barr virus or cytomegalovirus infection; consequently, costly diagnostic tests and unnecessary treatments are undertaken. Seventeen cases of clinically atypical and 11 cases of clinically typical infectious mononucleosis were diagnosed through screening for atypical and apoptotic lymphocytes in the peripheral blood samples by means of an automated hematologic analyzer. Atypical and typical cases did not differ significantly with respect to peripheral white blood cell counts; percentages of lymphocytes, atypical lymphocytes, CD4(+) lymphocytes, human leukocyte antigen--DR positivity in CD3 lymphocytes, or apoptotic cells in blood smear after incubation; or levels of aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Only the percentage of CD8(+) lymphocytes was significantly higher in patients with typical infectious mononucleosis than it was in patients with atypical infectious mononucleosis. Because certain atypical cases of infectious mononucleosis display laboratory abnormalities that are characteristic of typical infectious mononucleosis, enhanced awareness can help in the diagnosis." }, { "id": "wiki20220301en218_4165", "title": "List of skin conditions", "score": 0.009699823032488564, "content": "Giant condyloma acuminatum (Buschke–Löwenstein tumor, giant condyloma of Buschke–Löwenstein tumor) Hand-foot-and-mouth disease Heck's disease (focal epithelial hyperplasia) Hemorrhagic fever with renal syndrome Hepatitis B Hepatitis C Herpangina Herpes gladiatorum (scrum pox) Herpes simplex Herpes zoster oticus (Ramsay–Hunt syndrome) Herpetic keratoconjunctivitis Herpetic sycosis Herpetic whitlow HIV-associated pruritus Human monkeypox Human T-lymphotropic virus 1 infection Human tanapox Immune reconstitution inflammatory syndrome (immune recovery syndrome) Infectious mononucleosis (glandular fever) Inflammatory skin lesions following zoster infection (isotopic response) Intrauterine herpes simplex Kaposi sarcoma Lassa fever Lipschütz ulcer (ulcus vulvae acutum) Measles (rubeola, morbilli) Milker's nodule Modified varicella-like syndrome Molluscum contagiosum Myrmecia Neonatal herpes simplex Ophthalmic zoster" }, { "id": "pubmed23n1017_5164", "title": "Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a crosssectional study in a tertiary care hospital.", "score": 0.009665652082994493, "content": "Çağlar İ, Topal S, Çokboz M, Düzgöl M, Kara A, Bayram SN, Apa H, Devrim İ. Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a cross-sectional study in a tertiary care hospital. Turk J Pediatr 2019; 61: 368-373. Epstein-Barr virus (EBV) is widespread all over the world. It causes infectious mononucleosis (IM) mostly in adolescents and adults. Although IM is considered to be rare in younger children and infants, acute EBV infection may have various manifestations in this age group. We aimed to describe the clinical features and laboratory findings of children hospitalized with acute EBV infection. All children hospitalized at Dr. Behçet Uz Children`s Hospital, between January 2010 and January 2017, who tested positive by presence of EBV-specific antibodies and had the diagnosis of acute EBV infection, were included (n=66). Thirty four of the patients (51.5%) were under 6 years of age, and 23 (34.8%) children were below 3 years of age. The most common physical finding was fever (92.4%) followed by cervical lymphadenopathy and tonsillopharyngitis. Leukocytosis (65.1%) and lymphocytosis (42.4%) were the most common laboratory findings. Reactive and atypical lymphocytes were present in 77.2% of the patients. Fifty-three (80.3%) of the patients had a doctor visit before hospitalization, and the ratio of patients using antibiotics was 77.3%. Skin rash was observed in 14 (27.4%) of the patients who used antibiotic treatment and in 2 (13.3%) of the patients who did not (p &gt; 0.05). EBV infection resulting in admission to hospital is common in younger children, even in pre-school period. Serological tests for EBV specific antibody responses and peripheral blood smear evaluation are important diagnostic tools. In addition, rapid streptococcal antigen test and throat culture should be performed in patients presenting with tonsillopharyngitis in order to exclude Group A beta-hemolytic streptococci and reduce unnecessary antibiotic consumption." }, { "id": "pubmed23n1043_7936", "title": "[A Case of Simultaneous Acute Lymphoblastic Leukemia Diagnosis with Crimean-Congo Hemorrhagic Fever].", "score": 0.009545356604180134, "content": "Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease that can be presented with fever, fatigue, generalized joint/body pain, diarrhea and bleeding in various parts of the body. The risk of developing a severe fatal disease in humans, the possibility of being infected with aerosols and the risk of being used as a biological weapon make the disease still an important health problem all over the world as there is no a specific treatment and vaccine that has proven effective againt the virus today. The pathogenesis of the disease is not known, but vascular endothelial damage is prominent. Therefore, it progresses with thrombocytopenia, anemia, leukopenia and this hematological findings can be confused with hematological malignancies. Acute lymphoblastic leukemia (ALL) is a malignancy included in differential diagnoses and occurs as a result of mutations occuring at a stage of differentiation in the lymphoid precursor cells in the bone marrow. In this study, we present a case of ALL who was diagnosed with CCHF simultaneously. A 43-year old female patient who works in the library and does not have a chronic disease other than asthma and thyroid disorder, has admitted to our hospital with the complaints of intermittent fever, weakness, generalized joint and body pain for about 3 weeks. She had fever and the physical examination revealed bilateral cervical and right postauricular lymphadenopathies. Her aspartate aminotransferase: 77 U/L, alanine aminotransferase: 117 U/L, lactate dehydrogenase: 616 U/L, hemoglobin: 8.27 g/dl, leukocyte count: 15.690/mm3 , neutrophil count: 550/mm3 (%3.5), lymphocyte count: 6690/mm3 (%42.6), platelet count: 102.100/mm3 , C-reactive protein: 163.6 mg/L was detected and the patient was hospitalized on 5 August 2019 for further examination and treatment. Considering that the patient may have viral infection in the foreground the requested test results were detected as; anti-CMV IgM negative, anti-CMV IgG positive, anti-toxoplasma IgM negative, anti-toxoplasma IgG positive, anti-rubella IgM negative, anti-rubella IgG positive, HBsAg negative, anti-HBc IgM negative, antiHBs positive, anti-HAV IgM negative, anti-HAV IgG positive, anti-HCV negative, anti-HIV negative, EpsteinBarr virus (EBV) VCA IgM negative, EBV VCA IgG positive, EBV EBNA IgG positive. Brucella Rose Bengal and Coombs tube agglutination was found be negative. As the cytopenia of the patient deepened, the patient was accepted to have neutropenic fever and it was planned to start piperacillin-tazobactam 4 x 4.5 g/day and two units of erythrocyte replacement therapy. When the patient's history was questioned again, it was learned that she had a tick on her neck about three weeks ago and she had removed the tick herself; 4-5 days later she had the complaints of fever and flu like symptoms and also diarrhea complaints lasting for 3-4 days. Considering the current anamnesis and laboratory findings, the patient was thought to have CCHF and the patient was isolated. The serum sample taken from patient with an initial diagnosis of CCHF and sent to Department of Microbiology Reference Laboratory Public Health Agency of Turkey. The patient was referred to the Antalya Training and Research Hospital. The patient's CCHF serum result was positive. Ribavirin treatment was not initiated in the patient who was accepted to be in the convalescence period, piperacillin-tazobactam 4 x 4.5 g/day treatment was continued and supportive treatment was given. In the follow-up, as the patient's neutropenia, thrombocytopenia and lymphocytopenia still continuing, she was transferred to hematology clinic for malignancy examination and bone marrow biopsy performed by hematology and B cell ALL was diagnosed. She was accepted to be convalescent in terms of CCHF and chemotherapy was started for ALL treatment by hematology. The patient is still being followed up by the hematology clinic and allogenic hematopoietic stem cell tranplantation is planned for the patient. As a result, CCHF is a disease that can be confused with many differential diagnosis. With this case, it is aimed to draw attention to the diagnostic difficulties of CCHF and ALL and to be the first case in the literature." }, { "id": "pubmed23n1083_4142", "title": "Primary Epstein-Barr virus infection shortly after primary Cytomegalovirus infection: a case report.", "score": 0.009523809523809525, "content": "Infectious mononucleosis (IM) and mononucleosis-like illnesses are common viral infectious diseases which are often accompanied by a high fever, pharyngitis and lymphadenopathy in adults, although such infection in childhood is generally subclinical. Most cases of IM are caused by the Epstein-Barr virus (EBV) or Cytomegalovirus (CMV). However, it is difficult to diagnose IM only with subjective symptoms, and thus EBV and CMV are nearly indistinguishable in clinical practice. A 20-year-old healthy Japanese woman had a 2-day history of high fever and consulted us. She had sex for the first time 6 months earlier. Her virus antibodies showed that she was infected with primary CMV. About 5 months later, she again experienced high fever and lymph node enlargement at the posterior cervical region. Her virus antibodies showed that she was infected with primary EBV at that time. Herein, we report a healthy adult Japanese woman with primary EBV infection relatively soon after primary CMV infection. It is very interesting to compare the symptoms and/or clinical data after EBV and CMV infection in the same patient within a short period of time. Our patient was diagnosed based only on subjective symptoms, physical examination and laboratory data, without tests of such virus-related antibodies. Therefore, clinicians should bear in mind that primary EBV infection and/or primary CMV infection is possible when patients have symptoms such as high fever, pharyngitis and lymphadenopathy, even in healthy adults." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 156, 317 ] ], "word_ranges": [ [ 23, 48 ] ], "text": "The rest of the answers can be made for differential diagnosis, but the performance of complementary tests does not justify delaying the initiation of treatment." }, "2": { "exist": true, "char_ranges": [ [ 156, 317 ] ], "word_ranges": [ [ 23, 48 ] ], "text": "The rest of the answers can be made for differential diagnosis, but the performance of complementary tests does not justify delaying the initiation of treatment." }, "3": { "exist": true, "char_ranges": [ [ 156, 317 ] ], "word_ranges": [ [ 23, 48 ] ], "text": "The rest of the answers can be made for differential diagnosis, but the performance of complementary tests does not justify delaying the initiation of treatment." }, "4": { "exist": true, "char_ranges": [ [ 156, 317 ] ], "word_ranges": [ [ 23, 48 ] ], "text": "The rest of the answers can be made for differential diagnosis, but the performance of complementary tests does not justify delaying the initiation of treatment." }, "5": { "exist": true, "char_ranges": [ [ 0, 155 ] ], "word_ranges": [ [ 0, 23 ] ], "text": "The correct answer is to initiate treatment with L-dopa, since the clinical picture described is of a parkinsonism whose diagnosis is exclusively clinical." } }

{ "1": "Assess visual acuity.", "2": "Perform an MRI.", "3": "Tilt table study.", "4": "Measure blood pressure lying down and standing up.", "5": "Therapeutic attempt with L-dopa." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "InternalMed_Harrison_3641", "title": "InternalMed_Harrison", "score": 0.013004413619167718, "content": "A 76-year-old woman presented with a several-month history of diarrhea, with marked worsening over the 2–3 weeks before admission (up to 12 stools a day). Review of systems was negative for fever, orthostatic dizziness, nausea and vomiting, or headache. Past medical history included hypertension, kidney stones, and hypercholesterolemia; medications included atenolol, spironolactone, and lovastatin. She also reliably consumed >2 L of liquid per day in management of the nephrolithiasis. The patient received 1 L of saline over the first 5 h of her hospital admission. On examination at hour 6, the heart rate was 72 sitting and 90 standing, and blood pressure was 105/50 mmHg lying and standing. Her jugular venous pressure (JVP) was indistinct with no peripheral edema. On abdominal examination, the patient had a slight increase in bowel sounds but a nontender abdomen and no organomegaly." }, { "id": "pubmed23n0540_20027", "title": "[Three Japanese cases of hypnic headache].", "score": 0.012164975279729378, "content": "We described three cases of hypnic headache with successful treatment by lithium carbonate or caffeine. This is the first detail report of Japanese cases. An endocrinological test and rhythm analyses of ambulatory blood pressure (ABP) and heart rate variability in a case suggested possible association between hypnic headache and hypothalamic-pituitary dysfunction. Case 1: A 48-year-old female migraineur complained of new-onset nocturnal headaches. Her headache awakened her from sleep between 1 AM and 2 AM. The headache occurred 3-4 times per week and lasted from 1 hour to 2 hours. The headache were moderate intensity and bilateral dull throbbing pain that located in the forehead to temples. There was no accompanying symptoms such as nausea, phonophobia, photophobia, nor the other autonomic features including conjunctival injection or tearing during the headache attacks. Physical and neurological examinations showed normal results except slight weakness and mild dysesthesia of the left arm due to a vertebral disk herniation at C5/6 level. In the pituitary endocrinological test, the prolactin level remarkably increased in response to the TRH loading. The single cosinor analysis demonstrated significant circadian rhythm of ABP parameters. However, the analysis did not demonstrate any significant circadian rhythm of Holter ECG parameters of time domain analysis and frequency analysis. Receiving 200 mg lithium bicarbonate before sleep, her nocturnal headache completely disappeared. Case 2: A 68-year-old woman had been followed up by her chronic tension-type headache since her forties. At her 66-years, she suffered from a new nocturnal headache. She awoke from sleep by the headache about 3 AM and the headache lasted 30 min. Moderate, dull headache located on her left temple to parietal head, 3-4 times/week. She was able to go back asleep without any medication after spontaneous headache cessation. She first complained the nocturnal headache at the 10 months later of the new headache appearance. She received 200 mg caffeine just before sleep and her headache has been disappeared. Case 3: 70-year-old women had been regularly visited our clinics for her migraine and chronic tension-type headache. She received amitriptyline and her headaches was well controlled. At her 69 years, she complained nocturnal headache. It occured every other day. The headache was moderate pulsative dull pain on the occipital region and lasted 90 minutes without any autonomic symptoms. Headache began between midnight and 1 AM. She told us her new nocturnal headache one year later of the onset. Oral caffeine (200 mg) just before sleep did not improve her headache and caused insomnia. Receiving 100 mg lithium before sleep, her hypnic headache disappeared completely. These three cases are compatible with the diagnostic criteria proposed in ICHD-II. There were some patients with hypnic headache in Japan and neurologists should pay attentions to this form of benign headache, because some beneficial treatments are currently available." }, { "id": "Neurology_Adams_4215", "title": "Neurology_Adams", "score": 0.01003851791253366, "content": "These are among the simplest and most important tests of autonomic function and most laboratories have automated techniques to quantitate them. McLeod and Tuck state that in changing from the recumbent to the standing position, a fall of more than 30 mm Hg systolic and 15 mm Hg diastolic is abnormal; others give figures of 20 and 10 mm Hg. They caution that the arm on which the cuff is placed must be held horizontally when standing, so that the decline in arm pressure will not be obscured by the added hydrostatic pressure. As emphasized in Chap. 17 on syncope, the determination of blood pressure in orthostatic testing is ideally done by having the patient remain supine for as long as it is practical before testing, and shifting from a supine to standing position, without the interposition of sitting. Moreover, blood pressure is most informative if measured immediately after standing and again at approximately 1 and 3 min. The expected response is a momentary and slight increase in" }, { "id": "pubmed23n0712_25047", "title": "Diagnosis and management of carbon monoxide poisoning in the emergency department.", "score": 0.009900990099009901, "content": "An 89-year-old female is found by her family, lying unconscious on her kitchen floor after they had been unable to reach her by phone for several hours. EMS is activated and when the paramedics arrive, they note that the gas oven is on, and there is thin, gray smoke coming from around the door. The house gas supply is turned off, windows are opened, and the family and the patient are immediately evacuated from the home. En route to the hospital, the patient is placed on high-flow oxygen at 15 liters per minute by non-rebreather mask. Her bedside glucose determination is 229 mg/dL. Vital signs are within normal limits during transport. She opens her eyes to sternal rub, and makes spontaneous movements of all extremities. Upon arrival to the ED, the patient becomes more alert and is able to respond to your questions. She tells you that she remembers putting a tray of calzones into the oven, after which she has no recall of the day's events. She has a past medical history of \"well-controlled\" hypertension, hyperlipidemia, and non-insulin-dependent diabetes. Her medications include hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, simvastatin 20 mg daily, and metformin 1000 mg twice daily. On physical examination, weight is 65 kg, blood pressure is 97/50 mm Hg, heart rate is 113 beats per minute, respiratory rate is 22 breaths per minute, temperature is 37.1 degrees C (98.8 degrees F), and oxygen saturation is 99% on 15 liters per minute via non-rebreather mask. She appears her stated age. Cardiopulmonary examination is remarkable only for tachycardia. Her abdomen is soft and non-tender with normal bowel sounds. Her skin is warm and dry, and there is no peripheral edema. Her cranial nerves are intact, with briskly reactive, symmetric pupils. Motor and sensory examination is non-focal, and cerebellar testing is notable only for an intention tremor on finger-nose-finger test. Gait is normal and speech is fluent and without errors. Laboratory testing shows a hemoglobin of 10.3 g/dL and a leukocyte count of 11.7 x 10(9)/L. Electrolyte results fall within the normal range, and her serum creatinine is 1.7 mg/dL. Qualitative CK-MB and troponin I tests are positive, and the sample has been sent to the STAT lab for quantitative testing. Serum carboxyhemoglobin level is 15% with normal serum pH on an arterial blood gas. An ECG reveals deep, down-sloping inferior and lateral ST-segment depressions which were not present on a routine cardiogram 1 month prior. You have many questions about this patient's care. What symptoms and physical signs need to be addressed and treated? What additional diagnostic testing should be performed? What treatment regimen is appropriate and what should be avoided? What are the risks or delayed complications from her illness? Are there special considerations for this or other patient populations?" }, { "id": "article-143691_11", "title": "Evaluation of the Dizzy and Unbalanced Patient -- History and Physical", "score": 0.009900990099009901, "content": "Vital signs Frank hypotension Orthostatic hypotension (defined as blood pressure drop from sitting to standing:  systolic blood pressure decrease of 20 mm Hg or a diastolic blood pressure decrease of 10 mm Hg) Delayed orthostatic hypotension (usually detected on tilt-table testing)" }, { "id": "wiki20220301en004_124163", "title": "Orthostatic hypotension", "score": 0.009863910774583035, "content": "Diagnosis Orthostatic hypotension can be confirmed by measuring a person's blood pressure after lying flat for 5 minutes, then 1 minute after standing, and 3 minutes after standing. Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg or the diastolic blood pressure of at least 10 mmHg between the supine reading and the upright reading. Also, the heart rate should be measured for both positions. A significant increase in heart rate from supine to standing may indicate a compensatory effort by the heart to maintain cardiac output. A related syndrome, postural orthostatic tachycardia syndrome (POTS), is diagnosed when at least a 30 bpm increase in heart rate occurs with little or no change in blood pressure. A tilt table test may also be performed." }, { "id": "pubmed23n0270_16163", "title": "[A 77-year-old woman with myoclonus and epilepsy].", "score": 0.00980392156862745, "content": "We present a 77-year-old woman with myoclonus and epilepsy. She was well until 35 years of age, when she noted an onset of trembling of the legs upon standing. Her symptom slowly progressed, and she felt a difficulty in standing when she was 39-year-old. She had a major motor seizure without an apparent focal onset when she was 46-year-old. She also developed tremor in her hands, and she felt difficulty in holding a glass filled with water. She was admitted to our service for the first time in 1965 when she was 51-year-old. She showed wide-based ataxic gait with truncal titubation. In finger to nose test, myoclonic jerks were induced in the upper extremities. Otherwise neurological examination was unremarkable. She was treated with primidone and phenobarbital, and was discharged for out patient follow up. Her symptoms slowly progressed, and gait and station became more difficult. Mentally she was sound. Three months prior to the present admission, she developed more difficulty in gait, and decrease in food intake. On the 14th of September in 1991, she was seen by a local physician who found an abnormal shadow in her chest X-ray, and she was admitted to our service for further work-up on September 18, 1991. On admission, the patient was a chronically ill and emaciated woman. Her blood pressure was 140/84 mmHg, heart rate 115/minutes and regular, and the body temperature 36.9 degrees C. The palpebral conjunctivae were anemic. No cervical adenopathy was noted. The lung fields were clear, and no heart murmur was audible. The abdomen was soft, and no organomegaly was present. On neurologic examination, she looked somnolent with disorientation to time and place. Her memory was poor, and she could not do well serial 7s. The disc was flat and the ocular movements appeared intact. Other cranial nerves were also unremarkable. She showed diffuse muscle wasting. She was unable to stand or walk. Maintaining the sitting position was also difficult. She was able to raise her arms, but almost unable to move her lower extremities. The precise muscle testing was impossible. No abnormal involuntary movement was seen. Finger to nose test could not be performed.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0694_11720", "title": "[Merits of paracetamol in osteoarthritic hypertensive patients].", "score": 0.00980392156862745, "content": "Nonsteroidal anti-inflammatory drug (NSAID) side effects can impair quality of life in patients with osteoarthritis. Due to its particular mechanism of action, paracetamol might bypass these negative effects. To determine both the role of paracetamol in the treatment of osteoarthritis patients and optimal combination of antihypertensives and antirheumatics for these patients. A prospective clinical trial in a family practice included 110 treated hypertensives aged over 55 years: 50 controls and 60 also taking NSAIDs for osteoarthritis. This 3-month study compared two antihypertensives, lisinopril/hydrochlorothiazide fixed combination and amlodipine, with two NSAIDs, ibuprofen and piroxicam, and with paracetamol. Following clinical work-up and NSAID discontinuation for at least 3 days (run-in period of only 3-7 days), osteoarthritis subjects were randomized to 1-month periods of ibuprofen (400-600 mg t.i.d.) or piroxicam (10-20 mg o.d.) with one month of paracetamol (1000 mg t.i.d.) in the middle as a \"wash-out\" interval, continuing the prescribed amlodipine (5-10 mg o.d.) or lisinopril/hydrochlorothiazide fixed drug combination (10/6.25-20/12.5 mg o.d.), while control subjects (hypertensives with no osteoarthritis) were just keeping their antihypertensive therapy. Blood pressure was measured with standard mercury sphygmomanometer and with an automatic device, in standing, sitting and supine position. The intensity of arthritic pain (on a visual analogue scale from 1 to 10, where 0 means \"no pain\" and 10 \"the worst pain you may imagine\") and the patient's quality of life estimate (on a visual analogue scale from 1 to 10, where 0 means \"general condition excellent\" and 10 \"the worst possible\") were recorded. Blood pressure control was unchanged in the amiodipine group across the study periods and impaired in the lisinopril/ hydrochlorothiazide group during either ibuprofen or piroxicam, but not during paracetamol. In the amlodipine +/- ibuprofen subgroup, the reduction of the average pain intensity score throughout the study was significant (chi2 = 8.250; df 3; P = 0.037). In the lisinopril/hydrochlorothiazide +/- piroxicam subgroup, the assessed quality of life differed significantly (chi2 = 9.716; df 3; P = 0.018), while in the amlodipine +/- ibuprofen and amlodipine +/- piroxicam subgroups the changes were marginal (chi2 = 6.936; df 3; P = 0.072 and chi2 = 7146; df 3; P = 0.065, respectively)." }, { "id": "pubmed23n0323_11406", "title": "[A 74-year-old woman with parkinsonism and dementia who died four years after the onset].", "score": 0.009708737864077669, "content": "We report a 74-year-old woman with parkinsonism and dementia, who died 4 years after the onset of the disease. She was well until 70 years of the age (1993) when she noted slowness in the movement in her left hand. She also developed gait disturbance and the similar symptoms spread to the right upper and lower extremities. Two years after the onset, she had difficulty in walk, and was admitted to our hospital on March 9, 1995. Her daughter had the onset of hand tremor at 50 years of the age and gait disturbance at 52. Her gait improved after levodopa treatment, but her MRI revealed a liner T2-high signal lesion along the outer surface of each putamen. On admission, the patient was alert but slighted demented. Higher cerebral functions were normal. She had a masked face and small voice. Her gait was of small step without arm swing. Retropulsion was present. Rigidity was noted in the neck but not in the limbs. She was bradykinetic but tremor was absent. She was treated with levodopa/carbidopa, dops, and bromocriptine with considerable improvement and was discharged on March 30, 1995. On January 19, 1996, she developed fever and hallucination; she became more akinetic and admitted again. She showed marked dementia and stage IV parkinsonism. She was treated by supportive measures with improvement in the general condition, but she was found to have a gastric cancer for which a subtotal gastrectomy was performed on March 11, 1996. Post-operative course was uneventful, but her parkinsonism progressed to stage V. She was transferred to another hospital on May 13, 1996. In July 21, 1996, she developed dyspnea and fever and was admitted to our hospital again. She was somnolent. Rigidity was moderate to marked and she was unable to stand or walk. By supportive cares, her general condition improved and was discharged to home on November 4, 1996. She developed fever on June 13, 1997 and admitted to our service again. Her BP was 150/90 mmHg. She was alert but markedly demented. Laboratory examination revealed increases in liver enzymes (GOT 75 IU/l, GPT 101 IU/l) and renal dysfunction (BUN 68 mg/dl, creatinine 3.27 mg/dl). Subsequent hospital course was complicated by renal failure and thrombocytopenia (33,000/ml). She expired on July 1, 1997. The patient was discussed in a neurologic CPC, and a chief discussant arrived at the conclusion that the patient had diffuse Lewy body disease and her daughter striatonigral degeneration. Some participants thought both the patient and her daughter had diffuse Lewy body disease. Post-mortem examination revealed marked degeneration of the substania nigra and the locus coeruleus. The medial part of the nigra also showed marked cell loss. Lewy bodies were found in the remaining nigral and coeruleus neurons. Cortical Lewy bodies were very few and the striatum was intact. Pathologic diagnosis was Parkinson's disease. Dementia was in part attributed to the marked degeneration of the medial part of the substantia nigra." }, { "id": "pubmed23n1132_19120", "title": "Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms.", "score": 0.009708737864077669, "content": "Orthostatic hypotension (OH) based on a change from seated-to-standing blood pressure (BP) is often used interchangeably with supine-to-standing BP. The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial of vitamin D3 supplementation and fall in adults aged ≥70 years at high risk of falls. OH was defined as a drop in systolic or diastolic BP of at least 20 or 10 mmHg, measured at pre-randomization, 3-, 12-, and 24-month visits with each of 2 protocols: seated-to-standing and supine-to-standing. Participants were asked about orthostatic symptoms, and falls were ascertained via daily fall calendar, ad hoc reporting, and scheduled interviews. Among 534 participants with 993 paired supine and seated assessments (mean age 76 ± 5 years, 42% women, 18% Black), mean baseline BP was 130 ± 19/68 ± 11 mmHg; 62% had a history of high BP or hypertension. Mean BP increased 3.5 (SE, 0.4)/2.6 (SE, 0.2) mmHg from sitting to standing, but decreased with supine to standing (mean change: -3.7 [SE, 0.5]/-0.8 [SE, 0.3] mmHg; P-value &lt; 0.001). OH was detected in 2.1% (SE, 0.5) of seated versus 15.0% (SE, 1.4) of supine assessments (P &lt; 0.001). While supine and seated OH were not associated with falls (HR: 1.55 [0.95, 2.52] vs 0.69 [0.30, 1.58]), supine systolic OH was associated with higher fall risk (HR: 1.77 [1.02, 3.05]). Supine OH was associated with self-reported fainting, blacking out, seeing spots and room spinning in the prior month (P-values &lt; 0.03), while sitting OH was not associated with any symptoms (P-values ≥ 0.40). Supine OH was more frequent, associated with orthostatic symptoms, and potentially more predictive of falls than seated OH." }, { "id": "pubmed23n0325_2840", "title": "[A 64-year-old woman with progressive gait disturbance and dementia for one year].", "score": 0.009615384615384616, "content": "We report a 64-year-old Japanese woman who died one year after the onset of progressive gait disturbance and dementia. She noted a difficulty in holding a glass and hand tremor in June of 1996 when she was 63 years old. In July of 1996, she tended to lean toward left when she walked. She also noted truncal titubation. In November of 1996, she started to have visual hallucination and delusion in which she said \"I see something is flying on the wall.\", \"Somebody has come into my room\", and things like that. She was admitted to our service on November 22, 1996. On admission, she was alert and general physical examination was unremarkable. Neurologic examination revealed disturbance in recent memory. Hasegawa's dementia rating scale was 22/30. She showed vivid visual hallucination with colors in which she saw faces of dwarfs and angels, a space ship, and others. Higher cerebral functions were normal. She showed left oculomotor palsy which was a sequel of an aneurysm and subarachnoid hemorrhage nine years before. Otherwise cranial nerves were unremarkable. She showed ataxic gait, limb ataxia, truncal titubation, and postural hand tremor. She had no weakness and no muscle atrophy. Deep tendon reflexes were within normal limits. Plantar response was flexor. Sensation was intact. Laboratory examination was also unremarkable. Complete survey for occult malignancy was negative. CSF was under a normal pressure and cell count was 1/microliter, total protein 27 mg/dl, and sugar 68 mg/dl. Cranial CT scan was unremarkable. MRI was not obtained because of the presence of an aneurysm clip in the left internal carotid-posterior communication artery junction. She showed progressive deterioration in her mental function. By January 1997, she became unable to stand or walk with marked dementia. Repeated CSF exams and cranial CT scans were unremarkable. She suffered from several episodes of aspiration pneumonia. A trial of three days methylprednisolone pulse therapy was given starting on March 7, 1997, which was of no effect on her neurologic status. On March 28, 1997, she was intubated because of acute respiratory distress syndrome. In April 2, her body temperature rose to 38 degrees C. On April 9, 1997, her blood pressure dropped and resuscitation was unsuccessful. She was pronounced dead on the same day. The patient was discussed in a neurologic CPC and the chief discussant arrived at the conclusion that the patient had primary leptomeningeal lymphoma. Other possibilities entertained among the audience included brain stem encephalitis of unknown type, carcinomatous cerebellar degeneration plus limbic encephalitis, Creutzfeldt-Jakob disease, thalamic degeneration, and progressive multifocal leukoencephalopathy. Post-mortem examination revealed thickening and clouding of the leptomeninges; Gram-positive diplococci were found in the leptomeninges. This meningitis appeared to have been an complication in the terminal stage of her illness. Microscopic examination revealed astrocytosis in the midbrain tegmentum. Cerebral cortices showed only mild astrtocytosis. No cerebellar atrophy was seen and Purkinje cells were retained which excluded paraneoplastic cerebellar degeneration. Neuropathologic diagnosis was bacterial meningitis, however, the presence of brain stem encephalitis prior to the onset of bacterial meningitis could not be excluded. It is interesting to note that the diagnosis of the primary neurologic disease of this patient was not easy even after autopsy. As autopsy permission was obtained only for the brain, it was not clear whether or not this patient had an occult malignancy somewhere in her body, however, there was no evidence to indicate paraneoplastic degeneration of the central nervous system. As the patient did not have meningeal signs until one month before her death, it is difficult to ascribe her entire neurologic problems to her meningitis. Finally, her visual hallucination was vivid and colorful; we thought this might have been" }, { "id": "pubmed23n0382_5738", "title": "[Variation of several volume regulating hormones during 21 d - 6 degrees head-down bed rest].", "score": 0.009615384615384616, "content": "Objective To investigate variations of plasma renin activity, a prostaglandin I2 (PGI2) during 21 d -6 degrees head-down tilt (HDT) with and without lower body negative pressure (LBNP). -6 degrees head-down tilt for 21 d were used to simulate weightlessness. 12 healthy male, aged 23.7 +/- 5.0, were equally and randomly divided into control group (CON) and LBNP group. The latter subjected to LBNP (-30 mm Hg, 1 h/d) in the last week of HDT. Samples of plasma were taken before HDT and on the 2nd, 4th, 11th and 22nd day during HDT. Compare to control levels, Ald declined significantly on the 2nd (CON -30%, P &lt; 0. 05; V. S. LBNP -38%, P &lt; 0.01), and increased significantly on the 11th day (CON +30%, P &lt; 0.05; LBNP +48%, P &lt; 0.01). PRA reached peak value on the 4th day (P &lt; 0.05), and declined to below the control level on the 22nd day. PGI2 increased constantly during HDT, and increased significantly on the 22nd day (CON P &lt; 0.01), 11th, 22nd (LBNP P &lt; 0.05). No apparent difference was found between groups after LBNP concerning PRA and Ald; and PGI2 didn't increase further in LBNP group. Conclusion HDT induced a timely increasing in PRA and Ald, constant increasing in PGI2." }, { "id": "pubmed23n0650_13044", "title": "[Therapeutic behavior to follow in the following clinical case: treatment of type 2 diabetes].", "score": 0.009523809523809525, "content": "A 62-year old woman with obesity, high blood pressure and type 2 diabetes mellitus (DM2) was referred to a Vascular Risk Unit of the Internal Medicine Department due to elevated HbA1C (8.1%) in spite of having taken metformin (850 mg/12h) and glipizide (10 mg/12 h) regularly. She tries to exercise daily (walking 30 min) and has lost weight (from 5 to 12 kg) several times, but always regains what she has lost. Furthermore, she monitors her glucose levels in fasting every two weeks and generally has between 120 and 160 mg/dL. Her high blood pressure is being treated with enalapril/HCTZ and she also takes aspirin 100mg/day and simvastatin 20 mg/day. It is seen in her family background that one brother died suddenly at 50 years of age. Her physical examination shows a BMI of 32.4 Kg/m(2), and she has no edemas in the lower limbs. Her BP is 154/82 mmHg and creatinine 0.9 mg/dL. She has no microalbuminuria and her liver function is normal. What treatment do you think would be the more appropriate? 1 - Add glitazones. 2 - Add incretin mimetics (GLP 1/ DPP-4). 3 - Slow acting insulin." }, { "id": "wiki20220301en309_2180", "title": "Orthostatic vital signs", "score": 0.009523809523809525, "content": "A patient is considered to have orthostatic hypotension when the systolic blood pressure falls by more than 20 mm Hg, the diastolic blood pressure falls by more than 10 mm Hg, or the pulse rises by more than 20 beats per minute within 3 minutes of standing References Medical signs Physical examination" }, { "id": "pubmed23n0253_17043", "title": "[A 57-year-old woman with gait disturbance, headache, character change, convulsion, and coma].", "score": 0.009433962264150943, "content": "We report a 57-year-old woman with progressive gait disturbance, headache, character change, convulsion and coma. She was well until 55 years of age, when she noted an onset of unsteady gait. At times she experienced transient weakness in her right hand, which was followed some difficulty in articulation. She was admitted to our service for the work up on April 6, 1992. Neurologic examination at that time revealed an alert Japanese lady in no acute distress. She was oriented to all spheres, however, she was somewhat bradyphrenic and had some disturbance in recent memory. Higher cerebral functions appeared intact. The visual acuity and visual fields were normal as were the optic fundi. Pupils were round and isocoric reacting promptly to light. Ocular movement was full, however, horizontal nystagmus was noted upon right lateral gaze. The sensation of the face was intact. She showed right facial paresis of the central type. Hearing was intact. She showed slurred speech and some difficulty in swallowing. The tongue was deviated to the right. Her gait was wide based and unsteady; tandem gait was difficult, however, walking on toes and on heels were performed well. No cerebellar ataxia was noted, but she showed some clumsiness in her right hand. Deep reflexes were symmetric and normally reactive; plantar response was extensor bilaterally. Sensation was intact; no meningeal sign was elicited. Routine laboratory work up was unremarkable; the CSF was under a borderline pressure (180 mmH2O) and contained 39 mg/dl of protein and 59 mg/dl of sugar. Cranial CT scan revealed diffuse low density areas involving bilateral cerebral white matter as well as the brain stem; MRI revealed high signal intensity lesions in those areas; gadolinium enhancement was negative; cortical sulci were effaced and the anterior part of the left lateral ventricle was compressed without deviation of the midline structure. The patient was treated with steroid pulse therapy without effect. She was discharged for out patient follow up, however, she developed a convulsion which was followed by loss of consciousness, and was admitted again to our service. She had never gained consciousness after this episode, and remained in the state of akinetic mutism. Follow-up CT and MRI did not show much change, although the area of high signal density lesions slightly enlarged on June 1, 1993. Her clinical course was complicated by drug induced bone marrow suppression and nephrotic syndrome. She expired on September 8, 1993 after developing sudden drop of blood pressure and bradycardia.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0050_7158", "title": "Orthostatic reactions in the 85-year olds.", "score": 0.009433962264150943, "content": "Testing of the orthostatic reaction is recommended in the examination of elderly fallers. This test usually includes blood pressure and instantaneous heart rate measurement but is difficult to perform in very elderly people according to the guidelines suggested for younger subjects. One reason for this is that old people often stand up slowly. The use of a tilt table, which enables a rapid change in posture from recumbent to erect position, is tempting as it could provide a method for a better standardized test. To study the usefulness of the tilt table as well as the degree of orthostatic reaction in the very elderly, we examined a sample of 85-year olds who did not suffer from falls. All were tested both with the tilt table and with active rising. The drop in blood pressure was equal in the two test types, but the increase in heart rate was significantly larger in active rising. Many test subjects were afraid of the tilt table, and two developed cardiac arrhythmia, i.e., atrial fibrillation, during the test. In our opinion, active rising is the method of choice in old persons. While the test subjects were in unusually good health for their age and thus could provide a suitable reference group for this test, the systolic blood pressure dropped considerably in several during the test. Criteria and indexes developed for younger subjects are not useful, and different evaluation criteria should be developed for the very elderly." }, { "id": "pubmed23n0800_14851", "title": "Breathlessness with pulmonary metastases: a multimodal approach.", "score": 0.009345794392523364, "content": "Case Study  Sarah is a 58-year-old breast cancer survivor, social worker, and health-care administrator at a long-term care facility. She lives with her husband and enjoys gardening and reading. She has two grown children and three grandchildren who live approximately 180 miles away. SECOND CANCER DIAGNOSIS  One morning while showering, Sarah detected a painless quarter-sized lump on her inner thigh. While she thought it was unusual, she felt it would probably go away. One month later, she felt the lump again; she thought that it had grown, so she scheduled a visit with her primary care physician. A CT scan revealed a 6.2-cm soft-tissue mass in the left groin. She was referred to an oncologic surgeon and underwent an excision of the groin mass. Pathology revealed a grade 3 malignant melanoma. She was later tested and found to have BRAF-negative status. Following her recovery from surgery, Sarah was further evaluated with an MRI scan of the brain, which was negative, and a PET scan, which revealed two nodules in the left lung. As Sarah had attended a cancer support group during her breast cancer treatment in the past, she decided to go back to the group when she learned of her melanoma diagnosis. While the treatment options for her lung lesions included interleukin-2, ipilimumab (Yervoy), temozolomide, dacarbazine, a clinical trial, or radiosurgery, Sarah's oncologist felt that ipilimumab or radiosurgery would be the best course of action. She shared with her support group that she was ambivalent about this decision, as she had experienced profound fatigue and nausea with chemotherapy during her past treatment for breast cancer. She eventually opted to undergo stereotactic radiosurgery. DISEASE RECURRENCE  After the radiosurgery, Sarah was followed every 2 months. She complained of shortness of breath about 2 weeks prior to each follow-up visit. Each time her chest x-ray was normal, and she eventually believed that her breathlessness was anxiety-related. Unfortunately, Sarah's 1-year follow-up exam revealed a 2 cm × 3 cm mass in her left lung, for which she had a surgical wedge resection. Her complaints of shortness of breath increased following the surgery and occurred most often with anxiety, heat, and gardening activities, especially when she needed to bend over. Sarah also complained of a burning \"pins and needles\" sensation at the surgical chest wall site that was bothersome and would wake her up at night. Sarah met with the nurse practitioner in the symptom management clinic to discuss her concerns. Upon physical examination, observable signs of breathlessness were lacking, and oxygen saturation remained stable at 94%, but Sarah rated her breathlessness as 7 on the 0 to 10 Borg scale. The nurse practitioner prescribed duloxetine to help manage the surgical site neuropathic pain and to assist with anxiety, which in turn could possibly improve Sarah's breathlessness. Several nonpharmacologic modalities for breathlessness were also recommended: using a fan directed toward her face, working in the garden in the early morning when the weather is cooler, gardening in containers that are at eye level to avoid the need to bend down, and performing relaxation exercises with pursed lip breathing to relieve anxiety-provoked breathlessness. One month later, Sarah reported relief of her anxiety; she stated that the fan directed toward her face helped most when she started to feel \"air hungry.\" She rated her breathlessness at 4/10 on the Borg scale. SECOND RECURRENCE: MULTIPLE PULMONARY NODULES  Sarah's chest x-rays remained clear for 6 months, but she developed a chronic cough shortly before the 9-month exam. An x-ray revealed several bilateral lung lesions and growth in the area of the previously resected lung nodule. Systemic therapy was recommended, and she underwent two cycles of ipilimumab. Sarah's cough and breathlessness worsened, she developed colitis, and she decided to stop therapy after the third cycle. In addition, her coughing spells triggered bronchospasms that resulted in severe anxiety, panic attacks, and air hunger. She rated her breathlessness at 10/10 on the Borg scale during these episodes. She found communication difficult due to the cough and began to isolate herself. She continued to attend the support group weekly but had difficulty participating in conversation due to her cough. Sarah was seen in the symptom management clinic every 2 weeks or more often as needed. No acute distress was present at the beginning of each visit, but when Sarah began to talk about her symptoms and fear of dying, her shortness of breath and anxiety increased. The symptom management nurse practitioner treated the suspected underlying cause of the breathlessness and prescribed oral lorazepam (0.5 to 1 mg every 6 hours) for anxiety and codeine cough syrup for the cough. Opioids were initiated for chest wall pain and to control the breathlessness. Controlled-release oxycodone was started at 10 mg every 12 hours with a breakthrough pain (BTP) dose of 5 mg every 2 hours as needed for breathlessness or pain. Sarah noted improvement in her symptoms and reported a Borg scale rating of 5/10. Oxygen therapy was attempted, but subjective improvement in Sarah's breathlessness was lacking. END OF LIFE  Sarah's disease progressed to the liver, and she began experiencing more notable signs of breathlessness: nasal flaring, tachycardia, and restlessness. Opioid doses were titrated over the course of 3 months to oxycodone (40 mg every 12 hours) with a BTP dose of 10 to 15 mg every 2 hours as needed, but her breathlessness caused significant distress, which she rated 8/10. The oxycodone was rotated to IV morphine continuous infusion with patient-controlled analgesia (PCA) that was delivered through her implantable port. This combination allowed Sarah to depress the PCA as needed and achieve immediate control of her dyspneic episodes. Oral lorazepam was also continued as needed. Sarah's daughter moved home to take care of her mother, and hospice became involved for end-of-life care. As Sarah became less responsive, nurses maintained doses of morphine for control of pain and breathlessness and used a respiratory distress observation scale to assess for breathlessness since Sarah could no longer self-report. A bolus PCA dose of morphine was administered by Sarah's daughter if her mother appeared to be in distress. Sarah died peacefully in her home without signs of distress. " }, { "id": "pubmed23n0387_14731", "title": "How far should we lower blood pressure in the elderly.", "score": 0.009345794392523364, "content": "In the last few years several large intervention trials have addressed the treatment of hypertension in the elderly and how far blood pressure should be lowered in such patients. The positive results of intervention against high blood pressure in the elderly has resulted in a positive attitude towards treatment and today this is an accepted and highly effective medical intervention. Both stroke and coronary morbidity have been shown to be positively affected as has total mortality. The specific issue, how far to lower blood pressure in the elderly was probably best addressed in the Hypertension Optimal Treatment (HOT) stduy in which about a third of the patients, i.e. &gt;6,000 patients, were &gt; or =65 years of age. In most of the early intervention studies of antihypertensive treatment in elderly patients diuretics or beta-blockers or the two in combination were used as the therapy by which blood pressure was lowered. However, novel therapies, in particular calcium antagonists, have shown benefits of the same magnitude as the older therapies, e.g. in the STONE trial, the Syst-Eur study, the Syst-China study and the STOP-Hypertension-2 study. In the latter study a regimen based on either of two ACE inhibitors was also shown to be equally effective as conventional treatment, based on diuretics and/or betablockers, in the elderly. These trials will be briefly reviewed here as will the SCOPE study which is an ogoing trial in which hypertensive patients aged 70-89 years are being treated with an angiotensin II receptor antagonist under double-blind and placebo-controlled conditions. It can be concluded that a wealth of information, based on large intervention trials, has been accumulated during the last decade. It is quite obvious that the elderly hypertensive patients benefit from antihypertensive treatment to at least the same extent as the young and middle-aged. It appears that blood pressure ought to be lowered down to normotensive values also in the elderly in order to minimize their risk if cardiovascular complications, although more studies would be welcome to address this issue specifically in the elderly." }, { "id": "pubmed23n0404_1932", "title": "Nefopam abuse.", "score": 0.009259259259259259, "content": "To report 3 patients who abused nefopam, a central analgesic that inhibits serotonin, norepinephrine, and dopamine reuptake. CASE 1: A 42-year-old white woman with migraines started nefopam therapy about 10 years ago. She now obtains nefopam by prescription forgery and self-administers intramuscular nefopam 300 mg/d. She experiences anticholinergic effects of nefopam and, when attempting withdrawal, depressive symptoms. CASE 2: A 40-year-old white woman with osteoporosis has injected 120 mg of nefopam intramuscularly daily for several years. When she tried to increase doses due to worsening of her symptoms, she experienced tremor, involuntary movements, and dry mouth, and became aggressive. She then resumed the initial doses. She now reports symptoms of depression when attempting withdrawal. CASE 3: A 33-year-old white man, with a history of alcohol and benzodiazepine dependence and ileostomy, and an implanted drug delivery system, has been prescribed nefopam. Fifteen days after therapy was initiated, his daily consumption was 840 mg/d, and further increased to 1840 mg/d. He experienced violent behavior, agitation, facial dysesthesia and myoclonus, tremor of fingers, and sweating. He did not attempt withdrawal. The patients described above are drug-dependent according to the Diagnostic and Statistical Manual, 4th Edition. All patients developed a pharmacodynamic tolerance phenomenon, which can develop rapidly. Violent behavior, tremor after massive intake, and depressive symptoms during withdrawal are similar to those reported with psychostimulant abuse. When abused, nefopam has primarily psychostimulant-like effects, which are probably linked to its dopamine reuptake inhibition properties." }, { "id": "pubmed23n0581_16612", "title": "[What is the most relevant definition of orthostatic hypotension: systolic blood pressure drop, diastolic blood pressure drop, or both?].", "score": 0.009259259259259259, "content": "The agreed definition of orthostatic hypotension (OH) is a drop of 20 mmHg systolic and/or 10 mmHg diastolic blood pressure (BP) within the first 3 min of erect posture. For elderly people, a question can be raised about diastolic BP relevance in OH's definition. To determinate HO's prevalence and risks factors considering systolic blood pressure (SBP)'s drop, or diastolic blood pressure (DBP)'s drop, or either. We assessed OH for 554 consecutive, ambulatory, elderly subjects, attending a geriatric outpatient clinic. OH was defined as a SBP drop&gt;20mmHg (SBP-OH), or a DBP drop&gt;10 mmHg (DBP-OH), or a drop in either (SBP. DBP-OH). OH's prevalence and risks factors were determined. In this population, 76 +/- 6 years of age, (70% hypertension), SBP-OH's prevalence was 17%, DBP-OH's prevalence was 12% and SBP. DBP-OH's prevalence was 25%. OH's risks factors varied considering OH's definition. After adjusting for significant determinants, SBP-OH's risk factors were: Antihypertensive therapy (OR=2.95; IC 95%: 1.21-4.04), age&gt;75years (OR=2.11; IC 95%: 1.22-3.66), anti-hypertensive poly therapy (OR=2.01; IC 95%: 1.39-2.92) and SBP level (OR=1.16; IC 95%: 1.01-1.33). Considering DBP-OH, the only significant risk factor was DBP's level (OR=2.64; IC 95%: 1.89-3.68). SBP. DBP-OH was only determined by anti-hypertensive poly therapy (OR=1.61; IC 95%: 1.13-2.29) and DPB level (OR=1.32; IC 95%: 1.08-1.60). For elderly people, OH's prevalence and risks factors vary considering OH's definition. SBP's drop seems to be more relevant than DBP's drop. A long term follow up is necessary to determine if SBP-OH is correlated with HO' s side effects and to establish the dangerous level of SBP' s drop." }, { "id": "pubmed23n1085_24991", "title": "Case 294.", "score": 0.009174311926605505, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, 150-400 × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L) and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0864_18025", "title": "When should orthostatic blood pressure changes be evaluated in elderly: 1st, 3rd or 5th minute?", "score": 0.009174311926605505, "content": "Detection of orthostatic hypotension (OH) is very important in geriatric practice, since OH is associated with mortality, ischemic stroke, falls, cognitive failure and depression. It was aimed to determine the most appropriate time for measuring blood pressure in transition from supine to upright position in order to diagnose OH in elderly. Comprehensive geriatric assessment (CGA) including Head up Tilt Table (HUT) test was performed in 407 geriatric patients. Orthostatic changes were assessed separately for the 1st, 3rd and 5th minutes (HUT1, HUT3 and HUT5, respectively) taking the data in supine position as the basis. The mean age, recurrent falls, presence of dementia and Parkinson's disease, number of drugs, alpha-blocker and anti-dementia drug use, and fasting blood glucose levels were significantly higher in the patients with versus without OH; whereas, albumin and 25-hydroxy vitamin D levels were significantly lower (p&lt;0.05). However, different from HUT3 and HUT5, Charlson Comorbidity Index and the prevalence of diabetes mellitus were higher, the use of antidiabetics, antipsychotics, benzodiazepine, opioid and levodopa were more common (p&lt;0.05). Statistical significance of the number of drugs and fasting blood glucose level was prominent in HUT1 as compared to HUT3 (p&lt;0.01, p&lt;0.05). Comparison of the patients that had OH only in HUT1, HUT3or HUT5 revealed no difference in terms of CGA parameters. These results suggests that orthostatic blood pressure changes determined at the 1st minute might be more important for geriatric practice. Moreover, 1st minute measurement might be more convenient in the elderly as it requires shorter time in practice." }, { "id": "pubmed23n1102_22675", "title": "Case 294: Catastrophic Antiphospholipid Syndrome.", "score": 0.00909090909090909, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, [150-400] × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L), and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L]). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/ day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0102_11497", "title": "Point of view: why hypertension is overdiagnosed and overtreated in 1987.", "score": 0.00909090909090909, "content": "1. The decision whether arterial blood pressure (BP) is elevated or normal is usually based on inadequate data: few readings in the presence of great variability of BP; levels higher in the presence of the doctor; and diastolic BP often higher sitting and standing than lying. 2. Assessments of response and of the need for increases in drug dosage are also based on insufficient data. 3. Increased morbidity and mortality from stroke and heart attack, and incomplete correction with treatment have been interpreted as suggesting further benefit from aggressive reduction of BP to 'normal' in all patients. 4. The emergence of powerful drugs with few side-effects, and the promise of lowering office BP to 'normal' as monotherapy, has removed the hesitation to treat 'mild' hypertension. 5. Attempts to lower sitting office diastolic BP to 'normal' have led to increasing drug dosage, dose-related, drug-specific side-effects, and lethargy due to hypotension. 6. Newer self-measurement BP units can be used easily by most patients, cost less than five visits to the doctor and provide a cheap method of obtaining sufficient data on which to base informed management decisions. Supported by normal echocardiographic left ventricular mass, normal 'home BP' (including lying diastolic) permits many mild hypertensives to remain off medications. 7. Non-drug therapy avoids or reduces long-term drug therapy, with its side-effects." }, { "id": "pubmed23n0346_1689", "title": "[A case report of dementia with cluttering-like speech disorder and apraxia of gait].", "score": 0.009009009009009009, "content": "A 57-year-old woman presented with a slowly progressive gait disturbance in 1992 (53 years of age). Over the next year, she gradually began to talk less, but her speech itself became more rapid than before. He speech was frequently too fast even for family members to understand. In 1997, she was admitted to our hospital. On admission, the patient was disoriented but able to follow simple verbal commands, to name things, and to write simple words. Neither apraxia, aphasia, hemispatial neglect, nor a corpus callosum disconnection syndrome was observed. There was no muscle weakness or atrophy. She showed a positive Babinski sign with mild spasticity in the legs and Gegenhalten, but no rigidity. Her speech was monotonous and abnormally fast (cluttering-like speech). Her speech became faster and faster toward the end of sentences, skipping several syllables or even words. She was unable to speak slowly and clearly, even when efforts were made to pace her speech to the speed set by the examiner. She was able to stand only with a wide base of support and body flexion. When standing, she was unable to place one foot directly beside the other; as she tried to have one foot near the other, the former repelled the latter. She had great difficulties in taking her first step forward, and showed rapid freezing of gait even when she managed to succeed in starting. She was able to imitate walking or bicycling with her legs unloaded, indicating that her gait disturbance was a kind of apraxia of gait. Her intelligence was somehow difficult to assess because of her peculiar speech disturbance. However, her family members had noticed her memory disturbance and personality change (offensiveness) since 3 to 4 years before the admission. Moreover, she was defective not only on Hasegawa Damentia Scale-Revised but also on Raven's Colored Progressive Matrices which estimates non-verbal intelligence. It was also noted that she was inattentive and lazy in thinking on questionnaires. Thus we considered that she was at least mildly demented and the type of dementia was of frontal pathology. Laboratory data were all normal except for the head MRI, which demonstrated prominent and thinness of the corpus callosum from the anterior part of the body to splenium without any other brain lesions that could cause the thinness secondarily. Our case resembles two cases reported by Sunohara et al in 1985, together comprising a unique clinical feature. Although Sunohara et al did not refer to the thinness of the corpus callosum in their cases, the clinical profiles in our case and theirs raise the possibility that they form a new disease entity. A further study in a large number of similar cases, including autopsies will provide a conclusion." }, { "id": "Neurology_Adams_4268", "title": "Neurology_Adams", "score": 0.009009009009009009, "content": "Treatment of orthostatic hypotension consists of adequate hydration (at least 1.5 L of fluids per day) with high salt intake, up 8 g of sodium per day, small and frequent meals (to reduce postprandial hypotension) and compression stockings or corset. Fainting can sometimes be avoided by the countermaneuvers of having the patient tightly cross his legs upon standing. Medical treatment can be initiated if nonmedical approaches fail. The peripherally acting alpha agonist, midodrine can be started at 2.5 mg q4h, slowly raising the dose to 5 mg q4h, taking the last dose before about 7 p.m. to void supine hypertension while asleep. The mineralocorticoid fludrocortisone acetate (Florinef) alleviates orthostatic hypotension by volume expansion due to the sodium retention by kidneys. Florinef can be started at dose 0.1 mg daily which may be slowly (over weeks) titrated up 0.9 mg daily. Fludrocortisone may cause hypokalemia and should be used cautiously in patients with severe supine" }, { "id": "pubmed23n0278_9876", "title": "[Glucocorticoid monotherapy for Cogan syndrome?].", "score": 0.008928571428571428, "content": "A 27-year-old woman suddenly developed persistent rotatory dizziness with unsteadiness on standing and walking, associated with symptoms relating to the autonomic nervous system, all signs and symptoms disappearing without treatment in 3 days. Ten days before this episode she had noticed progressive bilateral impairment of hearing accompanied by tinnitus. Caloric and audiometric tests confirmed bilateral impairment of the audiovestibular organ. A week later she also developed bilateral iritis and papillitis. The constellation of ocular and audiovestibular signs suggested Cogan's syndrome. Under high-dosage glucocorticoid treatment (initially 1,000 mg/d prednisolone intravenously for 3 days, then 100 mg/d orally in decreasing doses down to 10 mg daily) the ocular signs improved, but the bilateral hearing impairment persisted. A recurrence occurred after 5 months, while on a prednisolone dosage of 10 mg daily, together for the first time with arthralgias, suggesting systemic involvement. Although the symptoms quickly subsided when dosage was increased to 100 mg daily, repeated attempts at dose reduction brought about renewed exacerbation at 70 mg daily. As the necessary high steroid dosage led to severe side effects, an immunosuppressive drug was added (100 mg cyclophosphamide and 20 mg prednisolone, both daily; later 5 mg methotrexate weekly and 4 mg prednisolone every other day). The symptoms had not recurred when re-examined 7 months later." }, { "id": "pubmed23n0052_5267", "title": "[An elderly case of hypertension with persistent orthostatic hypotension].", "score": 0.008928571428571428, "content": "The authors report the successful control of labile hypertension associated with orthostatic hypotension in a 75-year-old male patient, by means of L-DOPS, a synthetic precursor of norepinephrine in combination with antihypertensive drugs. He had been known to be hypertensive for 15 years and developed a persistent floating sensation 2 years age. Despite good control of hypertension after admission, orthostatic hypotension was still observed. Passive tilt produced a blood pressure reduction of 60/20 mmHg. Spectral analysis of heart rate variability showed a disturbance in the activation of the sympathetic nervous system. Treatment with L-DOPS attenuated the blood pressure reduction in response to passive tilt (35/12 mmHg) and improved the sympathetic response. Because of an increase in blood pressure by L-DOPS, addition of either a calcium channel blocker or an angiotensin-converting enzyme inhibitor was necessary. These combinations of treatment successfully controlled blood pressure as well as orthostatic hypotension." }, { "id": "pubmed23n0310_17171", "title": "Treatment with electromagnetic fields reverses the long-term clinical course of a patient with chronic progressive multiple sclerosis.", "score": 0.008849557522123894, "content": "It is estimated that 10-20% of patients with multiple sclerosis (MS) have a chronic progressive (CP) course characterized by an insidious onset of neurological deficits followed by steady progression of disability in the absence of symptomatic remission. To date no therapeutic modality has proven effective in reversing the clinical course of CP MS although there are indications that prolonged treatment with picotesla electromagnetic fields (EMFs) alters the clinical course of patients with CP MS. A 40 year-old woman presented in December of 1992 with CP MS with symptoms of spastic paraplegia, loss of trunk control, marked weakness of the upper limbs with loss of fine and gross motor hand functions, severe fatigue, cognitive deficits, mental depression, and autonomic dysfunction with neurogenic bladder and bowel incontinence. Her symptoms began at the age of 18 with weakness of the right leg and fatigue with long distance walking and over the ensuing years she experienced steady deterioration of functions. In 1985 she became wheelchair dependent and it was anticipated that within 1-2 years she would become functionally quadriplegic. In December of 1992 she began experimental treatment with EMFs. While receiving regularly weekly transcortical treatments with AC pulsed EMFs in the picotesla range intensity she experienced during the first year improvement in mental functions, return of strength in the upper extremities, and recovery of trunk control. During the second year she experienced the return of more hip functions and recovery of motor functions began in her legs. For the first time in years she can now initiate dorsiflexion of her ankles and actively extend her knees voluntarily. Over the past year she started to show signs of redevelopment of reciprocal gait. Presently, with enough function restored in her legs, she is learning to walk with a walker and is able to stand unassisted and maintain her balance for a few minutes. She also regained about 80% of functions in the upper limbs and hands. Most remarkably, there was no further progression of the disease during the 4 years course of magnetic therapy. This patient's clinical recovery cannot be explained on the basis of a spontaneous remission. It is suggested that pulsed applications of picotesla EMFs affect the neurobiological and immunological mechanisms underlying the pathogenesis of CP MS." }, { "id": "pubmed23n0053_20225", "title": "[Shy-Drager syndrome and the syndrome of inappropriate secretion of antidiuretic hormone].", "score": 0.008849557522123894, "content": "We report a 52-year-old male patient with Shy-Drager syndrome (SDS) complicated by an occurrence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The patient first developed impotence at the age of 48, accompanied by urinary incontinence, and episodes of dizziness while standing. The following year, the patient had developed a staggering gait and speech became monotonous. At age 52, the patient was admitted to the hospital after experiencing frequent episodes of syncope associated with complete loss of consciousness. Upon examination, blood pressure was 100/70 in a recumbent position, and 80/60 when standing. The pulse rate varied from 60 per minute to 62. The patient was alert. The alternating Horner sign was observed, and a paucity of facial movements was visible. His speech was slow and monotonous. Muscle tone was increased bilaterally. There was incoordination. A laboratory examination revealed reduced serum sodium levels of 127 mEq/L and increased sodium excretion with plasma hypoosmolality (262 mOsm/kg/H), urine hyperosmolality and low serum renin activity (0.2 ng/ml/h). Renal functions were normal and the levels of adrenocortical and thyroid hormones were normal. There were no abnormalities observed in the chest roentgenogram taken. The level of antidiuretic hormone (ADH) was unreasonably high (5.74 pg/ml). A water-load test demonstrated failure of both water diuresis and inhibition of ADH secretion. These data suggested that hyponatremia in this case was caused by SIADH. The correlation between plasma osmolality and the concentration of ADH suggested that osmolality that initiates ADH release appeared to have been reset to around 230 mOsm/kg lower than normal.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0797_22175", "title": "Efficacy and tolerability of delapril plus indapamide versus lisinopril plus hydrochlorothiazide combination treatments in mild to moderate hypertension: a multicenter, randomized clinical study.", "score": 0.008771929824561403, "content": "Several studies have shown that antihypertensive monotherapy is commonly insufficient to control blood pressure (BP) in hypertensive patients and that concomitant use of ≥2 drugs is necessary in ∼50% of these patients. The combination of an angiotensin-converting enzyme (ACE) inhibitor and a diuretic, delapril plus indapamide (D + I), has been shown to be effective and tolerable, with no interaction between the 2 components. Another widely used combination of ACE inhibitor and diuretic is lisinopril plus hydrochlorothiazide (L + H). The aims of this study were to confirm the antihypertensive efficacy and tolerability of the fixed combination of D + I in mild to moderate hypertension, and to compare its therapeutic efficacy and tolerability with that of L + H. The antihypertensive efficacy and tolerability of a fixed combination of D + I (30-mg + 2.5-mg tablets once daily) or L + H (20-mg + 12.5-mg tablets once daily) in patients with mild to moderate hypertension were compared in a multinational, multicenter, randomized, 2-armed, parallel-group study. Eligible patients were aged 18 to 75 years and had a diastolic blood pressure (DBP) 95 to 115 mm Hg and a systolic blood pressure (SBP) ≤180 mm Hg, both measured in the sitting position. After a single-blind, placebo run-in period of 2 weeks, patients were randomized to receive 1 of the 2 treatments for a 12-week period. The primary efficacy end point was the BP normalization rate (ie, the percentage of patients with a sitting DBP ≤90 mm Hg) after 12 weeks of treatment. Secondary end points were as follows: (1) the responder rate (ie, the percentage of patients whose sitting DBP was reduced by ≥10 mm Hg from baseline or had a DBP ≤90 mm Hg after 12 weeks of treatment), (2) the percentage of patients with a DBP ≤85 mm Hg, and (3) changes in sitting SBP and DBP after 4, 8, and 12 weeks of treatment. A total of 159 hypertensive patients (88 women, 71 men) were randomized to receive D + I (44 women, 36 men; mean [SD] age, 53 [(11)] years) or L + H (44 women, 35 men; mean [SD] age, 55 [(10)] years). No significant between-group differences were found in any of the primary or secondary end points of the study. Both combinations induced a significant reduction in sitting DBP and SBP from baseline (P&lt;0.001 for both groups at week 12), without significant differences between the groups. Five mild to moderate adverse drug reactions (ADRs) occurred in each treatment group. No patient dropped out of the study because of an ADR. This study showed no difference between D + I and L + H interms of antihypertensive efficacy or tolerability in patients with mild to moderate hypertension." }, { "id": "pubmed23n0026_8212", "title": "[Orthostatic hypotension in the aged].", "score": 0.008771929824561403, "content": "Caird and his colleagues reported posture-dependent falls in systolic blood pressure of 20 mm Hg and more in 24% of a population aged 65 and above. In about 5% of the group, moreover, the falls were in excess of 40 mm Hg. Our investigations in 160 residents in an old people's home in the age range 59-88 years largely confirmed Caird's figures. Using Schellong's test we recorded systolic pressure falls of 20 mm Hg and more in 25% of our subjects. These cases of circulatory dysregulation were all manifestations of the hypodynamic form of the orthostatic syndrome. This means that only systolic blood pressure fell, diastolic pressure as well as heart rate being largely unaffected. The phenomenon appears to be due to age-related deterioration in circulatory regulation; at least no evidence has been found to suggest that it has a specific aetiology. In a double-blind cross-over study the effect of dihydroergotamine (DHE) was compared to placebo in 40 patients. Half the patients were given 2 mg DHE three times daily for 14 days and the other half placebo tablets; following 1 week's wash-out, the treatments were then reversed for a further 2-week period. Schellong's test (measurement of blood pressure and pulse after 10 min in the supine position and then after 1, 2, 5 and 10 min standing) was performed at the beginning and end of each treatment period. The average falls in upright systolic pressure for all 40 patients were as follows: before treatment 20 mm Hg (150 leads to 130); end of placebo period 19 mm Hg (147 leads to 128); end of DHE periods 7 mm Hg (145 leads to 138). The differences between the values recorded after treatment with DHE and the other two values are statistically significant (p less than 0.05). Similarly there was a significant difference in the numbers of patients experiencing dizziness during Schellong's test (16-17 out of 40 patients before treatment and after placebo, 6 out of 38 patients after DHE). From this finding conclusions can be drawn regarding the causes of vertigo in old age." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 383, 649 ] ], "word_ranges": [ [ 62, 105 ] ], "text": "The tissues that compose the tumor are well differentiated (mature or adult type); apart from skin structures many other tissues can be observed, particularly in a thickening or spur that eminences into the cavity, in which there are often teeth, cartilage and bone." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Teratocarcinoma.", "2": "Immature teratoma.", "3": "Mature cystic teratoma.", "4": "Dysgerminoma.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0721_21912", "title": "Malignant transformation of ovarian mature cystic teratoma with a predominant pulmonary type small cell carcinoma component.", "score": 0.016601495506620018, "content": "A 68-year-old woman was diagnosed with mature cystic teratoma of the left ovary when she was 44 years old. The tumor recently enlarged rapidly, and abdominal magnetic resonance imaging revealed an intrapelvic cystic lesion, which measured 123 × 120 × 107 mm and contained a mural nodule. Under a clinical diagnosis of malignant transformation of mature cystic teratoma, bilateral salpingo-oophorectomy with total hysterectomy and omentectomy were performed. The resected specimen showed a unilocular cystic lesion containing a well-demarcated mural nodule measuring 35 × 30 × 25 mm in the left ovary. A microscopic examination revealed various types of carcinoma in the mural nodule: pulmonary type small cell carcinoma (65%), adenocarcinoma (25%), squamous cell carcinoma (5%), and transitional cell carcinoma (5%). Small cell carcinoma was positive for CD56, synaptophysin, and chromogranin A. The adenocarcinoma component showed intestinal phenotypes; i.e. cytokeratin (CK) 7(-), CK20(+), CDX2(+), estrogen receptor(-), and progesterone receptor (-). Interestingly, CDX2 positivity was retained in all of the carcinomas. It was assumed that the adenocarcinoma had arisen from an intestinal epithelium in the mature cystic teratoma and then differentiated into the diverse histological types mentioned above." }, { "id": "pubmed23n0572_20287", "title": "A case of concomitant occurrence of struma ovarii and malignant transformation of cystic teratoma.", "score": 0.01626651050816579, "content": "A 77-year-old woman received a total abdominal hysterectomy and bilateral salpingo-oophorectomy because of a tumor in the left ovary. The surgical specimen measured 8.5x4.5x4.0 cm, and the solid lesion measured 4.0x3.5x3.5 cm. The solid lesion was diagnosed as struma ovarii. The cyst wall partially comprised squamous epithelium-like and ciliated columnar epithelium-like cells. The tumorous lesion of the cyst wall revealed a poorly differentiated adenocarcinoma. Immunohistochemically, the tumor cells were positive for cytokeratin7, and were negative for cytokeratin20 and thyroid transcription factor-1. The authors diagnosed that struma ovarii and other parats coexisted as a poorly differentiated adenocarcinoma that had arisen from a mature ovarian cystic teratoma. As for the identification of the origin of adenocarcinomas arising from mature ovarian cystic teratomas, more cases need to be identified and investigated." }, { "id": "pubmed23n0622_6174", "title": "Adenocarcinoma arising from the respiratory ciliated epithelium in a benign cystic teratoma of the ovary.", "score": 0.015889896778229592, "content": "Benign cystic teratoma of the ovary (BCTO) is the most common benign ovarian tumor, accounting for 15-20% of all ovarian tumors. It is usually diagnosed in the third and fourth decades of life. Malignant transformation is rare, occurring in approximately 1-2% of reported cases, with squamous cell carcinoma being the most common form. Adenocarcinoma arising from mature cystic teratoma is extremely rare. We present the patient with a BCTO, where a malignant transformation of respiratory ciliated epithelium resulted in well differentiated adenocarcinoma. Although respiratory epithelium is often found in BCTOs, adenocarcinoma arising from this cell type is uncommon. To our knowledge, this is the fourth reported case of adenocarcinoma arising from the respiratory epithelium of a BCTO." }, { "id": "pubmed23n0555_19922", "title": "A case of ovarian mature cystic teratoma presenting as a pedunculated ileal tumor.", "score": 0.015101410934744267, "content": "We report on a 34-year-old Japanese woman who presented with a pedunculated ileal tumor and who was finally diagnosed as having a right ovarian mature cystic teratoma penetrating and protruding into the ileum. She had undergone laparoscopic left ovarian cystectomy, whose specimen was diagnosed as dermoid cyst when she was 27 years old. The colon fiberscope revealed an ileal polyp, diagnosed as mature teratoma. Because of adhesion to the necrotic nodule between the tumor and the right ovary, ileocecal resection and right ovarian cystectomy were performed. The ileal tumor contained tissues of skin, neuroglia, ganglion, choroid, retina, smooth muscle, as well as fibrous and adipose tissues, cartilage, bone, mucous epithelium, and bronchial structures with bronchial glands. The necrotic nodule showed abscess, granulation tissue, foreign body reaction, hairs, normal ileal epithelium, and the ovary with ovums." }, { "id": "pubmed23n0902_19530", "title": "Ovarian Teratoma in Routine Biopsy Material During a Five-Year Period.", "score": 0.015055629274267634, "content": "Teratomas are tumors derived from germ cells, most frequently arising in the gonads. The aim of this study was to determine the number of ovarian teratomas diagnosed in the routine biopsy material at Ljudevit Jurak Clinical Department of Pathology, Sestre milosrdnice University Hospital Center during a 5-year period, as well as their clinical, gross and microscopic characteristics. Teratomas accounted for 48.6% (n=166) of primary ovarian tumors. The patient mean age was 34.74±12.37 years. Difference in the incidence of teratoma between the left and right ovary was not significant; bilateral teratoma was found in 13 patients. Teratomas were detected by ultrasonography in 115 (69.27%) cases and the rest were found during surgery performed for other indications. Most teratomas (n=161; 96.9%) were mature and cystic (dermoid cysts). Mature and solid teratomas were diagnosed in 5 (3.01%), ovarian struma in 2 (1.8%) cases and strumal carcinoid in 1 (1.2%) case. Mature cystic teratomas contained sebaceous material in 123 (76.8%) cases, and a total of 16 teeth were found; 157 (94.5%) teratomas measured &lt;10 cm in largest diameter. Microscopically, mature cystic teratomas most frequently contained ectodermal (skin with appendages, mature glia and nerve ganglia) and mesodermal (fi brous, fat tissue, cartilage and bone) tissues. Frequently found tissues of endodermal origin were respiratory and intestinal epithelia. Small foci of thyroid tissue were found in 20 (12%) teratomas. Chronic granulomatous foreign body reaction in the wall of mature cystic teratomas was found in 11 (6.8%) tumors." }, { "id": "pubmed23n0352_14243", "title": "[Malignant transformation of thyroid tissue in an ovarian dermoid cyst: case report].", "score": 0.014815627743634766, "content": "Mature cystic teratoma is the most common type of ovarian teratomas and also the most frequent tumor originating from germ cells. Usually unilateral, it is, by definition, composed of well-differentiated derivates which originate from all three layers. It is most frequently diagnosed in the female reproductive period; in its pure form, it is generally benign, but occasionally it may undergo malignant transformation in one of its elements. The authors report a case of a 43-year-old woman who underwent a thyroid regulation substitutive therapy 12 years after thyroidectomy which had been performed because of Basedow's disease. On the occasion of her fourth delivery by cesarean section, bilateral cystical formations in both ovaries were found. Upon ending the delivery, the right ovary with the cyst was surgically removed, as well as part of the cystically changed left ovary. The pathohistological analysis of the samples taken from the left ovary cyst pointed to the following diagnosis: dermoid cyst of the ovary a mature cystic teratoma, whereas the samples from the cystic tumor of the right ovary were diagnosed as: ovarian teratoma malignant a papillary carcinoma of the thyroid tissue and cystadenoma papillare serosum ovarii. The histological type of the malignant thyroid tissue neoplasm in the teratoma was a papillary carcinoma consisting of papillary proliferations lined by cuboidal, cylindrical and pseudostratified epithelium with charasteristic \"ground glass\" nuclei, but without invasion into the blood vessels. Malignant transformation of the ectopic thyroid tissue, which is one of the elements of the ovarian cystic teratoma, is extremely rare: it is diagnosed on basis of the histological picture and criteria which are the same as for the tumor of the thyroid gland. One should not exclude a pssibility that the identical or different pathological alterations characteristic of the thyroid gland may also be detected in the ectopic thyroid tissue of a dermoid cyst. The reported case was chosen due to its complex and rich clinical and pathohistological picture characterized by the occurrence of a bilateral dermoid cyst with the malignant transformation of the thyroid tissue. The malignant neoplasm in the mature ovarian cystic teratoma was papillary carcinoma of the thyroid tissue with all histological properties typical for the thyroid gland carcinoma. The possibility of the malignant transformation of the endodermal thyroid tissue in the mature ovarian cystic teratoma and changes in the thyroid gland of the Basedow's disease type diagnosed before are without clear causation." }, { "id": "pubmed23n0602_9674", "title": "Adenocarcinoma arising from respiratory ciliated epithelium in benign cystic teratoma of the ovary: a case report with analyzes of the CT, MRI, and pathological findings.", "score": 0.013638638638638638, "content": "The malignant transformation of mature cystic teratoma is rare, thus occurring in only 1-2% of all cases. The most common malignancy arising in mature cystic teratoma is squamous cell carcinoma. Adenocarcinoma occurs with less frequency. We herein present a patient with an ovarian mature cystic teratoma who demonstrated a malignant transformation to well-differentiated adenocarcinoma. Malignant transformation was diagnosed preoperatively by contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI). Microscopically and immunohistochemically, the adenocarcinoma was considered to have arisen from the ciliated respiratory epithelium. After a 28-month of follow-up period, she remains free of the disease. This is the third reported case of adenocarcinoma arising in the respiratory epithelium of an ovarian mature cystic teratoma. Contrast enhanced CT and MRI are useful for making a preoperative diagnosis and an immunohistochemical study is helpful for defining its origin." }, { "id": "wiki20220301en013_56033", "title": "Teratoma", "score": 0.013596164972311761, "content": "Malignant transformation A \"benign\" grade 0 (mature) teratoma nonetheless has a risk of malignancy. Recurrence with malignant endodermal sinus tumor has been reported in cases of formerly benign mature teratoma, even in fetiform teratoma and fetus in fetu. Squamous cell carcinoma has been found in a mature cystic teratoma at the time of initial surgery. A grade 1 immature teratoma that appears to be benign (e.g., because AFP is not elevated) has a much higher risk of malignancy, and requires adequate follow-up. This grade of teratoma also may be difficult to diagnose correctly. It can be confused with other small round cell neoplasms such as neuroblastoma, small cell carcinoma of hypercalcemic type, primitive neuroectodermal tumor, Wilm's tumor, desmoplastic small round cell tumor, and non-Hodgkin lymphoma." }, { "id": "wiki20220301en017_65513", "title": "Ovarian cancer", "score": 0.013418026009170863, "content": "Immature, or solid, teratomas are the most common type of ovarian germ cell tumor, making up 40–50% of cases. Teratomas are characterized by the presence of disorganized tissues arising from all three embryonic germ layers: ectoderm, mesoderm, and endoderm; immature teratomas also have undifferentiated stem cells that make them more malignant than mature teratomas (dermoid cysts). The different tissues are visible on gross pathology and often include bone, cartilage, hair, mucus, or sebum, but these tissues are not visible from the outside, which appears to be a solid mass with lobes and cysts. Histologically, they have large amounts of neuroectoderm organized into sheets and tubules along with glia; the amount of neural tissue determines the histologic grade. Immature teratomas usually only affect one ovary (10% co-occur with dermoid cysts) and usually metastasize throughout the peritoneum. They can also cause mature teratoma implants to grow throughout the abdomen in a disease" }, { "id": "pubmed23n1138_23523", "title": "Well-differentiated cerebellum in an ovarian mature cystic teratoma: a case report and review of the literature.", "score": 0.013163536574907812, "content": "Mature teratoma is the most common germ cell tumor as it represents 95% of germ cell tumors. Although common in children and young adults, ovarian teratoma can occur at any age. Mature teratomas are composed of mature tissues representing elements derived from more than one embryonic germ layer (ectoderm, mesoderm, and endoderm), with ectodermal derivatives being the usual predominant component; however, the finding of a well-differentiated cerebellum is extremely rare. A 20-year-old Saudi female presented to the emergency department with severe abdominal pain of 1-day duration. Pelvic ultrasound showed a large ovoid- to bilobed-shaped cystic pelvic structure extending to the lower abdomen. The patient underwent left ovarian cystectomy. Microscopic examination showed a cyst wall with skin tissue, including adnexal structures (sebaceous glands), a well-differentiated cerebellum, and mature glial tissue. After extensive sampling, no immature component was identified. Thus, the final diagnosis of a mature cystic teratoma with well-differentiated cerebellum was established. The patient was well postoperatively and was discharged in a stable condition. We report this case of well-differentiated cerebellum within ovarian teratoma to expand the pool of cases reported in literature of this extremely rare entity, as only 22 cases with such findings have been reported in literature to the best of our knowledge. This finding poses a diagnostic challenge to the pathologist due to its rarity and its similarity to immature teratoma. We thus emphasize that thorough sampling of ovarian teratoma is of paramount importance and to keep the aforementioned diagnosis in mind and not confuse it with immature elements, especially in intraoperative consultation and frozen sections." }, { "id": "wiki20220301en195_23573", "title": "Immature teratoma", "score": 0.01312170714735412, "content": "An immature teratoma is a teratoma that contains anaplastic immature elements, and is often synonymous with malignant teratoma. A teratoma is a tumor of germ cell origin, containing tissues from more than one germ cell line, It can be ovarian or testicular in its origin. and are almost always benign. An immature teratoma is thus a very rare tumor, representing 1% of all teratomas, 1% of all ovarian cancers, and 35.6% of malignant ovarian germ cell tumors. It displays a specific age of incidence, occurring most frequently in the first two decades of life and almost never after menopause. Unlike a mature cystic teratoma, an immature teratoma contains immature or embryonic structures. It can coexist with mature cystic teratomas and can constitute of a combination of both adult and embryonic tissue. The most common symptoms noted are abdominal distension and masses. Prognosis and treatment options vary and largely depend on grade, stage and karyotype of the tumor itself." }, { "id": "wiki20220301en574_16633", "title": "Ovarian germ cell tumors", "score": 0.012702472293265132, "content": "Teratomas Teratoma are most common germ cell tumor of ovary. Teratomas can be divided into two types: mature teratoma (benign) and immature teratoma (malignant). Immature teratomas contain immature or embryonic tissue which significantly differentiates them from mature teratomas as they carry dermoid cysts. It is commonly observed in 15 to 19-year-old women and rarely in women after menopause. Immature teratomas are characterized with a diameter of 14–25 cm, encapsulated mass, cystic areas, and occasional appearance of hemorrhagic areas. The stage of immature teratomas is determined depending on the amount of immature neuroepithelium tissue detected. Yolk sac tumor" }, { "id": "pubmed23n0787_21579", "title": "[Pelvic retroperitoneal teratoma. A case report].", "score": 0.01235827664399093, "content": "Teratomas are congenital tumors comprising of tissues arising from pluripotent embryonic cells. Their common sites of occurrences are ovary, testis, mediastinum and retroperitoneum. Retroperitoneal teratomas are extremely rare in adults but occur in 3% of children. The presence of a cystic or complex adnexal mass during pregnancy is common with mature teratoma reported in approximately 30-50% of pregnancies. The ultrasound is the number one method of detection. The use of tumor markers is limited because it alters its value during pregnancy. We report a case of a 18 year old female patient who came to the General Hospital Dr. Miguel Silva in Morelia, Michoacán with a gestation age of 10.2 weeks and a recent diagnosis of an asymptomatic adnexal mass. Using the transvaginal approach, the ultrasound reported an irregular gestational sac with the absence of cardiac activity in the embryo. A diffusely echogenic adnexal mass with oval appearance, wall regularity and homogeneous internal echos of 12.96 x 8.99 cm. Exploratory laparotomy was performed finding normal uterus and ovaries, with the posterior retroperitoneal resection of the 15 cm multi-lobed tumor. The surgical specimen measured 13 x 12 x 8 cm, had a brownish color, wall irregularity, soft consistency, multi-lobed, and a yellowish interior greasy material. Microscopically the tumor is delimited with a firm capsule composed of a hyaline-fibrous tissue, lined by squamous keratinized epithelium, with multiple layers of keratin. This anato-pathologic finding is diagnostic of retroperitoneum mature teratoma." }, { "id": "pubmed23n0408_4863", "title": "Adenocarcinoma arising from respiratory ciliated epithelium in mature ovarian cystic teratoma.", "score": 0.012224591329068942, "content": "Malignant transformation of a mature cystic teratoma of the ovary is rare, that of an adenocarcinoma is extremely rare. A 32-year-old woman was suspected as having a malignant transformation of her mature cystic teratoma of the ovary because the preoperative level of carcinoembryonic antigen (CEA) was extremely high. Resections of her ovarian cysts were performed, and this particular tumor was histopathologically diagnosed as an adenocarcinoma arising from a mature cystic teratoma of the left ovary. Because adenocarcinomas arising from mature cystic teratomas of the ovary are extremely rare, we report this case with a review of some of the literature." }, { "id": "wiki20220301en017_65518", "title": "Ovarian cancer", "score": 0.011488990625681272, "content": "Histologically, embryonal carcinoma appears similar to the embryonic disc, made up of epithelial, anaplastic cells in disorganized sheets, with gland-like spaces and papillary structures. Polyembryoma Polyembryomas, the most immature form of teratoma and very rare ovarian tumors, are histologically characterized by having several embryo-like bodies with structures resembling a germ disk, yolk sac, and amniotic sac. Syncytiotrophoblast giant cells also occur in polyembryomas. Squamous cell carcinoma Primary ovarian squamous cell carcinomas are rare and have a poor prognosis when advanced. More typically, ovarian squamous cell carcinomas are cervical metastases, areas of differentiation in an endometrioid tumor, or derived from a mature teratoma." }, { "id": "pubmed23n0600_18102", "title": "[Benign mature teratomas of the mediastinum].", "score": 0.011383647798742139, "content": "Mature teratomas of the mediastinum are rare. However, they represent the most common mediastinal germ cell tumours. The aim of this study is to describe their clinical and pathological characteristics. Fourteen cases of mediastinal mature teratoma, diagnosed between January 1992 and December 2006, were reviewed retrospectively, noting the clinical, radiological, surgical, and pathological findings. The patient population consisted of 10 females and 4 males with mean age of 29 years (5-56 years). Chest pain was the main symptom. Imaging features comprised a heterogeneous anterior mediastinal mass containing soft-tissue, fluid, fat, or calcium attenuation, or any combination of the four. Macroscopically all the tumours were cystic, or predominantly cystic, containing mostly grumous material. The mean size was 9 cm (5-12 cm). Histological examination constantly revealed skin with or without appendages. Other components identified were bronchial mucosa (12 cases), fat (12 cases), muscle (10 cases), cartilage (8 cases), bone (7 cases), gastrointestinal mucosa (7 cases), pancreas (5 cases), urothelial epithelium (3 cases), nervous and prostatic tissues (one case each). All the teratomas were mature, and 7 of them were intrathymic. Every form of teratoma occurs in the mediastinum (mature, immature and with malignant transformation) but, in our study, they were exclusively mature. The histology is essentially similar to that of teratomas of gonads. However, pancreatic tissue occurs frequently in mediastinum (54% in literature, 25% in our study) but not in the gonads. On the other hand, thyroid follicles have not yet been seen in mediastinal teratomas." }, { "id": "wiki20220301en022_99046", "title": "Dermoid cyst", "score": 0.01135786682713101, "content": "A dermoid cyst is a teratoma of a cystic nature that contains an array of developmentally mature, solid tissues. It frequently consists of skin, hair follicles, and sweat glands, while other commonly found components include clumps of long hair, pockets of sebum, blood, fat, bone, nail, teeth, eyes, cartilage, and thyroid tissue. As dermoid cysts grow slowly and contain mature tissue, this type of cystic teratoma is nearly always benign. In those rare cases wherein the dermoid cyst is malignant, a squamous cell carcinoma usually develops in adults, while infants and children usually present with an endodermal sinus tumor. Location Due to its classification, a dermoid cyst can occur wherever a teratoma can occur. Vaginal and ovarian dermoid cysts" }, { "id": "wiki20220301en195_23575", "title": "Immature teratoma", "score": 0.010755042947173759, "content": "Ovarian cancer is staged using the FIGO staging system and uses information obtained after surgery, which can include a total abdominal hysterectomy via midline laparotomy, unilateral (or bilateral) salpingo-oophorectomy, pelvic (peritoneal) washings, assessment of retroperitoneal lymph nodes and/or appendectomy. The AJCC staging system, identical to the FIGO staging system, describes the extent of tumor (T), the presence of absences of metastases to lymph nodes (N), the presence or absence of distant metastases (M). Pathology An immature teratoma contains varying compositions of adult and embryonic tissue. The most common embryonic component identified in immature teratomas is the neuroectoderm. Occasionally, tumors may present neuroepithelium that resemble neuroblasts. Tumors may also present embryonic components such as immature cartilage and skeletal muscle of mesodermal origin. Immature teratomas composed of embryonic endodermal derivatives are rare." }, { "id": "pubmed23n0206_1363", "title": "Morphological characteristics of different types of cystic teratoma of the ovary. A study of surface ultrastructure in relation to tumor classification and development.", "score": 0.010536823425022181, "content": "In this study the surface ultrastructure of 28 cystic ovarian teratomas was examined to determine their morphological appearance and the relation to biological behavior. The squamous epithelium of cystic tumors showed abnormal maturation and keratinization of surface cells with keratinous flakes occasionally in polypoid configurations. The respiratory epithelium showed an abundance of microvillous and ciliated cells, areas with disorganized surface structures were also seen. Piling up of squamous cells in heaps, piles, cauliflower- or onion-like arrangements were seen in lesions histologically regular. This study showed a distinct difference in surface ultrastructure as compared to ovarian cystadenomas emphasizing the difference in development. Surface ultrastructural studies also were useful in deciding the nature of histologically indeterminable lesions as well as in revealing areas of malignant potential." }, { "id": "wiki20220301en013_56020", "title": "Teratoma", "score": 0.009900990099009901, "content": "Types Mature teratoma A mature teratoma is a grade 0 teratoma. They are highly variable in form and histology, and may be solid, cystic, or a combination of the two. A mature teratoma often contains several different types of tissue such as skin, muscle, and bone. Skin may surround a cyst and grow abundant hair (see dermoid cyst). Mature teratomas generally are benign, with 0.17-2% of mature cystic teratomas becoming malignant. Immature teratoma Immature teratoma is the malignant counterpart of the mature teratoma and contains immature tissues which typically show primitive or embryonal neuroectodermal histopathology. Immature teratoma has one of the lowest rates of somatic mutation of any tumor type and results from one of five mechanisms of meiotic failure." }, { "id": "pubmed23n0541_8717", "title": "[Laparoscopic extirpation of retroperitoneal bronchogenic cyst].", "score": 0.00980392156862745, "content": "The retroperitoneal bronchogenic cyst is an extremely rare anomaly. During the examination of an 18-year-old female patient due to her extreme thinness, the abdominal ultrasound and later the CT indicated as an accidental finding--a left side adrenal/suprarenal adenoma, which turned out to be hormonally inactive. But while we were doing a laparoscopic surgical intervention we found a 6-8-cm cyst in the retroperitoneum, between the greater curvature and the spleen. It contained light grey, mucinous liquid. The left suprarenal gland had normal size and appearance. During the microscopic examination the removed terime showed cystic structures, which were covered inside with multilayer ciliated columnar epithelium, mucous excretory glands, a whole layer of connective/interstitial and smooth muscle tissue. Neither cartilage, nor gastrointestinal epithelium was found. Only a few publications have reported about retroperitoneal bronchogenic cyst so far. These lesions occur very rarely at the greater curvature. Although this alteration is really unusual, bronchogenic cysts have to be expected in the differential diagnostics of the retroperitoneal tumors." }, { "id": "pubmed23n0546_2919", "title": "[Mature cystic teratoma of the ovary with a small ganglioneuroma].", "score": 0.009708737864077669, "content": "A case of ganglioneuroma arising within a cystic mature teratoma of the ovary in a 34-year-old woman is reported. Patient underwent right adnexectomy. The ovary was completely replaced by a bilocular cystic lesion, measuring 8 cm in diameter and filled with adipose tissue and pilosebaceous material. Microscopically the cyst was composed by a mature cystic teratoma containing skin with dermal appendages, fatty tissue and bronchial epithelium. Furthermore a nodule (0.5 cm in size) composed of mature ganglion cells, axons and Schwann cells, was identified. Ganglion cells were positive for NSE and synaptophysin, while Schwann cells stained positively with S100 protein and GFAP. To the best of our knowledgment this is the first reported cases of ganglioneuroma arisen within a cystic mature teratoma of the ovary." }, { "id": "pubmed23n1069_8899", "title": "Primary Mature Teratoma of the Rectum: A Case Report.", "score": 0.009615384615384616, "content": "BACKGROUND Teratomas are embryonal neoplasms that contain tissues derived from 1 or more of the 3 germ layers. They commonly are found in the sacrococcygeal-gonadal location, sometimes in midline locations such as the mediastinum, retroperitoneum, and head and neck region. Primary rectal teratomas are extremely rare. Extragonadal teratomas can originate from pluripotent germ cells present in abnormal embryonic rests. CASE REPORT Here, we report a rare case of a primary mature, solid teratoma of the rectum. A 68-year-old woman presented with hematochezia and denied any history of abdominal pain or a change in bowel habits. Colonoscopy revealed a 4-cm pedunculated polyp in the rectum. No hair was present on its surface. The polyp was completely removed by polypectomy. Histologically, the tumor consisted of mature components from all 3 germ layers. Its surface was covered by squamous epithelium with hair follicles and sweat glands. Adipose tissue, blood vessels, bone, and glandular epithelium were present inside the mass. No evidence was found of immature elements or malignant features. CONCLUSIONS When polypoid lesions are found in the rectum, teratoma should be considered in the differential diagnosis. Histopathological confirmation is necessary to diagnose teratoma. Primary rectal teratomas should be distinguished from other neoplastic polyps as well as from local spread of teratomas arising in adjacent organs. These neoplasms are usually mature (benign) but may undergo malignant transformation. Therefore, complete resection is recommended to alleviate symptoms and avoid the risk of malignancy." }, { "id": "pubmed23n0016_922", "title": "[Mature benign teratomas with malignant tumors and malignant monodermal ovarian teratomas. Anatomo-clinical presentation of 10 cases].", "score": 0.009615384615384616, "content": "The clinicopathologic features are presented of 8 malignant neoplasms occurring in adult teratomas, and of 2 malignant monodermal teratomas found in a continuous series of 1029 cases of ovarian adult teratomas. The age of the patients was 44--76 years. The first 8 observations included 6 epidermoid carcinomas, 1 undifferentiated carcinoma and 1 strumal carcinoid. In the epidermoid carcinomas malignancy was recognized peroperatively only in three instances. One tumor had infiltrated the broad ligament on one side and another the urinary bladder. The neoplasm appeared as a mass which thickened the wall of a typical dermoid cyst. Four patients died of the tumor from 3 months to 1 year after operation; one is alive more than 19 years later and one is lost to follow-up. The crucial factor in prognosis is the integrity of the ovarian capsule. The undifferentiated carcinoma, which had infiltrated the pelvic walls, could only be incompletely resected and caused death within 3 1/2 months. The strumal carcinoid was discovered by chance during laparotomy for a far-advanced adenocarcinoma of the pancreas which led to death within 2 months. The two cases of malignant monodermal teratoma comprised 1 thyroid papillary carcinoma and 1 carcinoid. Both patients are alive more than 8 and 5 years after operation. The carcinoid manifested itself by persistant diarrhea which ceased soon after operation and did not recur subsequently." }, { "id": "wiki20220301en063_44842", "title": "International Classification of Diseases for Oncology", "score": 0.009523809523809525, "content": "M9064/3 Germinoma Germ cell tumor, NOS M9065/3 Germ cell tumor, nonseminomatous M9070/3 Embryonal carcinoma, NOS Embryonal adenocarcinoma M9071/3 Yolk sac tumor Endodermal sinus tumor Polyvesicular vitelline tumor Orchioblastoma Embryonal carcinoma, infantile Hepatoid yolk sac tumor M9072/3 Polyembryoma Embryonal carcinoma, polyembryonal type M9073/1 Gonadoblastoma Gonocytoma M9080/0 Teratoma, benign Adult cystic teratoma Adult/cystic teratoma, NOS Teratoma, differentiated Mature teratoma M9080/1 Teratoma, NOS Solid teratoma M9080/3 Teratoma, malignant, NOS Embryonal teratoma Teratoblastoma, malignant Immature teratoma, malignant or NOS M9081/3 Teratocarcinoma Mixed embryonal carcinoma and teratoma M9082/3 malignant teratoma, undifferentiated Malignant teratoma, anaplastic M9083/3 Malignant teratoma, intermediate M9084/0 Dermoid cyst, NOS Dermoid, NOS" }, { "id": "pubmed23n1132_5448", "title": "Clinicopathological observation of mature teratoma with malignant transformation, a single center retrospective study.", "score": 0.009523809523809525, "content": "To investigate the clinicopathological features of mature teratoma with malignant transformation. Retrospectively analysis of 1179 cases mature teratoma was done from August 1999 to December 2019 in Institution. 14 cases of mature teratoma with malignant transformation were discussed mainly for the pathological characteristics and clinical manifestations. 4 of them were less than 40 years old. All but one occurred in the ovaries, and the one was in the left anterior mediastinum which was the only male. The clinical manifestations of the patients were atypical. Imaging showed cystic solid mass. Surgery was performed. Polypoid mass, solid nodule and thickened area of cyst wall can be seen on the section of tumor. Pathological results show that there were 5 cases of squamous cell carcinoma, 3 cases of carcinoid, 2 cases of serous carcinoma and 2 cases of thyroid papillary carcinoma, 1 case of carcinosarcoma and 1 case of strumal carcinoid. Two cases of squamous cell carcinoma had pelvic and abdominal metastasis. Immunohistochemistry of case 14 showed that AE1/AE3, CD56, SYN, NSE, PSAP, CDX2 were positive in carcinoid. EMA and CK20 were positive in mucinous glands around carcinoid. Calretinin and inhibin were positive in the mesenchyme adjacent to intestinal mucinous gland. Teratoma with malignant transformation is a rare malignancy, although teratoma is a common germ cell tumor. And it's more common in patients over 40 years, especially those patients who were in menopause. Squamous cell carcinoma is the most common type and prone to metastasis. Strumal carcinoid was well-defined, but as an endocrine tumor, it may cause a series of digestive, respiratory or hormonal disorders. Therefore, the mature teratomas should be removed in time after detection." }, { "id": "pubmed23n0043_4765", "title": "Pulmonary blastoma. Comparison between its epithelial components and fetal bronchial epithelium.", "score": 0.009433962264150943, "content": "Three cases of pulmonary blastoma exhibiting biphasic epithelial and stromal patterns, and a case of fetal lung-type adenocarcinoma, were examined by immunohistochemistry and electron microscopy (EM) and compared with fetal bronchial epithelium in order to explore the multidirectional differentiation of their epithelial components. The glandular cells of all four tumors resembled fetal bronchial epithelial cells in the pseudoglandular stage. Neuroendocrine (NE) cells were also present; they were argyrophilic and expressed pan-NE markers, neurosecretory granules and peptide hormones. The neural cell adhesion molecule (NCAM) was strongly expressed on the cell membranes of glandular cells, as in the case of proximal bronchial epithelial cells at the pseudoglandular stage in fetal lung. Sialosylated Lewis X was also expressed, indicating that the epithelial cells were possibly of endodermal origin. Two of the four cases showed considerable immunoreactivity for alpha-fetoprotein (AFP). The epithelial cells of pulmonary blastomas may occasionally de-differentiate into cells functionally resembling fetal hepatic, foregut and yolk sac cells expressing AFP. Tumor examination by immunohistochemistry and EM suggested that the glandular cells of the tumors may differentiate to some extent like those of fetal large bronchi at the pseudoglandular stage, but there was concordance and discordance in the expression of neuroendocrine and oncofetal markers between blastomatous tumors and fetal bronchial epithelium." }, { "id": "pubmed23n0359_12455", "title": "An intrapulmonary teratoma associated with bronchiectasia containing various kinds of primordium: a case report and review of the literature.", "score": 0.009345794392523364, "content": "An intrapulmonary teratoma (IPT), multiloculated and bronchiectatic, with two polyps inside a 23-year-old man is reported. The IPT, a very rare benign cystic lesion, was communicating with segmental bronchus and was removed by a segmental resection from the upper lobe of the left lung. The teratoma contained various kinds of primordial derivatives, such as mesoderm, ectoderm, and endoderm. Though 65 cases of IPT have been reported in the literature (1839-1996), in the present case there were over 15 germ derivatives, the largest number reported to date. The tumor contained thymic tissue, apart from mediastinum, which may be significant in relation to the pathogenesis of IPT. Clinical manifestations, age, and gender distributions and the kind of germ cell derivatives are discussed." }, { "id": "pubmed23n0636_16507", "title": "Benign cystic teratoma of the parotid gland: a case report.", "score": 0.009259259259259259, "content": "Mature cystic teratomas of the major salivary glands are rare. This report describes a case of a mature cystic teratoma of the left parotid gland, including the cytologic and histopathologic findings. A 17-year-old young woman presented with a slow-growing left parotid mass that had been present for 4 years. Preoperative fine needle aspiration cytology showed the presence of acinar and ductal cells, foamy cells and multinucleated giant cells. Imprint cytology of the surgical material showed the presence of some squamous cells and sebaceous gland-like cells with hair shafts. Cellular atypia was inconspicuous. Grossly, the 3-cm lesion was unicystic and embedded within the parotid gland parenchyma. Microscopically, the inner surface of the cyst was lined with keratinized squamous epithelium. The cyst wall contained skin adnexa such as sebaceous, eccrine and apocrine glands, as well as hair follicles. Some mature cartilage tissue was also detected. Foreign body granulomatous change was seen focally. No immature tissue or malignant transformation was found. There is no previous report describing the cytologic findings of a mature cystic teratoma of the parotid gland. Mature cystic teratomas should therefore be considered in the differential diagnosis of a cystic lesion of the parotid" }, { "id": "pubmed23n0052_19843", "title": "[Primary malignant teratoma of the thyroid. Two cases involving immunohistochemical and ultrastructural studies].", "score": 0.009259259259259259, "content": "Two cases of primary malignant teratoma of the thyroid are reported. The first case, which occurred in a 21-year-old female, was mostly composed of tumoral neural tissue and foci of foetal cartilage. The patient died with lung metastases within 5 months after the first symptoms. The second case, which occurred is a 8-year-old infant female, had epithelial and mesenchymal components without neural tissue. This case had a better prognosis with survival of four years after initial diagnosis. The different tumoral components were identified by a thorough histopathological examination of the thyroidectomy with immunological and ultrastructural studies. As for other teratomas, presence of immature neural tissue bore a poor prognosis. The clinical, histopathological features and the histogenesis of this rare tumour are described and literature is reviewed." }, { "id": "pubmed23n0830_16830", "title": "Ovarian Small Cell Carcinoma of Pulmonary Type Arising in Mature Cystic Teratomas With Metastases to the Contralateral Ovary.", "score": 0.009174311926605505, "content": "A bilateral small cell ovarian carcinoma pulmonary-type (SCCOPT), arising in bilateral mature cystic teratomas (MCTs) presented as stage IIIB in a 37-year-old woman. Microscopically, tumor nests were related to the dermoid protuberance and expressed pancytokeratin, EMA, CD56, chromogranin A, NSE, synaptophysin, and SOX2. SALL4 was also focally positive. CDX2, TTF1, PAX8, CK7, CK20, and several neuroendocrine gut hormones were negative. Serum NSE was elevated. This case represents a SCCOPT arising in an MCT in the right ovary with metastasis to the left one also containing a synchronous MCT. Surface implants and lymphovascular invasion suggested metastasis from the right ovarian SCCOPT and excluded a metastatic origin from usual locations of small cell carcinoma (SCC). SCCOPT is morphologically identical to SCC elsewhere, even sharing NSE serum elevation. Although the tumor was closely related to teratomatous mature tissues, a complex immunohistochemical panel failed to provide a tissue of origin. " }, { "id": "article-29964_19", "title": "Testicular Teratoma -- Histopathology", "score": 0.009139248919906945, "content": "Microscopy : Any epithelial, mesenchymal, or neural-derived tissue can be seen. Less common are tissues derived from the respiratory, gastrointestinal, or genitourinary tract. Skin-derived structures such as epithelial-derived (epidermoid cyst) or appendages is a quite common finding, especially in prepubertal-type teratomas, while postpubertal-type teratomas tend to appear as multiloculated cysts lined by other tissue types such as glandular epithelium and contain solid areas formed by parenchymal structure or mesenchymal tissues. A certain element of immature tissues can also be encountered, consisting of ectodermal, endodermal, or mesenchymal structures. Neuroectodermal tissue is the most common immature type and often has several differentiation stages of embryonic/fetal nervous system tissue. Historically teratoma has been differentiated into mature and immature, but this distinction is not recommended any more due to the lack of a prognostic significance. Teratoma can occur paired with other histotypes of germ cell neoplasia, such as yolk sac tumor or embryonal carcinoma." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 86, 279 ] ], "word_ranges": [ [ 14, 44 ] ], "text": "The Gram stain tells us that it is a staphylococcus, most of the species of this genus acquired in-hospital are methicillin resistant, so they are considered resistant to Cloxacillin, Cefazolin" }, "2": { "exist": true, "char_ranges": [ [ 86, 279 ] ], "word_ranges": [ [ 14, 44 ] ], "text": "The Gram stain tells us that it is a staphylococcus, most of the species of this genus acquired in-hospital are methicillin resistant, so they are considered resistant to Cloxacillin, Cefazolin" }, "3": { "exist": true, "char_ranges": [ [ 415, 516 ] ], "word_ranges": [ [ 66, 81 ] ], "text": "the experience with vancomycin use in this setting is considered the empirical choice for vancomycin." }, "4": { "exist": true, "char_ranges": [ [ 284, 403 ] ], "word_ranges": [ [ 45, 64 ] ], "text": "there are no clinical data about the efficacy of linezolid for the treatment of systemic infection related to catheter." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Cefazolin.", "2": "Cloxacillin.", "3": "Vancomycin.", "4": "Linezolid.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0249_21469", "title": "[Study on sepsis in the elderly at Nagoyashi-Koseiin Geriatric Hospital].", "score": 0.016628206868467492, "content": "A study based on clinical analysis was conducted regarding the 125 episodes in the elderly 112 patients of sepsis who were 70 (average 83.8 +/- 7.5) years old at Nagoyashi-Koseiin Geriatric Hospital from 1985 through 1994. 1) The backgrounds of the elderly patients with sepsis were as follows: bedridden (72.8%), urinary catheter in place (61.2%), central venous catheter in place (48.8%), and prior antibiotic use (40.8%). All patients had an underlying disease. 2) Organisms isolated were Escherichia coli (21.2%), Staphylococcus aureus (18.4%); Coagulase-negative staphylococci (CNS) (17.4%) and Candida albicans (6.1%). Chronologically, the quantity of gram-positive cocci increased while that of gram-negative bacilli decreased. As the age of the patients increased, the frequency of infections by Methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and/or multiple bacteria increased, while that of infections by CNS and gram-negative bacilli excluding E. coli decreased. 3) The primary infected sites were the urinary tract system (24.8%), central venous catheter (21.6%) and unknown (31.2%). 4) The primary clinical observations were fever exceeding 38.0 degrees C (88.0%), tachycardia (60.8%), shivering (44.0%) and cyanosis (32.8%). 5) Complications were multiple organ failure (33.6%), septic shock (26.4%) and disseminated intravascular coagulation (22.4%). 6) The prognosis indicated that 65.6% were survivors, and 34.4% were nonsurvivors. At the onset of sepsis, weight, blood pressure, serum albumin, and total cholesterol in the nonsurvivors were significantly lower than those in the survivors, whereas heart rate, GOT, LDH, and BUN in the nonsurvivors were significantly higher than those in the survivors." }, { "id": "pubmed23n0766_14043", "title": "[Peripheral venous catheter-related E. faecalis sepsis with fatal outcome].", "score": 0.016569667921944538, "content": "A 82 year-old man was admitted with a facial Herpes zoster reactivation and a zoster-related meningoencephalitis. He was treated with Aciclovir over a peripheral venous catheter that was placed in the right elbow pit. The meningoencephalitis subsided without neurological deficits, but the patient developed a catheter-associated phlebitis. An oral cephalosporin was prescribed and the patient discharged. After developing a fever and general discomfort he was readmitted to hospital three days later. A 3 × 3 cm abscess in the elbow pit was incised and drained, but no swab or blood cultures were taken. When the patient's condition got worse an echocardiogram was ordered. It showed vegetations on the aortic and mitral valves as well as on the cardiac pacemaker wires. Blood cultures were positive for Enterococcus faecalis. Although a therapy with vancomycin and ampicillin was started, the patient's condition impaired. Surgical valve replacement was initiated, but the patient expired 5 weeks later due to septic multi-organ failure. The danger of peripheral venous catheter infections is frequently underrated, early identification of the causing pathogen, sensitivity testing and proper antibiotic treatment are of tremendous importance. Clinical sings of sepsis must under no circumstances be overlooked." }, { "id": "pubmed23n0801_5684", "title": "[Elizabethkingia meningosepticum bacteremia in a patient with Bardet-Biedl syndrome and chronic renal failure].", "score": 0.016382868937048503, "content": "Elizabethkingia meningosepticum, a gram-negative opportunistic pathogen may cause life-threatening nosocomial infections especially in newborns and immunosuppressive patients. This bacterium has a peculiar antibiotic resistance profile. It is resistant to most of the antibiotics against gram-negative bacteria and susceptible to antibiotics that are used to treat gram-positive bacteria, such as vancomycin and trimethoprim-sulphamethoxazole (SXT). For this reason appropriate treatment of E.meningosepticum infections are based on the proper identification of bacteria. In this report, a case of catheter-related E.meningosepticum bacteremia in a patient with chronic renal failure due to Bardet-Biedl syndrome, a genetic disorder characterized by multiorgan dysfunction, was presented. A 25-year-old male patient with Bardet-Biedl syndrome was admitted to the emergency room with the complaints of high fever with shivers that started the day before. The patient had a femoral dialysis catheter. Venous blood samples drawn at the time of administration were cultured immediately. Two days later, blood cultures which yielded positive signals were passaged onto blood and MacConkey agar plates and after incubation at 37°C for 16 hours, wet-raised colonies with clear margin, gray colour and large size similar to gram-negative bacterial colonies were detected on blood agar medium. No growth was observed on MacConkey agar plate at the end of five days. The isolate was found positive for KOH, oxidase, catalase, urease, esculine and MOI (Motility Indole Ornithine) tests, whereas it was citrate negative. Gram staining revealed faintly stained thin gram-negative bacilli. The isolate was identified as E.meningosepticum by Vitek® 2 system (bioMérieux, USA), and confirmed by sequence analysis of 16S RNA gene region amplified with PCR method. The antibiotic susceptibility profile of the strain was detected by the Vitek 2 system, while vancomycin susceptibility was investigated by Kirby-Bauer disc diffusion method. The isolate was found resistant to ampicillin/sulbactam, piperacillin/tazobactam, ceftazidime, cefepime, meropenem, imipenem, amikacin, gentamicin, netilmicin, levofloxacin, tetracycline, colistin and rifampicin; intermediate to tigecyclin and tetracyclin; susceptible to cefoperazone/sulbactam, ciprofloxacin, levofloxacin, SXT and vancomycin. One gram vancomycin once every four days was administered to the patient, however on the ninth day of the treatment he developed fever again. Blood cultures obtained again yielded E.meningosepticum. After changing his dialysis catheter and extending the vancomycin treatment to 15 days, the patient was discharged with cure. In conclusion, clinicians should consider E.meningosepticum as a possible causative agent of bacteremia non-responsive to the empirical antibiotic regimens and when gram-negative bacteria are isolated from the blood cultures of such patients with underlying diseases. Accurate and prompt identification of E.meningosepticum will allow immediate administration of the specific antibiotic treatment, thereby decreasing the mortality and morbidity rates. " }, { "id": "pubmed23n0619_22342", "title": "[A case of vancomycin resistant Leuconostoc meningitis].", "score": 0.015079365079365078, "content": "Although Leuconostoc species are rarely pathogenic for humans, they may sometimes give rise to serious infections. In this report, a case of meningitis caused by vancomycin resistant Leuconostoc spp. was reported. Fifty-seven years old female patient was admitted to the hospital with the complaints of headache and sudden onset of unconsciousness and hospitalized in the neurosurgery department because of subarachnoidal hemorrhage. Patient was followed up with dexamethasone treatment and daily lumbar puncture without any surgical intervention. The findings of hemorrhage were receded in the cerebrospinal fluid (CSF) and the consciousness of the patient improved gradually. However, on the ninth day of the hospitalization, the patient became febrile and confused; white blood cell count was 7920/mm3, protein level was 1952 mg/l in the CSF examination. Nosocomial meningitis was diagnosed and empirical treatment with ceftazidime (3 x 2 g/day) and vancomycin (4 x 500 mg/day) was started. CSF culture revealed growth of gram-positive cocci which were identified as Leuconostoc spp. by VITEK 2 Compact (Biomerieux, France) and Phoenix Instrument (Becton-Dickinson, USA) systems. Since the isolate was found susceptible to penicillin, ampicillin, cefotaxime, cefepime, chloramphenicol, clindamycin, erythromycin and linezolid, and resistant to vancomycin by disk diffusion and miniAPI ATB STREP 5 (Biomerieux, France) methods, the treatment was switched to linezolid (2 x 600 mg/day). Vancomycin and teicoplanin resistance was confirmed by E-test. The treatment was continued with linezolid and the patient's clinical condition improved after 14 days of treatment. The possible way of Leuconostoc transmission in this case was thought to be the lumbar punctures performed during the follow-up of subarachnoid hemorrhage. This presentation which demonstrated that Leuconostoc spp. might rarely lead to meningitis, also pointed out that when a vancomycin resistant gram-positive coccus was identified, Leuconostoc spp. should always be kept in mind." }, { "id": "pubmed23n0735_11107", "title": "Changes in 4-year antimicrobial resistance pattern of gram-positive bacteria at the main referral teaching hospital, Tehran, Iran.", "score": 0.013432323405716248, "content": "Infectious diseases are one of the most common causes of morbidity and mortality and the spread of resistant microorganisms is playing a significant role in this regard. The purpose of this study was to assess the trend in antimicrobial resistance of gram-positive bacteria at the main referral teaching hospital in Tehran during a 4-year period. All patients' biological isolates such as blood, urine, wound drainage, synovial fluid, sputum, and cerebrospinal fluid sent to the central laboratory of the hospital from 2007 to 2010 for identification and subsequently, antimicrobial susceptibility testing by Kirby-Bauer disc diffusion method were considered. All isolates (100%) of S. aureus were sensitive to vancomycin and linezolid and resistant to amoxicillin. The rate of S. aureus resistance to oxacillin increased from 60.78% in 2007 to 72% in 2010. All isolates of Streptococci in 2007 and 2008 were sensitive to vancomycin; while, 3.33% and 4.76% of Streptococci isolates were reported to be vancomycin-resistant in 2009 and 2010, respectively. Enterococci isolated from the entire specimens were identified to be sensitive to teicoplanin and linezolid and resistant to cloxacillin and oxacillin. The rates of Enterococci sensitivity to vancomycin were 90.91%, 81.25%, 86.67%, and 93.3% in 2007, 2008, 2009, and 2010, respectively. Changes of antibiotics sensitivity against g positive pathogens were significant during four years in this study. To minimize the spread of resistant gram positive pathogens, periodic and regular surveillance of antimicrobial resistance pattern is highly recommended." }, { "id": "pubmed23n0529_21290", "title": "Diagnosis and management of Staphylococcus aureus bacteraemia.", "score": 0.012117022050796886, "content": "Staphylococcus aureus bacteraemia (SAB) is common. Around 8000 cases occur per year in Australia, of which 60% are hospital- or healthcare-associated. Risk factors for SAB include injectable drug use, haemodialysis, indwelling vascular catheters and immunosuppression. Metastatic infection develops in up to one-third of patients with SAB, with joints and heart valves being the most commonly affected sites. Community-acquisition,persistent fever, positive blood cultures after 48 h of treatment and the presence of embolic lesions correlate with the presence of complicated SAB (i.e. high risk of endocarditis and/or other metastatic complications). All patients require careful clinical evaluation to exclude endocarditis and other metastatic foci. Echocardiography,preferably transoesophageal echocardiography, should be performed to exclude endocarditis. Most patients with SAB, and all with features of complicated SAB, require prolonged intravenous antibiotic therapy (at least 4 weeks), but a subgroup with good prognostic features may be suitable for shorter intravenous therapy (2 weeks). Penicillinase-resistant penicillins (e.g.flucloxacillin) are the agents of choice for SAB with methicillin-sensitive strains. Vancomycin or first-generation cephalosporins are alternatives but have lower antimicrobial activity than flucloxacillin. However, vancomycin remains the therapy of choice for SAB due to methicillin-resistant strains. Combination therapy with gentamicin may be useful for the first few days of treatment in selected patients, but otherwise there are few data to support the use of combination regimens in SAB. Newer agents such as linezolid and quinupristin/dalfopristin may have a role in selected patients, especially in SAB due to S. aureus strains with reduced susceptibility to vancomycin." }, { "id": "InternalMed_Harrison_11893", "title": "InternalMed_Harrison", "score": 0.01195664320035758, "content": "if the organism does not exhibit high-level resistance to aminoglycosides (see Table 174–1, footnote c). eQuinupristin-dalfopristin (Q/D) and linezolid are listed in the American Heart Association’s recommendations for the treatment of endocarditis caused by vancomycinand ampicillin-resistant E. faecium. fAgents that may be useful in combination with Q/D (if the isolate is susceptible to each agent) include doxycycline with rifampin (one reported case) and fluoroquinolones (one reported case). gIn selected cases of catheter-associated bacteremia, removal of the catheter and a short course of therapy (~5–7 days) may be sufficient. A single positive blood culture that is likely to be associated with a catheter in a patient who is otherwise doing well may not require therapy after removal of the catheter. hFluoroquinolone antibiotics (e.g., moxifloxacin) and rifampin (if the isolate is susceptible to each agent) reach therapeutic levels in the cerebrospinal fluid (CSF). iIntrathecal Q/D" }, { "id": "wiki20220301en017_112817", "title": "Linezolid", "score": 0.01183862433862434, "content": "Linezolid was associated with significantly greater mortality than the comparator antibiotics. When data from all participants were pooled, the study found that 21.5% of those given linezolid died, compared to 16% of those not receiving it. The difference was found to be due to the inferiority of linezolid in the treatment of Gram-negative infections alone or mixed Gram-negative/Gram-positive infections. In participants whose infection was due to Gram-positive bacteria alone, linezolid was as safe and effective as vancomycin. In light of these results, the FDA issued an alert reminding healthcare professionals that linezolid is not approved for the treatment of catheter-related infections or infections caused by Gram-negative organisms, and that more appropriate therapy should be instituted whenever a Gram-negative infection is confirmed or suspected." }, { "id": "InternalMed_Harrison_10265", "title": "InternalMed_Harrison", "score": 0.011577311577311579, "content": "Blood Cultures Isolation of the causative microorganism from blood cultures is critical for diagnosis and for planning treatment. In patients with suspected NVE, PVE, or CIED endocarditis who have not received antibiotics during the prior 2 weeks, three 2-bottle blood 820 culture sets, separated from one another by at least 2 h, should be obtained from different venipuncture sites over 24 h. If the cultures remain negative after 48–72 h, two or three additional blood culture sets should be obtained, and the laboratory should be consulted for advice regarding optimal culture techniques. Pending culture results, empirical antimicrobial therapy should be withheld initially from hemodynamically stable patients with suspected subacute endocarditis, especially those who have received antibiotics within the preceding 2 weeks. Thus, if necessary, additional blood culture sets can be obtained without the confounding effect of empirical treatment. Patients with acute endocarditis or with" }, { "id": "pubmed23n0602_20135", "title": "[Use of antibiotics for the treatment of multiresistant gram positive cocci infections in critical patients].", "score": 0.01134455112970181, "content": "This study has been designed to know the use of these antibiotics (ATB) in Intensive Care Units (ICUs). A multicentric, prospective, observational study was conducted. In cluded as cases were the indications of vancomycin (VAN), teicoplanin (TPN), quinupristin/dalfopristin (Q/D) and linezolid (LZD). A total of 826 indications (VAN 52.1%, TPN 36.6%, LZD 11.6% and Q/D 0%) were analyzed, 793 (96%) as treatment and 33 (4%) as prophylaxis in 818 patients. Serious sepsis or septic should occurred in 55.9% of the patients treated. The most common infections were pneumonia and catheter-related bacteremia, 48.3% of all the infections being acquired in ICUs. LZD was used mostly in mechanical-ventilation related pneumonia (p = 0.001), VAN in community Central Nervous System infections (p = 0.01) and in catheter-related bacteremia (p = 0.001), TPN in community pneumonia (p = 0.01) and in catheter-related bacteremia (p = 0.001). Treatments were empirical in 65.8% and diagnosis of gram positive cocci was confirmed in 48.3% of them. Staphylococcus aureus was isolated more in the LZD-treated group. Initial treatment was modified 224 times, this occurring more frequently in the VAN-treated group. The reason for this change was clinical failure 59 times, this being more frequent in the TPN group and less frequent in the patients treated with LZD, which was the drug used the most in rescue therapies (43/69, 62.3%). Adverse events, probably related to the ATB, were identified in 36/826 (4.4%) cases. The most common use of this ATB was to treat ICU-acquired infections. VAN was the most frequently used drug. Treatments with LZD were modified less frequently for clinical failure and this drug was the one most used in rescue therapies. This information indicates an appropriate use of these ATB in an important percentage of critically patients." }, { "id": "InternalMed_Harrison_10303", "title": "InternalMed_Harrison", "score": 0.010451612903225806, "content": "Blood cultures should be repeated daily until sterile in patients with endocarditis due to S. aureus or difficult-to-treat organisms, rechecked if there is recrudescent fever, and performed again 4–6 weeks after therapy to document cure. Blood cultures become sterile within 2 days after the start of appropriate therapy when infection is caused by viridans streptococci, enterococci, or HACEK organisms. In S. aureus endocarditis, β-lactam therapy results in sterile cultures in 3–5 days, whereas in MRSA endocarditis, positive cultures may persist for 7–9 days with vancomycin or daptomycin treatment. MRSA bacteremia persisting despite an adequate dosage of vancomycin may indicate infection due to a strain with reduced vancomycin susceptibility and therefore may point to a need for alternative therapy. When fever persists for 7 days despite appropriate antibiotic therapy, patients should be evaluated for paravalvular abscess, extracardiac abscesses (spleen, kidney), or complications" }, { "id": "wiki20220301en017_112816", "title": "Linezolid", "score": 0.010157518318634548, "content": "Catheter-related infections In March 2007, the FDA reported the results of a randomized, open-label, phase III clinical trial comparing linezolid to vancomycin in the treatment of catheter-related bloodstream infections. Patients treated with vancomycin could be switched to oxacillin or dicloxacillin if the bacteria that caused their infection was found to be susceptible, and patients in both groups (linezolid and vancomycin) could receive specific treatment against Gram-negative bacteria if necessary. The study itself was published in January 2009." }, { "id": "wiki20220301en003_188048", "title": "Central venous catheter", "score": 0.010026737967914439, "content": "Antibiotics are nearly always given as soon as a patient is suspected to have a catheter-related bloodstream infection. However, this must occur after blood cultures are drawn, otherwise the culprit organism may not be identified. The most common organisms causing these infections are coagulase negative staphylococci such as staphylococcus epidermidis. Infections resulting in bacteremia from Staphylococcus aureus require removal of the catheter and antibiotics. If the catheter is removed without giving antibiotics, 38% of people may still develop endocarditis. Evidence suggests that there may not be any benefit associated with giving antibiotics before a long-term central venous catherter is inserted in cancer patients and this practice may not prevent gram positive catheter-related infections. However, for people who require long-term central venous catheters who are at a higher risk of infection, for example, people with cancer who at are risk of neutropenia due to their" }, { "id": "pubmed23n0381_4002", "title": "Treatment of mycobacterial exit-site infections in patients on continuous ambulatory peritoneal dialysis.", "score": 0.009900990099009901, "content": "Exit-site infections (ESIs) are frequently due to gram-positive organisms and occasionally to gram-negative organisms. Initial empiric antibiotic therapy is therefore directed against these organisms until culture reports are available. Two cases of ESI associated with Mycobacterium are here reported. The first patient, a 63-year-old man with type 2 diabetes, recently treated for Staphylococcus epidermidis peritonitis, presented with acute purulent drainage at the catheter exit site, accompanied by pain and erythema. No tunnel abscess was identified by ultrasound. Empiric antibiotic therapy was initiated with ofloxacin and vancomycin. A rapid-growing acid-fast bacillus (AFB) noted four days after culture was eventually identified as Mycobacterium fortuitum. Ofloxacin was continued, vancomycin was discontinued, and clarithromycin was added. The ESI initially showed improvement; therapy was therefore continued for several months. However, cultures remained positive for M. fortuitum, and the catheter was removed 5 months after therapy was initiated. The second patient, a 28-year-old woman, presented with severe pain and tenderness at the exit site without erythema or drainage. Empiric therapy with cefazolin, gentamicin, and cephalexin was initiated. Gram-positive cocci and an AFB were identified from the exit-site culture, and antibiotics were initially changed to clarithromycin, trimethoprim/sulfamethoxazole, and ofloxacin. The organisms were subsequently identified as M. chelonae-M. abscessus complex and coagulase-negative Staphylococcus. The patient continued to improve after 3 weeks of antibiotic therapy. However, despite the initial improvement in the ESI, the M. chelonae-M. abscessus complex continued to grow, and amikacin was added intravenously. Despite continued treatment, the ESI did not resolve, and the catheter was removed after 4 months of therapy. Despite unusual exist-site infections with rapidly growing AFBs, both patients continued continuous ambulatory peritoneal dialysis (CAPD) while undergoing treatment for ESI. Catheters were left intact, as improvement was initially seen with no evidence of tunnel infection or peritonitis. Rapid-growing AFB should be considered another possible causative agent for ESI. Two cases of atypical mycobacterial exit-site infection are presented to illustrate the difficulties in managing this complication of peritoneal dialysis. Ofloxacin--or other quinolones--may provide a better spectrum of coverage when choosing empiric therapy in patients presenting with ESI." }, { "id": "pubmed23n0291_7018", "title": "[A case report of an infective endocarditis caused by methicillin-resistant Staphylococcus aureus with successful mitral valve replacement].", "score": 0.009900990099009901, "content": "We report a case of successful mitral valve replacement performed on the patient who is an infective endocarditis due to MRSA. She was 27-year-old female and treated by antibiotics medication because of remittent fever two years ago. On August 1995, cerebral infarction occurred and she was pointed out endocarditis. After high fever continued, blood cultures demonstrated MRSA. Furthermore, echocardiography showed vegetation on posterior mitral valve leaflet and moderate mitral regurgitation so, mitral valve replacement with a S.J.M. 25 mm performed to control MRSA sepsis condition. During operation, we used VCM 2 g into the extracorporeal circulation and after operation 0.5 g intravenously every 6 hours. Two weeks later we changed antibiotics to FOM, Viccillin and ABK according to the result of minimum inhibitory concentration (MIC) obtained through blood culture. The patient was discharged on the 44 th postoperative day because of her uneventful postoperative course." }, { "id": "pubmed23n0667_14053", "title": "[Healthcare associated infection: emerging problem in a neurology department].", "score": 0.00980392156862745, "content": "Healthcare-associated infection (HAI) is, nowadays, a serious problem, contributing a lot to the burden of the hospital stays. Its impact is really huge and the study of these matters is taking a growing interest. To compare, in terms of HAI, the current Neurology Department (localized inside the building of Hospital Geral) and the oldest one, which was far away from the institutional campus. To identify difficulties regarding the management of HAI, trying to propose measures for quality improvement. We revised the clinical files of the patients with HAI documented by culture, on a homologue period of 6 months. Variables like more frequently isolated microorganisms, antibiotics sensibilities, patients' comorbidities, treatment adequacy and duration of hospitalization were analyzed. In the oldest Department, 23 patients were identified, 8 men (mean +/- 2SD: 80.4 +/- 9.04 years old) and 15 women (77.3 +/- 21.28 years old), with positive microbiological studies (51). Ischemic stroke caused 73.9% of these hospitalizations. Escherichia coli - EC - (27%), methicillin-resistant Staphylococcus aureus - MRSA - (22%) and Klebsiella pneumoniae - KP - (10%) were the most frequently identified microorganisms in the biological samples studied (sputum, urine, blood, urethral exudate and eschar). Amoxicillin/clavulanic acid was the most empirically used antibiotic (only effective on 37% of the cases, according to the sensibility tests). Hospitalizations had an average of 22 days and 1.3 antibiotics per patient were used. At discharge, Rankin had a mode of 5. In the current Department, 46 patients were studied, 22 men (76.4 +/- 22.6 years old) and 24 women (74.1 +/- 32.6 years old), having 119 positive cultures. Again, ischemic stroke caused the majority of the admissions (52.2%). MRSA (26%), Pseudomonas aeruginosa - PA - (17%) and EC (17%) were the most prevalent pathogens (the same biological products were studied, plus lingual exudates and central venous catheter tips). Ciprofloxacin was the most used antibiotic (suitable on 75% of the cases). Internments had an average of 24.3 days and, this time, 2.5 antibiotics were used per patient, by mean. At discharge, Rankin evaluation had again a mode of 5. Despite the taken measures and change in facilities, HAI had really increased in the Neurology Department. Since human resources are the same, we think are important, as possible aggravating conditions, space restriction and ward sharing with patients of other medical specialities, as it happens in the current Department. More aggressive pathogens require a rapid and comprehensive intervention, in order to minimize its impact on daily clinical practice and in the management of hospital stays." }, { "id": "pubmed23n0376_11416", "title": "Linezolid for the treatment of community-acquired pneumonia in hospitalized children. Linezolid Pediatric Pneumonia Study Group.", "score": 0.009708737864077669, "content": "To determine the safety, tolerance, pharmacokinetics and efficacy of linezolid, a new oxazolidinone antibiotic in the treatment of community-acquired pneumonia in hospitalized children. A Phase II, open label multicenter study of intravenous linezolid followed by oral linezolid suspension, both at a dose of 10 mg/kg every 12 h. Efficacy was assessed at 7 to 14 days after the last dose of linezolid. Children 12 months to 17 years old with community-acquired pneumonia admitted to the hospital of 14 participating centers. From July 21, 1998, through May 14, 1999, 79 children were enrolled and 78 received linezolid. Sixty-six children completed treatment and follow-up and were evaluable for clinical outcome. The median age of the evaluable patients was 3 years (range, 1 to 12 years); 47 were 2 to 6 years old. Pathogens were isolated from blood or pleural fluid cultures in 8 children: Streptococcus pneumoniae, 6 (2 penicillin-resistant); Group A Streptococcus, 1; methicillin-resistant Staphylococcus aureus, 1. Chest tubes were placed in 9 patients. The mean total duration of intravenous and oral administration was 12.2 +/- 6.2 days (range, 6 to 41 days). The mean peak and trough plasma concentrations of linezolid were 9.5 +/- 4.8 and 0.8 +/- 1.2 microg/ml, respectively. At the follow-up visit 7 to 14 days after the last dose of linezolid, 61 patients (92.4%) were considered cured including all the patients with proven pneumococcal pneumonia, one failed (methicillin-resistant Staphylococcus aureus) and 4 were considered indeterminate. The most common adverse effects in the intent to treat group were diarrhea (10.3%), neutropenia (6.4%) and elevation in alanine aminotransferase (6.4%). Linezolid was well-tolerated and could be considered an alternative to vancomycin for treating serious infections caused by antibiotic-resistant Gram-positive cocci in children pending results of additional studies." }, { "id": "pubmed23n0325_18004", "title": "[Fever, negative blood culture findings and absence of response to antibiotic therapy in a patient after a second aortic valve prosthesis].", "score": 0.009708737864077669, "content": "A 53-year-old patient had a prosthetic valve (St. Jude Medical 25) 9 years ago because of a Staphylococcus aureus endocarditis with severe aortic regurgitation. An initially mild, progressively more severe, aortic regurgitation then developed as a result of an empty paravalvular abscess cavity, requiring another valve replacement. Fever started on the 3rd postoperative day and persisted despite combined treatment with beta-lactam antibiotics and aminoglycoside. At first no infectious focus could be identified radiologically or by echocardiography. But transoesophageal echocardiography revealed vegetations in the old abscess cavity. Several blood cultures were negative, while serological tests gave markedly raised antibody titers against Coxiella burnetii. Assuming Coxiella burnetii endocarditis the patient was given doxycycline, 2 x 100 mg daily and cotrimoxazole, 1 x 960 mg daily. The fever subsided and the vegetations had disappeared after four weeks. Because of the high risk of recurrence the antibiotic treatment was to be continued for two years. Coxiella burnetii should be considered as a possible cause of fever of unknown origin, especially in patients with existing or operated cardiac valvar defects, when endocarditic vegetations have been demonstrated and several blood cultures have been negative." }, { "id": "pubmed23n0786_22012", "title": "Antibiogram for haemodialysis catheter-related bloodstream infections.", "score": 0.009615384615384616, "content": "Background. Haemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are a major complication of long-term catheter use in HD. This study identified the epidemiology of HD CRBSIs and to aid in the choice of empiric antibiotics therapy given to patients with HD CRBSIs. Methods. Patients with HD CRBSIs were identified. Their blood cultures were performed according to standard sterile technique. Specimens were sent to the microbiology lab for culture and sensitivity testing. Results were tabulated in antibiograms. Results. 18 patients with a median age of 61.0 years (IQR: 51.5-73.25) were confirmed to have HD CRBSIs based on our study criteria. Eight (44.4%) patients had gram-negative infections, 7 (38.9%) patients gram-positive infections, and 3 (16.7%) patients had polymicrobial infections. We noted that most of the gram-negative bacteria were sensitive to ceftazidime. Unfortunately, cloxacillin resistance was high among gram-positive organisms. Coagulase-negative Staphylococcus and Bacillus sp. were the most common gram-positive organisms and they were sensitive to vancomycin. Conclusion. Our study revealed the increased incidence of gram-negative organism in HD CRBSIs. Antibiogram is an important tool in deciding empirical antibiotics for HD CRBSIs. Tailoring your antibiotics accordingly to the antibiogram can increase the chance of successful treatment and prevent the emergence of bacterial resistance. " }, { "id": "pubmed23n0810_10099", "title": "Etiologic diagnosis and clinical treatment of multiple drug-resistant bacteria infection in elderly patients with stroke-associated pneumonia after neurosurgery.", "score": 0.009615384615384616, "content": "Our objective is to analyze the etiology and antibiotics resistance rate of multiple drug-resistant bacteria infection in elderly patients with stroke-associated pneumonia from Neurosurgery Department, providing a reference for clinical treatment. Sputum of 372 elderly patients with stroke-associated pneumonia (SAP) from Neurosurgery Department was collected for sputum culture and drug sensitivity test, and pathogenic bacteria distribution and drug resistance rate of antibiotics were discussed. Among 372 pathogenic bacteria, there were 95 cases with Gram-positive cocci, the percentage was 15.32 %; there were 277 cases with Gram-negative bacilli, the percentage was 59.95 %; there were 54 cases with fungus, the percentage was 14.51 %; the common Gram-positive cocci included Staphylococcus aureus, Staphylococcus haemolyticus and Staphylococcus epidermidis, with percentages of 15.32 %, 2.96 % and 4.30 % respectively; the common Gram-negative bacilli included Pseudomonas aeruginosa, Escherichia coli and Klebsiella pneumoniae, with percentages of 23.92 %, 14.25 % and 9.95 % respectively; the highest drug resistance rates of Staphylococcus aureus were 100.00 % to penicillin, erythrocin and oxacillin, the highest drug resistance rate of Staphylococcus epidermidis was 87.50 % to erythrocin, the highest drug resistance rate of Staphylococcus haemolyticus was 100.00 % to penicillin and erythrocin, the lowest drug resistance rates of three Gram-negative bacilli were 0 % to teicoplanin and vancomycin; the highest drug resistance rates of Escherichia coli were 100.00 % to ceftriaxone and ticarcillin, and the lowest drug resistance rate was 11.32 % to ciprofloxacin; the highest drug resistance rate of Pseudomonas aeruginosa was 100.00 % to ceftriaxone, and the lowest drug resistance rate was 22.47 % to imipenem; the highest drug resistance rate of Klebsiella pneumoniae was 81.08 % to aztreonam, and the lowest drug resistance rate was 0.00 % to imipenem. Stroke-associated pneumonia is common clinically in elderly patients from Neurology Department, the early-stage and rational use of antibiotics should be applied according to the etiologic distribution and drug resistance characteristics. Meanwhile, prevention measures should be applied." }, { "id": "pubmed23n0494_7763", "title": "Successful treatment of disseminated cerebritis complicating methicillin-resistant Staphylococcus aureus Endocarditis unresponsive to vancomycin therapy with linezolid.", "score": 0.009523809523809525, "content": "A unique case of community acquired methicillin resistant Staphylococcus aureus (MRSA) sepsis, with endocardial and cerebral metastatic seeding, caused by a strain representative of the Italian clone, is described. The patient was a 47-y-old man without apparent risk factors for endocarditis and for MRSA infection who developed coma with multiple cerebritis lesions under vancomycin plus amikacin therapy. He was eventually cured with the addition of linezolid to the initial antimicrobial regimen. This observation seems to confirm previous reports of the efficacy of linezolid for the treatment of central nervous system infections caused by multidrug resistant Gram-positive bacteria. To our knowledge, this is the first report of MRSA disseminated cerebritis, a nearly always fatal disease, cured with this oxazolidinone drug. The increase in community acquired MRSA may have some impact on empirical treatment of serious infections caused by this organism." }, { "id": "pubmed23n1007_21511", "title": "Infective endocarditis caused by Streptococcus acidominimus.", "score": 0.009433962264150943, "content": "A case of infective endocarditis caused by Streptococcus acidominimus is reported. An 81-year-old Caucasian man underwent an elective transcatheter aortic valve implantation due to his severe aortic valve stenosis. He presented to the hospital 3 weeks later with a 1-week history of fever (39ºC) that did not resolve following a 3-day course of azithromycin and a 5-day course of ciprofloxacin. Three sets of blood sample cultures were taken. Empirical antimicrobial treatment was initiated to target gram-positive and gram-negative microorganisms and consisted of vancomycin 1 g intravenous (i.v.) every 12 hours and imipenem-cilastatin 500 mg i.v. every 6 hours. After 48 hours, the blood culture was positive for S. acidominimus. The strain was sensitive to ampicillin, cephalosporins, tetracycline, and vancomycin. It was resistant to penicillin, macrolides, trimethoprim-sulfamethoxazole, and fosfomycin. Transesophageal echocardiography showed a small mobile vegetation attached to the anterior mitral valve leaflet, along with mild mitral regurgitation. The patient was diagnosed with native mitral valve infective endocarditis, and imipenem-cilastatin was discontinued. The patient showed clinical and laboratory improvement during his 2-week hospitalization. A peripherally inserted central catheter was put in place, and the patient was discharged on i.v. vancomycin to complete a total of 6 weeks treatment, after which the infection resolved. An 81-year-old man diagnosed with mitral valve endocarditis caused by S. acidominimus was successfully treated with vancomycin." }, { "id": "pubmed23n1152_1705", "title": "Pattern and Sensitivity of Bacterial Colonization on the Tip of Non-Tunneled Temporary Hemodialysis Catheters: Results of a Tertiary Hospital in Somalia.", "score": 0.009345794392523364, "content": "Bacterial colonization on the tip of non-tunneled temporary hemodialysis catheters (NTHCs) and associated catheter-related infections (CRI) is a common complication in hemodialysis (HD) patients. In this study, we aimed to investigate the pattern of bacterial colonization formed on the tip of non-tunneled temporary hemodialysis catheters and their antibiotic sensitivity. This retrospective analysis was performed in the HD unit of an Education and Research Hospital that follows up a universe of approximately 300 patients, primarily from Mogadishu, Somalia. From September 2020 to September 2021, a total of 137 temporary HD catheters were removed and their tips were sent for culture after there was a suspicion of CRI and other sources of infection were excluded. HD Catheter tips were cultured semi-quantitatively, and the antibiogram of the positive cultures was studied. Gram-positive cocci were found to be the most predominant bacterial organisms in positive cultures with 27 (31.0%) for <iStaphylococcus aureus</i, 9 (10.3%) for <iStaphylococcus haemolyticus</i and 5 (5.7%) for <iStaphylococcus epidermidis</i. We found Enterococci to be 5.7% of the isolated microorganisms. Gram-negative pathogens isolated included <iEscherichia coli</i 13 (14.9%) as the most common, followed by <iKlebsiella pneumoniae</i 10 (11.5%) and <iAcinetobacter baumannii</i (4.6%). Methicillin-resistant <iStaphylococcus aureus</i (MRSA) was found to be 9.4%. Gram-positive isolates showed high sensitivity (100%) to Linezolid, Daptomycin, Vancomycin, and Tigecycline, but a low sensitivity rate to Oxacillin (41.2%). Gram-negative isolates had the highest sensitivity to Tigecycline (100%), Imipenem (88.9%), and Amikacin (87%) but low sensitivity to Ampicillin (4.8%), Trimethoprim/Sulfamethoxazole (TMP-SMX) (23.1%), and Ceftazidime (7.1%). We conclude that each institution should have its own antibiogram in the management of HD CRIs. According to our findings in this study, we recommend intravenous Vancomycin and Imipenem as empirical therapy in patients with suspected HD CRIs." }, { "id": "pubmed23n1051_25732", "title": "Panton-Valentine leukocidin-positive novel sequence type 5959 community-acquired methicillin-resistant Staphylococcus aureus meningitis complicated by cerebral infarction in a 1-month-old infant.", "score": 0.009345794392523364, "content": "Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has become a pathogen of major importance in pediatric patients. CA-MRSA can cause skin and soft tissue infection in children and young active adults with no predisposing factors, and life-threatening infections such as meningitis or necrotizing pneumonia have been reported. We report here a case of CA-MRSA meningitis complicated by acute left middle cerebral artery (MCA) infarction and necrotizing pneumonia in a previously healthy 1-month-old Vietnamese boy. He was firstly treated with vancomycin, but changed to linezolid because of persistent fever and low vancomycin trough level. He recovered successfully with residual right-sided hemiparesis. The mode of transmission of CA-MRSA and the mechanism of cerebral infarction (thrombotic or embolic) were unknown. The isolate was genotyped as staphylococcal cassette chromosome (SCC) mec type V with a novel sequence type (ST) 5959 harboring the Panton-Valentine leukocidin (PVL) gene. ST 5959 is a double locus variant of ST 59, which is a major PVL-positive CA-MRSA strain isolated in invasive disease in Asian countries. This case report may serve as a warning about the dissemination of PVL-positive CA-MRSA in and around Japan, with the possibility of causing serious life-threatening disease. The potential of linezolid for the treatment of MRSA meningitis as one of the alternative MRSA therapeutic drugs is also discussed." }, { "id": "pubmed23n0557_18428", "title": "[Cathether related blood stream infection in ICU patients with prolonged central venous catheterisation--cause and prevention].", "score": 0.009259259259259259, "content": "Colonization of the tip of the intravenous catheter is often observed in the ICU practice and can be the source of dangerous bacteriemia (CRBSI--catheter related bloodstream bacteraemia) and sepsis with multiorgan failure. There are many cases conected with bacterial colonization of the tip of the catheter in the ICU practice, which could be the source of dangerous bacteriemia--CRBSI (catheter related bloodstream bacteriemia) and sepsis with organs failure. 105 patients with sepsis were examined, which clinical state pointed, that CVC was the source of infection. We removed the CVC in this patient, and its tip and patient's blood were examined microbiologically. In the case of positive result, the antibiogram was made. Evaluation of colonisation and infections of central venous catheters and catheter related blood stream infections (CRBSI) in general ICU patients' and with identification of most frequent microorganisms and their antibiotic sensibility. Results. After examining of 105 samples in 37 (35, 24%) cases we did not culture bacteria. From the rest of 68 (64, 76%) samples we cultured 110 bacterial colonies. 8 of them were admitted to be contaminated samples. 60 tips of the catheter were used to proper analysis from which we isolated 102 bacterial colonies: 44 (43.1%) Gram positive cocci, 32 (31.5%) Enterobacteriaceae, 23 (22.5%) glucose non-fermentative gram-negative rods rods Gram negative non glucose fermentation and 3 (2.9%) fungi (C. albicans). We analized 60 blood samples that derived from patients with confirmed catheter colonisation. It was found that 8 blood samples indicated bacteriemia, but only in 2 cases isolated bacteria came from the CVC. Conclusions. (1) The majority of central venous catheters on ICU are colonized by pathogenic microorganisms. (2) Aerobic Gram positive and Gram negative bacteria are responsible for CVCs' infection. (3) Bacterial colonization of CVCs' is not very often the reason of CRBSI. (4) Prolonged use of central venous catheters needs careful prophylactic standards of an microbiological monitoring." }, { "id": "pubmed23n0940_16196", "title": "Brain abscess after stent-assisted coiling for ruptured middle cerebral artery aneurysm.", "score": 0.009259259259259259, "content": "A 24-year-old man was admitted with sudden severe headache. Brain computed tomography (CT) revealed a subarachnoid hemorrhage in the basal cistern and both Sylvian cisterns and a left internal carotid artery angiogram showed a small aneurysm on the bifurcation of the left middle cerebral artery. We performed Y-configured stent-assisted coil embolization. On the fifth post-embolization day, the patient had chills, and his body temperature was over 38℃. Staphylococcus aureus was cultured from the venous blood sample. Central venous catheter-induced bacteremia was suspected. The central venous catheter was immediately removed, and an antibiotic to which the organism was susceptible (nafcillin) was injected for 15 days according to the result of the antibiotics sensitivity test. He was discharged without any clinical or neurological symptoms on the 32nd hospital day. Three months after treatment, the patient complained in the outpatient department of headache, nausea and vomiting. Brain magnetic resonance imaging showed several well-rimmed enhancing lesions in the left temporoparietal lobe. The headache, nausea and vomiting was aggravated, and brain CT showed more enlarging cysts and aggravation of the midline shift. Stereotactic aspiration was performed for the three biggest cysts, and greenish-white colored pus was aspirated. The identified pathogen was methicillin-sensitive Staphylococcus aureus in the culture study. Vancomycin and ceftriaxone were administered intravenously for three weeks, followed by intravenous injection of nafcillin for five weeks. The patient's postoperative course was clinically uneventful, and brain CT on postoperative day 57 showed total disappearance of the rim-enhanced abscess." }, { "id": "pubmed23n0890_17157", "title": "Emerging Trends of Bloodstream Infections: A Six-Year Study at a Paediatric Tertiary Care Hospital in Kabul.", "score": 0.009174311926605505, "content": "To determine the frequency of pathogens causing bloodstream infections and evaluate their trends and antibiogram patterns among in-patients in a paediatric tertiary care centre. Descriptive study. French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan in two phases, from January 2010 to December 2015. Results of blood cultures from suspected cases of sepsis admitted in the FMIC, from January 2010 to December 2012 (Period-1), and from January 2013 to December 2015 (Period-2) were completed. Standard microbiological methods were followed for blood culture and antibiotic sensitivity testing. Out of total 1,040 cases of culture proven sepsis, 528 (50.77%) Gram-negative bacilli (GNB), 474 (45.58%) Gram-positive cocci (GPC), and 38 (3.65%) Candida species were isolated during the entire study period. Out of 528 GNB isolates, 373 (70.64%) belonged to the Enterobacteriaceae and 155 (29.36%) were non-fermenters. Among Enterobacteriaceae, 168 (31.82%) were Klebsiella species (K. pneumoniae=124, K. oxytoca=44), 70 (13.26%) were Enterobacter species (E. cloacae=52, E. aerogenes=18), 65 (12.31%) were E. coli, 37 (7.01%) were Serratia marcescens and 31 (5.87%) were others. Out of 155 non-fermenters, 88 (16.67%) were Pseudomonas aeruginosa, 39 (7.39%) were Burkholderia cepacia and 18 (3.41%) were Stenotrophomonas maltophilia. There was a drop in the frequency of Enterobacteriaceae from 85% in Period-1 to 58.68% in Period-2. There was an increase in the frequency of nonfermenters from 15% to 41.32%, particularly 18 new cases of sepsis caused by Stenotrophomonas maltophilia during Period-2. Among GPC, there was an overall rise of 16.14% in the prevalence of Staphylococcus epidermidis during Period-2 and a drop of 9.64% in the frequency of Staphylococcus aureus during Period-2. The majority of Gram-negative isolates were multidrug-resistant to commonly used antibiotics. However, most of the isolates were sensitive to amikacin and imipenem (except S. maltophilia). The frequency of those producing ESBL reduced by 11.22% during the Period-2. Among Gram-positive cocci, the pattern of antibiogram did not show a significant change during both periods, and majority remained resistant to commonly used antibiotics. All Staphylococci were sensitive to vancomycin but resistant to penicillin. There was a substantial decline of 18.87% in the frequency of Methicillin-resistant Staphylococci (MRSA/MRSE) during Period-2. Staphylococci and Klebsiellae remain the most important bacteria responsible for bloodstream infections in a tertiary healthcare facility in Kabul. Yet, there has been an increase in the prevalence of Pseudomonas and Burkholderia cepacia. Moreover, Stenotrophomonas maltophilia emerged as a new hospital acquired pathogen. This study could possibly help in suggesting choices eluding the misuse of appropriate antibiotics." }, { "id": "pubmed23n1120_5824", "title": "Adult Coagulase-Negative Staphylococcal Meningitis in Qatar: Clinical Characteristics and Therapeutic Outcomes.", "score": 0.009174311926605505, "content": "Coagulase-negative staphylococci (CoNS) have emerged as a major pathogen in nosocomial meningitis. This study was designed to describe the clinical profile, laboratory parameters, treatment, and outcomes of CoNS meningitis in patients admitted to Hamad General Hospital, Qatar. This retrospective hospital-based study described the patients with CoNS meningitis from 2009 to 2013. Twelve patients were recruited for the study, of which there were 10 (83.3%) males and 2 (16.7%) females with a median age of 39 years (interquartile range [IQR]: 29-46 years). Fever was the most common presenting symptom being present in all patients, followed by mental alterations 7 (58.3%). All CoNS meningitis cases in this study were nosocomially acquired after neurosurgery and in most cases after external ventricular drain (EVD) insertion. The median time between the procedure and acquisition of infection was 13 days (IQR: 10-15.7 days). The isolated species include 8 (66.7%) <iStaphylococcus epidermidis</i, 2 (16.7%) <iStaphylococcus capitis</i, and 2 (16.7%) <iStaphylococcus haemolyticus</i. All CoNS isolates were sensitive to vancomycin while 75% of them were oxacillin resistance. In the eight patients with EVDs, the infected EVDs were removed, while all patients received empirical antibiotics involving mainly vancomycin and ceftriaxone that were modified upon receipt of culture results. All patients were cured, and no mortality was reported. CoNS meningitis is a recognized complication related to the introduction of neurosurgical devices. Because of its nonspecific clinical presentation, treating physicians should have a high suspicion index. If CoNS meningitis is highly suspected, vancomycin is the empirical treatment of choice while awaiting results of sensitivity." }, { "id": "pubmed23n0908_5557", "title": "[A rarely isolated bacterium in microbiology laboratories: Streptococcus uberis].", "score": 0.00909090909090909, "content": "Streptococcus uberis is a gram-positive bacterium that is mostly responsible for mastitis in cattle. The bacterium rarely has been associated with human infections. Conventional phenotyphic methods can be inadequate for the identification of S.uberis; and in microbiology laboratories S.uberis is confused with the other streptococci and enterococci isolates. Recently, molecular methods are recommended for the accurate identification of S.uberis isolates. The aim of this report is to present a lower respiratory tract infection case caused by S.uberis and the microbiological methods for identification of this bacterium. A 66-year-old male patient with squamous cell lung cancer who received radiotherapy was admitted in our hospital for the control. According to the chest X-Ray, patient was hospitalized with the prediagnosis of ''cavitary tumor, pulmonary abscess''. In the first day of the hospitalization, blood and sputum cultures were drawn. Blood culture was negative, however, Candida albicans was isolated in the sputum culture and it was estimated to be due to oral lesions. After two weeks from the hospitalization, sputum sample was taken from the patient since he had abnormal respiratory sounds and cough complaint. In the Gram stained smear of the sputum there were abundant leucocytes and gram-positive cocci, and S.uberis was isolated in both 5% sheep blood and chocolate agar media. Bacterial identification and antibiotic susceptibility tests were performed by VITEK 2 (Biomerieux, France) and also, the bacterium was identified by matrix assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) based VITEK MS system as S.uberis. The isolate was determined susceptible to ampicillin, erythromycin, clindamycin, levofloxacin, linezolid, penicillin, cefotaxime, ceftriaxone, tetracycline and vancomycin. 16S, 23S ribosomal RNA and 16S-23S intergenic spacer gene regions were amplified with specific primers and partial DNA sequence analysis of 16S rRNA polymerase chain reaction (PCR) products were performed by 3500xL Genetic Analyzer (Applied Biosystems, USA). According to the partial 16S rRNA gene sequencing results, bacterium was confirmed as S.uberis. This report makes a significant contribution to the number of case reports of human infections caused by S.uberis as the identification was performed by current microbiological methods in our case. In conclusion, S.uberis should be evaluated as an opportunistic pathogen among the immunosuppressed patients and in addition to phenotypic bacteriological methods, the other recent microbiological methods should also be utilized for the identification." }, { "id": "pubmed23n1152_16962", "title": "The First Case Report of Community-Acquired Infective Endocarditis Due to Sequence Type 1223 <i>Staphylococcus argenteus</i> Complicated with Convexity Subarachnoid Hemorrhage.", "score": 0.00909090909090909, "content": "<iStaphylococcus argenteus</i is a new species classified as part of the <iStaphylococcus aureus</i-related complex in 2015 and has been recognized to be as pathogenic as <iS. aureus</i. We describe the first case of endocarditis caused by <iS. argenteus</i. A 51-year-old man presented with chief complaints of fever and headaches. On admission, he showed a slight decrease in consciousness level (Glasgow Coma Scale, E4V4M6). Careful physical examination and imaging revealed a systolic heart murmur, Janeway lesions, and complicating convexity subarachnoid hemorrhage (cSAH) of the left frontal lobe. Ceftriaxone 4 g/day was administered immediately after blood cultures were obtained. The next day, all blood cultures grew Gram-positive cocci, identified as <iStaphylococcus aureus</i or <iStaphylococcus argenteus</i by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). However, the version of MALDI-TOF MS used could not distinguish these bacteria. Although we could not find valvular vegetation, he was clinically diagnosed with infective endocarditis according to the modified Duke's criteria. Meropenem 6 g/day and linezolid 1.2 g/day were started to cover <iS. aureus</i and methicillin-resistant <iS. aureus</i. Finally, ampicillin was selected based on drug susceptibility, and the patient was treated for 8 weeks and recovered without permanent damage. The isolated strain formed white colonies on blood agar plates, characteristic of <iS. argenteus</i, and differs from golden colony-forming <iS. aureus</i. Genetic analysis revealed the isolated strain as <iS. argenteus</i (sequence type 1223). Although distinguishing <iS. argenteus</i from <iS. aureus</i using routine conventional laboratory tests is difficult, the updated library version of MALDI-TOF MS is useful in identifying <iS. argenteus</i. Interestingly, all published cases of infection caused by ST1223 have been reported in Japan. Therefore, the trend of infections from the ST1223 strain should be carefully monitored, particularly in Japan. Further investigation is needed to clarify the epidemiology and clinical characteristics of <iS. argenteus</i infection, as there are few studies regarding this pathogen." }, { "id": "pubmed23n0633_11334", "title": "Bacterial incidence and antibiotic sensitivity pattern in moderate and severe infections in hospitalised patients.", "score": 0.009009009009009009, "content": "Infectious diseases are among the leading causes of death and sometimes curable. Bacteria are the most common aetiology in hospitalised patients. Objectives of this study were to evaluate the incidence of bacterial infections and their pattern of susceptibility to antibiotics in moderate and severe infections in hospitalised patients. The study was performed in the apical teaching hospital of West Bengal in the first half of 2005. Patients admitted in medical wards and medical ICU, suffering from moderate and severe infections having APACHE-II score &gt; 5 were studied. Clinical evaluation, routine and specific investigations were done in each case. Microbiological samplings were tried on day 1, after completion of antibiotic therapy and in between as required. Aerobic BACTEC bacterial culture and sensitivity tests were done. Pending initial culture and sensitivity report empiric antibiotic therapy was started, which was modified on getting the culture and sensitivity report. Outcome was observed as no response, cured, resolved, inconclusive, died and left against medical advice. Out of 40 patients total number of samples were 54 and that of sites of infections were 48. Primary site could not be detected in 11 infections (22.9%). Commonest form was urinary tract infection and abdominal infection in community acquired infection (n=18) and pneumonia in hospital acquired infection (n = 15). Culture was positive in 33 (61.11%), Gram-negative infection was more common in general, but incidence of Gram-positive infection was also quite high and Gram-positive infection was more common in community acquired infection. In general S aureus was most common bacteria -8 (24.24%). In community acquired infection S aureus 4 (22.22%) predominated followed by E coli and in hospital acquired infection S aureus -4 (26.66%) followed by E coli and P aeruginosa. Incidence of methicillin resistant Staph aureus was low. But it constituted 50% of S aureus. No methicillin resistant Staph aureus was found in community acquired infection. Two isolates of vancomycin intermediate sensitive Staph aureus were observed. Methicillin resistant Staph aureus showed maximum sensitivity to linezolid (100%) and all methicillin resistant Staph aureus but one vancomycin intermediate sensitive Staph aureus were sensitive to vancomycin. Coagulase negative Staph aureus were all sensitive to vancomycin and linezolid. Gram-negatives were mostly resistant to aminoglycosides and P aeruginosa were all sensitive to aztreonam. Single strain of S typhi as isolated was resistant to ceftriaxone and ciprofloxacin. P miribalis, P aeruginosa and coagulase negative Staph aureus were notoriously multidrug resistant; 82.5% of cases responded to treatment of which 35% were cured microbiologically. Gram-negative infection was more common overall, but incidence of Gram-positive infection was also very high. Gram-negative infections were responsible for more severe infections and case fatality. Multidrug resistant Gram-positive infections are rising." }, { "id": "pubmed23n0678_21049", "title": "[A case of cerebral abscess due to methicillin-resistant Staphylococcus aureus which is treated with linezolid + rifampin combination].", "score": 0.009009009009009009, "content": "Methicillin-resistant Staphylococcus aureus (MRSA) is a rare cause of cerebral abscesses, however it is a relatively more common etiologic agent in post-neurosurgical abscesses and the main antibacterial therapy option is vancomycin. In this report, a case of brain abscess due to MRSA which did not respond neither to moxifloxacin + vancomycin nor vancomycin + rifampin combination therapies, and merely treated by linezolid + rifampin combination, has been presented. Fifty-one years old female patient who was operated 40 days ago for subarachnoid bleeding and aneurysm in middle cerebral artery bifurcation, was hospitalized due to purulent leakage from the operation area. She did not have fever and her physical examination, including the neurologic system, was normal. Computerized tomography revealed an approximately 1 cm lesion compatible with subdural empyema and cerebral abscess in the right frontoparietal area in supratentorial sections. The patient was operated for wound revision and moxifloxacin was initiated. Since the operation materials revealed MRSA growth, vancomycin (4 x 500 mg, IV) was added to the treatment. The isolate was identified by conventional methods, and antibiotic susceptibility test performed by disk diffusion method showed that it was susceptible to levofloxacin, linezolid, rifampin, vancomycin and teicoplanin. Since no clinical response was obtained in two weeks, moxifloxacin was switched to rifampin (300 mg 1 x 2). On the 10th day of vancomycin + rifampin therapy, radiological findings showed development of cerebritis and therefore vancomycin was changed with linezolid (2 x 600 mg, IV). The control CT of the patient revealed regression of the brain lesion and linezolid + rifampin treatment continued for six weeks. The patient did not develop any hematological, liver or renal toxicity during the therapy and the radiological findings regressed. No relapse were detected in the one year follow-up period. This case suggested that linezolid might be a treatment alternative in the therapy of vancomycin-refractory MRSA brain abscess." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 337, 457 ] ], "word_ranges": [ [ 54, 70 ] ], "text": "the drugs most frequently and classically associated with lingual angioedema are ACE inhibitors (frequency around 0.2%)," }, "2": { "exist": true, "char_ranges": [ [ 462, 520 ] ], "word_ranges": [ [ 71, 80 ] ], "text": "their association with simvastatin is also less than 0.1%." }, "3": { "exist": true, "char_ranges": [ [ 66, 173 ] ], "word_ranges": [ [ 12, 28 ] ], "text": "metformin very rarely causes lingual angioedema (in March 2020 there was only one case described worldwide)" }, "4": { "exist": true, "char_ranges": [ [ 188, 306 ] ], "word_ranges": [ [ 31, 49 ] ], "text": "among the adverse reactions of levodopa, angioedema is classified among the very rare ones (frequency less than 0.1%)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Enalapril.", "2": "Simvastatin.", "3": "Metformin or levodopa equally.", "4": "Levodopa.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0650_13044", "title": "[Therapeutic behavior to follow in the following clinical case: treatment of type 2 diabetes].", "score": 0.01281493493651861, "content": "A 62-year old woman with obesity, high blood pressure and type 2 diabetes mellitus (DM2) was referred to a Vascular Risk Unit of the Internal Medicine Department due to elevated HbA1C (8.1%) in spite of having taken metformin (850 mg/12h) and glipizide (10 mg/12 h) regularly. She tries to exercise daily (walking 30 min) and has lost weight (from 5 to 12 kg) several times, but always regains what she has lost. Furthermore, she monitors her glucose levels in fasting every two weeks and generally has between 120 and 160 mg/dL. Her high blood pressure is being treated with enalapril/HCTZ and she also takes aspirin 100mg/day and simvastatin 20 mg/day. It is seen in her family background that one brother died suddenly at 50 years of age. Her physical examination shows a BMI of 32.4 Kg/m(2), and she has no edemas in the lower limbs. Her BP is 154/82 mmHg and creatinine 0.9 mg/dL. She has no microalbuminuria and her liver function is normal. What treatment do you think would be the more appropriate? 1 - Add glitazones. 2 - Add incretin mimetics (GLP 1/ DPP-4). 3 - Slow acting insulin." }, { "id": "wiki20220301en339_16625", "title": "History of Parkinson's disease", "score": 0.012307808831326213, "content": "with Parkinson's disease resulting from treatment with levodopa was published in 1968. Levodopa brought about a revolution in the management of PD. By the late 1980s deep brain stimulation introduced by Alim-Louis Benabid and colleagues at Grenoble, France, emerged as a possible treatment and it was approved for clinical use by the FDA in 1997." }, { "id": "article-23965_13", "title": "Levodopa (L-Dopa) -- Contraindications", "score": 0.011931947933318109, "content": "Per the Food and Drug Administration (FDA)  label, Levodopa should not be used in patients with a history of malignant melanoma due to the risk of activating melanoma. However, several studies suggested drug exposure is not the reason for the increased risk of melanoma but may reflect the association of Parkinson disease with melanoma. More studies are required to verify the correlation between levodopa and dermatologic effects. [17]" }, { "id": "wiki20220301en247_35915", "title": "Dopamine dysregulation syndrome", "score": 0.011638853230637571, "content": "Management First choice management measure consists in the enforcement of a dopaminergic drug dosage reduction. If this decrease is maintained, dysregulation syndrome features soon decrease. Cessation of dopamine agonists therapy may also be of use. Some behavioral characteristics may respond to psychotherapy; and social support is important to control risk factors. In some cases antipsychotic drugs may also be of use in the presence of psychosis, aggression, gambling or hypersexuality. Based upon five case reports, valproic acid may have efficacy in controlling the symptoms of levodopa-induced DDS that arise from the use of levodopa for the treatment of Parkinson's disease. Epidemiology DDS is not common among PD patients. Prevalence may be around 4%. Its prevalence is higher among males with an early onset of the disease. Previous substance abuse such as heavy drinking or drug intake seems to be the main risk factor along with a history of affective disorder. History" }, { "id": "InternalMed_Harrison_30359", "title": "InternalMed_Harrison", "score": 0.010835058661145617, "content": "Centrally acting anticholinergic drugs such as trihexyphenidyl and benztropine were used historically for the treatment of PD, but they lost favor with the introduction of dopaminergic agents. Their major clinical effect is on tremor, although it is not certain that this benefit is superior to what can be obtained with agents such as levodopa and dopamine agonists. Still, they can be helpful in individual patients with severe tremor. Their use is limited particularly in the elderly, due to their propensity to induce a variety of side effects including urinary dysfunction, glaucoma, and particularly cognitive impairment. Carbidopa/levodopa 10/100, 25/100, 25/ 200–1000 mg 250 mg levodopa/d 2–4 times/d Benserazide/levodopa 25/100, 50/200 mg Carbidopa/levodopa CR 25/100, 50/200 mg Benserazide/levodopa 25/200, 25/250 mg MDS Parcopa 10/100, 25/100, 25/250 Carbidopa/levodopa/ 12.5/50/200, entacapone 18.75/75/200, 25/100/200, 31.25/125/200, 37.5/150/200, 50/200/200 mg" }, { "id": "InternalMed_Harrison_8144", "title": "InternalMed_Harrison", "score": 0.010706835760831443, "content": "Therapy with colchicine, para-aminosalicylate, neomycin, slow-release potassium chloride, anticonvulsant drugs, metformin, phenformin, cytotoxic drugs Alcohol in close relatives and in persons with other organ-specific autoimmune diseases, e.g., thyroid diseases, vitiligo, hypoparathyroidism, and Addison’s disease. It is also associated with hypogammaglobulinemia, with premature graying or blue eyes, and persons of blood group A. An association with human leukocyte antigen (HLA) 3 has been reported in some but not all series and, in those with endocrine disease, with HLA-B8, -B12, and -BW15. Life expectancy is normal in women once regular treatment has begun. Men have a slightly subnormal life expectancy as a result of a higher incidence of carcinoma of the stomach than in control subjects. Gastric output of hydrochloric acid, pepsin, and IF is severely reduced. The serum gastrin level is raised, and serum pepsinogen I levels are low." }, { "id": "pubmed23n1025_12186", "title": "Extrapyramidal side effect of donepezil hydrochloride in an elderly patient: A case report.", "score": 0.010488516882378774, "content": "Alzheimer disease (AD) is a neurodegenerative disease characterized by progressive cognitive dysfunction, which is mainly manifested as memory impairment and a reduced ability to self-care, often accompanied by neuropsychiatric and behavioral disorders. Donepezil is the second drug to be approved by the US FDA for the treatment of AD. Of the five FDA-approved drugs for AD treatment, donepezil is currently the most widely used. Here, we report an extrapyramidal adverse reaction to donepezil in an elderly patient with AD. An 87-year-old woman presented with a 1-year history of forgetfulness that was aggravated since the past 2 months. She had a long-term history of multiple major conditions, including hypertension, diabetes, osteoporosis, and arterial plaques. Brain imaging showed age-related changes, and her Mini Mental State Examination score was 20. Other tests revealed no abnormalities apart from multiple thyroid nodules on ultrasonography. She was diagnosed with AD, hypertension, type 2 diabetes mellitus, diabetic neuropathy, osteoporosis, carotid and lower-extremity arterial plaques, thyroid nodules. She was treated with donepezil (5 mg/day), amlodipine besylate (5 mg/day), glimepiride (4 mg/day), methylcobalamin (1.5 mg/day), calcium carbonate D3 (600 mg/day), simvastatin (20 mg/day) and enteric-coated aspirin (100 mg/day). Four days later, she experienced fatigue, panic, sweating, and one episode of vomiting. On the 5th day, she developed increased muscle tension, speech difficulty, and involuntary tremors. Imaging and blood tests revealed no obvious abnormality, and the patient was not receiving psychotropic drugs. An extrapyramidal adverse reaction to donepezil was considered, and the drug was discontinued, after which the symptoms gradually disappeared. Serious adverse reactions to donepezil can occur in elderly patients, who typically require multiple medications for a variety of comorbidities. In particular, extrapyramidal reactions have occurred when donepezil is administered in combination with psychotropic drugs. However, in our patient, an extrapyramidal adverse reaction occurred in the absence of psychotropic drugs. Thus, clinicians must be aware of inter-individual differences in drug actions and possible serious adverse reactions, and carefully monitor these patients to ensure the timely detection of adverse events and their safe treatment." }, { "id": "wiki20220301en291_41931", "title": "Levodopa-induced dyskinesia", "score": 0.009900990099009901, "content": "Nicotine (administered by dermal adhesive patches) has also been shown to improve Levodopa-induced dyskinesia and other PD symptoms. Patients with prominent dyskinesia resulting from high doses of antiparkinsonian medications may benefit from deep brain stimulation (DBS), which may benefit the patient in two ways: 1) DBS theoretically allows a reduction in l-DOPA dosage of 50–60% (tackling the underlying cause); 2) DBS treatment itself (in the subthalamic nucleus or globus pallidus) has been shown to reduce dyskinesia. Mavoglurant is also currently studied by Novartis for the treatment of this disease. On August 24, 2017 the FDA approved a drug to treat levodopa-induced dyskinesia for Parkinson's patients. The drug, Gocovri, is amantadine manufactured by Adamas Pharmaceuticals. It is the first FDA approved treatment for this condition. References External links Parkinson's disease" }, { "id": "wiki20220301en339_16623", "title": "History of Parkinson's disease", "score": 0.009900990099009901, "content": "History of treatments" }, { "id": "wiki20220301en359_15068", "title": "Sitagliptin/simvastatin", "score": 0.00980392156862745, "content": "History In 1991, Merck & Co's simvastatin was approved as an HMG-COA inhibitor to lower the levels of LDL cholesterol. In 2006, Merck & Co's sitagliptin was approved by the FDA for treatment of diabetes mellitus type 2. The patent for simvastatin expired in 2006 and many companies began to create a generic product of simvastatin. By creating a combined-dosage form of simvastatin and sitagliptin, Merck was able to increase their sales of simvastatin while meeting the need of patients who take both simvastatin and sitagliptin. Regulation Juvisync was the first product to combine a cholesterol lowering drug with a type 2 diabetes drug in the same tablet. Due to the potential for patients to need different doses of the two drugs, different dosage strengths were approved. These doses are for sitagliptin/simvastatin of 100 mg/10 mg, 100 mg/20 mg, 100 mg/40 mg, 50 mg/10 mg, 50 mg/20 mg, or 50 mg/40 mg. Nonclinical toxicology" }, { "id": "pubmed23n0388_1051", "title": "[Parkinsonism probably induced by manganese].", "score": 0.00980392156862745, "content": "In all cases of young persons with clinical Parkinson s disease it should be suspected that it is secondary to some primary disorder. Therefore a battery of diagnostic tests should be done before classification as idiopathic Parkinson s disease. A 31 year old woman whose only previous illness had been Graves disease. She complained of difficulty with movements of her right arm and leg for some months (she had problems with walking and with rapid, repeated movements of her right hand). She also complained of tremor of her right limbs at rest. She denied taking drugs, having dysphagia, dysarthria, visual changes or sphincter disorders. Neurological examination showed her to have monotonous speech, slight facial hypomimia, slight reduction in spontaneous blinking, walking with less swing of her right arm; postural tremor of both arms, worse on the right; bradykinesia (2/4) of both right limbs and rigidity (1/4), axial and of the right limbs. The results of all the investigations done to rule out secondary Parkinsonism were normal, except for the plasma manganese level which was raised, although it returned to normal when the probable source of exposure to this metal was removed. However, the alterations of movement only disappeared after treatment with levodopa was started. In cases of Parkinsonism in young adults secondary causes should always be rules out, such as exposure to certain metals." }, { "id": "wiki20220301en228_18849", "title": "Carbidopa/levodopa/entacapone", "score": 0.009708737864077669, "content": "Carbidopa/levodopa/entacapone may be combined with the drugs rasagiline or selegiline. These drugs are a different type of MAO inhibitor known as selective MAO inhibitors that are often prescribed for Parkinson's disease. Many drug interactions involving selegiline are theoretical, primarily based on interactions with non-selective MAO inhibitors; at oral doses the risk of these interactions may be very low. However, transdermal selegiline, known by its trade name Emsam, is still contraindicated. Transdermal selegiline results in higher plasma levels at which it behaves like a non-selective MAO inhibitor. Concominant use of entacapone, a component of carbidopa/levodopa/entacapone, with MAO inhibitors may increase toxicity of MAO inhibitors. Levodopa, also a component of carbidopa/levodopa/entacapone, in combination with MAO inhibitors may result in hypertensive reactions. Mechanism of action" }, { "id": "wiki20220301en030_9544", "title": "L-DOPA", "score": 0.009708737864077669, "content": "History" }, { "id": "wiki20220301en124_4202", "title": "Dihydroergocryptine", "score": 0.009615384615384616, "content": "The relatively long half-life and lack of dietary influence of dihydroergocriptine is considered to contribute to the compound's effectiveness in Parkinson's disease, particularly since it allows for more continuous stimulation of brain dopaminergic receptors than short-acting drugs such as levodopa. DHEC is also proven to be a safe and effective in improving symptoms in Parkinson's patients. Motor improvements in Parkinson's patients are usually observed in patients who take at least a mean daily dose of approximately 40 mg. Patients on DHEC demonstrate a better score than if they were on levodopa on the Webster scale, a standardized rating scale of Parkinson's Disease symptoms such as gait parameters and dyskinesia. Another clinical study has shown that DHEC had superior efficacy in reducing the clinical and motorcomplications associated with long-term levodopa use, as well as in reducing the incidence and severity of adverse effects." }, { "id": "wiki20220301en058_69216", "title": "Carbidopa/levodopa", "score": 0.009615384615384616, "content": "History" }, { "id": "pubmed23n0042_579", "title": "Cardiovascular effects of levodopa in aged versus younger patients with Parkinson's disease.", "score": 0.009596712279275617, "content": "The cardiovascular effects of prolonged administration of levodopa were studied in 54 men and women with Parkinson's disease; 23 of them were younger than 70 and 31 were 70 or older. The patients were evaluated clinically before treatment was started and at regular intervals thereafter. The average optimal dosage of levodopa for both age groups was 3.0 and 2.5 gm per day, respectively, during an average treatment period of 20.7 months. Eleven patients showed hypotension (systolic BP of 105 mm Hg or less) that was not related to dosage; in only 6 did the drug have to be permanently discontinued because of syncope; 3 of this group had an associated psychiatric disorder. Four patients had pretreatment hypertension; in 3 the BP fell to normal during therapy; in the remaining patient the hypertension persisted and was successfully treated by an antihypertensive drug. In 5 patients an occasional atrial or ventricular ectopic beat was noted both before and during levodopa therapy but no therapeutic intervention was required. Thirty of the 46 patients with adequate ECG follow-up did not show any significant changes; 5 others showed an increase, and 11 a decrease in myocardial ischemia. Thus the administration of levodopa in elderly patients with or without heart disease is a relatively safe procedure. The only exception would be patients over 70 years of age with a history of previous myocardial infarction. In this group there seems to be a higher incidence of clinically significant hypotension. In such patients, levodopa therapy should be carried out with great caution." }, { "id": "wiki20220301en274_19660", "title": "Befiradol", "score": 0.009523809523809525, "content": "Befiradol was discovered and developed by Pierre Fabre Médicament, a French pharmaceuticals company. In September 2013, befiradol was out-licensed to Neurolixis, a California-based biotechnology company. Neurolixis announced that it intends to re-purpose befiradol for the treatment of levodopa-induced dyskinesia in Parkinson's disease. In support of this indication, Neurolixis received several research grants from the Michael J. Fox Foundation and preclinical data was published describing the activity of befiradol in animal models of Parkinson's disease. In January 2018, the British charity Parkinson's UK announced that it had awarded Neurolixis a grant to advance development of befiradol up to clinical phase in Parkinson's disease patients. In March 2019, Neurolixis announced that the US Food and Drug Administration (FDA) gave a positive response to Neurolixis' Investigational New Drug (IND) application for NLX-112 to be tested in a Phase 2 clinical study in Parkinson's disease" }, { "id": "pubmed23n0763_11218", "title": "[Severe parkinsonism due to metoclopramide: the importance of early recognition].", "score": 0.009523809523809525, "content": "In this article, we present 3 women aged 73, 85 and 88 years who developed metoclopramide-induced parkinsonism. Shortly after starting metoclopramide, bradykinesia and rigidity developed in all 3 patients; tremor and postural instability in 2 of them. We discontinued the metoclopramide after 3-6 months; 2 of the patients had fully recovered 4-6 months later. The 3rd patient died from pneumonia, however, 2 months after discontinuation. Metoclopramide, a dopamine D2-antagonist, is a frequently prescribed anti-emetic drug; however, evidence of its efficacy is limited. In many patients, domperidone, another dopamine D2-antagonist, seems to be a better alternative. Movement disorders due to domperidone are uncommon, presumably because it does not cross the blood-brain barrier. It is likely that metoclopramide-induced parkinsonism is not uncommon; however, it is under-recognized. Risk factors are female sex, advanced age, diabetes mellitus and polypharmacy. Follow-up on patients using metoclopramide is advised. " }, { "id": "wiki20220301en103_27595", "title": "Vildagliptin", "score": 0.009433962264150943, "content": "Vildagliptin, sold under the brand name Galvus among others, is an oral anti-hyperglycemic agent (anti-diabetic drug) of the dipeptidyl peptidase-4 (DPP-4) inhibitor class of drugs. Vildagliptin inhibits the inactivation of GLP-1 and GIP by DPP-4, allowing GLP-1 and GIP to potentiate the secretion of insulin in the beta cells and suppress glucagon release by the alpha cells of the islets of Langerhans in the pancreas. Vildagliptin has been shown to reduce hyperglycemia in type 2 diabetes mellitus. Combination with metformin The European Medicines Agency has also approved a combination of vildagliptin and metformin, vildagliptin/metformin (Eucreas by Novartis) as an oral treatment for type-2 diabetes. Adverse effects Adverse effects observed in clinical trials include nausea, hypoglycemia, tremor, headache and dizziness. Rare cases of hepatoxicity have been reported." }, { "id": "pubmed23n0303_22147", "title": "Drugs inducing or aggravating parkinsonism: a review.", "score": 0.009433962264150943, "content": "Drug-induced parkinsonism (DIP) is frequent. The list of drugs able to induce parkinsonism is long and probably incomplete, because new drugs, with previously unknown antidopaminergic activity, are constantly being added. Not all the drugs have the same potency for inducing parkinsonism. We classify these drugs in three groups: (1) drugs with obvious antidopaminergic activity which regularly induce parkinsonism; (2) drugs able to induce parkinsonism in particular individuals and (3) drugs which may aggravate Parkinson's disease treated with levodopa. The reports of isolated cases of parkinsonism induced by widely-used drugs (drugs in group 2) may be the result of either an idiosyncratic side effect or a misdiagnosis of parkinsonism. The antidopaminergic activity of the drugs of this group is weak and not sufficiently demonstrated. Maybe, in these cases, the blockage of other neurotransmitters different from dopamine plays a role in the induction of parkinsonism. Probably, the number of patients with DIP is higher than reported or detected, because many patients suffer from weak symptoms that quickly disappear after drug withdrawal. One of the main points of interest is knowing the list, because all these drugs, specially those of group 1, should be avoided or used with caution in the treatment of some common symptomatic problems in patients with Parkinson's disease, such as depression, arterial hypertension, diabetes mellitus and cardiac disorders. The precautions should extent to other populations especially susceptible to suffer from DIP, such as the elderly or patients with other neurodegenerative disorders, such as Alzheimer's disease." }, { "id": "wiki20220301en002_78800", "title": "Substantia nigra", "score": 0.009345794392523364, "content": "Levodopa The substantia nigra is the target of chemical therapeutics for the treatment of Parkinson's disease. Levodopa (commonly referred to as L-DOPA), the dopamine precursor, is the most commonly prescribed medication for Parkinson's disease, despite controversy concerning the neurotoxicity of dopamine and L-DOPA. The drug is especially effective in treating patients in the early stages of Parkinson's, although it does lose its efficacy over time. Levodopa can cross the blood–brain barrier and increases dopamine levels in the substantia nigra, thus alleviating the symptoms of Parkinson's disease. The drawback of levodopa treatment is that it treats the symptoms of Parkinson's (low dopamine levels), rather than the cause (the death of dopaminergic neurons in the substantia nigra). MPTP" }, { "id": "pubmed23n0306_7415", "title": "[Movement disorders of drug origin].", "score": 0.009345794392523364, "content": "The involvement of a drug must be suspected in each patient suffering from a movement disorder. Besides classical neuroleptics used as antipsychotics (butyrophénones, phenothiazines or benzamides), many drugs, mainly \"hidden\" neuroleptics (prescribed as antinausea, antivomiting, antivertigo, antispasmodic or antihypertensive drugs) or agents prescribed in psychiatric (antidepressants, lithium) or neurological (levodopa in Parkinson's disease, antiepileptics) diseases are known to be able to reveal or produce a movement disorder. Other drug prescribed in internal medicine can also be involved. This review discusses the main characteristics of drug-induced movement disorders as well as their pharmacological approach." }, { "id": "wiki20220301en420_29449", "title": "Neurolixis", "score": 0.009259259259259259, "content": "and Drug Administration (FDA) gave a positive response to Neurolixis' Investigational New Drug (IND) application for befiradol to be tested in a Phase 2 clinical study in Parkinson's disease patients with troublesome Levodopa-induced dyskinesia. Studies published in 2020 using non-human primate models of Parkinson's disease, (MPTP-treated marmosets and MPTP-treated macaques), found that befiradol potently reduced Levodopa-induced dyskinesia at oral doses as low as 0.1 to 0.4 mg/kg." }, { "id": "pubmed23n0679_8989", "title": "A brief history of levodopa.", "score": 0.009259259259259259, "content": "This article highlights some landmarks in the history of levodopa, beginning with its isolation in 1910-13 from seedlings of Vicia faba to the demonstration, in 1961, of its \"miraculous\" effect in patients with Parkinson's disease (PD). Midway between these two time points, in 1938, L: -dopa decarboxylase was discovered, the enzyme that produces dopamine (DA) from levodopa. In 1957, DA was shown to occur in the brain, and in 1959 it was found to be enriched in the basal ganglia. At that time the striatal localization of DA, together with studies done in 1957-58 in naive and reserpine-treated animals regarding DA in the brain and the central effects of levodopa, suggested its possible involvement in \"extrapyramidal control\" and \"reserpine parkinsonism\". Following these discoveries, a study of (postmortem) brains of patients with basal ganglia disorders, including PD, was started, demonstrating, in 1960, a severe striatal DA deficit specifically in PD, thus furnishing a rational basis for the concept of \"DA replacement therapy\" with levodopa. Accordingly, in 1961, the first highly successful clinical trial with i.v. levodopa was carried out. In 1963, the DA deficit in the PD substantia nigra was found, indicative of a nigrostriatal DA pathway in the human brain, subsequently established in animal studies in 1964-65. In 1967, the chronic, high dose oral levodopa regimen was introduced in treatment of PD. Besides the above highlights in the history of levodopa, the article also cites critical opinions of world authorities in brain research of the time, harmful to the cause of DA, levodopa and PD. Today, the concept of DA replacement with levodopa is uncontested, with levodopa being the \"gold standard\" of modern drug treatment of PD." }, { "id": "wiki20220301en231_12553", "title": "Safinamide", "score": 0.009174311926605505, "content": "Safinamide (INN; brand name Xadago) is a drug used as an add-on treatment for Parkinson's disease with \"off\" episodes; it has multiple modes of action, including the inhibition of monoamine oxidase B. It was approved in Europe in February 2015, in the United States in March 2017, and in Canada in January 2019. Medical uses Safinamide is used to treat idiopathic Parkinson's disease as add-on for people taking a stable dose of levodopa (L-dopa) alone or in combination with other Parkinson drugs, to help with \"off\" episodes when levodopa stops working. Contraindications Safinamide is contraindicated in people with severe liver impairment, with albinism, retinitis pigmentosa, severe diabetic neuropathy, uveitis and other disorders of the retina. Combination with other monoamine oxidase (MAO) inhibitors and pethidine is also contraindicated." }, { "id": "pubmed23n0679_8991", "title": "Has drug therapy changed the natural history of Parkinson's disease?", "score": 0.009174311926605505, "content": "This narrative review examines the effects of drug therapy on the natural history of Parkinson's disease. In terms of modifying the underlying disease process, it is possible that immediate therapy, rather than deferred treatment, can have a positive effect on the underlying disease process. However, it is unlikely that drug therapy has changed mortality from the condition and there is no evidence that it can delay the onset of non-motor features such as dementia and falls. The beneficial effects of drug therapy on the motor symptoms of Parkinson's disease are unquestionable, but these are at the expense of short-term dopaminergic side effects, long-term motor complications, and impulse control disorders. Major questions remain regarding which initial therapeutic approach should be taken which may possibly be answered by the ongoing PD MED trial. The beneficial effects of drug therapy on the motor features of Parkinson's disease have had a fundamental impact on the suffering of patients. The mainstay of these therapies continues to be levodopa, although it is now used at lower doses than in the past and in combination with other drug classes." }, { "id": "wiki20220301en291_41926", "title": "Levodopa-induced dyskinesia", "score": 0.00909090909090909, "content": "In the context of Parkinson's disease (PD), dyskinesia is often the result of long-term dopamine therapy. These motor fluctuations occur in up to 80% of PD patients after 5–10 years of l-DOPA treatment, with the percentage of affected patients increasing over time. Based on the relationship with levodopa dosing, dyskinesia most commonly occurs at the time of peak l-DOPA plasma concentrations and is thus referred to as peak-dose dyskinesia (PDD). As patients advance, they may present with symptoms of diphasic dyskinesia (DD), which occurs when the drug concentration rises or falls. If dyskinesia becomes too severe or impairs the patient's quality of life, a reduction in l-Dopa might be necessary, however this may be accompanied by a worsening of motor performance. Therefore, once established, LID is difficult to treat. Amongst pharmacological treatments, N-methyl-D-aspartate (NMDA) antagonist, (a glutamate receptor), amantadine, has been proven to be clinically effective in a small" }, { "id": "pubmed23n0752_15682", "title": "The history of parkinsonism: descriptions in ancient Indian medical literature.", "score": 0.00909090909090909, "content": "The clinical syndrome of parkinsonism was identified in ancient India even before the period of Christ and was treated methodically. The earliest reference to bradykinesia dates to 600 bc. Evidences prove that as early as 300 bc, Charaka proposed a coherent picture of parkinsonism by describing tremor, rigidity, bradykinesia, and gait disturbances as its components. The scenario was further developed by Madhava, Vagbhata, and Dalhana all through history. The 15th-century classic \"Bhasava rajyam\" introduced the term kampavata, which may be regarded as an ayurvedic analogue of parkinsonism. The pathogenesis of kampavata centered on the concept of imbalance in the vata factor, which controls psychomotor activities. The essential element in therapy was the administration of powdered seed of Mucuna pruriens, or atmagupta, which as per reports, contains 4%-6% of levodopa. In addition to proving the existence and identification of parkinsonism in ancient India, the study points to the significance of ancient Indian Sanskrit works in medical history." }, { "id": "wiki20220301en028_93494", "title": "Multiple system atrophy", "score": 0.009009009009009009, "content": "Drug therapy Levodopa (L-Dopa), a drug used in the treatment of Parkinson's disease, improves parkinsonian symptoms in a small percentage of MSA patients. A recent trial reported that only 1.5% of MSA patients experienced any improvement at all when taking levodopa, their improvement was less than 50%, and even that improvement was a transient effect lasting less than one year. Poor response to L-Dopa has been suggested as a possible element in the differential diagnosis of MSA from Parkinson's disease. The drug riluzole is ineffective in treating MSA or PSP. Rehabilitation Management by rehabilitation professionals including physiatrists, physiotherapists, occupational therapists, speech therapists, and others for difficulties with walking/movement, daily tasks, and speech problems is essential." }, { "id": "pubmed23n0118_14986", "title": "Juvenile Parkinsonism: clinical and metabolic characteristics.", "score": 0.009009009009009009, "content": "Twenty one patients with idiopathic Parkinsonism beginning before the age of 40 years were investigated. The mean duration of the disease was 19 years. There was a good and sustained response to levodopa. Only four patients reached stages IV and V (Hoehn and Yahr). Intolerance to levodopa was observed in the more advanced stages of the disease. In the series the familial incidence of Parkinsonism (2 cases) and essential tremor (3 cases) was very low. Thyroid disorder, diabetes mellitus or macrocytic anaemia was not found in any of the cases." }, { "id": "pubmed23n0972_2158", "title": "Which drugs cause treatment-related problems? Analysis of 10,672 problems within the outpatient setting.", "score": 0.008928571428571428, "content": "Treatment-related problems (TRPs) may pose risks for patients if unaddressed. With the increased complexity of health care, it is important to target pharmacists' efforts to patients that are at high risk for TRPs. The present study aimed to identify medications most commonly associated with TRPs. Outpatient departments of five public and teaching hospitals in Jordan. TRPs and drugs most commonly implicated with TRPs were assessed for patients recruited from outpatient clinics in five major hospitals in Jordan using a standardized and validated pharmaceutical care manual. Drugs associated with different types of TRPs. Ultimately, 2,747 patients, with a total of 10,672 TRPs, were included in the study. The medication groups most commonly associated with TRPs were cardiovascular (53.0%), endocrine (18.1%), and gastrointestinal (7.7%) drugs. The most common specific drugs associated with TRPs from any category were atorvastatin (12.5%), metformin (8.5%), simvastatin (6.2%), and enalapril (5.9%). Cardiovascular medications were the most common drugs implicated with multiple subtypes of TRPs - most commonly, allergic reaction or undesirable effect (88.5%), drug product not available (87.3%), safety interaction issues (81.8%), a need for additional or more frequent monitoring (78.0%), and more effective drugs available (77.2%). Hypertension, diabetes mellitus, and dyslipidemia were the most common diseases associated with different subtypes of TRPs. The present study identified high-risk drugs for TRPs, which can be used as identification of targeting approach TRPs. Such an approach would improve care provided to patients and can inform health care policies." }, { "id": "pubmed23n1087_875", "title": "Gout and Levodopa: An unknown adverse effect?", "score": 0.008928571428571428, "content": "We report the case of a 77-year-old man with Parkinson's disease (PD) who experimented for the first time gout crisis after the initiation of levodopa. Levodopa was withdrawn, and colchicine and allopurinol were initiated to treat the gout crisis. Because of PD progression, levodopa was reintroduced, and the patient presented relapse of gout flare. To further explore the association between gout and levodopa, we extracted and synthetized all Individual Case Safety Reports of gout associated with levodopa in the World Health Organization pharmacovigilance database, VigiBase<sup®</sup , up to April 2021. 43 cases of gout were reported in VigiBase<sup®</sup with drugs from N04BA ATC class. Levodopa was suspected in fifteen cases among which improvement was noticed in six cases (two after levodopa withdrawal, two despite treatment continuation, and two cases lacking details about action taken with levodopa); three cases did not recover; in the remaining six cases, evolution was not known. \"Hyperuricemia\" was not mentioned in the Summary of Product Characteristics of medicine containing levodopa; however, \"abnormality biologics test with uric acid\" was mentioned. Despite few cases of recovery after reduced doses of levodopa, the above-described case of positive reintroduction was an argument in favor of the role of levodopa in gout flare. This study highlights a potential association between levodopa and gout through an analysis of the cases reported in the WHO pharmacovigilance database." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 246 ] ], "word_ranges": [ [ 0, 42 ] ], "text": "After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test." }, "2": { "exist": true, "char_ranges": [ [ 0, 246 ] ], "word_ranges": [ [ 0, 42 ] ], "text": "After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test." }, "3": { "exist": true, "char_ranges": [ [ 0, 246 ] ], "word_ranges": [ [ 0, 42 ] ], "text": "After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test." }, "4": { "exist": true, "char_ranges": [ [ 0, 246 ] ], "word_ranges": [ [ 0, 42 ] ], "text": "After a TBI in a patient who is not anticoagulated or antiplatelet, with no known risk factors for hemorrhage, and who does not present alarming data in the anamnesis or physical examination, it is not necessary to perform a cranial imaging test." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Cranial CT scan without contrast.", "2": "Cranial CT with contrast.", "3": "No imaging test.", "4": "Simple skull radiography.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0524_15481", "title": "[Indications for computed tomography in patients with mild head injuries].", "score": 0.0186932215234102, "content": "To identify clinical parameters that may be associated with intracranial lesions in patients with mild head injuries, Glasgow Coma Scale (GCS) scores of 15 but without any focal neurological deficit. All head trauma patients admitted to the emergency room within 3 months with GCS scores of 15 (n = 371) were evaluated. Patients with focal neurological deficits, penetrating or multiple traumas, gun shot wounds were not evaluated. Mean age of 222 male and 149 female patients was 22.4 years. Frequency of intracranial lesions detected in CT was higher in patients older than 60 years of age. A significant difference was not found between both genders. Detection rate of abnormalities was higher after motorway accidents. Loss of consciousness and post-traumatic fits were associated with higher rates of pathological sequelae. A significant difference was not found between patients with or without headache, nausea, and vomiting. Sensitivity and specificity of cranial x-ray were estimated to be 38.2% and 93.2% when compared with cranial CT respectively. The incidence of intracranial lesions in patients with mild head injuries, GCS scores of 15, younger than 60 years of age, and without any focal neurological deficits, loss of consciousness, post-traumatic fits, gun shot wound, and penetrating injury is 0.6%." }, { "id": "pubmed23n0658_19748", "title": "Prospective study of validity of neurologic signs in predicting positive cranial computed tomography following minor head trauma.", "score": 0.018295739348370928, "content": "The ability to discriminate among a large number of patients with mild head injury to detect those most likely to have an intracranial abnormality may offer an advantage in mass-casualty situations and when clinical needs exceed diagnostic capabilities. In patients with mild head injury (Glasgow Coma Scale score = 13-15), the likelihood of intracranial abnormality, as defined by cranial computed tomography (CT), varies according to presenting neurologic signs and symptoms. This prospective study consisted of 152 patients with blunt head trauma and one or more of the following: initial loss of consciousness (LOC), headache, vomiting, convulsions, or amnesia. All underwent cranial CT within one hour of presentation. Positive CT findings were defined as cerebral contusion, extra-axial hematoma, intra-ventricular or subarachnoid hemorrhage, brain edema, and skull fracture. Clinical findings were tabulated and compared with CT findings. The most common symptoms were headache (61%) followed by followed by LOC (45%), vomiting (39%), amnesia (29%), and convulsions (4%). Convulsions were the most predictive of a CT positive finding (80%); history of LOC was least predictive (29%). The presence of two or more clinical findings tended to increase the likelihood of intracranial abnormality, but the association was neither consistent nor additive. Convulsions occurring in a patient with mild head injury are highly predictive of a positive intracranial finding on CT. Headache, amnesia, and vomiting are each likely to show positive findings in approximately 40-45% of cases. Although the least predictive of the neurologic findings studied, loss of consciousness still correlates with a positive cranial CT in 29% of cases. More than one sign or symptom increases the likelihood of concurrent brain injury." }, { "id": "pubmed23n0286_14268", "title": "Minor head trauma: Is computed tomography always necessary?", "score": 0.017284495439835245, "content": "To determine the clinical value of routine computed tomography (CT) of the head in patients with normal mental status after minor head trauma. We carried out a prospective study of a consecutive series of patients of all ages who presented to our urban university Level I trauma center emergency department with a Glasgow Coma Scale score of 15 and underwent CT of the head after loss of consciousness (LOC) or amnesia to event. A data form was filled out for each patient before CT. Patients with abnormal CT results were followed to discharge. We analyzed data with the chi 2 and student t tests. Of 1,382 patients, traumatic intracranial abnormality was identified on CT of the head in 84 (6.1%). Three patients in this group (.2%) required surgery. The subgroup of patients with history of LOC/amnesia but no symptoms or signs of a depressed skull fracture had a rate of abnormal CT findings of only 3% (24 of 789), and no patient in this group required medical or surgical intervention. Nausea and vomiting and signs of head trauma were significantly more common in the group with abnormal CT findings. Routine CT of the head in patients with history of LOC/amnesia but no symptoms or signs of depressed skull fracture has minimal clinical value and is not warranted. Patients with symptoms of head injury or apparent depressed skull fracture should undergo head CT because a small number will require surgery." }, { "id": "pubmed23n0513_23431", "title": "Mild head injury: revisited.", "score": 0.016592171204117566, "content": "1. To define the incidence of positive CT scans in patients with different grades of mild head injury (MHI), 2. To identify clinical predictors of positive CT scans, 3. To evaluate the usefulness of plain radiographs in the triage of patients with MHI, 4. To evaluate frequency and nature of surgical intervention in MHI, 5. To evaluate the risk of deterioration in MHI, and 6. To find out whether patients with normal neurological examination and normal CT can be safely discharged. In a prospective study conducted over a period of four months in our center, all patients with mild head injury (defined as Glasgow Coma Scores (GCS) 13-15) were admitted to the head injury unit. Patients underwent standard clinical examination, skull radiography and cranial CT. No clinical criteria were used to select patients for CT scanning and all the patients were subjected to CT. Patients with negative findings on CT and a normal neurological examination were discharged after 24 hours of observation. Patients with positive findings on cranial CT were treated either medically or surgically as deemed necessary. Outcome measures included safe discharge, clinical deterioration, need for surgical intervention or death. The following factors were analyzed statistically to find out whether they can be used as predictive factors for positive cranial CT. They were: age, sex, mode of injury, loss of consciousness, post-traumatic seizures, ear/ nose/throat bleeding, vomiting, admission GCS score, scalp injury, polytrauma, focal neurological deficit, fractures visualized on skull radiography. Three hundred and eighty one patients were included in the study. Of these males constituted 63%, females 17% and children 20%. RTA was the most common mode of injury. Seventy five percent of the patients had GCS of 15, 15% had GCS of 14 and 10% had GCS of 13. Thirty eight percent of the patients had positive findings on the CT. Age, mode of injury, loss of consciousness, post-traumatic seizures, ENT bleeding, vomiting, scalp injury and polytrauma were not found to be predictors of positive CT. Admission GCS score, focal neurological deficits, and fractures detected by skull radiography were found to be statistically significant predictors of positive findings on CT. Seven percent of patients required surgical intervention. Six percent of patients showed neurological deterioration and there was one death in this series of MHI patients. Patients with multiple lesions on CT had a higher chance of deterioration than those with a single lesion. No patient who had a GCS of 15 and normal CT developed any complication during the hospital stay or after discharge. The incidence of positive CT scans in this prospective, consecutive, unselected cohort of MHI patients was 38%. Lower admission GCS scores, focal neurological deficits, and fractures detected by skull x-rays were found to be significant predictors of positive CT. Other clinical parameters were not found to be predictors of positive CT. CT was found to be superior to plain x-rays in detecting skull fractures. Seven percent of this cohort required neurosurgical intervention. Six percent showed neurological deterioration and there was one death in this series. Patients with multiple lesions on CT had a higher chance of deterioration than those with single lesions. The duration of hospital stay was prolonged in patients with positive CT. As no patient with a normal neurological examination and a normal CT deteriorated, we believe these patients can be safely discharged without need for admission and observation." }, { "id": "pubmed23n0494_5077", "title": "Loss of consciousness: when to perform computed tomography?", "score": 0.016504329004329004, "content": "To determine the diagnostic value of physical examination (including neurologic exam) for positive computed tomography scan findings in children with closed head injury, Glasgow Coma Scale score 13-15 in the emergency department, and loss of consciousness or amnesia. Prospective descriptive study. A large, tertiary, pediatric trauma center in San Diego County. Children ages 2-16 with an isolated closed head injury, history of loss of consciousness or amnesia, and Glasgow Coma Scale 13-15 who were referred for pediatric trauma evaluation and received a head computed tomography as part of this evaluation. A standardized physical examination including skull/scalp exam, pupils, tympanic membrane, and brief neurologic exam was documented on each patient. Subjects age 2-16 being evaluated by the pediatric trauma team for closed head injury with loss of consciousness or amnesia and Glasgow Coma Scale 13-15 received a standardized physical exam, noncontrast head computed tomography scan, and follow-up telephone call at 4-6 wks. Outcome variables include intracranial injury visualized on computed tomography scan and need for neurosurgical intervention. Ninety-eight subjects were enrolled in the study over a 1-yr period. Computed tomography scans revealed evidence of intracranial injury in 13 of 98 subjects (13%). Normal examination increased the probability of a normal computed tomography scan from.87 pretest to.90 posttest. Four of 38 subjects with normal examination were noted to have evidence of intracranial injury on computed tomography. These four subjects did not require neurosurgical intervention. Two of 98 subjects underwent neurosurgical procedures. One intracranial pressure monitor was placed for decreasing level of consciousness. One subject underwent surgical elevation of a depressed skull fracture. Detailed clinical examination is of no diagnostic value in detecting intracranial injuries found on head computed tomography scan. Patients with observed loss of consciousness or amnesia and Glasgow Coma Scale 13-15 should have a head computed tomography scan as part of their evaluation to avoid missing an intracranial injury." }, { "id": "pubmed23n0280_475", "title": "Limitations of neurological assessment in mild head injury.", "score": 0.016483516483516484, "content": "The authors have investigated two commonly used methods of assessing neurological status in patients with mild head injury to determine whether they can predict intracranial damage. Of 686 such patients with cranial computed tomography (CT) scans, scan results were recorded, along with total and motor components of the Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85). Despite relatively normal admission neurological examinations, 127 of the 689 patients (18.4%) had intracranial lesions, and 38 (5.5%) required surgery. There was no significant difference in distribution of the GCS in patients with and without intracranial lesions. The RLS85 was superior to the GCS in predicting intracranial pathology, and a significant association between RLS85 and lesions on CT scanning was noted. However, even this test was normal in 19 patients found to have intracranial pathology, including nine who required surgery. The authors conclude that a normal or near-normal mental status examination in a head-injured patient on arrival at the emergency room is inadequate to exclude a potentially serious intracranial lesion. It is unlikely that further refinements in the clinical evaluation will result in diagnostic accuracy comparable with that of CT scanning. Accordingly, we recommend that any patient who has suffered a loss of consciousness or amnesia following head injury have an urgent cranial CT scan." }, { "id": "pubmed23n0563_13312", "title": "Indications for brain CT scan in patients with minor head injury.", "score": 0.016447590158409166, "content": "Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury. A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals. Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan. Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury." }, { "id": "pubmed23n0293_8378", "title": "The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department.", "score": 0.01641810570381999, "content": "Head injury is a frequent cause of morbidity and mortality in pediatric trauma. Guidelines for obtaining computed tomographic (CT) scans in the child with mild head injury are poorly defined. This study investigated the utility of head CT scanning in the pediatric patient presenting with normal neurologic examination. All patients undergoing head CT scanning for trauma in the emergency department (ED) at a tertiary care pediatric trauma center during 1992 were identified (508). Charts were reviewed for historical and physical examination findings, CT results, and need for neurosurgical intervention. Patients were excluded if they had an abnormal neurologic examination (179), known depressed skull fracture (11), bleeding diathesis (3), age older than 18 years (1), or developmental delay (1). Included were 313 patients (median 5.5 years) who presented with clinical variables including sleepiness (38%), vomiting (34%), headache (30%), loss of consciousness (LOC) (25%), irritability (22%), amnesia (20%), and seizures (8%). An abnormal head CT was noted in 88 cases (28%); 79 (25%) were traumatic abnormalities involving the skull and/or contents. Thirteen patients (4%) had intracranial injuries (ICI); all had either a linear (10), basilar (2), or depressed (1) skull fracture noted on CT. Four patients required neurosurgery, three for epidural hematoma, and one for a complicated orbital fracture (without ICI). No clinical variables (seizure, LOC, vomiting, headache, confusion, irritability, sleepiness, amnesia) were associated with ICI (P &gt; 0.05). In pediatric head trauma patients, with normal neurologic examinations in the ED, ICI occurs &lt; 5% of the time and neurosurgery is needed in 1% of the cases. Commonly used clinical variables are not associated with ICI in these children." }, { "id": "pubmed23n0710_18342", "title": "Indications for brain computed tomography scan after minor head injury.", "score": 0.016064516129032258, "content": "Minor head injury (MHI) is a common injury seen in Emergency Departments (ED). Computed tomography (CT) scan of the brain is a good method of investigation to diagnose intracranial lesions, but there is a disagreement about indications in MHI patients. We surveyed the post-traumatic symptoms, signs or past historical matters that can be used for the indication of brain CT scan. All patients with MHI who were older than 2 years, had a Glasgow Coma Scale (GCS) score ≥13 and were referred to the ED, underwent brain CT scan. Data on age, headache, vomiting, loss of consciousness (LOC) or amnesia, post-traumatic seizure, physical evidence of trauma above the clavicles, alcohol intoxication, and anticoagulant usage were collected. The main outcome measure was the presence of lesions related to the trauma in brain CT scan. For categorical variables, Chi-square test was used. Six hundred and forty-two patients were examined by brain CT scan after MHI, and 388 patients (60.4%) did not have any risk indicator. Twenty patients (3.1%) had abnormal brain CT scans. The logistic regression model showed that headache (P=0.006), LOC or amnesia (P=0.024) and alcohol (P=0.036) were associated with abnormal brain CT. WE SUGGESTED THAT ABNORMAL BRAIN CT SCAN RELATED TO THE TRAUMA AFTER MHI CAN BE PREDICTED BY THE PRESENCE OF ONE OR MORE OF THE FOLLOWING RISK INDICATORS: Headache, vomiting, LOC or amnesia, and alcohol intoxication. Thus, if any patient has these indicators following MHI, he must be considered as a high-risk MHI." }, { "id": "pubmed23n0778_6012", "title": "Risk factors indicating the need for cranial CT scans in elderly patients with head trauma: an Austrian trial and comparison with the Canadian CT Head Rule.", "score": 0.015783343040186373, "content": "This study presents newly defined risk factors for detecting clinically important brain injury requiring neurosurgical intervention and intensive care, and compares it with the Canadian CT Head Rule (CCHR). This prospective cohort study was conducted in a single Austrian Level-I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department with witnessed loss of consciousness, disorientation, or amnesia, and a Glasgow Coma Scale (GCS) score of 13-15. The studied population consisted of a large number of elderly patients living in Vienna. The aim of the study was to investigate risk factors that help to predict the need for immediate cranial CT in patients with mild head trauma. Among the 12,786 enrolled patients, 1307 received a cranial CT scan. Four hundred eighty-nine patients (37.4%) with a mean age of 63.9 ± 22.8 years had evidence of an acute traumatic intracranial lesion on CT. Three patients (&lt; 0.1%) were admitted to the intensive care unit for neurological observation and received oropharyngeal intubation. Seventeen patients (0.1%) underwent neurosurgical intervention. In 818 patients (62.6%), no evidence of an acute trauma-related lesion was found on CT. Data analysis showed that the presence of at least 1 of the following factors can predict the necessity of cranial CT: amnesia, GCS score, age &gt; 65 years, loss of consciousness, nausea or vomiting, hypocoagulation, dementia or a history of ischemic stroke, anisocoria, skull fracture, and development of a focal neurological deficit. Patients requiring neurosurgical intervention were detected with a sensitivity of 90% and a specificity of 67% by using the authors' analysis. In contrast, the use of the CCHR in these patients detected the need for neurosurgical intervention with a sensitivity of only 80% and a specificity of 72%. The use of the suggested parameters proved to be superior in the detection of high-risk patients who sustained a mild head trauma compared with the CCHR rules. Further validation of these results in a multicenter setting is needed. Clinical trial registration no.: NCT00451789 ( ClinicalTrials.gov .)." }, { "id": "pubmed23n0108_10791", "title": "Value of skull radiography, head computed tomographic scanning, and admission for observation in cases of minor head injury.", "score": 0.015597605948854362, "content": "A retrospective review of 373 adult patients admitted to Harbor General Hospital between 1980 and 1984 for minor closed head injury (Glasgow coma scale 13-15) was performed to determine the benefits of skull radiography, computed tomographic (CT) scanning of the head, and admission for observation. Variables reviewed were mental status, neurological examination, presence or absence of loss of consciousness, clinical evidence of basilar skull fracture, and fracture on skull radiography. The neurological examination (including mental status and Glasgow coma scale) in the emergency room was the best predictor of subsequent deterioration or the presence of an operative hematoma. The only patients with Glasgow coma scale scores of 15 who required surgical evacuation of an extraaxial hematoma had focal neurological deficits referable to hemispheric compression, with or without an abnormal mental status. A Glasgow coma scale score of 13 or 14 places the patient at risk either of having a hematoma requiring surgery or of deteriorating. We recommend that a head CT scan be obtained on all patients with Glasgow coma scale scores of less than 15, abnormal mental status, or hemispheric neurological deficits. If no operative lesion is found on the CT scan, the patient should be admitted for observation because there is still a risk of deterioration. Those with a Glasgow coma scale score of 15, a normal mental status, and no hemispheric neurological deficit may be discharged to be observed at home by a competent observer despite basilar or calvarial skull fracture, loss of consciousness, or cranial nerve deficit. No benefit was gained from skull radiography in any group." }, { "id": "wiki20220301en407_19569", "title": "Sports-related traumatic brain injury", "score": 0.015141242937853107, "content": "Case study example History: The individual is possibly unconscious when examined by medical personnel on the field. A common symptom is prolonged unconsciousness (coma), however this player reports headache, dizziness, nausea, vomiting, and weakness of the extremities (paresis) and makes inappropriate responses to questions. Physical exam: The individual's level of consciousness is disturbed. A neurological examination may not reveal any localizing signs. The individual with no other serious injuries than cerebral contusion will not have a fractured skull or any signs of opening or penetration of the skull. Tests: Skull x-rays check for a fracture. CT or MRI detect any bleeding in the skull. The Glasgow Coma Scale classifies the severity of brain injury, with a score of 15 as normal and progressively lower scores indicating greater neurologic injury to the brain." }, { "id": "pubmed23n0703_18545", "title": "An assessment of clinical predictors of intracranial head injury identified by computed tomography scan.", "score": 0.015012254901960783, "content": "A prospective study was done during a six-month period on 104 consecutive patients who were seen at the Accident and Emergency (A&amp;E) Department of the UHWI and referred for CT scans of the head within 24 hours of sustaining head injuries. There were 74 (71.1%) males and 30 (28.8%) females. The mean age for females was 40.6 years and 32.4 years for males. Patients were clinically assessed for the presence or absence of vomiting, amnesia, loss of consciousness, bleeding of ear, nose and throat (ENT) and Glasgow Coma score (GCS). Negative predictive values were calculated for each parameter individually as well as the combination of all five. The absence of vomiting, amnesia, \"loss of consciousness\" (LOC) or ENT bleed had negative predictive values of 68%, 73%, 76% and 61.6% respectively. An assessment of Glasgow Coma Scale (GCS) of 15 had a 77.5% negative predictive value. When the history was indeterminate, the negative predictive values were 19%, 25%, 60% and 18% respectively for vomiting, amnesia, LOC and ENT bleed. When all four clinical indicators were absent in the history and examination and the GCS score 15, the negative predictive value for intracranial injury was 89.4%. In summary, the clinical indicators reviewed, alone or in combination, cannot exclude the presence of intracranial injury." }, { "id": "pubmed23n0387_8341", "title": "[The role of computed tomography for minor head injury].", "score": 0.014615384615384617, "content": "Head trauma is a major health problem which affects young people, especially young males and also causes serious economic losses. Although major head injuries are cause greater morbidity and mortality, minor head injuries are more common presentations to emergency departments. In this study our goal is to determine the prevalence of CT usage in minor, adult head injury patients and determine clinical variables for the use of head CT scans. In our study we retrospectively examined 230 adult head injury patients who were presented to the Dokuz Eylül University Medical School Hospital Emergency Department. We recorded age, gender, symptoms of nausea, vomiting, headache, alcohol use, physical examination findings, history of loss of consciousness prior to presentation, concurrent injuries, and Glasgow Coma Scale (GCS) scores. Head CT ordering and abnormal findings were correlated with the above clinical variables. We ascertained that all variables affected the ordering of CT scans except age, gender and alcohol use. The prevalence of abnormal head CT in all patients were 21.7%. We found that GCS is only one clinical variability of which statistically significant relationship to acquaint abnormal CT findings." }, { "id": "pubmed23n0853_11499", "title": "Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?: The Rational Clinical Examination Systematic Review.", "score": 0.01452714154278243, "content": "Adults with apparently minor head trauma (Glasgow Coma Scale [GCS] scores ≥13 who appear well on examination) may have severe intracranial injuries requiring prompt intervention. Findings from clinical examination can aid in determining which adults with minor trauma have severe intracranial injuries visible on computed tomography (CT). To assess systematically the accuracy of symptoms and signs in adults with minor head trauma in order to identify those with severe intracranial injuries. We performed a systematic search of MEDLINE (1966-2015) and the Cochrane Library to identify studies assessing the diagnosis of intracranial injuries. Studies were included that measured the performance of findings for identifying intracranial injury with a reference standard of neuroimaging or follow-up evaluation. Fourteen studies (range, 431-7955 patients) met inclusion criteria with patients having GCS scores between 13 and 15 and 50% or more older than 18 years. Three authors independently performed critical appraisal and data extraction. The prevalence of severe intracranial injury (requiring prompt intervention) among the 23,079 patients with minor head trauma was 7.1% (95% CI, 6.8%-7.4%) and the prevalence of injuries leading to death or requiring neurosurgical intervention was 0.9% (95% CI, 0.78%-1.0%). The presence of physical examination findings suggestive of skull fracture (likelihood ratio [LR], 16; 95% CI, 3.1-59; specificity, 99%), GCS score of 13 (LR, 4.9; 95% CI, 2.8-8.5; specificity, 97%), 2 or more vomiting episodes (LR, 3.6; 95% CI, 3.1-4.1; specificity, 92%), any decline in GCS score (LR range, 3.4-16; specificity range, 91%-99%;), and pedestrians struck by motor vehicles (LR range, 3.0-4.3; specificity range, 96%-97%) were associated with severe intracranial injury on CT. Among patients with apparent minor head trauma, the absence of any of the features of the Canadian CT Head Rule (≥65 years; ≥2 vomiting episodes, amnesia &gt;30 minutes, pedestrian struck, ejected from vehicle, fall &gt;1 m, suspected skull fracture, or GCS score &lt;15 at 2 hours) had an LR of 0.04 (95% CI, 0-0.65), lowering the probability of severe injury to 0.31% (95% CI, 0%-4.7%). The absence of all the New Orleans Criteria findings (&gt;60 years, intoxication, headache, vomiting, amnesia, seizure, or trauma above the clavicle) had an LR of 0.08 (95% CI, 0.01-0.84), lowering the probability of severe intracranial injury to 0.61% (95% CI, 0.08%-6.0%). Combinations of history and physical examination features in clinical decision rules can identify patients with minor head trauma at low risk of severe intracranial injuries. Certain findings, including signs of skull fracture, GCS score of 13, 2 or more vomiting episodes, decrease in GCS score, and pedestrians struck by motor vehicles, may help identify patients at increased risk of severe intracranial injuries." }, { "id": "pubmed23n0356_18459", "title": "Use of a complete neurological examination to screen for significant intracranial abnormalities in minor head injury.", "score": 0.013978748524203069, "content": "Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation." }, { "id": "pubmed23n1077_2023", "title": "Repeat CT after blunt head trauma and Glasgow Coma Scale score 13-15 without neurological deterioration is very low yield for intervention.", "score": 0.013354700854700854, "content": "Due to the increase in accessibility of computed tomography (CT), repeat head CT scans are routinely ordered for patients with minor head injuries. The aim of this study is to evaluate the necessity and outcomes of routine repeat head CT in patients with GCS score of 13-15 who presented to the emergency department (ED) of Antalya University Hospital in Turkey with blunt head trauma. We retrospectively reviewed the charts of patients with minor head trauma that received initial and repeat head CT results from July 1, 2013 to June 30, 2015. Clinical characteristics of patients were compared for two groups of patients: those with neurological deterioration, and those who had routine head CT not required by change in neurological status. Repeat head CT results were analyzed for radiological worsening and the necessity of a surgical or medical intervention such as craniotomy, ICP monitoring, VP shunt and mannitol or hypertonic saline administration. Of 3578 patients with blunt head trauma, 656 (18.3%) patients had repeat head CT; 449 of these (68.4%) had a GCS score of 13-15. We analyzed 441 patients for CT and clinical changes. Eight patients were excluded because of poor image quality and/or penetrating injury. Neurological deterioration was the reason for repeat head CT in 73 (16.5%) patients Rates of medical (mannitol treatment) or surgical (craniotomy) intervention in this group were 26% (95% Confidence Interval [95% CI], 15.7-36.3%) in contrast to 0.8% (95% CI 0.1-1.7%) in the group of patients with routinely ordered head CT but without clinical deterioration. The following factors were statistically associated with need for intervention: use of anticoagulant or antithrombotic medication, fracture in middle meningeal artery territory, even a single point decrease in GCS score, increased headache, recurrent vomiting, neurological deficit, and finally, changes in repeat head CT. In patients with minor head injuries, those without neurological deterioration have a very low risk of need for medical or surgical intervention. Routinely ordering repeat head CT scans in this group may not be routinely indicated." }, { "id": "wiki20220301en016_130038", "title": "Concussion", "score": 0.013296816702389459, "content": "If the Glasgow coma scale is less than 15 at two hours or less than 14 at any time, a CT is recommended. In addition, a CT scan is more likely to be performed if observation after discharge is not assured or intoxication is present, there is suspected increased risk for bleeding, age greater than 60, or less than 16. Most concussions, without complication, cannot be detected with MRI or CT scans. However, changes have been reported on MRI and SPECT imaging in those with concussion and normal CT scans, and post-concussion syndrome may be associated with abnormalities visible on SPECT and PET scans. Mild head injury may or may not produce abnormal EEG readings. A blood test known as the Brain Trauma Indicator was approved in the United States in 2018 and may be able to rule out the risk of intracranial bleeding and thus the need for a CT scan for adults." }, { "id": "pubmed23n0297_4013", "title": "Mild head injury: differences in prognosis among patients with a Glasgow Coma Scale score of 13 to 15 and analysis of factors associated with abnormal CT findings.", "score": 0.012720077531901148, "content": "We performed a retrospective study of 2484 consecutive patients with mild head injury (Glasgow Coma Scale score 13-15) who were seen during a period of 18 months. Of these, 2351 (94.6%) patients scored 15 points, 88 (3.5%) scored 14 points and 45 (1.3%) 13 points. A multivariate analysis showed that advanced age, a lower GCS (13-14) and the presence of skull fracture, and focal signs, significantly increased the incidence of abnormal computed tomography (CT) findings. By contrast, the gender, the mechanism of injury, the occurrence of initial loss of consciousness, posttraumatic amnesia and coagulation disorders did not significantly increase the incidence of abnormal CT findings. Patients with 13-14 GCS had a significantly higher incidence of initial loss of consciousness, of skull fracture, abnormal CT findings, need for hospital admission, delayed neurological deterioration and need for operation than patients with a GCS of 15. Thus, we suggest separating patients with a GCS of 13-14 into a different category and recommend performing CT in all those not improving within 4-6 h of injury. Such a policy makes skull radiography unnecessary in this subgroup. By contrast, skull radiographs may be useful for the triage of patients with a GCS of 15 that represent most of the mild head injury cases; radiographs should be obtained in patients presenting with initial loss of consciousness or posttraumatic amnesia (27.9% of the total cases) as these two findings were associated with a significantly higher incidence of fracture. Patients without these two findings (72.1% of the cases) showed a very low incidence of skull fracture (0.9% in this study) and may be discharged home with a warning sheet." }, { "id": "pubmed23n0351_11427", "title": "[The risk of an organic lesion in mild craniocerebral injuries with loss of consciousness].", "score": 0.012551836492890996, "content": "Despite its high frequency, there is not a consensus for the management of a patient with mild head trauma. In this prospective study we analyzed wether the transient loss of consciousness was associated with a higher risk of cranioencephalic injury in function of patient's age. Fifty-two patients with a Glasgow score of 15 at the Emergency Department but who reported a transient loss of consciousness were included. Patients were divided into two groups, patients aged &gt; or = 60 years (n = 21) and patients aged &lt; 60 years (n = 31). In all patients a head CT scan was performed. Nine abnormal CT scans were found in the group of patients aged &gt; or = 60 years (three head fractures, three brain contusion, two subarachnoid haemorrhages, and one subdural haematoma) and one abnormal CT scan in the group of patients aged &lt; 60 years (cranial fracture). This difference was statistically significant (p &lt; 0.001). In conclusion, an urgent head CT scan should be performed in patients aged over 60 years with mild head trauma and loss of consciousness. In younger patients this scan should be performed when the patient presents with headache and vomiting." }, { "id": "pubmed23n0567_2196", "title": "[Indications for brain scan in patients presenting benign cranial injury].", "score": 0.012537382102599495, "content": "Validate the clinical criteria, which, when absent, would make it safe to bypass CT scan examination in mild cranial injuries. and methods. Prospective study including 285 patients with mild cranial injury with a Glasgow score of 15, a normal clinical examination but transitory loss of consciousness or suspected transitory loss of consciousness. The following clinical parameters were systematically reviewed: history of stroke; post-injury headache; post-injury vomiting; alcohol, medication, or drug intoxication; clinical signs of cervico-cranio-facial injury; post-injury convulsions; or coagulation impairment. Systematic CT exploration looked for cranial, encephalic, and facial lesions and individualized the lesions requiring neurosurgical or maxillofacial treatment. Of the patients studied, 7% presented a cranioencephalic lesion and 7% a facial bone lesion. Neurosurgical intervention was necessary in 0.4% of the patients and maxillofacial surgery in 2.5%. Patients with a positive CT all had at least one clinical risk factor and patients with cranioencephalic lesions had at least two risk factors present. Had patients with no risk factors not been scanned, 15% of the patients would not have had the CT procedure. Selecting CT indications in cases of mild cranial injury with loss of consciousness using a simple and validated evaluation can save 15% of CT procedures without missing any cranial, encephalic, or facial lesions." }, { "id": "pubmed23n0308_14217", "title": "Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients.", "score": 0.012401310889319232, "content": "Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings." }, { "id": "pubmed23n0543_16235", "title": "Evaluation of mild head injury in a pediatric population.", "score": 0.012228609087247832, "content": "Approximately 5 million children present to emergency departments, seeking care for head injuries, each year, and 80% of these children are classified as cases of mild head injury. Due to the huge number of patients and low frequency of intracranial lesions in this group, obtaining a computed tomography scan for each and every patient is a significant economic problem. This study was conducted to identify the clinical parameters and the radiographic findings that may be associated with intracranial lesions in children with mild head injury. 421 patients, with a Glasgow Coma Scale score of 15 and without any focal neurological deficit, were studied. Intracranial lesion was noted in 37 cases (8.8%). Sensitivity of a plain radiogram was 43.2%, and specificity was 93%. An intracranial pathology was demonstrated in 28.9% of the patients with a linear skull fracture. The only clinical parameters associated with an increase in the frequency of detection of intracranial lesions were posttraumatic seizures and loss of consciousness. Age, sex, headache, vomiting and scalp lacerations were not associated with a higher frequency. Even when patients with a history of loss of consciousness or posttraumatic seizure were subtracted from the study group, intracranial lesions were noted in 4.1% of the cases, and in 1.8% neurosurgical intervention was required. Computed tomography is the gold standard in the evaluation of pediatric patients with mild head trauma, and every child who has experienced a head injury should undergo a cranial computed tomography evaluation, even if he or she appears in perfect health." }, { "id": "wiki20220301en627_18717", "title": "Canadian CT head rule", "score": 0.01208395906820801, "content": "Under the CCTHR, patients with minor head injuries should only receive CT scans if one or more of the following criteria are met: Glasgow Coma Scale score lower than 15 at 2 hours after injury Suspected open or depressed skull fracture Any sign of basal skull fracture Two or more episodes of vomiting Age 65 or older Amnesia before impact of 30 or more minutes Dangerous mechanism (this is defined by Stiell et al. (2005) as \"a pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from an elevation of 3 or more feet or 5 stairs.\") The first five criteria are considered \"high-risk\", whereas criteria 6 and 7 are considered \"medium-risk\". References External links Canadian CT head rule on Radiopaedia Medical scales Tomography" }, { "id": "Neurology_Adams_7021", "title": "Neurology_Adams", "score": 0.011858079493051416, "content": "With the current focus on the cost-effective use of ancillary studies, criteria that justify obtaining a cranial CT following minor forms of head trauma have been developed as discussed in the next paragraph. We have generally advised a CT in cases of head injury that was associated with loss of consciousness (more than 1 min), severe and persisting headache, nausea and vomiting, a confusional state, and any new, objective neurologic signs, but these are admittedly arbitrary criteria. The CT scan may be particularly important in elderly patients with minor head trauma, in whom the presence of an intracranial lesion (mainly subdural hematoma) may not be predicted by clinical signs and, of course, imaging may be advisable if the patient is taking anticoagulants or antiplatelet agents of any type beyond small doses of aspirin. In children, it may be advisable to perform the scans more liberally. This is underscored by the results of a study of 215 children with minor head trauma" }, { "id": "wiki20220301en016_130035", "title": "Concussion", "score": 0.011322966802418857, "content": "Diagnosis Head trauma recipients are initially assessed to exclude a more severe emergency such as an intracranial hemorrhage. This includes the \"ABCs\" (airway, breathing, circulation) and stabilization of the cervical spine which is assumed to be injured in any athlete who is found to be unconscious after head or neck injury. Indications that screening for more serious injury is needed include worsening of symptoms such as headaches, persistent vomiting, increasing disorientation or a deteriorating level of consciousness, seizures, and unequal pupil size. Those with such symptoms, or those who are at higher risk of a more serious brain injury, may undergo brain imaging to detect lesions and are frequently observed for 24–48 hours. A brain CT or brain MRI should be avoided unless there are progressive neurological symptoms, focal neurological findings or concern of skull fracture on exam." }, { "id": "pubmed23n1069_18798", "title": "Risk factors for positive brain CT scan in children with traumatic brain injury and GCS = 15: A retrospective study.", "score": 0.011186304502333055, "content": "It is controversial whether it is necessary to carry out head computed tomography (CT) examination for children who had a traumatic brain injury (TBI) but are conscious (Glasgow Coma Scale (GCS) = 15). The present study explored the risk/predictive factors of positive CT results in children with mild closed head injury and GCS = 15.This was a retrospective study of children (0-18 years of age) with TBI and GCS = 15 and treated at the First People's Hospital of Wenling between 06/2013 and 06/2018. The outcome was a positive head plain CT result. Univariable and multivariable logistic regression analyses were carried out to determine the factors independently associated with positive CT results.A total of 279 children were included. The majority of the injured were boys (180/279, 64.5%). The top three causes of injury were traffic accidents (100/279, 35.8%), falling from height (92/279, 33.0%), and tumble (72/279, 25.8%). The top three clinical symptoms were headache (201/279, 72.0%), scalp hematoma (133/279, 47.7%), and nausea with or without vomiting (105/279, 37.6%). The multivariable analysis showed that scalp hematoma (OR = 3.040, 95%CI: 1.791-5.159, P &lt; .0001), ear and nostril bleeding or periorbital soft tissue contusion (OR = 2.234, 95%CI: 1.087-4.590, P = .029), and nausea with or without vomiting (OR = 2.186, 95%CI: 1.255-3.810, P = .006) were independently associated with positive results of head CT.For children with TBI and GCS = 15, the factors independently associated with positive CT results are scalp hematoma, ear and nostril bleeding or periorbital soft tissue contusion, and nausea with or without vomiting." }, { "id": "InternalMed_Harrison_30897", "title": "InternalMed_Harrison", "score": 0.011042253521126762, "content": "Persistent severe headache and repeated vomiting in the context of normal alertness and no focal neurologic signs is usually benign, but CT should be obtained and a longer period of observation is appropriate. The decision to perform imaging tests also depends on clinical signs that indicate that the impact was severe (e.g., persistent confusion, periorbital or mastoid hematoma, repeated vomiting, palpable skull fracture), on the seriousness of other bodily injuries, and on the degree of surveillance that can be anticipated after discharge. Two studies have indicated that older age, two or more episodes of vomiting, >30 min of retrograde or persistent anterograde amnesia, seizure, and concurrent drug or alcohol intoxication are sensitive (but not specific) indicators of intracranial hemorrhage that justify CT scanning. It may be appropriate to be more liberal in obtaining CT scans in children because a small number, even without loss of consciousness, will have intracranial traumatic" }, { "id": "pubmed23n0530_15858", "title": "Which mild head injured patients should have follow-up after discharge from an accident and emergency ward? A study in a university hospital setting in Kelantan, Malaysia.", "score": 0.011019367372958534, "content": "Mild head injury (MHI) is a common presentation to many hospitals in both rural and urban settings in Southeast Asia, but it is not well studied. We studied 330 patients that presented to Hospital Universiti Sains Malaysia Emergency Department with possible MHI, with the intentions to identify prognostic factors that may improve the diagnosis of MHI in the emergency setting as well as to determine which patients would need follow-up. Patients' one-year outcomes were classified as discharged well (DW) for patients without post-traumatic signs and symptoms and discharged with long term follow-up (DFU) for patients with such signs and symptoms. Four patients died and 82 were DFU. An abnormal skull X ray was associated with mode of accident and type of transportation, older age, presence of vomiting, confusion, bleeding from ear, nose or throat, abnormal pupil size on the right side associated with orbital trauma, unequal pupillary reflexes, absence of loss of consciousness (LOC), a lower Glasgow Coma Scale (GCS) score, multiple clinical presentations, and DFU. An abnormal CT scan was associated with older age, multiple clinical presentation, skull X-ray findings, and DFU. A similar analysis on outcomes revealed that mode of accident, older age, vomiting, confusion, headache, bleeding from ear, nose and throat, neurological deficits, absence of LOC, pupil size, multiple presentation, abnormal skull X ray, CT scan of the brain, and a GCS of 13 was associated with DFU. In conclusion, all patients involved in motor vehicle accidents (MVAs), especially motorcycles, aged over 30 years of age, with multiple clinical presentations, including a lower GCS, and with abnormal radiological findings should have a longer follow-up due to persistent post-traumatic symptomatology." }, { "id": "pubmed23n1046_8209", "title": "Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department.", "score": 0.010805472448949952, "content": "Older age is a risk factor for intracranial injury after head trauma, and computed tomography (CT) is generally recommended. We aimed to develop a clinical prediction rule for risk stratification to avoid CT head imaging in older adult patients with minor head injury, named Computed Tomography of the Head for the patients at Advanced age (CTHEAD). This was a single-center observational study in Japan that used retrospective chart review data to service a prediction rule that was prospectively validated. Patients aged ≥ 65 years who presented to our emergency department with a chief complaint of head trauma and a Glasgow Coma Scale (GCS) of ≥13 were eligible. Patients were excluded if they had GCS score &lt; 13, anticoagulant therapy, focal neurologic symptoms, posttraumatic seizures, penetrating injury, evident depressed fracture, unknown mechanism, or CT not undertaken. The primary outcome was acute traumatic lesion on head CT. We screened 1,494 patients; 538 were included in the derivation cohort, and 580, in the validation cohort. Multivariable analysis of the derivation group found that high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, and anterograde amnesia were significantly associated with traumatic head findings on CT. A clinical prediction rule was developed from these four risk factors. The negative predictive value (NPV) of the absence of the four components was 95.1% (95% confidence interval [CI] = 92.9% to 96.7%), and the positive predictive value (PPV) of one or more risk factors was 20.6% (95% CI = 17.3% to 24.4%). The rule was validated prospectively with an NPV of zero risk factors of 94.5% (95% CI = 92.4% to 96.1%) and a PPV of one or more risk factors of 15.9% (95% CI = 13.0% to 19.3%). Fifty-three (9.1%) patients in the validation cohort experienced the primary outcome. The results suggest that older adult patients with minor head injury may forgo head CT if they do not have high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, or anterograde amnesia. External validation of this rule is needed." }, { "id": "wiki20220301en350_15351", "title": "Computed tomography of the head", "score": 0.01067906452521837, "content": "Even in emergency situations, when a head injury is minor as determined by a physician's evaluation and based on established guidelines, CT of the head should be avoided for adults and delayed pending clinical observation in the emergency department for children. Many people visit emergency departments for minor head injuries. CT scans of the head can confirm a diagnosis of skull fracture or brain bleeding, but even in the emergency department, such things are uncommon and not minor injuries, so CT of the head is usually not necessary. Clinical trials have shown the efficacy and safety of using CT of the head in emergency settings only when indicated, which would be at the indication of evidence-based guidelines following the physical examination and a review of the person's history." }, { "id": "pubmed23n0050_6580", "title": "[Head trauma in a general surgery department: observations, diagnostic and therapeutic indications].", "score": 0.010512736056214316, "content": "The authors reviewed the records of 927 patients admitted to Surgical Clinic University of L'Aquila from November 1986 to July 1990 with head trauma. The 5.6% (52 patients) had skull fractures. 23 (2.4%) patients sustained significant intracranial sequelae from their injuries, but only 4 (17.3%) of these also sustained fractures, 17 did not. Of the four fractures 1 were simple, 2 was depressed and 1 was basilar. The patients (17) without a skull fracture and positive CT were transferred to a neurosurgical department, where 12 underwent operation. The patients (4) with a skull fracture and positive CT and 2 patients with a depressed skull fracture and negative CT were transferred to a neurosurgical department where 5 (except 1 patient with simple fracture) underwent operation. The severity of coma was evaluated according to Glasgow Coma Scale (G.C.S.). The 2.4% of patients had the Glasgow Coma Scale = or less than 7. The CT or MNR are indicate in the presence of neurologic abnormalities. Overall mortality rate was about 0.53%. In the severe head trauma (G.C.S. = or less than 7) was of 17,3. the skull radiography is not indicated of routine and are performed for the evaluation of depressed fractures, of fracture of the cranial base and of cervical vertebrae: the MNR was found to be superior to CT and to be very effective in the detection of traumatic head lesions: the Glasgow Coma Scale is important for monitoring, stratification and prognostic evaluation of patients." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 26, 169 ] ], "word_ranges": [ [ 3, 27 ] ], "text": "This is syphilis (both by antecendent and serology) in the secondary stage, so treatment is with Benzathine Penicillin 2.4 MU in a single dose." } }

{ "1": "None.", "2": "Intravenous penicillin G, 24 MU every day for 14 days.", "3": "Benzathine penicillin 2.4 MU intramuscular, 3 doses in three consecutive weeks.", "4": "Ceftriaxone 2 grams intramuscular in a single dose.", "5": "Benzathine penicillin 2.4 MU intramuscularly in a single dose." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0823_24556", "title": "Lues maligna praecox: an important consideration in HIV-positive patients with ulceronodular skin lesions.", "score": 0.01869812145041503, "content": "Syphilis is commonly known as \"the great imitator\" owing to its varied clinical manifestations. Secondary syphilis has a variety of presentations, with the most common manifesting as a diffuse papulosquamous eruption on the palms and soles. Lues maligna praecox is a rare form of secondary syphilis, with severe constitutional symptoms, seen primarily in HIV-positive individuals. We report an atypical case of suspected lues maligna in a 45-year-old male. The patient was HIV-positive with a CD4 count of 441. He presented to our clinic with large painful gummatous ulcers in the groin and lower back. He also reported daily fevers, night sweats, and weight loss consistent with secondary syphilis. Prior to this episode the patient had a history of acute active syphilis (RPR 1:128) in 2012 treated at that time with a single dose of 2.4 million units intramuscular benzathine penicillin; he had no reported exposures since that time. The patient was treated with three weekly doses of benzathine penicillin, 2.4 million units, given intramuscularly. This case demonstrates the importance of recognizing the varied clinical presentation of secondary syphilis and keeping lues maligna in consideration for ulceronodular skin lesions in patients who are HIV-positive." }, { "id": "pubmed23n0896_16454", "title": "Single Dose Versus 3 Doses of Intramuscular Benzathine Penicillin for Early Syphilis in HIV: A Randomized Clinical Trial.", "score": 0.018205892088712344, "content": "Patients coinfected with syphilis and human immunodeficiency virus (HIV) may have a slower decrease in rapid plasma reagin (RPR) titers. Currently a single dose of 2.4 million units of intramuscular benzathine penicillin G (BPG) is recommended for the treatment of early syphilis. Some observational studies have suggested that this regimen may lead to high failure rates in coinfected patients. We conducted an open-label randomized clinical trial to compare the efficacy of single-dose and 3-dose regimens of BPG for the treatment of early syphilis in HIV-infected individuals. RPR titers were monitored every 3 months. Treatment success was defined as a decrease in RPR titers of ≥2 dilutions (4-fold) during a 12-month follow-up period. Sixty-four patients were included. In the intention-to-treat analysis, treatment success rates were 80% (28 of 35 subjects) and 93% (27 of 29 subjects) in the single-dose and 3-dose regimens, respectively (absolute difference, 13% [95% confidence interval {CI}, -5% to 30%; P = .17). In the per-protocol analysis, success rates were 93% (27 of 29) and 100% in the single-dose and 3-dose regimens, respectively (absolute difference, 7% [95% CI, -7% to 22%]; P = .49). CD4 T-cell count, RPR titer and syphilis stage did not affect treatment results. When compared with a single dose of BPG, a 3-dose regimen did not improve syphilis serological outcomes. Our results support the Centers for Disease Control and Prevention recommendation of a single dose of BPG in HIV-infected patients with early syphilis. NCT02611765." }, { "id": "pubmed23n0526_24202", "title": "Single-dose azithromycin versus penicillin G benzathine for the treatment of early syphilis.", "score": 0.018068384378544806, "content": "Pilot studies suggest that a single, 2-g oral dose of azithromycin may be an alternative to a 2.4-MU intramuscular dose of penicillin G benzathine in the prevention and treatment of syphilis. We evaluated the efficacy of treatment with azithromycin in a developing country. A total of 328 subjects, 25 with primary and 303 with high-titer (a titer of at least 1:8 on a rapid plasmin reagin [RPR] test) latent syphilis, were recruited through screening of high-risk populations in Mbeya, Tanzania, and randomly assigned to receive 2 g of azithromycin orally (163 subjects) or 2.4 million units of penicillin G benzathine intramuscularly (165 subjects). The primary outcome was treatment efficacy, with cure defined serologically (a decline in the RPR titer of at least two dilutions by nine months after treatment) and, in primary syphilis, by epithelialization of ulcers within one or two weeks. The average age of participants was 27.0 years, 235 (71.6 percent) were female, and 171 (52.1 percent) were seropositive for human immunodeficiency virus. Cure rates were 97.7 percent (95 percent confidence interval, 94.0 to 99.4) in the azithromycin group and 95.0 percent (95 percent confidence interval, 90.6 to 97.8) in the penicillin G benzathine group (95 percent confidence interval for the difference, -1.7 to 7.1 percent), achieving prespecified criteria for equivalence. Cure rates were also similar three and six months after treatment in the two groups and in all subgroups. Cure rates at three months were 59.4 percent (95 percent confidence interval, 51.8 to 67.1) in the azithromycin group and 59.5 percent (95 percent confidence interval, 51.8 to 67.3) in the penicillin G benzathine group and at six months were 85.5 percent (95 percent confidence interval, 79.4 to 90.6) and 81.5 percent (95 percent confidence interval, 74.8 to 87.4), respectively. Single-dose oral azithromycin is effective in treating syphilis and may be particularly useful in developing countries in which the use of penicillin G benzathine injections is problematic. However, recent reports of azithromycin-resistant Treponema pallidum in the United States indicate the importance of continued monitoring for resistance." }, { "id": "InternalMed_Harrison_13742", "title": "InternalMed_Harrison", "score": 0.016825733474726053, "content": "Stage of Syphilis Patients without Penicillin Allergy Patients with Confirmed Penicillin Allergyb Primary, secondary, or early latent Late latent (or latent of uncertain duration), cardiovascular, or benign tertiary Syphilis in pregnancy CSF normal or not examined: Penicillin G benzathine (single dose of 2.4 mU IM) CSF abnormal: Treat as neurosyphilis CSF normal or not examined: Penicillin G benzathine (2.4 mU IM weekly for 3 weeks) CSF abnormal: Treat as neurosyphilis Aqueous crystalline penicillin G (18–24 mU/d IV, given as 3–4 mU q4h or continuous infusion) for 10–14 days Aqueous procaine penicillin G (2.4 mU/d IM) plus oral probenecid (500 mg qid), both for 10–14 days According to stage CSF normal or not examined: Tetracycline HCl (500 mg PO qid) or doxycycline (100 mg PO bid) for 2 weeks CSF abnormal: Treat as neurosyphilis CSF normal and patient not infected with HIV: Tetracycline HCl (500 mg PO qid) or doxycycline (100 mg PO bid) for 4 weeks" }, { "id": "article-29822_31", "title": "Syphilis -- Treatment / Management", "score": 0.016741071428571428, "content": "Treatment depends on the disease stage. Primary, secondary, or early latent syphilis is treated with a single dose of intramuscular (IM) benzathine penicillin G 2.4 million units. Neurosyphilis is treated with IV penicillin G aqueous 18-24 million units daily for 14 days. An alternative regimen would be procaine penicillin G 2.4 million units IM once daily AND Probenecid 500 mg orally 4 times/day for 10–14 days. Tertiary and latent syphilis and HIV-infected patients should be treated with weekly benzathine penicillin G 2.4 million units IM for three weeks." }, { "id": "pubmed23n0401_19049", "title": "A randomized, comparative pilot study of azithromycin versus benzathine penicillin G for treatment of early syphilis.", "score": 0.016375404530744337, "content": "Penicillin is the only medication currently recommended for treatment of early syphilis in non-penicillin-allergic patients. Preliminary data suggest that azithromycin may be effective for syphilis therapy. This was a randomized, comparative pilot study of intramuscular injections of benzathine penicillin G and two oral azithromycin regimens for treatment of syphilis. We randomly assigned patients with early syphilis to treatment with either intramuscular injections of 2.4 million units of benzathine penicillin G or azithromycin administered orally, either as a single 2.0-g dose or as two 2.0-g doses given 1 week apart. Serological response to therapy was evaluated at 3, 6, 9, and 12 months following therapy. Participants whose rapid plasma reagin (RPR) test became nonreactive or whose RPR titer decreased &gt; or =2 dilutions were classified as responding to therapy. When serological tests did not show a response to therapy, the treatment was classified as a failure if RPR titers increased &gt; or =2 dilutions. Nonresponders were those whose serologic titers remained within +/-1 dilution of the initial RPR titer. Cumulative response rates were as follows: benzathine penicillin G, 86% (12 of 14); azithromycin, 2.0-g single dose, 94% (16 of 17); and azithromycin, two 2.0-g doses given 1 week apart, 83% (24 of 29). Therapy failed for one patient treated with benzathine penicillin and one patient treated with the two-dose azithromycin regimen, whereas in six patients the clinical manifestations of infection resolved but there was no serological response. Oral therapy with 2.0 g of azithromycin as a single dose or as two doses 1 week apart is a promising alternative to therapy with benzathine penicillin G for syphilis and should be studied further." }, { "id": "pubmed23n0892_23411", "title": "A Single Dose Oral Azithromycin versus Intramuscular Benzathine Penicillin for the Treatment of Yaws-A Randomized Non Inferiority Trial in Ghana.", "score": 0.01625226625226625, "content": "Yaws is a treponemal infection that was almost eradicated fifty years ago; however, the disease has re-emerged in a number of countries including Ghana. A single-dose of intramuscular benzathine penicillin has been the mainstay of treatment for yaws. However, intramuscular injections are painful and pose safety and logistical constraints in the poor areas where yaws occurs. A single center randomized control trial (RCT) carried out in Papua New Guinea in 2012 demonstrated the efficacy of a single-dose of oral azithromycin for the treatment of yaws. In this study, we also compared the efficacy of a single oral dose of azithromycin as an alternative to intramuscular benzathine penicillin for the treatment of the disease in another geographic setting. We conducted an open-label, randomized non-inferiority trial in three neighboring yaws-endemic districts in Southern Ghana. Children aged 1-15 years with yaws lesions were assigned to receive either 30mg/kg of oral azithromycin or 50,000 units/kg of intramuscular benzathine penicillin. The primary end point was clinical cure rate, defined as a complete or partial resolution of lesions 3 weeks after treatment. The secondary endpoint was serological cure, defined as at least a 4-fold decline in baseline RPR titre 6 months after treatment. Non- inferiority of azithromycin treatment was determined if the upper bound limit of a 2 sided 95% CI was less than 10%. The mean age of participants was 9.5 years (S.D.3.1, range: 1-15 years), 247(70%) were males. The clinical cure rates were 98.2% (95% CI: 96.2-100) in the azithromycin group and 96.9% (95% CI: 94.1-99.6) in the benzathine penicillin group. The serological cure rates at 6 months were 57.4% (95% CI: 49.9-64.9) in the azithromycin group and 49.1% (95% CI: 41.2-56.9) in the benzathine penicillin group, thus achieving the specified criteria for non-inferiority. A single oral dose of azithromycin, at a dosage of 30mg/kg, was non-inferior to a single dose of intramuscular benzathine penicillin for the treatment of early yaws among Ghanaian patients, and provides additional support for the WHO policy for use of oral azithromycin for the eradication of yaws in resource-poor settings. Pan African Clinical Trials Registry PACTR2013030005181 http://www.pactr.org/." }, { "id": "pubmed23n1083_9505", "title": "Comparisons of Serologic Responses of Early Syphilis to Treatment with a Single-Dose Benzathine Penicillin G Between HIV-Positive and HIV-Negative Patients.", "score": 0.016012909632571994, "content": "Poorer serologic responses of early syphilis to treatment have been inconsistently reported in HIV-positive patients compared with HIV-negative patients, but the interpretation of previous studies is limited by discrepant study designs. The present study aimed to evaluate the effect of HIV infection on the treatment response to a single dose of benzathine penicillin G (BPG) for early syphilis. From January 2015 to March 2020, adult patients with early syphilis who received a single dose of BPG were enrolled and rapid plasma reagin (RPR) titers were periodically determined. The primary outcome was serologic response, defined as at least a fourfold decline of RPR titer at 12 months of BPG treatment compared with that at baseline, which was examined in the intention-to-treat (ITT) and per-protocol analyses. Treatment failure included lack of at least a fourfold decline in RPR titers and at least a fourfold increase in RPR titers. We prospectively enrolled 184 HIV-positive and 68 HIV-negative participants with early syphilis, who were all men who have sex with men, with a higher proportion of previous syphilis (70.1%) and early latent syphilis (64.1%) among HIV-positive participants. In the ITT with last-observation-carried-forward analysis, HIV-positive participants had a significantly lower serologic response rate at 12 months of treatment than HIV-negative participants (73.4% vs. 91.2%). Of HIV-positive participants, 12.5% failed to achieve at least fourfold decline in RPR titers and 14.1% had at least a fourfold increase in RPR titers. The factors associated with 12-month serologic response were HIV infection (adjusted odds ratio [AOR] 0.33; 95% confidence interval [CI] 0.13-0.81) and RPR titer (per 1-log<sub2</sub increase, AOR 1.36; 95% CI 1.23-1.51). HIV-positive patients with early syphilis had poorer serologic responses to BPG treatment than HIV-negative patients during a 12-month follow-up period." }, { "id": "pubmed23n0903_10743", "title": "A Case of Early Neurosyphilis.", "score": 0.015814183345688165, "content": "Neurosyphilis is an infection of the central nervous system by Treponema pallidum, which can occur after the initial syphilis infection. Although commonly associated with late stage disease, patients with early neurosyphilis may present with acute syphilitic meningitis, meningovascular syphilis, or uveitis. A 28 year old man with a past medical history of HIV (CD4 364);, and recent diagnosis of uveitis presented to the Emergency Department with a positive RPR result. His visual acuity had been gradually declining over the past few months. He denied painless or painful ulcerating lesions on his penis, or scrotum, difficulty concentrating, dermatitis on the soles/palms, or difficulty with proprioception. Physical exam was notable for atrophic hyperpigmented polycyclic, annular plaques and patches along the hairline as well as several areas of confluent hyperpigmented polycyclic plaques and nodules on the patient's face, back, left arm, and right posterior leg. Fundoscopic exam revealed bilateral posterior uveitis and chorioretinitis. Evaluation of cerebrospinal fluid revealed a lymphocytic pleocytosis with a positive VDRL and FTA-ABS. Aqueous crystalline penicillin G was initiated for treatment of early neurosyphilis. Within six hours of beginning the infusion, the patient had a documented temperature of 101.8°F, heart rate of 128 beats per minute, blood pressure 142/84, with generalized malaise and headache. Fever and tachycardia resolved over the next 12 hours, with weakness and headache resolving within 1-2 days. His symptom complex was consistent with the Jarisch-Herxheimer reaction. Histopathology of skin biopsy of the back showed perivascular inflammation and rare spirochetes, consistent with secondary syphilis. The patient completed 14 days of aqueous crystalline penicillin G and was discharged after receiving the first of three benzathine penicillin injections. The initial manifestations of syphilis in this patient were posterior uveitis and pruritic skin plaques. His diagnosis should be appropriately classified as secondary syphilis with concomitant symptomatic early neurosyphilis, requiring 14 days of aqueous crystalline penicillin G. This type of presentation is not specific to immunocompromised populations and must be considered even in the general population. Making the diagnosis of early neurosyphilis, regardless of stage, is critical, as it necessitates a longer duration of treatment. Furthermore, clinicians should be reminded of the profound immunologic reaction, Jarisch-Herxheimer, which may occur when treating any treponemal disease." }, { "id": "pubmed23n0808_12460", "title": "One dose versus three weekly doses of benzathine penicillin G for patients co-infected with HIV and early syphilis: a multicenter, prospective observational study.", "score": 0.015483022477283597, "content": "One dose of benzathine penicillin G (BPG) has been recommended for HIV-infected patients with early syphilis (primary, secondary, and early latent syphilis) in the sexually transmitted diseases treatment guidelines, but clinical data to support such a recommendation are limited. We prospectively observed the serological response to 1 or 3 weekly doses of BPG in HIV-infected adults who sought treatment of early syphilis at 8 hospitals around Taiwan. Rapid plasma reagin (RPR) titers were followed every 3-6 months after treatment. The serological response was defined as a 4-fold or greater decline in RPR titers at 12 months of treatment. The missing values were treated by following the last-observed-carried-forward principle. We hypothesized that 1 dose was non-inferior to 3 weekly doses of BPG with the non-inferiority margin for the difference of serological response set to 10%. Between 2007 and 2012, 573 patients completed at least 12 months of follow-up: 295 (51.5%) receiving 1 dose of BPG (1-dose group) and 278 (48.5%) 3 doses (3-dose group). Overall, 198 patients (67.1%; 95% confidence interval [CI], 61.4-72.5%) in the 1-dose group achieved serological response at 12 months, as did 208 patients (74.8%; 95% CI, 69.3-79.8%) in the 3-dose group (one-sided 95% CI of the difference, 15.1%). In the multivariate analysis, secondary syphilis (adjusted odds ratio [AOR], 1.90; 95% CI 1.17-3.09), RPR titer ≥32 (AOR, 1.93; 95% CI, 1.38-2.69), and 3 doses of BPG (AOR, 1.68; 95% CI, 1.20-2.36) were independently associated with a serological response. The time to the first episode of treatment failure was 1184 (standard deviation [SD], 70.5) and 1436 (SD, 80.0) days for 1- and 3-dose group, respectively. Single-dose BPG resulted in a higher serological failure rate and shorter time to treatment failure than 3 weekly doses of BPG in the treatment of early syphilis in HIV-infected patients." }, { "id": "pubmed23n0945_15042", "title": "A 30-Year-Old Man with HIV, Fever, and a Rash.", "score": 0.014908130707448564, "content": "Patients who present with papular rashes have a wide differential diagnosis particularly in the setting of immune compromise. A 30-year-old male diagnosed with HIV since 2009, never on antiretroviral therapy, with a nadir CD4 count of 333 cells/mm<sup3</sup and a current viral load of 44,300 copies/mL, presented with a diffuse monomorphic papular eruption that began on his trunk and extremities and subsequently spread to the penis and scrotum, sparing the distal acral sites. A thorough infectious workup revealed a positive rapid plasma reagin (RPR) and varicella IgM and IgG antibodies. Interestingly, the patient had been diagnosed and treated for syphilis in the past with a recent downtrending RPR drawn prior to hospitalization. Repeat RPR was elevated and a preliminary histopathology report demonstrated folliculocentric inflammation with lymphocytes, plasma cells, and polymorphonuclear leukocyte predominance supported the diagnosis of syphilis. After receiving intramuscular penicillin G benzathine, he developed intermittent fevers and new papules. Intravenous (IV) acyclovir was initiated for presumed disseminated varicella given his positive varicella-zoster virus IgM and IgG. However, final pathology results revealed a large spirochete burden. The fevers and rash progression were attributed to the development of a Jarisch-Herxheimer reaction. IV acyclovir was discontinued and he completed a course of intramuscular penicillin G benzathine. He was also given a course of doxycycline for rectal chlamydia which was diagnosed during hospitalization." }, { "id": "pubmed23n0203_13809", "title": "[Single dose treatment of primary syphilis with Benzathine penicillin (author's transl)].", "score": 0.014906389906389907, "content": "Out of 40 male patients with primary syphilis diagnosed microscopically by dark field preparations and by serological tests 20 patients were treated with a single intramuscular injection of 4.8 millions I. U. Benzathine penicillin and 20 patients with a daily intramuscular injection of 1 million I. U. Clemizol penicillin over a period of 21 days. In all patients success of treatment was verified by complete remission of the clinical symptoms and by serological tests over a period of 2 years. Single dose treatment with Benzathine penicillin represents a simple and reliable method of treatment of primary syphilis." }, { "id": "pubmed23n0260_18039", "title": "Rheumatic fever prophylaxis in South Africa--is bicillin 1,2 million units every 4 weeks appropriate?", "score": 0.014550656012627011, "content": "Rheumatic fever is a major health problem in South Africa. Although intramuscular benzathine penicillin (bicillin) 1.2 million units (MU) every 4 weeks is widely used for secondary prophylaxis, studies in other countries have shown a recurrence rate of 3-8% over 5-6 years in patients on this regimen. It has been recommended that serum penicillin concentrations should be maintained above 0.02 mg/ml to prevent such recurrences. The World Health Organisation (WHO) and the American Heart Association have recommended since 1988 that patients in high-risk areas for the development of rheumatic fever should receive benzathine penicillin 1.2 MU every 3 weeks rather than every 4. The aims of this study were, firstly, to determine the prevalence of serum penicillin concentrations below 0.02 micrograms/ml in rheumatic fever patients on benzathine penicillin 1.2 MU 4-weekly and, secondly, to study the effect of increasing the dose of 1.8 MU 4-weekly in patients with subtherapeutic concentrations. Forty-five of 51 rheumatic fever patients (88%) in this study on benzathine penicillin 1.2 MU 4-weekly had low serum penicillin concentrations (&lt; 0.02 micrograms/ml) at the end of the 4th week after the injection. Penicillin was detected in the urine of 30 of the 45 patients (67%) with low concentrations, suggesting that such patients have tissue-bound penicillin which might be important in preventing rheumatic fever. The 15 patients (33%) with subtherapeutic serum penicillin concentrations and no detectable penicillin in the urine could be at very high risk for recurrent attacks of rheumatic fever. Fourteen of 29 patients (48%) given the higher dose of benzathine penicillin (1.8 MU 4-weekly) had subtherapeutic serum penicillin concentrations at the end of the 4th week after the injection, but in all 29 penicillin was detected in the urine. Review of our present policy of secondary prophylaxis for rheumatic fever is necessary. Concentrated preparations of benzathine penicillin (600,000 U/ml) are not available in South Africa; administration of a higher dose (1.8 MU) 4-weekly would therefore require a double injection, which could affect compliance adversely. We recommend that rheumatic fever patients in our area should receive benzathine penicillin 1.2 MU 3-weekly as recommended by the WHO until strategies for secondary prophylaxis have been evaluated further." }, { "id": "InternalMed_Harrison_11068", "title": "InternalMed_Harrison", "score": 0.014496532304322886, "content": "Syphilitic meningitis is treated with aqueous penicillin G in a dose of 3–4 million units intravenously every 4 h for 10–14 days. An alternative regimen is 2.4 million units of procaine penicillin G intramuscularly daily with 500 mg of oral probenecid four times daily for 10–14 days. Either regimen is followed with 2.4 million units of benzathine penicillin G intramuscularly once a week for 3 weeks. The standard criterion for treatment success is reexamination of the CSF. The CSF should be reexamined at 6-month intervals for 2 years. The cell count is expected to normalize within 12 months, and the VDRL titer to decrease by two dilutions or revert to nonreactive within 2 years of completion of therapy. Failure of the CSF pleocytosis to resolve or an increase in the CSF VDRL titer by two or more dilutions requires retreatment." }, { "id": "pubmed23n0811_17459", "title": "A single dose of benzathine penicillin G is as effective as multiple doses of benzathine penicillin G for the treatment of HIV-infected persons with early syphilis.", "score": 0.014475998994722291, "content": "Treatment guidelines recommend the use of a single dose of benzathine penicillin G (BPG) for treating early syphilis in human immunodeficiency virus (HIV)-infected persons. However, data supporting this recommendation are limited. We examined the efficacy of single-dose BPG in the US Military HIV Natural History Study. Subjects were included if they met serologic criteria for syphilis (ie, a positive nontreponemal test [NTr] confirmed by treponemal testing). Response to treatment was assessed at 13 months and was defined by a ≥4-fold decline in NTr titer. Multivariate Cox proportional hazard regression models were utilized to examine factors associated with treatment response. Three hundred fifty subjects (99% male) contributed 478 cases. Three hundred ninety-three cases were treated exclusively with BPG (141 with 1 dose of BPG). Treatment response was the same among those receiving 1 or &gt;1 dose of BPG (92%). In a multivariate analysis, older age (hazard ratio [HR], 0.82 per 10-year increase; 95% confidence interval [CI], .73-.93) was associated with delayed response to treatment. Higher pretreatment titers (reference NTr titer &lt;1:64; HR, 1.94 [95% CI, 1.58-2.39]) and CD4 counts (HR, 1.07 for every 100-cell increase [95% CI, 1.01-1.12]) were associated with a faster response to treatment. Response was not affected by the number of BPG doses received (reference, 1 dose of BPG; HR, 1.11 [95% CI, .89-1.4]). In this cohort, additional BPG doses did not affect treatment response. Our data support the current recommendations for the use of a single dose of BPG to treat HIV-infected persons with early syphilis." }, { "id": "pubmed23n1137_7081", "title": "Analysis of serological treatment response to doxycycline versus benzathine penicillin in syphilis infections, a retrospective single-center study.", "score": 0.014393052302888367, "content": "Doxycilicine is the second-line treatment of choice for infectious syphilis when treatment with penicillin G is not feasible. To date, difficulties in the penicillin supply chain make it necessary to evaluate and resort to antibiotic therapies which are currently considered a second-line choice. Moreover, systematic studies comparing the two treatments in affected patients are still few, and many do not consider late and indeterminate latent infections. The objective of this study was to assess the differences in the serological response of the treatment of syphilis infections with benzathine penicillin compared with doxycycline. We built an in-house database with all patients diagnosed with syphilis infection from January 2010 to January 2020 in the STD Centre of the S.Orsola-Malpighi Polyclinic of the University of Bologna, located in the North-east of Italy. We recorded all the principal independent (demographic, social status, reinfection rare, HIV infections, comorbidities, sexual behaviors, and initial TPHA values) and dependent variables (RPR values). We then extrapolated all patients treated with doxycycline (100 mg of doxycycline twice daily for 14 days for infections diagnosed within the first year and a 28 days course for infections older than 1 year or undetermined) and matched in 1:1 ratio numbers with a homogeneous group of patients treated with penicillin G (2.4 million units in a single dose intramuscularly for infections diagnosed within the first year and a cycle consisting in of 2.4 million units administered in a single dose per week for 3 weeks for infections older than 1 year or undetermined) We then analyzed the serological trends and outcomes in the primary, secondary and early latent groups versus late latent and undetermined infections. We retrieved 41 patients for each group with homogeneous initial characteristics. At the end of the 24-month observation period, a slight difference in a valid RPR reduction rate emerged, with a greater success rate emerged in patients receiving penicillin than those with doxycycline (26 vs. 22, p 0.615). Indeed, patients with latent or indeterminate syphilis treated with doxycycline appear to have a higher rate of serofast than those treated with penicillin. Linear regression analysis showed no strong correlation between the analyzed independent variables and the observed outcomes. Doxycycline had a slightly lower, though not statistically different, success rate when compared with penicillin in treating primary syphilis, but appeared to have a reduced success rate in attaining resolution in late and undetermined syphilis infection." }, { "id": "pubmed23n0723_14371", "title": "Treatment of late syphilis with 2.4 million units benzathine penicillin G (BPG): tolerance of single versus divided doses.", "score": 0.014308498519024836, "content": "Although there is no data in the literature, some textbooks recommend fractioning the injection of benzathine penicillin G (BPG) for alleviating the pain. In a monocentric study done in 50 consecutive patients with late syphilis. Patients were assigned to receive 1 dose of 2.4 million units BPG intramuscularly the first week and 2 doses of 1.2 million units BPG in each buttock the second week. In the third week, patients were asked to choose between the 2 options. It was demonstrated that the 2 techniques were equally well tolerated and equally preferred by patients." }, { "id": "article-18217_10", "title": "Benzathine Penicillin -- Administration -- Adult", "score": 0.01404120970422067, "content": "Pharyngitis/tonsillitis, group A streptococci (1.2 million units IM x 1) Upper respiratory infection, group A streptococci that are mild to moderate and are susceptible to low, prolonged concentrations of benzathine penicillin (1.2 million units intramuscularly [IM] x 1) Secondary prevention of glomerulonephritis (prophylaxis for patients with a history of acute glomerulonephritis) (1.2 million units IM every four weeks or 600,000 units IM twice monthly) Secondary prevention (prophylaxis) of rheumatic fever (1.2 million units IM every 3 to 4 weeks or 600,000 units IM twice monthly) Syphilis: Primary, secondary, or latent less than one year (2.4 million units IM x 1, may repeat dose x 1 after one week in pregnant patients); latent greater than one year (2.4 million units IM weekly for three weeks) Yaws, bejel, and pinta (1.2 million units IM x 1)" }, { "id": "pubmed23n0120_13203", "title": "Ceftriaxone for treatment of primary syphilis in men: a preliminary study.", "score": 0.014029923963698798, "content": "Eighteen male patients with primary syphilis were randomly assigned to one of the following treatment schedules: ceftriaxone (3 g in a single intramuscular [im] injection), ceftriaxone (2 g im daily for two days), ceftriaxone (2 g im daily for five days), and benzathine penicillin (2.4 X 10(6) units in a single im injection). The single 3-g dose of ceftriaxone cured three men, one had a sustained response, and one failed to be cured. Of the patients given 2 g of ceftriaxone im daily for two days, three were cured and two had a sustained response. All three men treated with 2 g of ceftriaxone daily for five days had a sustained response. In the group given penicillin, three men were cured, one had a sustained response, and one was lost to follow-up." }, { "id": "wiki20220301en001_138403", "title": "Syphilis", "score": 0.013999350754747605, "content": "Late infections For neurosyphilis, due to the poor penetration of benzathine penicillin into the central nervous system, those affected are given large doses of intravenous penicillin G for a minimum of 10 days. If a person is allergic to penicillin, ceftriaxone may be used or penicillin desensitization attempted. Other late presentations may be treated with once-weekly intramuscular benzathine penicillin for three weeks. Treatment at this stage solely limits further progression of the disease and has a limited effect on damage which has already occurred. Serologic cure can be measured when the non-treponemal titers decline by a factor of 4 or more in 6–12 months in early syphilis or 12–24 months in late syphilis. Jarisch–Herxheimer reaction" }, { "id": "Pharmacology_Katzung_4963", "title": "Pharmacology_Katzung", "score": 0.01352329262777024, "content": "Benzathine penicillin and procaine penicillin G for intramuscular injection yield low but prolonged drug levels. A single intramuscular injection of benzathine penicillin, 1.2 million units, is effective treatment for β-hemolytic streptococcal pharyngitis. Given intramuscularly once every 3–4 weeks, it prevents reinfection. Benzathine penicillin G, 2.4 million units intramuscularly once a week for 1–3 weeks, is effective in the treatment of syphilis. Procaine penicillin G was once a commonly used treatment for pneumococcal pneumonia and gonorrhea; however, it is rarely used now because many gonococcal strains are penicillin-resistant, and many pneumococci require higher doses of penicillin G or the use of more potent β-lactams. B. Penicillins Resistant to Staphylococcal Beta-Lactamase (Methicillin, Nafcillin, and Isoxazolyl Penicillins)" }, { "id": "InternalMed_Harrison_13780", "title": "InternalMed_Harrison", "score": 0.013245471704361071, "content": "The WHO-recommended therapy for patients and their contacts is benzathine penicillin G (1.2 million units IM for adults; 600,000 units for children <10 years old). This dose is half of that recommended for early venereal syphilis, and no controlled efficacy studies have been conducted. Definitive evidence of resistance to penicillin is lacking, although relapsing lesions have been reported after penicillin treatment in Papua New Guinea. A recent study in that nation demonstrated equivalence between IM benzathine penicillin G and a single oral dose of azithromycin (30 mg/kg, up to a maximum of 2 g). This 207e-3 finding provided the WHO’s revitalized yaws eradication program with a much easier regimen for use in mass treatment. Although macrolide resistance mutations are common in circulating strains of" }, { "id": "InternalMed_Harrison_13741", "title": "InternalMed_Harrison", "score": 0.01322841829170943, "content": "Early Syphilis Patients and Their Contacts Penicillin G benzathine is the most widely used agent for the treatment of early syphilis; a single dose of 2.4 million units is recommended. Preventive treatment is also recommended for individuals who have been exposed to infectious syphilis within the previous 3 months. The regimens recommended for prevention are the same as those recommended for early syphilis. Penicillin G benzathine cures >95% of cases of early syphilis, although clinical relapse can follow treatment, particularly in patients with concurrent HIV infection. Because the risk of neurologic relapse may be higher in HIV-infected patients, CSF examination is recommended in HIV-seropositive individuals with syphilis of any stage, particularly those with a serum RPR titer of ≥1:32 or a Stage of Syphilis Patients without Penicillin Allergy Patients with Confirmed Penicillin Allergyb Primary, secondary, or early latent" }, { "id": "pubmed23n0805_14300", "title": "Primary syphilis of the oropharynx: an unusual location of a chancre.", "score": 0.013166953528399312, "content": "A 33-year-old man presented with a two-week history of an asymptomatic ulcer of the oropharynx and submandibular lymph nodes swelling. Laboratory examinations were normal, but serological tests revealed positivity for rapid plasma reagin, Treponema pallidum haemagglutination assay and anti-T. pallidum IgM antibodies. Since the patient denied any homosexual relationship, a biopsy of the lesion was performed, which confirmed primary syphilis. The patient received an intramuscular injection of Benzathine Penicillin G (2.4 MU) with complete resolution of the lesion. Extragenital chancres occur in at least 5% of patients with primary syphilis, and the oral mucosa is the most frequent location as a consequence of orogenital/oroanal contact with an infectious lesion. Because of their transient nature, these oral ulcerations are often underestimated by the patient or by any unsuspecting clinician. Health professionals should consider the recent sexual history of their patients and should be prepared to recognise oral and systemic manifestations of sexually transmitted infections. " }, { "id": "pubmed23n1157_6395", "title": "The effectiveness of erysipelas prophylaxis depends on the cumulative dose of benzathine penicillin G.", "score": 0.013165846499179831, "content": "Erysipelas is an acute infection due to S. pyogenes and is characterized by a high risk of relapses. The number of patients suffering from one or more recurrences varied depending on the study and accounted for between 16% and 47% of the total number of those affected. Antibiotic prophylaxis with the use of penicillin can reduce the risk of recurrence by 47%. A number of 873 patients with erysipelas treated at the Hospital for Infectious Diseases in Warsaw from 2010 to 2018 was enrolled in the study. Benzathine-penicillin G was given intramuscularly at a dose of 1.2 MU or 2.4 MU or 3.6 MU. The earliest moment that prophylactic treatment was administered was the first episode of erysipelas recurrence. The decision to administer the antibiotic and the dose to use was discretionally made by the examining physician. Altogether 104 (11.9%) persons experienced at least one episode of erysipelas recurrence during the study period. A total of 2976 doses of benzathine- penicillin G (BP) were administered. The most common dose was that of 2.4 MU (2380, 80%). The dose of 1.2 MU was given 567 times (19%). The highest dose, <ii.e.</i 3.6 MU, was administered to only 5 patients (8 applications, 0.2%). No effect was shown by either the number of benzathine- penicillin G administered doses (p=0.07) or the median dose (p=0.65), whereas patients without relapse received a statistically higher cumulative dose of the antibiotic (p=0.047). Age was a risk factor of recurrence only in the group of diabetic patients (p=0.03). Benzathine penicillin G given in an appropriate cumulative dose is effective in preventing erysipelas recurrence." }, { "id": "article-131802_47", "title": "Bacterial Infections of the Oral Mucosa -- Treatment / Management", "score": 0.01304546841623436, "content": "The chancre and oral lesions in primary syphilis are self-limiting and heal without scar in three to six weeks. A single dose of long-acting benzathine penicillin G (2.4 million units) intramuscular is the drug of choice if primary lesions persist and for secondary syphilis. Tertiary syphilis is also treated with intramuscular benzathine penicillin G once weekly for three to four weeks. The duration of treatment depends on the stage of the disease and its manifestations. Patients who are allergic to penicillin are alternatively treated with doxycycline, tetracycline, or ceftriaxone. Patients diagnosed with syphilis, even if receiving treatment, should abstain from any sexual activity to prevent the spread of the disease. In addition, the sexual partners of a syphilis patient should be notified, tested, and treated accordingly. Post-treatment follow-up is required once every three months for a year using nontreponemal serological tests to ensure the effectiveness of treatment. [5] [19] [24]" }, { "id": "Gynecology_Novak_2922", "title": "Gynecology_Novak", "score": 0.012995429429019715, "content": "ND, no data. a May be self-applied by patients at home. bExpensive; reserve for patients who have not responded to other regimens. Latent syphilis is defined as those periods after infection with T. pallidum when patients are seroreactive but show no other evidence of disease. Patients with latent syphilis of longer than 1 year’s duration or of unknown duration should be treated with benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each, at 1-week intervals. All patients with latent syphilis should be evaluated clinically for evidence of tertiary disease (e.g., aortitis, neurosyphilis, gumma, and iritis). Quantitative nontreponemal serologic tests should be repeated at 6 months and again at 12 months. An initially high titer (1:32) should decline at least fourfold (two dilutions) within 12 to 24 months." }, { "id": "pubmed23n0811_15802", "title": "Treatment of syphilis: a systematic review.", "score": 0.012651162790697675, "content": "The incidence of syphilis in the United States is increasing; it is estimated that more than 55,000 new infections will occur in 2014. Treatment regimens are controversial, especially in specific populations, and assessing treatment response based on serology remains a challenge. To review evidence regarding penicillin and nonpenicillin regimens, implications of the \"serofast state,\" and treatment of specific populations including those with neurosyphilis or human immunodeficiency virus (HIV) infection and pregnant women. We searched MEDLINE for English-language human treatment studies dating from January 1965 until July 2014. The American Heart Association classification system was used to rate quality of evidence. We included 102 articles in our review, consisting of randomized trials, meta-analyses, and cohort studies. Case reports and small series were excluded unless they were the only studies providing evidence for a specific treatment strategy. We included 11 randomized trials. Evidence regarding penicillin and nonpenicillin regimens was reviewed from studies involving 11,102 patients. Data on the treatment of early syphilis support the use of a single intramuscular injection of 2.4 million U of benzathine penicillin G, with studies reporting 90% to 100% treatment success rates. The value of multiple-dose treatment of early syphilis is uncertain, especially in HIV-infected individuals. Less evidence is available regarding therapy for late and late latent syphilis. Following treatment, nontreponemal serologic titers should decline in a stable pattern, but a significant proportion of patients may remain seropositive (the \"serofast state\"). Serologic response to treatment should be evident by 6 months in early syphilis but is generally slower (12-24 months) for latent syphilis. Evidence defining treatment for HIV-infected persons and for pregnant women is limited, but available data support penicillin as first-line therapy. The mainstay of syphilis treatment is parenteral penicillin G despite the relatively modest clinical trial data that support its use." }, { "id": "pubmed23n0414_11226", "title": "Nodular secondary syphilis.", "score": 0.012544802867383513, "content": "Secondary syphilis can have protean clinical manifestations and may present with unusual lesions, which may go unrecognized. We report a case of secondary syphilis with nodular lesions. A 22 year old male presented with nodular and annular skin lesions over the face, back and limbs and condylomata lata lesion at the penoscrotal junction associated with generalized lymphadenopathy, fever and malaise. Prior to onset of these lesions the patient also had history of a painless genital sore, which healed within two weeks. The serology revealed a reactive VDRL(1:64) and positive TPHA. The HIV serology was non-reactive. The patient responded to a single dose of benzathine penicillin, 2.4 million units, given intramuscularly. This case highlights that secondary syphilis may present with nodular lesions and should be suspected in the appropriate clinical setting." }, { "id": "article-102378_32", "title": "TORCH Complex -- Treatment / Management", "score": 0.01244101244101244, "content": "Syphilis must be diagnosed and treated immediately. Expectant mothers should be tested during pregnancy and, if positive, treated. [25] Treatment of the neonate will depend on whether the mother was treated appropriately during pregnancy. Normal neonates born to mothers adequately treated during pregnancy and greater than four weeks before delivery or have a non-reactive RPR but were born to mothers not treated properly should receive a single intramuscular injection of benzathine penicillin G (50,000 U/kg), although no evaluation is required or recommended. Infants with serologic tests that confirm congenital syphilis should receive aqueous penicillin g (200,000 to 300,000 units/kg/day IV, administered as 50,000 units/kg every 4 to 6 hours for ten days). If the child has a negative evaluation for clinical and laboratory evidence of syphilis, treatment with up to 3 weekly doses of benzathine penicillin G (50,000 U/kg IM) can be considered. [21]" }, { "id": "pubmed23n0031_2311", "title": "Treatment of secondary syphilis: an evaluation of 204 patients.", "score": 0.011976474781678844, "content": "Our recommended treatment schedule for secondary syphilis is intramuscular benzathine penicillin G, 2.4 million units weekly for two consecutive weeks. If the patient is allergic to penicillin, we recommend that 2 gm of oral tetracycline be given each day for 12 days. Two hundred and four patients with secondary syphilis were treated with these schedules; 165 were given benzathine penicillin G and 39 received tetracycline. All of the patients were cured clinically and all achieved seronegativity within 24 months. There was a direct correlation between the duration of the rash and the secondary lesions that the patients exhibited. Patients who presented early in the course of illness tended to have macular and maculopapular lesions, whereas those who appeared later were more likely to have papular of pustular lesions. The serologic response to treatment was correlated with the duration of the rash and the appearance of the secondary lesions. Patients whose rash was of short duration and those with macular and maculopapular lesions became seronegative sooner than those patients whose rash was of longer duration and who had papular or pustular lesions." }, { "id": "article-26123_27", "title": "Syphilis Ocular Manifestations -- Treatment / Management", "score": 0.011972753471312549, "content": "Primary and secondary syphilis is treated with a single dose of intramuscular (IM) penicillin G benzathine 2.4 million units, or procaine penicillin, 2.4 million units IM daily, and probenecid, 1 g orally 4 times a day for 14 days. In patients who are allergic to penicillin, doxycycline 100 mg orally twice daily for 14 days or ceftriaxone 1 to 2 gm IM or intravenously (IV) daily for 10 to 14 days or tetracycline 100 mg orally 4 times daily for 14 days, can be used. Azithromycin has also been used. [29] [30] Latent and tertiary syphilis, including neurosyphilis, is treated with aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hourly for 10 to 14 days, or benzathine penicillin G, 2.4 million units IM weekly for 3 weeks. Ceftriaxone and azithromycin also have been used in patients allergic to penicillin. [31]" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 462, 1948 ] ], "word_ranges": [ [ 74, 300 ] ], "text": "All four vaccines in option 1 are administrable. In a little more detail: Vaccine against tetanus and diphtheria: all persons should be vaccinated against these two diseases. Hepatitis B vaccine: hepatitis B and HIV viruses share the same routes of transmission, so it is common for HIV-infected patients to also be infected with hepatitis B virus. It is therefore important to know whether the HIV-infected person has markers of hepatitis B infection and to proceed with vaccination if he/she does not have them. Vaccination against hepatitis A: Hepatitis A in a person with hepatitis B, hepatitis C or other liver disease can be very serious. Since these infections are more frequent in HIV-infected patients, vaccination against hepatitis A is recommended. Vaccination against influenza: influenza in a patient with a lack of immune response is more serious and presents a greater risk of complications, so annual vaccination against this disease is indicated. If the patient's immune status is very deteriorated, the response to vaccination is diminished. In this case, it is essential to vaccinate all the people living with the HIV-infected person to prevent them from transmitting the disease. Pneumococcal vaccine: pneumococcal infections (especially pneumonia) are up to 10 times more frequent in HIV-infected persons than in HIV-uninfected adults, so vaccination is recommended, although in patients with counts below 200/mm3 the protective response is usually not sufficient." }, "2": { "exist": true, "char_ranges": [ [ 221, 461 ] ], "word_ranges": [ [ 32, 74 ] ], "text": "Considering that the individual has received some vaccines, has a CD4 count >100 (if lower there would be a contraindication) and works in a center that helps AIDS patients (he is equated to \"health personnel\") answers 2, 4 and 5 are wrong." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 221, 461 ] ], "word_ranges": [ [ 32, 74 ] ], "text": "Considering that the individual has received some vaccines, has a CD4 count >100 (if lower there would be a contraindication) and works in a center that helps AIDS patients (he is equated to \"health personnel\") answers 2, 4 and 5 are wrong." }, "5": { "exist": true, "char_ranges": [ [ 221, 461 ] ], "word_ranges": [ [ 32, 74 ] ], "text": "Considering that the individual has received some vaccines, has a CD4 count >100 (if lower there would be a contraindication) and works in a center that helps AIDS patients (he is equated to \"health personnel\") answers 2, 4 and 5 are wrong." } }

{ "1": "Seasonal influenza, pneumococcal, tetravalent meningitis and hepatitis A.", "2": "Seasonal influenza, Td, pneumococcal and tetravalent meningitis.", "3": "Tetravalent meningitis, pneumococcal and seasonal flu.", "4": "Td, tetravalent meningitis, pneumococcal.", "5": "Triple viral, seasonal flu, pneumococcal." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0798_2697", "title": "Vaccination coverage against hepatitis A and B viruses, Streptococcus pneumoniae, seasonal flu, and A(H1N1)2009 pandemic influenza in HIV-infected patients.", "score": 0.01904761904761905, "content": "Several vaccines are recommended in HIV-infected patients due to an increased risk of vaccine-preventable infections, severe forms of the disease, or shared transmission routes. Few data are available regarding vaccination coverage and its determinants in this population. A cross-sectional study was performed in HIV-infected patients included in a hospital-based cohort in 2011. Vaccination coverage against hepatitis A virus (HAV), hepatitis B virus (HBV), seasonal and A(H1N1)2009 pandemic influenza, and invasive pneumococcal diseases (IPD) were recorded. Factors associated with vaccination were assessed by multivariate logistic regression. 2467 patients were included (median age: 47 years; male gender 71.5%; men having sex with men (MSM): 43.9%; CDC stage C: 24.3%; HBV and/or hepatitis C virus co-infection: 14.4%). Median duration of HIV infection was 10 years and 93.1% of patients received combination antiretroviral therapy. At baseline, the median CD4 count was 527 cells/mm(3) and HIV viral load was &lt;50 copies/mL in 83.3% of cases. Vaccination coverage for HBV, HAV, seasonal influenza, A(H1N1)2009 pandemic influenza, and IPD were 61.9%, 47.4%, 30.9, 48.3%, and 64.6%, respectively. Factors independently associated with vaccination were a younger (HBV) or an older age (influenza), male gender (HBV, HAV), MSM (HBV), CD4 count &gt;200/mm(3) and HIV-RNA &lt;50 copies/mL (IPD, influenza), longer duration of HIV infection (IPD, influenza), and follow-up by an experienced physician (HBV, IPD). Vaccination coverage remained insufficient for all vaccine-preventable infections investigated in this study. Determinants for vaccination were largely not evidence-based, and efforts should be focused on improving physicians' knowledge about guidelines." }, { "id": "pubmed23n0307_4758", "title": "Booster policy for adults.", "score": 0.01494107744107744, "content": "A little over 100 years ago the first vaccines were manufactured. Since this time of success no vaccines have been developed for the great scourges of our time i.e. Malaria, helminthic disease and HIV. The morbidity and mortality rates of pneumococcal infection, influenza, hepatitis B and lately diphtheria are high, while vaccination booster rates among adults are not of acceptable values. The following causes have been taken into consideration: (1) there is no acceptance of the necessity of vaccination (2) physicians themselves do not have sufficiently favourable attitudes towards vaccines to put a special emphasis on vaccination for their patients; (3) Quite often a period of 20-30 years will pass between the time of leaving school (at 18 years) and incidence of major illness (visit to a doctor), so that there is no medical counsel concerning prophylaxis for the adult population; (4) high-risk groups are clearly defined but few of them are properly advised and get proper medical attention. Suggested booster strategies are: (1) professional advisory service for population groups and special schooling for physicians; (2) development of a patient chip card containing information about vaccinations, booster intervals and person's history for every physician; and (3) development of new combined vaccines for adults such as influenza and pneumococcal vaccine alone or in combination with diphtheria and tetanus toxoid." }, { "id": "wiki20220301en594_15557", "title": "National Immunisation Program Schedule", "score": 0.014425876976837955, "content": "The national coverage rate has increased over the last 10 years, as of 2019. National Immunisation Program Schedule Childhood vaccinations Birth Hepatitis B 2 weeks (Can be given from 6 weeks of age) Diphtheria Tetanus Pertussis (whooping cough) Hepatitis B Polio Haemophilus influenzae type b Pneumococcal Rotavirus (\"First dose must be given by 14 weeks of age, and the second dose by 24 weeks of age\") 4 months Diphtheria Tetanus Pertussis (whooping cough) Hepatitis B, polio Haemophilus influenzae type b Pneumococcal Rotavirus 6 months Diphtheria Tetanus Pertussis (whooping cough) Hepatitis B, polio Haemophilus influenzae type b 12 months Meningococcal ACWY Measles, mumps, rubella (MMR Vaccine) Pneumococcal 18 months Haemophilus influenzae type b Measles, mumps, rubella (MMR Vaccine) Varicella (chickenpox) Diphtheria Tetanus Pertussis (whooping cough) 4 years Diphtheria Tetanus Pertussis (whooping cough) Polio" }, { "id": "pubmed23n0263_15881", "title": "Antibody response to influenza, tetanus and pneumococcal vaccines in HIV-seropositive individuals in relation to the number of CD4+ lymphocytes.", "score": 0.014062935115566694, "content": "To establish when the formation of antibodies against T-lymphocyte-dependent and -independent antigens is impaired during HIV infection. Prospective study on antibody formation before and 30 days and 60 days after vaccination with tetravalent influenza vaccine, tetanus toxoid and pneumococcal vaccine; booster with influenza vaccine was administered 30 days after initial vaccination. Outpatient clinic of University Hospital Leiden. Fifty-one HIV-infected individuals and 10 healthy controls. In HIV-infected individuals with &lt; 100 x 10(6)/l CD4+ lymphocytes almost no influenza antibodies were formed; CD4+ counts between 100 and 300 x 10(6)/l correlated with suboptimal antibody formation; CD4+ counts &gt; or = 300 x 10(6)/l yielded more individuals with protective antibody titres. Thirty days after vaccination, protective antibody titres against the four influenza strains had been achieved in 24% of all HIV-infected individuals for A/Beijing (H3N2) (controls, 90%), 59% for A/Taiwan (H1N1) (controls, 80%), 18% for B/Beijing (controls, 30%) and 37% for B/Panama (controls 90%). Booster vaccination after 1 month did not increase antibody levels. Anti-tetanus toxin antibody formation, which is also T-lymphocyte-dependent, was correlated with the number of CD4+ lymphocytes. After pneumococcal vaccination (T-lymphocyte-independent), normal antibody formation was observed in HIV-infected individuals, including those with low CD4+ counts. Influenza vaccination should not be administered to HIV-infected individuals with CD4+ counts &lt; 100 x 10(6)/l; pneumococcal vaccination can be offered to all HIV-infected individuals and a tetanus toxoid booster should be administered when indicated." }, { "id": "wiki20220301en369_22085", "title": "Universal Immunisation Programme", "score": 0.013480392156862746, "content": "Universal Immunisation Programme (UIP) is a vaccination programme launched by the Government of India in 1985. It became a part of Child Survival and Safe Motherhood Programme in 1992 and is currently one of the key areas under National Rural Health Mission since 2005. The programme now consists of vaccination for 12 diseases- tuberculosis, diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, measles, hepatitis B, diarrhoea, Japanese encephalitis, rubella, pneumonia (haemophilus influenzae type B) and Pneumococcal diseases (pneumococcal pneumonia and meningitis). Hepatitis B and Pneumococcal diseases were added to the UIP in 2007 and 2017 respectively. The cost of all the vaccines are borne by the state and the government spent in 2017 to purchase the vaccines to provide them for free." }, { "id": "wiki20220301en003_110383", "title": "Infant mortality", "score": 0.012679715918932964, "content": "Vaccinations The Centers for Disease Control and Prevention (CDC) defines infants as those 1 month of age to 1 year of age. For these infants, the CDC recommends the following vaccinations: Hepatitis B (HepB), Rotavirus (RV), Haemophilus Influenzae type B (HIB), Pneumococcal Conjugate (PCV13), Inactivated Poliovirus (IPV < 18 yrs), Influenza, Varicella, Measles, Mumps, Rubella (MMR), and Diphtheria, tetanus, acellular pertussis (DTapP < 7yrs). Each of these vaccinations are given at particular age ranges depending on the vaccination and are required to be done in a series of 1 to 3 doses over time depending on the vaccination." }, { "id": "pubmed23n0958_8886", "title": "Factors associated with poor adherence to vaccination against hepatitis viruses, streptococcus pneumoniae and seasonal influenza in HIV-infected adults.", "score": 0.012355356476297125, "content": "Vaccination against various pathogens is recommended for HIV positive adults. There are not sufficient data either on vaccination coverage of HIV positive adults or the risk factors associated with poor adherence to routine vaccination. During the period 2004-2014 vaccination coverage of a group of HIV infected adults against hepatitis A virus (HAV), hepatitis B virus (HBV), seasonal influenza virus and pneumococcal disease was recorded. Vaccination coverage was separated into two chronological periods, before and after 2010, as 2010 marks the start of the economic crisis in Greece. 1210 patients were included in our study. Vaccine coverage throughout the study for hepatitis B, hepatitis A, seasonal influenza and pneumococcal infection was 73.6%, 70.4%, 39% and 79%, respectively. The complete lack of insurance coverage was an independent factor of non-compliance in all proposed vaccines (vaccination against pneumococcal disease: OR: 0.82 95%CI: 0.49-1.35, vaccination against HBV: OR: 0.82, 95% CI: 0.45-1.49, vaccination against HAV OR: 0.54, 95%CI: 0.34-0.87, vaccination against influenza: OR: 1.27, 95% CI: 0.76-2.10). In addition, low educational level was associated with poor compliance to vaccination against pneumococcal disease, hepatitis A, hepatitis B, and influenza. Finally, the recommendation for vaccination after the onset of the economic crisis (2010) led to poor compliance to vaccination against HBV, HAV and pneumococcal disease, but not against influenza. In our study, vaccination coverage for vaccine-preventable diseases was found to be insufficient for HIV positive adults in Northern Greece. Also, low educational level, lack of insurance coverage and economic distress have contributed to poor vaccine compliance, leading to poor protection of the HIV positive population and decreased immune coverage in the community." }, { "id": "wiki20220301en460_3944", "title": "Mission Indradhanush", "score": 0.012274215056370469, "content": "It aims to immunise all children under the age of 2 years, as well as all pregnant women, against seven vaccine preventable diseases(like 7 colors of a rainbow/indradhanush). The diseases being targeted are diphtheria, whooping cough, tetanus, poliomyelitis, tuberculosis, measles, meningitis and Hepatitis B. In addition to these, vaccines for Japanese encephalitis and Haemophilus influenzae type B are also being provided in selected states. In 2016, four new additions have been made namely Rubella, Japanese Encephalitis, Injectable Polio Vaccine Bivalent and Rotavirus. In 2017, Pneumonia was added to the Mission by incorporating Pneumococcal conjugate vaccine under Universal Immunisation Programme. Intensified Mission Indradhanush" }, { "id": "wiki20220301en448_8290", "title": "HIV and pregnancy", "score": 0.011668077512640419, "content": "Immunizations All pregnant women should receive the inactivated influenza vaccine and the TdaP vaccine, which covers tetanus, diphtheria, and pertussis (whooping cough) during the first trimester, regardless of their HIV status. If a pregnant woman tests positive for HIV, she should also be administered the pneumococcal vaccine, meningococcal vaccine, and Hepatitis A vaccine and Hepatitis B vaccine following a conversation with her provider. Vaccination is important to prevent serious infectious complications associated with the aforementioned diseases, which patients with HIV are at higher risk of contracting. Pregnant women should notably not receive live vaccines, including the Human papilloma virus (HPV) vaccine, measles mumps and rubella (MMR) vaccine, live influenza vaccine, and varicella (Chicken pox) vaccine regardless of their HIV statuses, as these vaccines can potentially harm the fetus." }, { "id": "pubmed23n0995_21520", "title": "Causes of Pediatric Meningitis in Botswana: Results From a 16-Year National Meningitis Audit.", "score": 0.011519101703665463, "content": "Central nervous system infections are an important cause of childhood morbidity and mortality in high HIV-prevalence settings of Africa. We evaluated the epidemiology of pediatric meningitis in Botswana during the rollout of antiretroviral therapy, pneumococcal conjugate vaccine and Haemophilus influenzae type B (HiB) vaccine. We performed a cross-sectional study of children (&lt;15 years old) evaluated for meningitis by cerebrospinal fluid (CSF) examination from 2000 to 2015, with complete national records for 2013-2014. Clinical and laboratory characteristics of microbiologically confirmed and culture-negative meningitis were described and incidence of Streptococcus pneumoniae, H. influenzae and cryptococcal meningitis was estimated for 2013-2014. A total of 6796 unique cases were identified. Median age was 1 year [interquartile range 0-3]; 10.4% (435/4186) of children with available HIV-related records were known HIV-infected. Overall, 30.4% (2067/6796) had abnormal CSF findings (positive microbiologic testing or CSF pleocytosis). Ten percent (651/6796) had a confirmed microbiologic diagnosis; including 26.9% (175/651) Cryptococcus, 18.9% (123/651) S. pneumoniae, 20.3% (132/651) H. influenzae and 1.1% (7/651) Mycobacterium tuberculosis. During 2013-2014, national cryptococcal meningitis incidence was 1.3 cases per 100,000 person-years (95% confidence interval, 0.8-2.1) and pneumococcal meningitis incidence 0.7 per 100,000 person-years (95% confidence interval, 0.3-1.3), with no HiB meningitis diagnosed. Following HiB vaccination, a marked decline in microbiologically confirmed cases of H. influenzae meningitis occurred. Cryptococcal meningitis remains the most common confirmed etiology, demonstrating gaps in prevention-of-mother-to-child transmission and early HIV diagnosis. The high proportion of abnormal CSF samples with no microbiologic diagnosis highlights limitation in available diagnostics." }, { "id": "InternalMed_Harrison_15134", "title": "InternalMed_Harrison", "score": 0.011221829018439189, "content": "immunization with the 23-valent pneumococcal polysaccharide vaccine is one of the generally recommended prophylactic measures for patients with HIV infection. This is likely most effective if given while the CD4+ T cell count is >200/μL and, if given to patients with lower CD4+ T cell counts, should be repeated once the count has been above 200 for 6 months. Although clear guidelines do not exist, it also makes sense to repeat immunization every 5 years. The incidence of bacterial pneumonia is cut in half when patients quit smoking." }, { "id": "InternalMed_Harrison_9906", "title": "InternalMed_Harrison", "score": 0.011174603174603174, "content": "Because of the increased risk of infections due to Streptococcus pneumoniae and other bacterial pathogens that cause pneumonia after influenza, the conjugate pneumococcal vaccine (Prevnar 13) followed by the 23-valent polysaccharide vaccine (Pneumovax) as well as influenza vaccine should be administered. The estimated rates of response to influenza vaccine are >80% among persons with asymptomatic HIV infection and <50% among those with AIDS. In general, live attenuated vaccines are contraindicated for persons with immune dysfunction. Because measles (rubeola) can be a severe or lethal infection in HIV-positive patients, these patients should receive the measles vaccine (or the combination MMR vaccine) unless the CD4+ T cell count is <200/μL. Between 18% and 58% of symptomatic HIV-infected vaccinees develop adequate measles antibody titers, and 50–100% of asymptomatic HIV-infected persons seroconvert." }, { "id": "wiki20220301en348_23091", "title": "Vaccine Information Statement", "score": 0.011101551441813993, "content": "Requirements for distribution A VIS must be given prior to vaccination in the United States when a patient is being vaccinated for diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), influenza, pneumococcal conjugate, meningococcal, rotavirus, human papillomavirus (HPV), or varicella (chickenpox) according to the National Childhood Vaccine Injury Act (NCVIA). The VIS must be given to the person receiving the vaccine or to their parent/legal representative prior to each dose of the vaccine. The \"legal representative\" is defined as the person who can consent to the vaccination under the laws of the state in which the vaccine is being given. The CDC has also developed VISs for vaccines not covered by the NCVIA, which are recommended for use with these vaccines, and required if the vaccines are purchased under CDC contract under the \"duty to warn\" clause." }, { "id": "InternalMed_Harrison_15138", "title": "InternalMed_Harrison", "score": 0.010401721664275467, "content": "Recommended as Standard of Care for Primary and Secondary Prophylaxis Prior bout of PCP Close contact with case of active pulmonary TB Drug resistant Same with high probability of exposure to drug-resistant TB Trimethoprim/sulfamethoxazole (TMP/SMX), 1 DS tablet qd PO TMP/SMX, 1 SS tablet qd PO Aerosolized pentamidine, 300 mg via Respirgard II nebulizer every month TMP/SMX, 1 SS PO daily Human Immunodeficiency Virus Disease: AIDS and Related Disorders All patients, preferably before CD4+ T cell count ≤200/μL Hepatitis B vaccine: 3 doses Hepatitis A vaccine: 2 doses (13) 0.5 mL IM × 1 followed in 8 weeks or more by pneumococcal polysaccharide vaccine (23) if CD4+ T cell count >200/μL Oseltamivir 75 mg PO qd Streptococcus pneumoniae Reimmunize patients initially immunized at a CD4+ T cell count <100/μL whose CD4+ T cell count then increases to >200/μL Human papillomavirus All patients 13–26 years of age HPV vaccine; 3 doses" }, { "id": "Pediatrics_Nelson_2649", "title": "Pediatrics_Nelson", "score": 0.010243438188739731, "content": "Routine immunizations are recommended to prevent vaccine-preventable infections but may result in suboptimal immune responses. In addition to heptavalent pneumococcal conjugate vaccine, 23-valent pneumococcal polysaccharide vaccine is recommended for HIV-infected children at 2 years of age and adolescents and adults with CD4 counts at or above 200/mm3. Because of the risk of fatal measles in children with AIDS, children without severe immunosuppression should receive their first dose of MMR at 12 months of age and may receive the booster as soon as 4 weeks later. Varicella zoster virus (VZV) vaccine should be given only to asymptomatic, nonimmunosuppressed children beginning at 12 months of age as two doses of vaccine at least 3 months apart. Inactivated split influenza virus vaccine should be administered annually to all HIV-infected children at or after 6 months of age. HIV-infected children exposed to varicella or measles should receive varicella zoster immune globulin or" }, { "id": "wiki20220301en609_29297", "title": "Vaccination in Brazil", "score": 0.01019113254329279, "content": "Routine vaccinations Vaccination coverage includes: For children BCG vaccine, Intradermal, at birth Hepatitis B vaccine, at birth, 1 and 6 months Pentavalent vaccine, DTP (whole cell pertussis component), HB, and Hib, administered at 2, 4, and 6 months, with a booster (DTP) at 15 months and 4 years. Polio vaccine (inactivated), at 2 and 4 months Polio vaccine (oral), at 6 and 15 months Rotavirus vaccine (monovalent oral human rotavirus vaccine) at 2 and 4 months Pneumococcal vaccine 10-valent conjugate vaccine d at 2, 4, 6, and 10 months Yellow fever vaccine at 9 months and booster every 10 years MMR vaccine at 12 months and 4 years Meningococcal vaccine at 3, 5, and 15 months Influenza vaccine, annually MMRV vaccine, after 1 year of age Hepatitis A vaccine, at 0 and 6 to 12 months For adults:" }, { "id": "wiki20220301en642_11516", "title": "The Green Book (immunisation guidance, UK)", "score": 0.01018789517192073, "content": "Part two: diseases, vaccinations and vaccines Diseases and their vaccines are listed in alphabetical order and include all vaccines recommended in the routine immunisation programme for all children in the UK. Vaccine requirements for travellers and for contacts of people with infectious disease are included. The 2006 edition incorporated the then new vaccines for meningococcal group C and pneumococcal infections, included the cessation of the school's BCG programme and the introduction of the Hib-MenC booster at 12 months of age. Diseases included: Anthrax Cholera Diphtheria Haemophilus influenzae type b (Hib) Hepatitis A Hepatitis B Influenza Japanese encephalitis Measles Meningococcal Mumps Pertussis Pneumococcal Polio Rabies Rubella Smallpox and vaccinia Tetanus Tick-borne encephalitis Tuberculosis Typhoid Varicella Yellow fever" }, { "id": "wiki20220301en101_10633", "title": "Pneumococcal conjugate vaccine", "score": 0.009917677950464835, "content": "Evidence supporting addition to routine vaccination schedules After introduction of the pneumococcal conjugate vaccine in 2000, several studies described a decrease in invasive pneumococcal disease in the United States. One year after its introduction, a group of investigators found a 69% drop in the rate of invasive disease in those of less than two years of age. By 2004, all-cause pneumonia admission rates had declined by 39% (95% CI 22–52) and rates of hospitalizations for pneumococcal meningitis decreased by 66% (95% CI 56.3-73.5) in children younger than 2. Rates of invasive pneumococcal disease among adults have also declined since the introduction of the vaccine. Vaccination in low-income countries" }, { "id": "pubmed23n0987_8547", "title": "Incidence and risk factors for invasive pneumococcal disease in HIV-positive individuals in the era of highly active antiretroviral therapy.", "score": 0.009900990099009901, "content": "Invasive pneumococcal diseases (IPDs) remain a significant cause of morbidity and mortality in human immunodeficiency virus (HIV)-positive individuals despite the widespread use of highly active antiretroviral therapy (HAART) and availability of pneumococcal vaccines. The aim of this study was to measure temporal trends in incidence and risk factors for IPD (defined as culture of Streptococcus pneumoniae from blood, cerebrospinal fluid or both) in a cohort of HIV-positive patients attending an ambulatory HIV care centre in Dublin, Ireland over a 10-year period 2006-2015. Incidence of IPD was determined as events per 100,000 person-years' follow-up. Poisson regression was used to assess linear trend in incidence over time. A nested case-control study (four controls per case) was undertaken to assess risk factors for IPD. Forty-seven episodes of IPD were identified in 42 HIV-positive individuals (median [IQR] age 38 years [33-43], 69% male, 86% injecting drug users (IDUs), median CD4 T-cell count 213 cells/mm<sup3</sup) over 16,008 person-years' follow-up (overall incidence rate 293/100,000 person-years). Three patients had two episodes and one patient had three episodes of IPD during the study period. The overall case fatality rate was 15% (95% confidence interval [CI] 4-24%). The incidence of IPD per 100,000 person-years decreased from 728 (95% CI, 455-1002), to 242 (95% CI, 120-365) to 82 (95% CI, 40-154) in calendar periods 2006-2008, 2009-2012 and 2013-2015, respectively (p &lt; 0.01 for linear trend). Older age (p = 0.02), male gender (p = 0.05), detectable HIV viral load (p &lt; 0.01) and non-receipt of pneumococcal vaccine (p = 0.03) were associated with IPD while IDU as risk of acquisition of HIV was of borderline significance (p = 0.06). HIV-positive individuals remain at greater risk of IPD compared to the general population. Pneumococcal vaccine should be seen as a priority to ensure optimal protection for HIV-positive patients." }, { "id": "pubmed23n0736_1762", "title": "An audit of pneumococcal and hepatitis vaccination in an outpatient HIV clinic.", "score": 0.00980392156862745, "content": "HIV-positive adults are at risk of vaccine preventable infections including Streptococcus pneumoniae, hepatitis A virus (HAV) and hepatitis B virus (HBV). Uptake of immunisations in HIV patients is suboptimal despite evidence of efficacy. An audit was made of the vaccination records in 200 adult HIV-positive regular clinic attendees, with a CD4+ count &gt;200 cells μL(-1). Medical records or laboratory data revealed that 10% had been vaccinated against S. pneumoniae; 74% were immune or immunised against HAV; 40% had evidence of natural infection with HBV and 84% of nonimmune patients had been vaccinated. Strategies to improve vaccine uptake are required." }, { "id": "wiki20220301en166_44937", "title": "WHO Model List of Essential Medicines", "score": 0.009708737864077669, "content": "Sera, immunoglobulins and monoclonal antibodies Anti-rabies virus monoclonal antibodies Antivenom immunoglobulin Diphtheria antitoxin Equine rabies immunoglobulin Vaccines Recommendations for all BCG vaccine Diphtheria vaccine Haemophilus influenzae type b vaccine Hepatitis B vaccine Human papilloma virus (HPV) vaccine Measles vaccine Pertussis vaccine Pneumococcal vaccine Poliomyelitis vaccine Rotavirus vaccine Rubella vaccine Tetanus vaccine Recommendations for certain regions Japanese encephalitis vaccine Tick-borne encephalitis vaccine Yellow fever vaccine Recommendations for some high-risk populations Cholera vaccine Dengue vaccine Hepatitis A vaccine Meningococcal meningitis vaccine Rabies vaccine Typhoid vaccine Recommendations for immunization programmes with certain characteristics Influenza vaccine (seasonal) Mumps vaccine Varicella vaccine" }, { "id": "pubmed23n0324_19008", "title": "[Which are the vaccines that human immunodeficiency virus infected patients must receive?].", "score": 0.009708737864077669, "content": "Patients with aids are at increased risk of opportunistic and non opportunistic infections. It is now known that the incidence can be reduced by prophylactic measures and/or the use of vaccines. HIV infection produces an elevated frequency of severe pneumococcal disease with a rate of bacteriemia caused by Streptococcus pneumoniae 150-300 fold greater than rates reported in non-HIV infected people. For this reason, pneumococcal vaccine should be administered as early as possible in the course of the infection. Besides, the antibody response may be significantly higher for asymptomatic persons. Acute hepatitis caused by hepatitis B virus is milder than in non HIV infected patients but chronic disease is more frequent. The prognosis is worse and there is higher risk for infecting another persons. Hepatitis B vaccine is indicated for all the patients with HIV and negative serology for hepatitis B virus. Influenza vaccine is of limited effectiveness due to the high variability of the virus. Besides, influenza incidence is low among approximately young adults, HIV related immunodeficiency increased influenza risk only minimally, the vaccine is administered yearly and HIV-replication can increase in temporal association with vaccination. For all these reasons, fewer hospitalizations and deaths are prevented making it a far less cost-effective prevention strategy than pneumococcal vaccination. The risk of Haemophilus influenzae infections is elevated, but the vaccine is not routinely recommended because the more frequent serotype in HIV infected patients is b. For these subjects, passive immunization with immunoglobulin may also be necessary to provide protection. In conclusion, pneumococcal and hepatitis B vaccination is a reasonable prevention strategy for HIV infected patients at all stages of immunodeficiency. Influenza and H. influenzae vaccination are not recommended and alternative prevention strategies may be done." }, { "id": "pubmed23n1084_13634", "title": "Surveillance of Vaccination Coverage Among Adult Populations -United States, 2018.", "score": 0.009615384615384616, "content": "Adults are at risk for illness, hospitalization, disability and, in some cases, death from vaccine-preventable diseases, particularly influenza and pneumococcal disease. CDC recommends vaccinations for adults on the basis of age, health conditions, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults remains low. August 2017-June 2018 (for influenza vaccination) and January-December 2018 (for pneumococcal, herpes zoster, tetanus and diphtheria [Td]/tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap], hepatitis A, hepatitis B, and human papillomavirus [HPV] vaccination). The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. NHIS's objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. Adult receipt of influenza, pneumococcal, herpes zoster, Td/Tdap, hepatitis A, hepatitis B, and at least 1 dose of HPV vaccines was assessed. Estimates were derived for a new composite adult vaccination quality measure and by selected demographic and access-to-care characteristics (e.g., age, race/ethnicity, indication for vaccination, travel history [travel to countries where hepatitis infections are endemic], health insurance status, contacts with physicians, nativity, and citizenship). Trends in adult vaccination were assessed during 2010-2018. Coverage for the adult age-appropriate composite measure was low in all age groups. Racial and ethnic differences in coverage persisted for all vaccinations, with lower coverage for most vaccinations among non-White compared with non-Hispanic White adults. Linear trend tests indicated coverage increased from 2010 to 2018 for most vaccines in this report. Few adults aged ≥19 years had received all age-appropriate vaccines, including influenza vaccination, regardless of whether inclusion of Tdap (13.5%) or inclusion of any tetanus toxoid-containing vaccine (20.2%) receipt was measured. Coverage among adults for influenza vaccination during the 2017-18 season (46.1%) was similar to the estimate for the 2016-17 season (45.4%), and coverage for pneumococcal (adults aged ≥65 years [69.0%]), herpes zoster (adults aged ≥50 years and aged ≥60 years [24.1% and 34.5%, respectively]), tetanus (adults aged ≥19 years [62.9%]), Tdap (adults aged ≥19 years [31.2%]), hepatitis A (adults aged ≥19 years [11.9%]), and HPV (females aged 19-26 years [52.8%]) vaccination in 2018 were similar to the estimates for 2017. Hepatitis B vaccination coverage among adults aged ≥19 years and health care personnel (HCP) aged ≥19 years increased 4.2 and 6.7 percentage points to 30.0% and 67.2%, respectively, from 2017. HPV vaccination coverage among males aged 19-26 years increased 5.2 percentage points to 26.3% from the 2017 estimate. Overall, HPV vaccination coverage among females aged 19-26 years did not increase, but coverage among Hispanic females aged 19-26 years increased 10.8 percentage points to 49.6% from the 2017 estimate. Coverage for the following vaccines was lower among adults without health insurance compared with those with health insurance: influenza vaccine (among adults aged ≥19 years, 19-49 years, and 50-64 years), pneumococcal vaccine (among adults aged 19-64 years at increased risk), Td vaccine (among all age groups), Tdap vaccine (among adults aged ≥19 years and 19-64 years), hepatitis A vaccine (among adults aged ≥19 years overall and among travelers aged ≥19 years), hepatitis B vaccine (among adults aged ≥19 years and 19-49 years and among travelers aged ≥19 years), herpes zoster vaccine (among adults aged ≥60 years), and HPV vaccine (among males and females aged 19-26 years). Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting ≥1 physician contact during the preceding year compared with those who had not visited a physician during the preceding year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts during the preceding year, depending on the vaccine, 20.1%-87.5% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was significantly higher than that of foreign-born adults, including influenza vaccination (aged ≥19 years), pneumococcal vaccination (all ages), tetanus vaccination (all ages), Tdap vaccination (all ages), hepatitis B vaccination (aged ≥19 years and 19-49 years and travelers aged ≥19 years), herpes zoster vaccination (all ages), and HPV vaccination among females aged 19-26 years. Vaccination coverage also varied by citizenship status and years living in the United States. NHIS data indicate that many adults remain unprotected against vaccine-preventable diseases. Coverage for the adult age-appropriate composite measures was low in all age groups. Individual adult vaccination coverage remained low as well, but modest gains occurred in vaccination coverage for hepatitis B (among adults aged ≥19 years and HCP aged ≥19 years), and HPV (among males aged 19-26 years and Hispanic females aged 19-26 years). Coverage for other vaccines and groups with Advisory Committee on Immunization Practices vaccination indications did not improve from 2017. Although HPV vaccination coverage among males aged 19-26 years and Hispanic females aged 19-26 years increased, approximately 50% of females aged 19-26 years and 70% of males aged 19-26 years remained unvaccinated. Racial/ethnic vaccination differences persisted for routinely recommended adult vaccines. Having health insurance coverage, having a usual place for health care, and having ≥1 physician contacts during the preceding 12 months were associated with higher vaccination coverage; however, these factors alone were not associated with optimal adult vaccination coverage, and findings indicate missed opportunities to vaccinate remained. Substantial improvement in adult vaccination uptake is needed to reduce the burden of vaccine-preventable diseases. Following the Standards for Adult Immunization Practice (https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html), all providers should routinely assess adults' vaccination status at every clinical encounter, strongly recommend appropriate vaccines, either offer needed vaccines or refer their patients to another provider who can administer the needed vaccines, and document vaccinations received by their patients in an immunization information system." }, { "id": "pubmed23n1135_2009", "title": "Implementation of EACS vaccination recommendations among people living with HIV.", "score": 0.009615384615384616, "content": "With modern combination antiretroviral Treatment (cART) a normal life expectancy among people living with HIV (PLWH) has become reality if started early enough prior to the onset of more pronounced immunodeficiency. Therefore, prevention measures against other infectious diseases among this vulnerable group have gained increased attention. Indeed, the EACS guidelines recommend vaccinations against HAV, HBV, HPV, Influenza, Neisseria meningitidis, Streptococcus pneumoniae and VZV in HIV-infected adults. All PLWH under cART attending our ID outpatient clinic between April to June 2018, were assessed during consultation for vaccination status regarding pneumococcus, Hepatitis A and B, influenza, varicella, meningococcus and HPV using a pre-defined questionnaire, vaccination certificates and medical records. In addition, the cohort database was screened for Hepatitis A and B serology and HIV surrogate markers. A total of 305 PLWH (82.3% male, 17.7% female) was included, median age was 48 years (IQR 47-51). Median CD4 + T cell count was 543 (IQR 304-770), and for 297 (97.4%) PLWH CD4 + T cell count was ≥ 200/ul. The viral load was undetectable (&lt; 40 copies/ml) in 289 (94.8%) cases. Highest vaccination rates were observed for HAV (87.4%), Streptococcus pneumoniae (77.4%) and Influenza (76.5%). 64.3% PLWH got vaccinated against HBV, whereas VZV vaccination only played a minor role, in the context of the high rate of cleared infections (99.0%). Lowest vaccination rates were detected for HPV (0%) and Neisseria meningitidis (3.0%). Our data suggest that vaccination rates among PLWH are higher compared to the general German population. Implementation of EACS guidelines into daily routine though is not fully executed and the need for improving vaccination rates has to be emphasized. Centrally organized vaccination registers as well as electronic medical records could be helpful tools to detect a lack of vaccination coverage and send digital vaccination reminders particularly among risk groups." }, { "id": "wiki20220301en140_13570", "title": "Pneumococcal vaccine", "score": 0.009433962264150943, "content": "Pneumococcal vaccines are vaccines against the bacterium Streptococcus pneumoniae. Their use can prevent some cases of pneumonia, meningitis, and sepsis. There are two types of pneumococcal vaccines: conjugate vaccines and polysaccharide vaccines. They are given by injection either into a muscle or just under the skin. The World Health Organization (WHO) recommends the use of the conjugate vaccine in the routine immunizations given to children. This includes those with HIV/AIDS. The recommended three or four doses are between 71 and 93% effective at preventing severe pneumococcal disease. The polysaccharide vaccines, while effective in healthy adults, are not effective in children less than two years old or those with poor immune function. These vaccines are generally safe. With the conjugate vaccine about 10% of babies develop redness at the site of injection, fever, or change in sleep. Severe allergies are very rare." }, { "id": "pubmed23n0535_3532", "title": "Invasive pneumococcal disease in a cohort of HIV-infected adults: incidence and risk factors, 1990-2003.", "score": 0.009433962264150943, "content": "To investigate the association between the introduction of HAART and invasive pneumococcal disease (IPD) in HIV-infected patients. Incidence of IPD was determined from 1990 to 2003 in a cohort of HIV-infected individuals and a nested case-control study assessed risk factors of IPD. There were 72 cases over 19,020 person-years of follow-up (overall IPD rate, 379/100,000 person-years). In the calendar periods 1990-1995, 1995-1998, and 1998-2003, the IPD incidence per 100,000 person-years was 279 [95% confidence interval (CI), 150-519], 377 (95% CI, 227-625) and 410 (95% CI, 308-545), respectively (P = 0.516). CD4 cell count &lt; 200 cells/microl [odds ratio (OR), 3.0; 95% CI, 1.2-7.6), HIV RNA &gt; 50,000 copies/ml (OR, 2.8; 95% CI, 1.2-6.5), hepatitis C (OR, 4.9; 95% CI, 1.7-14.9), serum albumin (OR, 0.1; 95% CI, 0.04-0.5), injection drug use in women (OR, 3.8; 95% CI, 1.6-8.8), and education beyond high school (OR, 0.2; 95% CI, 0.05-0.8) were significantly associated with IPD in multivariate analysis. No treatment factor, including HAART (OR, 0.7; 95% CI, 0.3-1.5) and pneumococcal vaccination (OR, 0.9; 95% CI, 0.5-1.6), was associated with IPD. IPD incidence did not change significantly during the widespread dissemination of HAART in this cohort. IPD risk was associated with several sociodemographic and clinical factors." }, { "id": "wiki20220301en430_12897", "title": "Vaccine Damage Payment", "score": 0.009345794392523364, "content": "The vaccination must have been for one of the following diseases: diphtheria tetanus pertussis (whooping cough) poliomyelitis measles mumps rubella (German measles) tuberculosis (TB) haemophilus influenzae type B (HIB) meningococcal group C (meningitis C) pneumococcal infection human papillomavirus pandemic influenza A (H1N1) 2009 (swine flu) - up to 31 August 2010 smallpox - up to 1 August 1971 Coronavirus (COVID-19) The vaccination must also have been administered before the claimant's 18th birthday, unless the vaccination was administered during an outbreak of disease in the United Kingdom or the Isle of Man, or if it was a vaccine for poliomyelitis, rubella, Meningococcal Group C, human papillomavirus, pandemic influenza A (H1N1) 2009 (swine flu) or COVID-19. The vaccination must have been administered in the United Kingdom or the Isle of Man, or as part of Armed Forces medical treatment." }, { "id": "pubmed23n0899_20031", "title": "Community-Acquired Pneumococcal Pneumonia in Virologically Suppressed HIV-Infected Adult Patients: A Matched Case-Control Study.", "score": 0.009345794392523364, "content": "The study aimed to investigate whether the clinical presentations and outcomes (length of stay, ICU admission, and 30-day mortality) of pneumococcal pneumonia in virologically suppressed patients who were HIV-infected on ART with a CD4+ T-cell count &gt; 350 cells/mm<sup3</sup are comparable to those seen in patients with HIV, using a case-control design. A case-control study was carried out in Hospital Clinic, Barcelona, Spain (2001-2016). Control patients were matched by age (±10 years), sex, comorbidities, and pneumonia diagnosis in the same calendar period. Clinical presentation and outcomes of pneumococcal pneumonia in patients who were and were not infected with HIV were compared. Pneumococcal pneumonia was studied in 50 cases (HIV infection) and 100 control patients (non-HIV infection). Compared with the control patients, case patients had higher rates of influenza (14% vs 2%, P = .007) and pneumococcal vaccination (10% vs 1%, P = .016). The group of cases also presented a higher rate of coinfection with hepatitis B virus (6% vs 0%, P = .036). Both groups presented similar ICU admission (18% vs 27%, P = .22), need for mechanical ventilation (12% vs 8%; P = .43), length of stay (7 days vs 7 days, P = .76), and 0% of 30-day mortality. No evidence was found of a more severe presentation or a worse clinical outcome in cases than in control patients. Pneumococcal pneumonia episodes requiring hospitalization in virologically suppressed patients with HIV with &gt; 350 CD4+ T-cell count/mm<sup3</sup were neither more severe nor had worse prognosis compared with uninfected patients. These results support the fact that such patients do not need treatment, admission, or care sites different to the general population. ClinicalTrials.gov; No. 2009/5451; URL: www.clinicaltrials.gov." }, { "id": "wiki20220301en521_16287", "title": "WHO Model List of Essential Medicines for Children", "score": 0.009259259259259259, "content": "Immunologicals Diagnostic agents Tuberculin, purified protein derivative (PPD) Sera and immunoglobulins Antivenom immunoglobulin Diphtheria antitoxin Vaccines BCG vaccine Diphtheria vaccine Haemophilus influenzae type b vaccine Hepatitis B vaccine HPV vaccine Measles vaccine Pertussis vaccine Pneumococcal vaccine Poliomyelitis vaccine Rotavirus vaccine Rubella vaccine Tetanus vaccine Japanese encephalitis vaccine Yellow fever vaccine Tick-borne encephalitis vaccine Cholera vaccine Dengue vaccine Hepatitis A vaccine Meningococcal meningitis vaccine Rabies vaccine Typhoid vaccine Influenza vaccine Mumps vaccine Varicella vaccine Muscle relaxants (peripherally-acting) and cholinesterase inhibitors Neostigmine Suxamethonium Vecuronium Pyridostigmine Ophthalmological preparations Anti-infective agents Aciclovir Azithromycin Erythromycin Gentamicin Natamycin Ofloxacin Tetracycline Anti-inflammatory agents Prednisolone" }, { "id": "wiki20220301en422_7283", "title": "Medical exclusion of immigrants", "score": 0.0091765873015873, "content": "Vaccinations The vaccination requirement includes the following vaccinations: Mumps, Measles, Rubella, Tetanus, diphtheria, Meningococcal disease, Pneumococcal disease, Haemophilus influenzae type B, Rotavirus, Varicella, Influenza, Hepatitis A and B, Pertussis, and Polio. These requirements are established by the Advisory Committee on Immunization Practices (ACIP). Examination The examination “consists of a physical examination, an evaluation (skin test/chest x-ray examination) for tuberculosis, and blood test for syphilis”. All immigrants are required to have this examination conducted by a panel physician overseas before they come to America. Foreign nationals pay for their own exam but the cost is covered by the US government for refugees. I-693, the Report of Medical Examination and Vaccination Record, is used to report the medical examination to officials. There is no filing fee for the I-693 form." }, { "id": "pubmed23n0568_8506", "title": "Immunization histories given by adult caregivers accompanying children 3-36 months to the emergency department: are their histories valid for the Haemophilus influenzae B and pneumococcal vaccines?", "score": 0.009174311926605505, "content": "To obtain immunization histories from adult caregivers accompanying children to the emergency department (ED), to determine the accuracy of the caregiver's report for the Haemophilus influenzae B (Hib)and 7-valent pneumococcal vaccine (PCV7). This was a prospective, observational study of children age 3 to 36 months presenting to the Albert Einstein Medical Center ED during the period of November 1, 2004, through January 31, 2005. Caregivers were asked to complete a questionnaire about their child's immunization status and if the child's vaccinations were up-to-date. Immunization records were obtained from the child's most recent primary care physician (PCP) to determine whether the caregiver's report was correct for PCV7 and Hib. Children were considered delayed if they were more than 30 days past due date for one or both vaccines according to the PCP records. Of 205 PCP offices contacted, we were able to obtain 173 immunization records for our analysis. Examination of vaccine records showed that 109 (63.0%) of the 173 children were up-to-date on both immunizations. When the child's caregiver was asked if shots were up-to-date, 159 (91.9%) of 173 said that all shots were given, and only 14 (8.1%) of 173 reported being behind schedule. Of the adults reporting the child up to date, 105 (66.0%) of the 159 children were confirmed to be up-to-date. Thus, 34.0% of caregivers were incorrect in stating that their child's immunization status was up-to-date for both these vaccines. Caregiver report was determined to be inaccurate for Hib and PCV7. Despite 91.5% of caregivers stating that shots were up-to-date, only 66.0% were correct that their child was up-to-date with these 2 vaccines. The ED physician should use caution in making clinical decisions based on the history given by a caregiver regarding their child's immunization status." }, { "id": "pubmed23n0721_248", "title": "Managing vaccines: defining the remit of primary care and specialist HIV clinics in the delivery of immunization to individuals with HIV infection.", "score": 0.00909090909090909, "content": "The British HIV Association (BHIVA) has published guidelines for immunization of HIV-infected adults. A chart review of 200 HIV-infected patients diagnosed was conducted to determine shortcomings in previous practice and determine which vaccines should routinely be given in specialist HIV clinics and which might be able to be delegated to primary care clinics. Data were collected on administration of three categories of vaccinations: (1) vaccines used in all individuals with chronic disease (pneumococcal, influenza, swine flu H1N1); (2) targeted vaccinations used in non-immune individuals with HIV who are at risk of exposure (hepatitis A and hepatitis B); (3) routine vaccines traditionally delivered to the whole population (measles/mumps/rubella [MMR], diphtheria/tetanus/pertussis and meningitis C/ACWY). Pneumococcal vaccine was delivered to 54% of eligible patients, 52% of eligible individuals completed a full hepatitis B programme of vaccination and 21% (42/200) were naturally immune; hepatitis A vaccine was delivered to 36% of eligible individuals. With increasing demands on resources, it seems likely that HIV services will have to harness resources of primary care in vaccine programmes in relation to routine vaccines. By improving communication between primary and secondary care mistakes with live vaccination decisions could be avoided; HIV services should continue to perform targeted and chronic disease vaccines, i.e. for category 1 and category 2 vaccines." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 610, 873 ] ], "word_ranges": [ [ 94, 136 ] ], "text": "The clinical data could be consistent with a septic process, however, the main infectious foci have been reasonably ruled out and one of the most sensitive and specific markers of bacteremia (procalcitonin) is in the normal range, which should draw our attention." }, "2": { "exist": true, "char_ranges": [ [ 610, 873 ] ], "word_ranges": [ [ 94, 136 ] ], "text": "The clinical data could be consistent with a septic process, however, the main infectious foci have been reasonably ruled out and one of the most sensitive and specific markers of bacteremia (procalcitonin) is in the normal range, which should draw our attention." }, "3": { "exist": true, "char_ranges": [ [ 874, 1184 ] ], "word_ranges": [ [ 136, 180 ] ], "text": "On the other hand, a complication of the EBV mononucleosis suffered by our patient should be evaluated, among the possible complications are hemolytic anemia, meningoecephalitis (normal CSF) or Guillain-Barré sd. Guillain-Barré syndrome, which are not very consistent with the clinical picture presented to us." }, "4": { "exist": true, "char_ranges": [ [ 874, 1184 ] ], "word_ranges": [ [ 136, 180 ] ], "text": "On the other hand, a complication of the EBV mononucleosis suffered by our patient should be evaluated, among the possible complications are hemolytic anemia, meningoecephalitis (normal CSF) or Guillain-Barré sd. Guillain-Barré syndrome, which are not very consistent with the clinical picture presented to us." }, "5": { "exist": true, "char_ranges": [ [ 1657, 1938 ] ], "word_ranges": [ [ 237, 276 ] ], "text": "Hyperferritinemia >3000 in a suggestive clinical context necessitates treatment of the patient (mainly with immunosuppressants and corticosteroids) since mortality is very high and early treatment is essential. The definitive diagnosis is made by microscopic study of an OM biopsy." } }

{ "1": "She has a bacterial sepsis of undetermined origin and should be given ceftriaxone and supportive care.", "2": "She has bacterial sepsis of undetermined origin and should be given vancomycin, ceftacidime and supportive care.", "3": "This is infectious mononucleosis with a severe course and glucocorticoids should be administered.", "4": "This is an infectious mononucleosis of severe course and treatment with Acyclovir should be initiated.", "5": "I would perform a bone marrow biopsy/aspirate and, if hemophagocytosis is confirmed, initiate treatment with immunosuppressants." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0324_10987", "title": "[Agranulocytosis as a complication of acute infectious mononucleosis].", "score": 0.018637309292649097, "content": "Acute infections mononucleosis is the most common clinical manifestation of primary Epstein-Barr virus (EBV) infection occurring during adolescence. It is a benign lymphoproliferative, usually self-limiting disease. Complications are relatively rare, but they may occur, especially hematological. Most common are autoimmune hematolytic anemia and thrombocytopenia, and they respond to corticoid therapy. Deuteration of white blood cells is rather rare, whereas mild neutropenia is a normal finding during the course of acute disease. On the other hand, agranulocytosis is extremely rate, and almost every case has been reported in the literature. Filgrastim--the recombinant human granulocyte colony-stimulating factor (G-CSF) stimulates the activation, proliferation and maturation of progenitor granulocyte cells. This drug is usually applied in treatment of iatrogenic neutropenia, during chemotherapy of malignancies and in some idiopathic and cyclic neutopenias. A female patient, 18 years of age, has been hospitalized at the Clinic of Infectious Diseases in Novi Sad on two occasions. First because of severe acute infectious mononucleosis with acute hepatitis and jaundice 10 days after onset of symptoms. Physical examination revealed severe intoxication, dehydration, icteric skin, mucosis and massive hepatosplenomegaly. The diagnosis was confirmed by ELISA IgM, EBV VCA positive and ELISA IgG EBV VCA and IgG EBVNA negative results. The patient was discharged from hospital after 24 days without complaints and with normal physical and laboratory findings. For several days she felt well, but gradually severe fatigue and malaise occurred and she became febrile again. That was the reason why she was hospitalized again, two weeks later. This time she was febrile, extremely intoxicated with general lymphadenopathy, catarrhal gingivostomatitis and massive splenomegaly. The first laboratory findings showed severe neutropenia (absolute count of granulocytes was 0.156 x 10/l, with only 12% segmented neutrophils). Mild anemia--3.05 x 10/l was also registered, while the platelet count was normal. Other biochemical analyses were normal, the Coombs' test negative, while the serological response was also normal. Bone marrow puncture was performed and normocellular bone marrow was registered, somewhere hypercellular due to hyperplasia of granulocyte progenitor cells from promyelocytes to normal maturated cells. Anemia showed megaloblastoid proliferation, while megakaryocytes were normal. High doses of corticosteroids were applied (dexamethasone 160 mg daily) and filgrastim 5 micrograms every other day. From the very beginning of therapy the patient felt better, whereas granulocytes responded with elevation as soon as 48 hours after initiation of therapy. On the sixth day the treatment was stopped because the level of granulocytes was normal and the patient has completely recovered. She was discharged from hospital 4 weeks later with mild meteorism, but normal physical and laboratory findings and mild splenomegaly registered only by ultrasonography. During the last 10 years only several cases of severe leukopenia with acute infectious mononucleosis had been reported in literature. In all cases it was associated with some other hematological complications and it occurred in young adults without previously registered immunodeficiency. We have no knowledge about application of filgrastim in treatment of EBV-induced agranulocytosis, but the International Association for Studying Agranulocytosis and Aplastic Anemia reported that in 4% of patients Epstein-Barr virus can cause agranulocytosis even a year after the occurrence of acute disease." }, { "id": "pubmed23n0055_4833", "title": "[An autopsied case of chronic active Epstein-Barr virus (EBV) infection with various symptom].", "score": 0.018089960886571055, "content": "A 19-year-old boy, who complained of fever and fatigue was hospitalized in November 1986. On physical examination, he had a temperature of 37 degrees C, cervical lymphadenopathy and hepatosplenomegaly. Serum transaminase was elevated moderately, while serum alkaline-phosphatase was elevated severely. Extremely elevated antibody titers to the EBV capsid antigen (IgG: 2560x, IgA: 160x), early antigen (IgG: 1280x, IgA: 160x) and nuclear antigen (160x) were noted. PPD and DNCB skin test were negative. Severe mobilization of Kupfer cells and mild proliferation of pseudoductule were seen in liver biopsied specimen. Cervical lymphnode biopsy showed necrotizing lymphadenitis associated with proliferation of histiocyte. In February 1987 his temperature was elevated to 40 degrees C and he had arthralgia and exanthema. Intravenous Acyclovir (500 mg every 8 hours) and Interferon alpha (6 million u/day) were administered together for 1 month. After that he improved for about a week. In March 1987 he had dyspnea. Arterial blood gas analysis in room air showed a PO2 of 51.8 mmHg, a PCO2 of 28.9 mmHg. A chest radiograph showed thickening of bilateral bronchial walls and obscurity of pulmonary vascular shadows. The effects of transfer factor and Interleukin-2 were unremarkable. High antibody titers to EBV, liver dysfunction and hypo-oxygenemia continued. He died of respiratory and heart failure on 24 October 1987. The most interesting finding of autopsied specimens was stenosis of pulmonary artery associated with interstitial pneumonitis. Hemophagocytosis was seen in liver, spleen and bone marrow." }, { "id": "pubmed23n0085_21718", "title": "[Mosquito bite allergies terminating as hemophagocytic histiocytosis: report of a case].", "score": 0.017125292740046837, "content": "A 21-year-old woman had suffered from repeated vasculitis and panniculitis with fever and chills after following mosquito bites since age 7. These manifestations were confirmed with a direct mosquito bite test during her admission to another hospital at age 17. The patient presented to our hospital with progressive dyspnea, productive cough and intermittent fever for one week. In addition to the bilateral infiltrative lesions on chest roentgenography, hepatosplenomegaly with an abnormal liver function test, pancytopenia, and elevated IgE were also detected. Blood and sputum cultures grew no microorganisms. Epstein-Barr virus-IgM, Cytomegalovirus-IgM and Mycoplasma pneumonia antibodies were all negative. Bone marrow aspiration and biopsy revealed histiocytosis with hemophagocytosis. No atypical histiocyte was found. The patient was put on dexamethasone treatment with improvement. Unfortunately, symptoms relapsed two weeks later. A repeated bone marrow aspiration and biopsy revealed a picture similar to the previous one. Despite antibiotic administration and ventilator support, a rapidly deteriorated course terminated in the patient's death by respiratory failure. Mosquito bite allergies were reported to be associated with malignant histiocytosis in Japan. However, atypical histiocytes were not found in our case upon repeated bone marrow aspirations, biopsies and skin biopsies. Mature histiocytes with hemophagocytosis were prominent instead. Reactive histiocytosis was thus favored rather than malignant histiocytosis. Although opportunistic infection cannot be excluded, we propose that a mosquito bite allergy with consequent histiocytic activation by antigen, immune complex or IgE is the possible pathogenetic mechanism for hemophagocytic histiocytosis in this patient." }, { "id": "pubmed23n1145_22242", "title": "A Case of Severe Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis Successfully Treated With High Dose Steroids and Ganciclovir.", "score": 0.01595873786407767, "content": "Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematological disorder characterized by immune dysregulation with multiple organ involvement and carries a poor prognosis. The occurrence of HLH can be familial or sporadic, which is triggered by causes like infection or malignancy. This case report is about a 47-year-old male who presented to the hospital with a fever, chills, night sweats, and unintentional weight loss. He was found to have severely elevated ferritin, and computed tomography showed cirrhosis, a normal sized spleen, and retroperitoneal lymphadenopathy. He underwent an extensive battery of tests to identify the etiology. Meanwhile, he had recurrent fevers with worsening transaminitis and septic shock, requiring admission to the ICU. Blood tests for Epstein-Barr virus (EBV) deoxyribonucleic acid (DNA) and immunoglobulin G (IgG) were positive. Due to high suspicion of HLH, he was started on intravenous methylprednisone 1000 mg daily for three days with clinical improvement. A bone marrow biopsy showed hemophagocytosis and he was diagnosed with EBV-associated HLH. He was continued on steroids with oral prednisone and continued to clinically improve. He was later tapered off steroids over the course of five months. HLH is a rapidly progressive and fatal condition that requires prompt treatment, and thus a high index of suspicion is needed to make a timely diagnosis." }, { "id": "pubmed23n1151_7618", "title": "A 7-Year-Old With Persistent Fever and Cough.", "score": 0.015853371051390855, "content": "A previously healthy, fully immunized 7-year-old girl presented with a 7-week history of daily fevers and a worsening cough with persistently elevated inflammatory markers. Before admission, she had an unrevealing outpatient workup by infectious disease, rheumatology, pulmonology, and otorhinolaryngology for her fever and other symptoms. Multiple courses of antibiotics had no effect, but brief courses of steroids seemed to modestly alleviate her symptoms. At an outside hospital, a computed tomography neck and chest scan revealed mediastinal lymphadenopathy. She was subsequently transferred to the authors' institution. Her examination was notable for a febrile, tired-appearing girl in respiratory distress with a muffled voice and inspiratory stridor. Her laboratory tests revealed leukocytosis with left shift, microcytic anemia, and hypoalbuminemia, as well as elevated inflammatory markers, ferritin, and fecal calprotectin. Her peripheral smear, uric acid, and lactate dehydrogenase were all within normal limits. Infectious study results, including blood and urine cultures, cytomegalovirus serologies, and Bartonella serologies were negative. On the second read of her outside computed tomography imaging, her lymphadenopathy was felt to be nonpathologic. Based on a recommendation by rheumatology, an ophthalmologic examination was obtained, which revealed bilateral anterior uveitis; however, rheumatologic laboratory test results returned negative. Her fevers continued, and inflammatory markers remained elevated despite antibiotics. On day 6 of hospitalization, she developed worsening respiratory distress, necessitating intubation and transfer to the ICU. Repeat laryngoscopy and bronchoscopy revealed severe purulent tracheitis; however, throat cultures remained sterile. Her clinical deterioration without identification of an offending organism prompted additional evaluation for a systemic etiology." }, { "id": "pubmed23n0922_1450", "title": "Fever, rash, and leukopenia in a 32-year-old man · Dx?", "score": 0.015639481000926783, "content": "A 32-year-old man was admitted to our hospital with fever, chills, malaise, leukopenia, and a rash. About 3 weeks earlier, he'd had oral maxillofacial surgery and started a 10-day course of prophylactic amoxicillin/clavulanic acid. Fifteen days after the surgery, he developed a fever (temperature, 103° F), chills, arthralgia, myalgia, cough, diarrhea, and malaise. He was seen by his physician, who obtained a chest x-ray showing a lingular infiltrate. The physician diagnosed influenza and pneumonia in this patient, and prescribed oseltamivir, azithromycin, and an additional course of amoxicillin/clavulanic acid. Upon admission to the hospital, laboratory tests revealed a white blood cell count (WBC) of 3.1 k/mcL (normal: 3.2-10.8 k/mcL). The patient's physical examination was notable for lip edema, white mucous membrane plaques, submandibular and inguinal lymphadenopathy, and a morbilliform rash across his chest. Broad-spectrum antibiotics were initiated for presumed sepsis. On hospital day (HD) 1, tests revealed a WBC count of 1.8 k/mcL, an erythrocyte sedimentation rate of 53 mm/hr (normal: 20-30 mm/hr for women, 15-20 mm/hr for men), and a C-reactive protein level of 6.7 mg/dL (normal: &lt;0.5 mg/dL). A repeat chest x-ray and orofacial computerized tomography scan were normal. By HD 3, all bacterial cultures were negative, but the patient was positive for human herpesvirus-6 on viral cultures. His leukopenia persisted and he had elevated levels of alanine transaminase ranging from 40 to 73 U/L (normal: 6-43 U/L) and aspartate aminotransferase ranging from 66 to 108 U/L (normal range: 10-40 U/L), both downtrending during his hospitalization. He also had elevated levels of antinuclear antibodies and anti-Smith antibody titers. A posterior-auricular biopsy was consistent with lymphocytic perivasculitis. The rash continued to progress, involving his chest, abdomen, and face. Bacterial and viral cultures remained negative and on HD 4, broad-spectrum antibiotics were discontinued." }, { "id": "pubmed23n0287_15275", "title": "[Lemierre's post-tonsillitis sepsis with meningitis and intravascular consumption coagulopathy as complication of infectious mononucleosis with pansinusitis].", "score": 0.015445614865664575, "content": "24 days after the onset of infectious mononucleosis, clinically and serologically confirmed, an otherwise healthy 18-year-old schoolboy developed a fulminant septicaemia with acute meningitis and loss of consciousness, consumptive coagulopathy and acute renal failure. Computed tomography demonstrated pansinusitis. Lumbar puncture produced purulent cerebrospinal fluid with 11,500 cells/microliters, predominantly granulocytes, protein 205 mg/dl, glucose 19 mg/dl, indicating bacterial meningitis. The suspected diagnosis of posttonsillitis septicaemia (Lemierre's syndrome) was confirmed by repeated demonstration of fusiform gram-negative bacteria in anaerobic blood cultures, identified as Fusobacterium necrophorum. Anaerobic CSF culture grew Prevotella bivia of the Bacteroidaceae family. Both the consumptive coagulopathy and the renal failure were successfully treated and the patient's condition stabilized. The sinuses were surgically drained under high doses of piperacillin/sulbactam and chloramphenicol. Despite the sensitivity of the cultured bacteria to the administered antibiotics the septic temperature continued, but disappeared within 4 days of metronidazole having been added. After 5 weeks of antibiotic treatment, three of them in an intensive care unit, the patient was discharged in good general condition. This case illustrates that severe septicaemia caused by rare bacteria may follow an attack of infectious mononucleosis which had taken an uncomplicated course." }, { "id": "pubmed23n0565_20506", "title": "[Retrospective evaluation of patients who were diagnosed as infectious mononucleosis between 1984-2005].", "score": 0.015022265142979774, "content": "In this study, the clinical and laboratory features of 26 infectious mononucleosis (IMN) cases who have been diagnosed between the years of 1984-2005 were evaluated retrospectively. The mean age of the patients was 26+/-11 years, the rate of being hospitalized was 65%, and mean hospitalization period was 9.2+/-6 days. Fever (81%), weakness (50%), sore throat (50%), headache (50%) and swollen neck (35%) were the most common symptoms, while in the physical examination cervical lymphadenopathy (81%), splenomegaly (69%), hyperemic pharynx (65%), hepatomegaly (54%) and tonsillitis (50%) were observed. Laboratory results yielded leukocytosis in 21%, leucopenia in 12%, anemia in 44%, thrombocytopenia in 5% and elevated transaminase levels in 84% of the patients. Of the patients 15 (57.7%) had the history of using antibiotics before the diagnosis. Serological diagnosis was performed by Paul-Bunnel test and/or IgM positivity against Epstein-Barr virus (EBV) viral capsid antigen (VCA). Tonsillo-pharyngitis secondary to edema and respiratory distress due to lymphadenopathy pressure were detected in four patients, whereas pancytopenia was established only in one patient, as complications. This study emphasized that, although IMN is a self-limited infection, the diagnostic difficulties may arise when the clinical course is atypical, and rarely seen life-threatening complications may also develop during IMN course." }, { "id": "pubmed23n1126_15241", "title": "Tuberculosis Presenting as Acute Sepsis and Secondary Hemophagocytic Lymphohistiocytosis.", "score": 0.014585883312933496, "content": "We report the case of a 61-year-old man admitted to our emergency department with fever. At admission, he was hypotensive and tachycardic. In the initial investigation, elevation of inflammatory parameters, acute kidney injury (Kidney Disease Improving Global Outcomes (KDIGO) 3), hyperbilirubinemia, and hepatic cytocholestasis were evident. Empirical antibiotic therapy was started, after sepsis was assumed without an identifiable cause. His condition took an unfavorable clinical course, with respiratory failure, hepatosplenomegaly, pancytopenia, hyperferritinemia and hypofibrinogenemia. Microbial culture studies and a general immunological study were negative and lymphoproliferative disease was therefore excluded. Bone marrow aspirate revealed hemophagocytosis without granulomas. A diagnosis of hemophagocytic lymphohistiocytosis was assumed and pulse methylprednisolone therapy initiated. As this resulted in only a transient improvement, immunoglobulin and rituximab were initiated as a second-line therapy. The patient sadly had an unfavorable outcome despite all measures undertaken. In the postmortem study, <iMycobacterium tuberculosis</i complex was isolated in the bone marrow aspirate, which led to the postmortem diagnosis of disseminated tuberculosis and angioinvasive pulmonary aspergillosis. The clinical presentation of disseminated tuberculosis is non-specific and hemophagocytic lymphohistiocytosis is one of its rare presentations. The mortality rate of hemophagocytic lymphohistiocytosis is high and increases with delayed diagnosis of the underlying condition and respective treatment. Hemophagocytic lymphohistiocytosis should be considered in patients presenting with fever, lymphadenopathy, splenomegaly, cytopenias, hyperferritinaemia and hypertriglyceridemia.Despite its rarity, tuberculosis should be considered as an etiology of hemophagocytic lymphohistiocytosis and, if suspected, antituberculosis therapy should be initiated early, even in the absence of a definite diagnosis.Immunosuppressant therapy increases the risk of opportunistic infections, which establishes the need for prophylactic antibiotic, antifungal, and antiviral drugs." }, { "id": "pubmed23n0581_16754", "title": "[Fulminate liver failure in a 39-year-old female patient with leukocytosis, unclear fever, and arthralgic pain].", "score": 0.013969081765691935, "content": "Fulminate liver insufficiency can have many causes and is a challenge for differential diagnosis. A 39-year-old woman was admitted because of a nonitching macular-papular exanthema on both thighs with spreading to the trunk. In addition, the patient complained of dysphagia, symmetrical arthralgias, myalgias, fever of 38 degrees C, and night sweats. An outpatient treatment with nonsteroidal antirheumatics, antihistamines and penicillin was started for 3 days before admission. On admission, a neutrophilic leukocytosis (23.6 Gpt/l), an increase in C-reactive protein (185 mg/l), and a ferritin level of 1,740 microg/l were found. Liver enzymes were increased (alanine aminotransferase 1.03 micromol/l.s, aspartate aminotransferase 1.06 micromol/l.s, gamma-glutamyltransferase 2.73 micromol/l.s, and lactate dehydrogenase 12.48 micromol/l.s). Sonographic examination showed a mild hepatosplenomegaly, but otherwise normal findings. X-rays of the lungs, hands, and ankles were normal. An echocardiography was within normal limits. Extensive serologic investigations including assays for hepatitides A, B and C as well as repeated blood cultures were negative. Antibiotic therapy was continued without any improvement. In addition, acetaminophen (4 x 1,000 mg/day) and ibuprofen (3 x 600 mg/day) were given. Liver function worsened and an icterus developed. The patient was transferred to the authors' university hospital. Because of the clinical findings of fever episodes, a typical macular exanthema, lymphadenopathy, hepatosplenomegaly, arthralgias, myalgias, dysphagia, and the presence of neutrophilic leukocytosis, fever, an increase in ferritin, but negative serologic titers and no bacteremia, a working diagnosis of Still's disease was made. The patient was treated with high-dose methylprednisone (250 mg/day for 3 days, then 100 mg/day). Liver biopsy revealed subacute hepatitis with necrosis and accompanying cholangitis. The prednisone therapy induced a fast remission and improvement of liver function, liver transplantation was not necessary. The patient is, 16 months after the incident, without symptoms under prednisone 3 mg/day, and the liver function is normal. The etiology of Still's disease is unknown and the disease is characterized by fever episodes, a typical macular-papular exanthema, lymphadenopathy, hepatosplenomegaly, and arthralgias. A mild to moderate increase in liver enzymes is often found as part of this disease. Rarely, a fulminate liver failure has been described, particularly in the presence of co-administration of nonsteroidal antirheumatics or acetaminophen. Still's disease must be considered as part of the differential diagnosis of acute liver failure, because an early diagnosis and consequent therapy with prednisone may prevent the need for liver transplantation." }, { "id": "pubmed23n1032_10415", "title": "Hemophagocytic Lymphohistiocytosis in Renal Transplant Recipients: A 2-Case Report.", "score": 0.013615803563186559, "content": "Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome characterized by an excessive immune activation. HLH can be triggered by a variety of events that disrupt immune homeostasis, such as infections and immunosuppression. HLH presents with heterogeneous clinical symptoms and laboratory findings such as pancytopenia, elevated liver enzymes, impaired renal function, and hyperferritinemia. Case 1. A 58-year-old man was admitted because of a high fever and diarrhea. Laboratory findings showed acute renal impairment, pancytopenia, Epstein-Barr virus (EBV) DNA seropositivity with a replication index of 2 million copies/mL, and hyperferritinemia. A diagnosis of HLH was confirmed by bone marrow aspiration. He was treated with etoposide, steroids, and rituximab with initial good response and good kidney function restoration. He was discharged after 31 days but eventually died after 44 days after a disease relapse. Case 2. A 51-year-old kidney transplant recipient was admitted because of a fever of unknown origin. A worsening renal function, pancytopenia, EBV DNA of 4,356,222 copies/mL on blood, D-Dimer 7505 ng/mL, ferritinemia 9180.9 ug/L, and triglycerides 1273 mg/dL were found. Bone marrow aspiration was negative for HLH; a few days later, a diagnosis of HLH was made after a positive bone marrow biopsy. Continuous renal replacement therapy was started in the intensive care unit because of severe lactic acidosis due to sepsis. She died few days later. EBV infection could be a trigger for HLH in a renal transplant patient. Hyperferritinemia is useful for differential diagnosis in a septic patient. The outcome is very poor even with prompt treatment." }, { "id": "pubmed23n0416_15653", "title": "[Successful use of etoposide in an elderly patient with chronic recurrent hemophagocytic syndrome].", "score": 0.01346448087431694, "content": "A 66-year-old man was admitted to our hospital for fever on January 19, 1998. He began showing periodic high fever in June 1997 and an increased serum LDH in August 1997. His history included surgery for esophageal cancer in 1993. On admission, the patient's body temperature was 38.5 degrees C. Physical examination was negative for lymphadenopathy, hepatosplenomegaly, and skin rash. Peripheral blood revealed a hemoglobin level of 8.6 g/dl and a platelet count of 7.9 x 10(4)/microliter. Bone marrow examination showed hypocellularity with marked histiocytic hemophagocytosis. The various bacterial cultures were negative. Serum LDH was elevated to 1,606 IU/l, and ferritin was greater than 3,000 ng/ml. Antinuclear antibodies were negative. No significant elevation of viral antibody titers including that to Epstein-Barr virus was found. Hemophagocytic syndrome (HPS) was diagnosed, but no underlying diseases was identified. The patient's condition was complicated by interstitial pneumonia and pleural effusion. gamma-globulin and pulse methylprednisolone both proved ineffective for the HPS; however, complete remission was achieved with cyclic intravenous administration of etoposide (VP-16, 150 mg/day). Interestingly, the interstitial pneumonia resolved promptly with etoposide therapy. The patient relapsed, in July 2001, exhibiting high fever, cytopenia, and marrow hemophagocytosis. His condition was ameliorated by administration of etoposide. This was a rare case of chronic and recurrent HPS of unknown etiology accompanied by interstitial pneumonia. Etoposide should be considered as a primary therapy for HPS and its complications in cases such as our patients." }, { "id": "pubmed23n0870_7279", "title": "Intense myelofibrosis in a child: unusual result of EBV-associated hemophagocytic lymphohistiocytosis.", "score": 0.01335987613359876, "content": "A previously healthy 12-year-old girl was admitted to the intensive care unit with severe pulmonary bleeding. Her history revealed that she had suffered from high fever, fatigue, sore throat, myalgia and generalized rash for two weeks. Physical examination revealed hepatosplenomegaly. Laboratory investigation showed pancytopenia associated with unusual high levels of serum ferritin, triglyceride and lactate dehydrogenase (LDH) and low fibrinogen levels. Apparent hemophagocytosis was seen in bone marrow aspiration. Bone marrow biopsy revealed myelofibrosis, and confirmed hemophagocytosis. IgM for Epstein-Barr virus (EBV) viral capsid antigen was found to be positive. She received chemotherapy for 10 days according to hemophagocytic lymphohistiocytosis (HLH)-2004 treatment protocol, since the symptoms persisted despite supportive therapy and intravenous immunoglobulin (IVIG) administration. However, the clinical status and laboratory findings did not respond to treatment and she died from severe pulmonary bleeding associated with prolonged ventilator support and sepsis. Intense myelofibrosis, which is reported rarely, particularly in patients with EBV-related HLH, contributed to this fatal prognosis. " }, { "id": "pubmed23n1078_5134", "title": "Case of haemophagocytic lymphohistiocytosis following Epstein-Barr virus infection.", "score": 0.013128729752770674, "content": "Haemophagocytic lymphohistiocytosis (HLH) is a rare diagnosis that carries a high degree of mortality. We present this case of a previously healthy 22-year-old woman, who was admitted acutely ill to the hospital. One week prior, she had been seen by her primary care physician for fatigue and malaise. At that time, she was noted to have anterior and posterior cervical lymphadenopathy. She was referred to the emergency room and was diagnosed with acute Epstein-Barr virus (EBV) mononucleosis based on her clinical symptoms and positive heterophile antibody test. She was discharged after an uneventful 48-hour stay on the wards. She represented 7 days after discharge with cough, fatigue, nausea, vomiting, epigastric abdominal pain, diarrhoea, weight loss and subjective fevers. She had also reported haematemesis, epistaxis and melaena. Vital signs included temperature 36.9°C, blood pressure 90/50 mm Hg, heart rate 130 beats per minute and respiratory rate 32 breaths per minute. Physical examination was notable for an acutely ill appearing woman with scleral icterus, hepatosplenomegaly and palpable cervical and axillary lymphadenopathy. Complete blood count showed pancytopaenia with haemoglobin 59 g/L (normal 120-160 g/L), white blood cell count 2.7×10<sup9</sup/L (normal 4-10.5×10<sup9</sup/L) and platelet count 50×10<sup9</sup/L (normal 150-450×10<sup9</sup/L). The white blood cell count differential included 58% neutrophils (normal 38%-77%) with immature neutrophils in band form elevated at 45% (normal &lt;14%), 16% lymphocytes (normal 20%-48%), 7% monocytes (normal &lt;12%) and no eosinophils (normal &lt;6%). Blood smear revealed anisocytosis, poikilocytosis and hypochromia. Coagulation panel showed elevated levels of d-dimer level at 1.39 µg/mL (normal &lt;0.45 µg/mL), prolonged prothrombin time at 34.4 s (normal 11-15 s), prolonged activated partial thromboplastin time of 55.6 s (normal 25-34 s), prolonged international normalised ratio at 3.31 (normal &lt;1.1) and low fibrinogen 60 mg/dL (normal &gt;200 mg/dL). Lipid panel showed cholesterol at 114 mg/dL (normal 125-200 mg/dL), triglycerides 207 mg/dL (normal 30-150 mg/dL), high-density lipoprotein cholesterol 10 mg/dL (normal 40-60 mg/dL) and low-density lipoprotein cholesterol 63 mg/dL (normal &lt;100 mg/dL). Other lab abnormalities included elevated ferritin of 6513 ng/mL (normal 10-150 ng/mL) and elevated lactate dehydrogenase of 1071 unit/L (normal 95-240 unit/L). Soluble interleukin-2 receptor alpha level was elevated at 60 727 units/mL (normal 223-710 units/mL). Fluorodeoxyglucose-positron emission tomography (FDG-PET) scan showed abnormal tracer localisation within the paratracheal, hilar, pelvic, abdominal and subcarinal lymph nodes, along with FDG-PET positive hepatosplenomegaly. A bone marrow biopsy showed hypercellular marrow (95% cellularity) with trilineage haematopoiesis, haemophagocytic cells, polytypic plasmacytosis and T-cell lymphocytosis, along with positive latent membrane protein-1 immunohistochemical staining for EBV. EBV quantitative DNA PCR showed &gt;1 million copies. These findings were consistent with a diagnosis of HLH secondary to EBV infection. Despite intense therapy with the HLH-94 protocol, the patient expired from her illness after a prolonged hospital course." }, { "id": "pubmed23n0976_2143", "title": "Unusual manifestation of disseminated herpes simplex virus type 2 infection associated with pharyngotonsilitis, esophagitis, and hemophagocytic lymphohisitocytosis without genital involvement.", "score": 0.012824510797536447, "content": "Herpes simplex virus (HSV) has various presentations, depending on the patient's immune status, age, and the route of transmission. In adults, HSV type 1 is found predominantly in the oral area, and HSV type 2 (HSV-2) is commonly found in the genital area. HSV-2 infection without genital lesions is uncommon. Herein we report a unique case of pharyngotonsillitis as an initial manifestation of disseminated HSV-2 infection without genital involvement. A 46-year-old male was admitted to our hospital with a 1-week history of fever and sore throat. His past medical history included hypereosinophilic syndrome diagnosed at age 45 years. Physical examination revealed throat congestion, bilaterally enlarged tonsils with exudates, tender cervical lymphadenopathy in the left posterior triangle, and mild epigastric tenderness. The laboratory data demonstrated bicytopenia, elevated liver enzyme levels, and hyperferritinemia. A bone marrow smear showed hypocellular marrow with histiocytes and hemophagocytosis. The diagnosis of HLH was confirmed, and the patient was treated with methylprednisolone pulse therapy on days 1-3. On day 5, despite initial improvement of the fever and sore throat, multiple, new, small bullae developed on the patient's face, trunk, and extremities. Additional testing showed that he was positive for HSV-specific immunoglobulin M and immunoglobulin G. Disseminated HSV infection was suspected, and intravenous acyclovir (10 mg/kg every 8 h) was begun. A subsequent direct antigen test of a bulla sample was positive for HSV-2. Moreover, tonsillar and esophageal biopsies revealed viral inclusion bodies. Immunohistochemical staining and a quantitative real-time polymerase chain reaction (PCR) assay confirmed the presence of HSV-2. Disseminated HSV-2 infection with multiple bullae, tonsillitis, esophagitis, and suspected hepatic involvement was diagnosed. After a 2-week course of intravenous acyclovir, his hematological status and liver function normalized, and his cutaneous skin lesions resolved. He was discharged on day 22 in good general health and continued taking oral valacyclovir for viral suppression due to his immunosuppressed status. Disseminated HSV-2 infection should be considered as one of the differential diagnoses in patients with pharyngotonsillitis and impaired liver function of unknown etiology even if there are no genital lesions." }, { "id": "pubmed23n1129_1788", "title": "An Unusual Presentation of Glandular Fever.", "score": 0.012020586576424139, "content": "Epstein-Barr virus (EBV) is an ubiquitous DNA herpesvirus with &gt;90% of adults &gt;40 years of age showing a serological response. While in their youth, primary EBV infection may pass unnoticed, young adults have a high incidence of infectious mononucleosis (IM). This is characterized by a triad of pharyngitis, cervical lymphadenopathy, and fever because of a self-limiting lymphoproliferative disease. Common complications include but are not limited to hepatitis, splenomegaly, encephalitis, and haemophagocytic lymphohistiocytosis (HLH) with evidence that Caucasian males and smokers are more likely to suffer severe disease. Here we present a 21-year-old male who presented with a 2-week history of fever, dry cough, and a 4-week history of pharyngitis. He had no exposure to unwell contacts and denied any new sexual partners. Examination revealed general pallor with tender bilateral cervical lymphadenopathy and pharyngeal erythema. Admission bloods revealed pancytopenia (WCC 1.5 × 10<sup9</sup/L, Plt 84 × 10<sup9</sup/L, and Hb 82 g/L) with normal reticulocyte count and raised mean corpuscular volume (114 fL). Serum vitamin B12 and folate were low with serum ferritin raised (1027 <iµ</ig/L) suggesting a proinflammatory state. Admission liver function tests, coeliac serology, autoimmune panel (ANA, ANCA, and anti-dsDNA), hepatitic (hepatitis A, B, and E), human immunodeficiency virus (HIV), toxoplasmosis, parvovirus, and CMV serology were normal. The monospot test on day 1 of the presentation was negative. Ultrasound (US) of the abdomen on day 3 of the presentation revealed isolated splenomegaly (16.8 cm). Day 4 EBV serology (VCA IgM, VCA IgG, and EBNA IgG) was negative as such haematological investigations including JAK2, serum free light chains, and BCR-ABL were undertaken alongside cervical lymph node core biopsy. Repeat Monospot testing on day 7 came back positive. Repeat EBV serology now showed equivocal EBV VCA IgG (0.77 OD) and positive VCA IgM (9.04 OD) with concurrent new hepatitis. Histopathology of the core biopsy revealed Sternberg-reed cells and a mixed immunoblastic reaction in keeping with resolving IM. This case highlights the need for physicians to have a strong clinical suspicion of IM and understand the multiple ways in which IM may be present as well as the time lag to positivity in serological testing." }, { "id": "pubmed23n0752_11036", "title": "Mumps caused hemophagocytic syndrome: a rare case report.", "score": 0.011105092091007584, "content": "Mumps-associated hemophagocytic syndrome (HPS) is exceptionally rare. Here, we report a fatal case of concurrent mumps and HPS. A previously healthy 21-year-old male patient was admitted to the Department of Infectious Diseases on October 18, 2011,with complaints of parotid gland pain for 30 days and persistent fever (38.3°C-40°C) for 15 days. Admission examinations showed severe pancytopenia, liver dysfunction, hyperferritinemia, fibrinopenia, elevated lactalase dehydrase, bilateral pulmonary inflammation and pleural effusion, abdominal lymphadenopathy, and splenomegaly. The patient was accordingly suspected to have mumps-associated HPS and received nutrition support and hormonal therapies as well as platelet transfusions. On hospitalization day 3, the fever stayed high, and painful swelling in the right testicle was reported. A bone marrow biopsy evaluation and serological tests were then performed. Histiocytic hyperplasia and hemophagocytic macrophage infiltration were demonstrated in the bone marrow and antimumps virus immunoglobulin M was detected positive, but bacteria, Epstein-Barr virus, cytomegalovirus, and herpes simplex virus were detected negative in the peripheral blood. The initial diagnosis of mumps-associated HPS was eventually confirmed. Treatments with high doses of methylprednisolone, intravenous immunoglobulin, and etoposide were continued. By hospitalization day 20, patient's condition was improved, his body temperature and blood counts were almost normal, and the pain and swelling in his parotid glands and right testicle subsided considerably. On hospitalization day 28, however, patient's condition deteriorated rapidly, and pancytopenia became evident again. On hospitalization day 33, the patient died of multiple organ dysfunction." }, { "id": "wiki20220301en136_41454", "title": "Human betaherpesvirus 5", "score": 0.010461083631815339, "content": "CMV should be suspected if a person has symptoms of infectious mononucleosis but has negative test results for mononucleosis and Epstein–Barr virus, or if they show signs of hepatitis, but have negative test results for hepatitis A, B, and C. For best diagnostic results, laboratory tests for CMV antibody should be performed by using paired serum samples. One blood sample should be taken upon suspicion of CMV, and another one taken within 2 weeks. A virus culture can be performed any time the person is symptomatic. Laboratory testing for antibodies to CMV can be performed to determine if a woman has already had CMV infection. However, routine testing of all pregnant women is costly and the need for testing should therefore be evaluated on a case-by-case basis. Serologic testing" }, { "id": "pubmed23n0690_20825", "title": "Recurrent fever of unknown origin (FUO): aseptic meningitis, hepatosplenomegaly, pericarditis and a double quotidian fever due to juvenile rheumatoid arthritis (JRA).", "score": 0.009900990099009901, "content": "Fever of unknown origin (FUO) has been defined as a fever of ≥101°F that persists for 3 weeks or more. It is not readily diagnosed after 1 week of intensive in-hospital testing or after intensive outpatient or inpatient testing. Fevers of unknown origin may be caused by infectious diseases, malignancies, collagen vascular diseases, or a variety of miscellaneous disorders. The relative distribution of causes of FUOs is partly age-related. In the elderly, the preponderance of FUOs is attributable to neoplastic and infectious etiologies, whereas in children, collagen vascular diseases, neoplasms, and viral infectious disease predominate. The diagnostic approach to FUOs depends on a careful analysis of the history, physical findings, and laboratory tests. Most patients with FUOs exhibit localizing findings that should direct the diagnostic workup and limit diagnostic possibilities. The most perplexing causes of FUOs involve those without specific diagnostic tests, e.g., juvenile rheumatoid arthritis (JRA) or adult Still's disease. In a young adult with FUO, if all of the cardinal symptoms are present, JRA may present either a straightforward or an elusive diagnosis, if key findings are absent or if the diagnosis goes unsuspected. We present a 19-year-old man with a recurrent FUO. His illness began 3 years before admission and has recurred twice since. In the past, he did not manifest arthralgias, arthritis, or a truncal rash. On admission, he presented with an FUO with hepatosplenomegaly, aseptic meningitis, and pericarditis. An extensive diagnostic workup ruled out lymphoma and leukemia. Moreover, a further extensive workup eliminated infectious causes of FUO appropriate to his clinical presentation, ie, tuberculosis, histoplasmosis, brucellosis, Q fever, typhoid fever, Epstein-Barr virus, infectious mononucleosis, cytomegalovirus, human herpes virus (HHV)-6, babesiosis, ehrlichiosis, viral hepatitis, and Whipple's disease. The diagnosis of JRA was based on the exclusion of infectious and neoplastic disorders in a young adult with hepatosplenomegaly, aseptic meningitis, pericarditis, and a double quotidian fever. With JRA, tests for rheumatic diseases are negative, as they were in this case. The only laboratory abnormalities in this patient included elevated serum transaminases, a mildly elevated erythrocyte sedimentation rate, and a moderately elevated level of serum ferritin. Diagnostic fever curves are most helpful in cases where the diagnosis is most elusive, as was the case here. Relatively few disorders are associated with a double quotidian fever, ie, visceral leishmaniasis, mixed malarial infections, right-sided gonococcal acute bacterial endocarditis, and JRA. Because the patient received antipyretics during the first week of admission, fever was not present. After infectious disease consultation during week 2 of hospitalization, antipyretics were discontinued, and a double quotidian fever was present, which provided the key diagnostic clue in this case." }, { "id": "pubmed23n1050_5087", "title": "Sinister sinusitis.", "score": 0.00980392156862745, "content": "Two previously well Caucasian teenage girls with no significant travel or family history were admitted with sinusitis refractory to treatment with antibiotics. Both had progressive symptoms despite broad-spectrum antibiotics and developed involvement of other systems, ultimately requiring admission to the paediatric intensive care unit (PICU). They were subsequently diagnosed with the same condition and made an excellent recovery.The first girl, 14 years old, originally presented to her general practitioner with a sore throat, nasal congestion, and fever. Despite multiple courses of antibiotics over the following month she presented again multiple times with progressive symptoms including epistaxis, widespread myalgia and arthralgia, difficulty in breathing, haemoptysis, fatigue, and weight loss. Examination on admission found minimal discharge from her right tympanic membrane, ulcerated inferior turbinates with dried blood and yellow mucus in both nasal cavities, swollen tonsils without exudate, and an isolated aphthous ulcer on the tip of her tongue. She had small bilateral cervical lymph nodes. Examination of the cardiovascular system was unremarkable but on respiratory examination there was reduced air entry on the right side. Her abdomen was generally tender but soft with no organomegaly. A week into her admission she developed an oxygen requirement and increased work of breathing requiring intubation and ventilation.The second girl, 13 years old, presented to her local hospital with a 1-day history of epistaxis, right ear pain, and pain and swelling to the right periorbital tissues. Again, despite multiple courses of antibiotics, she had persistent symptoms and subsequently developed fever, fatigue, haemoptysis, and had a syncopal episode. She was admitted to her local district general hospital and, despite initial treatment, deteriorated over the following 2 weeks with persistent fever, new oxygen requirement, deteriorating renal function, and anaemia. She was transferred to a tertiary centre for respiratory support which escalated from Optiflow, through continuous then biphasic positive airway pressure, intubation and ventilation, and ultimately VV-ECMO.The investigations for both patients prior to admission to PICU at our centre are shown in table 1.edpract;107/2/113/T1T1T1Table 1Investigations Case 1 Case 2 Haematology  Leucocyte peak (×10<sup9</sup/L) 18.3 19.0  Neutrophil peak (×10<sup9</sup/L) 15.2 13.7  Lymphocyte peak (×10<sup9</sup/L) 3.5 2.3  Eosinophil peak (×10<sup9</sup/L) 0.9 2.5  Platelets Normal Normal  Haemoglobin nadir (g/L) 79 74  ESR (mm/hour) 104 44 Biochemistry  Creatinine peak (umol/L) Normal 153  CRP peak (mg/l) 321 280  ALT (IU/L) 122 Normal Microbiology Nasal swab: <iMoraxella catarrhalis</i Ear swab: <iPseudomonas aeruginosa</i Sputum negative for acid-fast bacilli, PCR negative ASOT 1600 IU/ml No growth on blood or urine culture Negative viral throat swab and MCS throat swab No positive microbiology including Monospot, Mantoux and TSpot Urine dipstick On day of admission: 1+pro, 4+Hb, 2+leu, 2+ket One week into admission: 3+pro, 4+Hb, 2+leu, 2+ket Three days prior to admission: 2+Hb, otherwise normal Radiology Echocardiogram: normal CXR at admission: normal CXR after 1 week: see figure 1 CT head: pansinusitis Abdominal USS: mild hepatomegaly, diffusely echogenic kidneys Echocardiogram: normal CT chest at local hospital: see figure 2 CXR on admission to PICU: bilateral consolidation with rounded lucency in right lower zone suggestive of cavity formation ALT, alanine aminotransferase; ASOT, anti-streptolysin O titre; CRP, C-reactive protein; CT, computed tomography; CXR, chest X-ray; ESR, erythrocyte sedimentation rate; Hb, haemoglobin; leu, leucocytes; ket, ketones; MCS, microscopy, culture, and sensitivity; PICU, paediatric intensive care unit; pro, protein; TSpot, measures T lymphocytes primed to <iMycobacterium tuberculosis</i antigens; USS, ultrasound scan. QUESTIONS: Describe findings in figures 1 and 2.Which causes of sinusitis could explain the presentation of both cases?Acute sinusitis following viral upper respiratory tract infection.Bacterial infection.Allergic sinusitis secondary to mould.Underlying diagnosis of cystic fibrosis.Sarcoidosis.Tuberculosis.Granulomatosis with polyangiitis.Samter's triad.Ciliary dysfunction.Immunodeficiency.What investigations should be performed in a child presenting with symptoms of sinusitis?edpract;107/2/113/F1F1F1Figure 1The chest X-ray for case 1, 1 week into her hospital admission.edpract;107/2/113/F2F2F2Figure 2The chest CT for case 2 at her local hospital, prior to transfer. <i<bAnswers can be found on page XX.</b</i" }, { "id": "pubmed23n0476_5155", "title": "[Clinical reasoning and decision making in practice. A 41-year old with periodic fever of unknown origin].", "score": 0.00980392156862745, "content": "A 41-year-old man presented with unexplained bleeding from the right tonsil. He subsequently developed periodic fever, cervical lymphadenopathy and hepatosplenomegaly. Despite extensive bacteriological, serological and radiographic investigations for infectious disease, rheumatic disease and malignancy no diagnosis was made. Although the fever pattern was very suggestive of Pel-Ebstein fever--commonly associated with lymphoproliferative disease--multiple biopsies of lymph nodes, bone marrow, tonsils and liver all proved negative. Empirical glucocorticoid therapy gave some temporary improvement lasting for a month. Splenectomy or splenic biopsy was not carried out because of the risk of excessive bleeding. Eventually the patient died of multi-organ failure and sepsis. At autopsy, a T-cell lymphoma with an unusual phenotype and focal involvement of bone marrow, liver and spleen was found. Clinicians are sometimes faced with the dilemma of whether to perform multiple, invasive and possibly harmful diagnostic tests or to start empirical therapy. Empirical therapy may only be started if the diagnosis has been made on strong clinical grounds and, if this is not the case, only after further diagnostic tests. The question of whether a potentially harmful diagnostic test is justified depends on the clinical course, the sensitivity and specificity of the test and the therapeutic possibilities." }, { "id": "InternalMed_Harrison_14488", "title": "InternalMed_Harrison", "score": 0.009678230266465561, "content": "Differential Diagnosis Whereas ~90% of cases of IM are due to EBV, 5–10% of cases are due to cytomegalovirus (CMV) (Chap. 219). CMV is the most common cause of heterophile-negative mononucleosis; less common causes of IM and differences from IM due to EBV are shown in Table 218-2. Therapy for IM consists of supportive measures, with rest and analgesia. Excessive physical activity during the first month should be avoided to reduce the possibility of splenic rupture, which often necessitates splenectomy. Glucocorticoid therapy is not indicated for uncomplicated IM and in fact may predispose to bacterial superinfection. Prednisone (40–60 mg/d for 2–3 days, with subsequent tapering of the dose over 1–2 weeks) has been used for the prevention of airway obstruction in patients with severe tonsillar hypertrophy, for Epstein-Barr Virus Infections, Including Infectious Mononucleosis Time of symptoms" }, { "id": "pubmed23n0620_7089", "title": "Glandular fever and pulmonary artery thrombosis in a paraplegic patient, who had undergone splenectomy for splenic trauma sustained along with spinal cord injury: misdiagnosed initially as urine infection and later as lymphoma when CT scan revealed enlarged lymph nodes: a case report.", "score": 0.009523809523809525, "content": "A 36-year-old male sustained fracture of first lumbar vertebra, splenic tear and paraplegia in a motorcycle accident in 2001; splenectomy was performed. In 2008, he presented with temperature and feeling rough. With a diagnosis of urine infection, he was prescribed ciprofloxacin, followed by trimethoprim, amoxicillin, and gentamicin, as temperature did not subside. White cell count was 21.2 x 109/L; lymphocytes were 13.05 x 109/L (1.00 - 4.00). Therefore, computerised tomography (CT) of chest and abdomen was performed. Thrombus was present in pulmonary arteries bilaterally involving the lobar and segmental branches. Enlarged lymph nodes were seen in axillae, chest, abdomen and inguinal regions. Radiological diagnosis was lymphoma. Cell marker showed an excess of large granular lymphocytes and activated lymphocytes. The Glandular Fever Slide Test was positive. Subsequently, Paul Bunnell test was also positive. Epstein Barr virus serology was consistent with recent Epstein Barr virus infection. Antibiotic was omitted; enoxaparin was prescribed for pulmonary artery thrombosis. Learning points from this case: (1) Although routine administration of antibiotic to a spinal cord injury patient with pyrexia may be acceptable in outpatient setting, other possibilities such as infection by multi-drug resistant organism, viral infection, venous or, arterial thrombosis should be considered if a patient does not respond promptly to antibacterial therapy. (2) When full blood count showed lymphocytosis (comprising &gt; 50% of white blood cells) with atypical morphology, lymphocyte surface markers, Paul Bunnell test, and Epstein Barr virus serology should be performed. These tests would have led to a diagnosis of infectious mononucleosis, and abdominal imaging studies could have been avoided. (3) Lymphoid hyperplasia is the hallmark of infectious mononucleosis; therefore, we should have suspected glandular fever rather than lymphoma when CT scan revealed enlarged lymph nodes in abdomen, mediastinum, axillae and inguinal regions in this patient, who had lymphocytosis with atypical morphology. (4) A soft tissue mass, situated inferior to left hemidiaphragm in this asplenic patient, was misinterpreted as lymph nodes; review of CT led to the correct diagnosis of splenunculus. (5) Acute infection with Epstein Barr virus may lead to transient induction of anti-phospholipid antibodies, which can cause vascular thrombosis. (6) This case illustrates the value of reviewing test results and discussion with senior doctors, as these measures help to recognize medical errors and improve patient care." }, { "id": "pubmed23n0886_1375", "title": "What is that rash?", "score": 0.009523809523809525, "content": "A healthy 15-month-old girl presented to the emergency department with a 24-hour history of fever and rash. The initial blanching rash developed into non-blanching areas with associated leg swelling. She had received no recent medications, had no known drug allergies and no unwell contacts.On examination, she was feverish at 38.6°C, capillary refill time was &lt;2 s with warm peripheries, heart rate 169 bpm and blood pressure 94/59 mm Hg. A palpable purpuric rash was evident on all four limbs and face (figure 1) although the trunk was spared. Her legs were tense and oedematous to the knee.edpract;103/1/25/EDPRACT2016311782F1F1EDPRACT2016311782F1Figure 1Rash at presentation.Initial investigations: Haemoglobin level: 131 g/L, white cell count: 16.6×10<sup9</sup/L, neutrophils: 11.1×10<sup9</sup/L and platelets: 407×10<sup9</sup/LCoagulation screen: normalC reactive protein level: 20 mg/LLactate level: 1.7 mmol/LIntravenous ceftriaxone was commenced following blood culture and meningococcal PCR. The following day, while remaining systemically well, she developed a vesicular rash on her trunk and back (figure 2).edpract;103/1/25/EDPRACT2016311782F2F2EDPRACT2016311782F2Figure 2Vesicular rash. What is the diagnosis? Henoch-Schonlein purpura (HSP)Meningococcal septicaemiaAcute haemorrhagic oedema of infancy (AHOI)Vasculitic urticariaGianotti-Crosti syndromeWhat further investigation is required? Check viral serology including Epstein-Barr virus and hepatitis B virusComplement levels and autoimmune screenSkin biopsyLumbar puncture and audiologyNo further investigationHow should this child be managed? Complete 7 days of ceftriaxone treatmentOral aciclovirOral steroidsRegular follow-up with urinalysis and blood pressure monitoringStop antibiotics if cultures were negative at 48 hours and discharge<iAnswers are on page</i▪▪." }, { "id": "wiki20220301en566_651", "title": "Epstein–Barr virus-associated lymphoproliferative diseases", "score": 0.009433962264150943, "content": "Systemic EBV-positive T cell lymphoma of childhood (TCLC) is an extremely rare and aggressive T cell lymphoma that occurs almost exclusively in children, adolescents, and young adults. It occurs more frequently in Asians and Latin Americans. The disease develops as a complication or progression of either Epstein–Barr virus-positive infectious mononucleosis (EPV+ IM) or chronic active Epstein–Barr virus infection (CAEBV)., that is, as a worsening of the signs/symptoms some three weeks after the onset of an EBV+ IM-like disease or an any time during the course of CAEBV. It presents in these diseases as the onset of progressive enlargements of the liver and spleen, worsening liver dysfunction, new skin rashes, pancytopenia (i.e. falls in the blood levels of leukocytes, red blood cells, and platelets), hemophagocytosis (i.e. ingestion of blood cells by histiocytes) in bone marrow and spleen), a coagulopathy (poor blood clotting), sepsis, and/or one or multiple organ failures. Unlike the" }, { "id": "pubmed23n0376_15872", "title": "[Clinical aspects of the diagnosis and treatment of infectious mononucleosis in primary care and in departments of infectious diseases].", "score": 0.009433962264150943, "content": "Medical documentation of the 342 patients hospitalised for infectious mononucleosis at the departments of infectious diseases of two county hospital was retrospectively reviewed between 1990 and 1996 and the most important clinical data were recorded. In order to document the effect of control measures, which were taken for the improvement diagnosis and therapy, data of the 105 infectious mononucleosis patients at one of the mentioned departments were also recorded in 1997 and 1998. The length of the time before the hospital admission (avg. 10.3 days), the length of the hospital stay (avg. 9.2 days) and the respectable amount of antibiotics taken for this indication show that this disease has great cost effect. High rate of classical clinical signs (fever, pharyngitis, lymphadenopathy, atypical cells) indicates, that the majority of the patients consulting their doctors presented the well-known signs of the disease. Only 43.6% of the patients were diagnosed as infectious mononucleosis by the G. P. s. Majority of the cases were treated for tonsillitis. 90.7% of the patients were given antibiotics before the hospital admission (avg. 1.6 antibiotics/person). 43.3% of the patients left the hospital without serologic diagnosis. After drowning lesson from the first part of this study, there was significant decrease in the rate of lack of serologic diagnosis and in the amount of consumption of antibiotics for this indication in the hospital, but there was no change at the level of G. P. s. The results of this paper demonstrate that the daily routine diagnosis and treatment of a well-known diseases differs remarkably from optimal practice. The fact is, that even if the physician has knowledge of a certain disease, does not necessarily mean that he uses it in his routine work. In order to reduce this failure, authors propose introduction of protocols and regular review of the practice." }, { "id": "InternalMed_Harrison_4584", "title": "InternalMed_Harrison", "score": 0.009345975232198142, "content": "Most lymphadenopathy patients do not require a biopsy, and at least half require no laboratory studies. If the patient’s history and physical findings point to a benign cause for lymphadenopathy, careful follow-up at a 2to 4-week interval can be used. The patient should be instructed to return for reevaluation if there is an increase in the size of the nodes. Antibiotics are not indicated for lymphadenopathy unless strong evidence of a bacterial infection is present. Glucocorticoids should not be used to treat lymphadenopathy because their lympholytic effect obscures some diagnoses (lymphoma, leukemia, Castleman’s disease), and they contribute to delayed healing or activation of underlying infections. An exception to this statement is the life-threatening pharyngeal obstruction by enlarged lymphoid tissue in Waldeyer’s ring that is occasionally seen in infectious mononucleosis. CHAPTER 79 Enlargement of Lymph Nodes and Spleen" }, { "id": "pubmed23n1045_11173", "title": "Kawasaki disease with a concomitant primary Epstein - Barr virus infection.", "score": 0.009345794392523364, "content": "Kwasaki disease (KD) is the leading cause of acquired heart disease in children in most developed countries. The cause of KD remains unknown. The presumed theory is that KD occurs due to one or more infectious agents who evoke an abnormal immunological response in susceptible individuals. Epstein - Barr virus (EBV) infection has been considered as a suspected causative agent because of the potential effect on the immune system. A previously healthy 19 month old boy presented with a 6 day history of fever accompanied by a diffuse macular erythematous rash that appeared 1 day after. The physical examination on admission revealed bilateral non-suppurative conjunctivitis, dry fissured and injected lips without \"strawberry\" tongue, diffuse macular rash on the trunk, face and limbs, swelling of the hands and feet, and right cervical lymphadenopathy (2 cm in diameter). Following fulfillment of all the clinical criteria, the diagnosis of KD was made and treatment with IVIG 2 g/Kg was administered along with oral aspirin (80 mg/ kg/day). However, despite the treatment, he remained febrile for an additional 2 days with persistent clinical manifestations. Therefore, he received a second 2 g/kg IVIG course with a favorable response. On the 14th day of illness the patient became febrile again and was readmitted. Blood examinations revealed remarkable leukocytosis up to 35.7 X 10<sup9</sup/L with 87.3% lymphocytes and the blood smear revealed atypical lymphocytes and monocytes. The liver enzymes were elevated. The serology for infectious mononucleosis from his first admission revealed: IgM CMV (+), IgG CMV (-); IgM VCA EBV (+) IgG VCA EBV (-), IgG EBNA (-). To confirm infectious mononucleosis following the administration of 2 doses of IVIG, serum EBV PCR was performed and was positive (1.6X 10<sup3</sup cp/ml). We describe here a case of KD with a concomitant primary EBV infection. To the best of our knowledge, this is the first case in western country that describes KD with acute EBV infection as confirmed by PCR. The case we described stands as a contribution in favor of the possible role of EBV in the development of KD." }, { "id": "pubmed23n0596_23545", "title": "[Clinical reasoning and decision-making in practice. A patient with fever and pancytopenia].", "score": 0.009345794392523364, "content": "An 82-year-old man was admitted with a 1-week history of chilling fever and dry cough. Laboratory tests revealed pancytopenia and elevated levels of C-reactive protein and lactic dehydrogenase (LDH). Screening for infectious diseases was negative. A bone marrow biopsy showed aspecific findings. The combination of pancytopenia, persistent fever, elevated LDH and hepatomegaly (demonstrated by ultrasound examination of the abdomen) was suggestive of the haemophagocytic syndrome. This was confirmed by very high levels of ferritin and soluble interleukin-2 receptor in the blood. In addition, re-examination of the bone marrow showed several haemophagocytic histiocytes. A polymerase chain reaction for Epstein-Barr virus (EBV) revealed a very high viral load. Since the patient had a history of an increased level of anti-EBV immunoglobulin-G, this was explained by a reactivation of the EBV infection. On the sixth day in hospital the patient developed signs of bilateral pneumonia and subsequent multiple organ failure. Despite intensive treatment the patient died. Autopsy revealed no haematological or other malignancies, but did show haemophagocytosis in many organs. It was then concluded that the patient had a virus-associated haemophagocytic syndrome, due to a reactivation of EBV, for which no underlying cause was found." }, { "id": "pubmed23n0710_18081", "title": "[Pneumonia caused by Fusobacterium necrophorum: is Lemierre syndrome still current?].", "score": 0.009259259259259259, "content": "Fusobacterium necrophorum is a non-spore-forming gram-negative anaerobic bacillus that may be the causative agent of localized or severe systemic infections. Systemic infections due to F.necrophorum are known as Lemierre's syndrome, postanginal sepsis or necrobacillosis. The most common clinical course of severe infections in humans is a progressive illness from tonsillitis to septicemia in previously healthy young adults. A septic thrombophlebitis arising from the tonsillar veins and extending into the internal jugular vein leads to septicemia and septic emboli contributing to the development of necrotic abscesses especially in lungs and other tissues such as liver, bone and joints. In this case report, a previously healthy man with pneumonia and empyema due to F.necrophorum has been presented. A 22 year-old man suffering from sore throat for seven days was admitted to emergency department with ongoing fever and dysphagia for three days. On admission he was already taking amoxicillin-clavulanic acid and his complaints were relieved with continuation of therapy to a total of 10 days. However, five days after the cessation of treatment he developed productive cough, fever and generalized myalgia. On physical examination, there were crackles on right lower lung, and chest X-ray revealed pulmonary consolidation on the right middle lobe. Levofloxacin therapy was started based on the diagnosis of pneumonia. While polymorphonuclear leucocytes and intracellular gram-negative bacilli were seen in Gram stained sputum smear, sputum culture was reported as normal flora. Although the patient's status had started to improve with treatment, his condition deteriorated with development of fever and dyspnea. Chest X-ray revealed consolidation, pulmonary infiltrates, pleural effusion and air-fluid level on the right. Meropenem, clarithromycin and linezolid were initiated and a chest tube was inserted with the preliminary diagnosis of necrotizing pneumonia, empyema and type-1 respiratory failure. While there was no growth on bronchoalveolar lavage fluid culture, thoracentesis material inoculated into thioglycolate broth revealed turbidity. Further inoculation onto Schaedler agar which was incubated under anaerobic conditions, yielded growth of catalase negative, indol positive, gram-negative anaerobic bacilli identified as F.necrophorum by BBL Crystal system (Becton Dickinson, USA). The detailed history of the patient revealed that fish bone had stuck in his throat a week ago. Clarithromycin and linezolid were discontinued and he was recovered within six weeks of meropenem treatment. F.necrophorum infection should be considered in the differential diagnosis of persistent head and neck infections with rapidly progressive metastatic necrotic lesions especially in healthy young adults and clindamycin or metranidazol should be added to the treatment protocols." }, { "id": "pubmed23n0035_129", "title": "Infectious mononucleosis.", "score": 0.009259259259259259, "content": "Infectious mononucleosis is a unique disease in its hematologic aspects; it is different from the frequently occurring acute microbial diseases in that it affects primarily the reticuloendothelial system; and it is interesting serologically because of the heterophil antibody reaction, as well as the multiplicity of antibodies which may be produced. The diagnosis should be suspected clinically before hematology is reported - by remembering the prototypes. In fact, a patient between 16 and 25 years old who complains of sore throat and fever is more likely to have infectious mononucleosis than another disease; and if - in addition - he is jaundiced, a diagnosis of infectious mononucleosis is almost certain. Finally, a negative result of treatment with corticosteroid has the diagnostic significance mentioned above. Positive effect of treatment has no diagnostic significance." }, { "id": "pubmed23n0056_3196", "title": "Mononucleosis and hepatic failure associated with diphenylhydantoin treatment in an infant.", "score": 0.009174311926605505, "content": "Diphenylhydantoin-induced hepatitis and mononucleosis are uncommon in children. The occurrence of these two diseases in the same individual, with progression to hepatic failure is rare and has not been reported in infants. This report represents a 6-month-old male infant who developed an infectious mononucleosis-like syndrome and hepatic failure 16 days after diphenylhydantoin administration. He took this anticonvulsant for controlling seizures after a head injury. Fever, skin rash, hepatosplenomegaly, lymphadenopathy, and atypical lymphocytosis led to the initial diagnosis of infectious mononucleosis. However, negative heterophil antibody did not support the diagnosis. Jaundice ensued in the following course and became more and more profound. Meanwhile, physical examination showed shrinking in liver size. Negative virology studies, including Epstein-Barr virus, cytomegalovirus, and hepatitis B virus, excluded them as causative agents. The patient lapsed into a stage I hepatic coma, but gradually recovered clinically and biochemically after eight successive exchange transfusions and supportive care. Two liver biopsies were performed 20 and 50 days after the onset of disease, respectively. Remarkable hepatic parenchymal loss, cholestasis, and fatty change were found on histologic examination of the first biopsy specimen, and portal fibrosis was noted on the second." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 145, 421 ] ], "word_ranges": [ [ 22, 70 ] ], "text": "Option 4 is describing to us a T4 stage, either by invasion of adjacent organs or perforation. The T4s carry a much higher chance of recurrence, in fact there are ongoing studies that propose prophylactic HIPEC in T4 and second look surgery + HIPEC in perforated colon tumors." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The presence of anemia at diagnosis.", "2": "The existence of a family history of colorectal cancer.", "3": "The size of the primary lesion and histological differentiation.", "4": "Perforation or adhesion of the tumor to adjacent organs.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0736_2331", "title": "[The primary tumour resection with extended D3 lymph node dissection, metastases of synchronous metastatic colorectal cancer].", "score": 0.013283828382838283, "content": "The progress in colorectal cancer treatment of IV stage that was shown in last decades was mainly due to modern chemotherapy schemes and aggressive surgical approach towards distant metastatic lesions. Meanwhile less attention is paid to primary tumour treatment - the questions of necessity and volume of its resection are still open. The AIM of this study was to evaluate safety and oncologic effectiveness of primary tumour resection with D3 lymph node dissection in synchronous metastatic colorectal cancer. Patients with colorectal cancer and synchronous metastatic lesion of distant organs who underwent surgical resection of primary tumour were chosen from prospectively collected department database. The analysis of short-term and long-term results of resections with and without extended D3 lymph node dissection and prognostic factors affecting overall survival was carried out. From 2006 to 2011 total of 190 patients underwent primary tumour resection, 157 (82.6%) among them - with extended D3 lymph node dissection. Twenty one patient (11%) developed postoperative complications that required reintervention, 30-days mortality rate was 2.6%. Three-year cumulative overall survival was 37%, median survival - 22 months (25 months with extended lymph node dissection and 4 months without, p&lt;0.001). Univariate analysis revealed following statistically significant prognostic factors improving overall survival: metastatic lesions in one distant organ, solitary haematogenous nodes, extended D3 lymph node dissection, postoperative chemotherapy, resection of metastatic lesions. Removal of primary tumour with extended lymph node dissection in metastatic colorectal cancer doesn't increase the number of postoperative complications and mortality. Performing D3 lymph node dissection favours increase of median survival and is a significant prognostic factor influencing outcomes." }, { "id": "wiki20220301en220_29197", "title": "Metastatic liver disease", "score": 0.011892029539088363, "content": "Diagnosis Hemoglobin decrease Liver function test: ALP elevated, bilirubin elevated, albumin decrease Carcinoembryonic antigen for colorectal secondaries Ultrasound scan CT scan Biopsy under ultrasound control Treatment Treatment can consist of surgery (hepatectomy), chemotherapy and/or therapies specifically aimed at the liver like radiofrequency ablation, transcatheter arterial chemoembolization, selective internal radiation therapy and irreversible electroporation. For most patients no effective treatment exists because both lobes are usually involved, making surgical resection impossible. Younger patients with metastases from colorectal cancer confined to one lobe of the liver and up to 4 in number may be treated by partial hepatectomy. In selected cases, chemotherapy may be given systemically or via hepatic artery." }, { "id": "wiki20220301en589_7883", "title": "Histopathology of colorectal adenocarcinoma", "score": 0.011538222305156436, "content": "Grading Conventional adenocarcinoma may be graded as follows Staging Staging is typically made according to the TNM staging system from the WHO organization, the UICC and the AJCC. The Astler-Coller classification (1954) and the Dukes classification (1932) are now less used. T stands for tumor stage and ranges from 0, no evidence of primary tumor, to T4 when the tumor penetrates the surface of the peritoneum or directly invades other organs or structures. The N stage reflects the number of metastatic lymph nodes and ranges from 0 (no lymph node metastasis) to 2 (four or more lymph node metastasis), and the M stage gives information about distant metastasis (M0 stands for no distant metastasis, and M1 for the presence of distant metastasis). A clinical classification (cTNM) is done at diagnosis and is based on MRI and CT, and a pathological TNM (pTNM) classification is performed after surgery." }, { "id": "wiki20220301en305_21270", "title": "Adenocarcinoma of the lung", "score": 0.009900990099009901, "content": "Adenocarcinoma is more common in patients with a history of cigarette smoking, and is the most common form of lung cancer in younger women and Asian populations. The pathophysiology of adenocarcinoma is complicated, but generally follows a histologic progression from cells found in healthy lungs to distinctly dysmorphic, or irregular cells. There are several distinct molecular and genetic pathways that contribute to this progression. Like many lung cancers, adenocarcinoma of the lung is often advanced by the time of diagnosis. Once a lesion or tumor is identified with various imaging modalities, such as computed tomography (CT) or X-ray, a biopsy is required to confirm the diagnosis. Treatment of this lung cancer is based upon the specific subtype and the extent of spread from the primary tumor. Surgical resection, chemotherapy, radiotherapy, targeted therapy and immunotherapy are used in attempt to eradicate the cancerous cells based upon these factors." }, { "id": "pubmed23n0335_10083", "title": "[Evaluation of the results of treatment of cancer of the large intestine based on our clinical data].", "score": 0.009900990099009901, "content": "Results of the treatment of 225 patients operated between 1991-1995 on the colorectal carcinoma in the II Clinic of Surgery, Medical Academy Wroclaw are evaluated. The analysis of the own material covers the tumor site, age of the patients, histologic grade and clinical stage according to Dukes. The type of surgical procedure--curative or palliative and the evaluation of the survival, death and recurrence rate is presented. Curative procedures were possible only in approximately 60% of cases. The Dukes stage C and D was established in 55.5% of the operated patients. Authors believe that such a significant number of advanced cases was the reason of so poor results. In conclusion they suggest to introduce screening tests for early detection of colorectal carcinoma." }, { "id": "wiki20220301en105_57118", "title": "Primitive neuroectodermal tumor", "score": 0.00980392156862745, "content": "Treatment The approach to management of a CNS PNET is first to obtain detailed imaging through MRI, as well as additional scans of the patient's body (X-ray, CT, PET, even bone marrow biopsies) to look for metastasis or other associated malignancies. The tumor will then need to be biopsied to confirm the diagnosis. After the diagnosis of a CNS PNET is confirmed, management includes neoadjuvant chemotherapy and radiation (to reduce tumor size burden), complete surgical resection with confirmed negative margins, and/or additional adjuvant post-surgical chemotherapy. CNS PNET is aggressive and must be managed as so. Palliative care services should also become involved in the patient's care team when the diagnosis is made. See also Medulloblastoma Ependymoma Ewing family of tumors References Pediatric cancers Rare cancers Nervous system neoplasia Small-blue-round-cell tumors" }, { "id": "pubmed23n0387_9310", "title": "[Gastrocolic tumor progression--a possibility or mere supposition?].", "score": 0.00980392156862745, "content": "The authors examined the five-years postoperative survival rate of fifty patients who suffered from colorectal cancer along with the fact that the large bowel one of the neighbouring organs were resected. The subjects were divided into four groups: the colorectal resection was associated with (1) stomach resection (13 patients); (2) liver metastasectomy (14 patients); (3) small bowel resection (10 patients); (4) the resection of other organs (13 patients). In the first two years of the study they were examined once in every three months, in the next two years once in every six months and then yearly. The following tests were carried out: chest X ray, abdominal sonography, irrigography or colonoscopy and CEA. On condition that the colonoscope reached the caecum and the result was negative, the test was repeated only a year later. The patients were operated on between 1985 and 1997. The statistical analysis was made with the help of the Kaplan-Meier method. During this period fifty-six complex resections were performed. Out of fifty-six patients fifty were followed. Compliance 89%. In group 1, where the average age of patients was sixty-two years, one patient died in the forty-first and the other in the fifty-second month after the surgery. Survival rate: 11/13 (83%). The survival rates for the other groups were as follows: group 2 (average age 64) twelve patients died within five years. Survival rate 2/14 (14%). The difference between the survival rates in the first two groups in significant (P = 0.0001). Group 3 (average age 67) seven died and only three survived. Survival rate: 3/10 (30%). The difference between group 1 and group 3 is significant (P = 0.0022). Group 4 (average age 64) seven patients died. Survival rate 6/13 (46%). Comparing this rate to that of the group 1, the difference is not significant (P &gt; 0.01). Having analysed the results of the four groups it can be concluded that the patients of group 1 lived the longest (stomach resection) and those of group 2 (liver metastasectomy) died the earliest after the operation. It is surprising that the patients of group 3 lived significantly shorter than the ones of group 1 in spite of the fact that they belong by far the greatest number to stage Dukes B (group 1: 12/13 = 92%; group 3: 7/10 = 70%). The authors assume that the partial or the total absence of the stomach keeps back the growth of the tumour (gastro-colic tumour growing dependency). They think that in case of colon cancer which infiltrates the stomach surgeons experienced in gastric and colorectal surgery should be encouraged to take the risk of the double resection providing the fact that the operation is accomplishable." }, { "id": "wiki20220301en253_6045", "title": "Marginal zone B-cell lymphoma", "score": 0.009708737864077669, "content": "Primary colonic EMZL, also termed primary colonic MALT lymphoma, usually presents at an early stage of disease with evidence of lower GI tract bleeding (e.g. tarry bowel movements and/or iron deficiency anemia), less commonly with lower abdominal pain, and rarely with bowel perforation or intussusception. Endoscopic examination most often reveals a single polyp or rarely multiple polyps, a mucosal ulcer, or a mucosal nodule. Diagnosis is passed on biopsy of the lesions showing a histology typical of EMZL, e.g. diffuse infiltrates composed of small to medium-sized lymphocytes that may show morphological features of monocytes and/or plasma cells. The lymphocytes in these lesions express B cell markers (e.g. CD19 and CD79a) typical of EMZL lesions. The best treatment regimen for this lymphoma is debated. Surgical resection, endoscopic resection, radiation, and chemotherapy have been employed. Surgery followed by chemotherapy (mitoxantrone + chlorambucil + prednisone or cyclophosphamide +" }, { "id": "pubmed23n0262_13481", "title": "[Diagnosis and staging of colorectal cancers].", "score": 0.009708737864077669, "content": "Early colorectal cancer produces no symptom, thus justifying efforts at detection in screening programs. Symptoms are usually secondary to obstruction, local invasion, perforation or bleeding. Any fecal bleeding must be investigated to rule out a colorectal cancer. The initial imaging study to identify a colorectal cancer is often colonoscopy, which is frequently supplemented with a double contrast barium enema. Once the presence of cancer is histologically proven, the preoperative evaluation includes detection of hepatic and extrahepatic spread, especially with ultrasound and CT scan. Endorectal ultrasonography has been shown to be a significant advance for staging rectal cancer. It provides the best staging in selecting patients for preservation of sphincter function and for adjuvant therapies. The most useful prognostic factors in tumors without distant metastases are the depth of tumor extension, the number of positive lymph nodes and the histologic grade. Preoperative CEA level, vascular invasion and ploidy are also important prognostic factors." }, { "id": "wiki20220301en057_6595", "title": "Malignant peripheral nerve sheath tumor", "score": 0.009615384615384616, "content": "Prognosis Patient response to treatment will vary based on age, health, and the tolerance to medications and therapies. Metastasis occurs in about 39% of patients, most commonly to the lung. Features associated with poor prognosis include a large primary tumor (over 5 cm across), high grade disease, co-existent neurofibromatosis, and the presence of metastases. It is a rare tumor type, with a relatively poor prognosis in children. In addition, MPNSTs are extremely threatening in NF1. In a 10-year institutional review for the treatment of chemotherapy for MPNST in NF1, which followed the cases of 1 per 2,500 in 3,300 live births, chemotherapy did not seem to reduce mortality, and its effectiveness should be questioned. Although with recent approaches with the molecular biology of MPNSTs, new therapies and prognostic factors are being examined. See also Keratinizing metaplasia List of cutaneous conditions 50/50 (2011 film) References External links" }, { "id": "pubmed23n0583_23554", "title": "[Clinicopathological analysis of 39 patients with multiple primary synchronous colorectal carcinoma].", "score": 0.009615384615384616, "content": "To investigate the clinicopathologic characteristics and prognosis of multiple primary synchronous colorectal carcinoma (synchronous CRC) and single colorectal carcinoma (single CRC). Clinicopathological data of 39 patients with synchronous CRC and 528 patients with single CRC from May 1996 to June 2001 were reviewed retrospectively. The patients with synchronous CRC accounted for 6.9% of all the patients with colorectal carcinoma treated in our hospital during the same period. Compared with concurrent lesions, Dukes stage of the index lesions of synchronous CRC was more developed and the lymph node metastasis and vessel invasion occurred more frequently. In addition, it also had poorer differentiation. There were significant differences of Dukes stages and lymph node metastasis between the index lesions and single CRC. The incidence of adenomatous polyp in synchronous CRC was higher than that in single CRC(59.0% vs 25.0%,P&lt;0.01). The sensitivity of preoperative colonoscopy examination was 76.9%, which was significantly higher than that of barium examination and exploration during operation. The total 5-year survival rate of synchronous CRC was significantly lower than that of single CRC (5.1% vs 28.2%,P=0.042), and no significant difference of total 5-year survival rate was found between single CRC patients and synchronous CRC patients undergone radical operation. Synchronous CRC patients undergone radical operation had longer survival as compared to those undergone palliative operation(P&lt;0.01). Multivariate analysis indicated that Dukes stages, lymph node metastasis, vessel invasion and the type of operation were independent prognostic factors of synchronous CRC. Synchronous CRC and single CRC are not always similar in clinicopathologic characteristics and prognosis. Early finding, early diagnosis and radical operation are the keys to improve the survival rate of synchronous CRC." }, { "id": "wiki20220301en073_12302", "title": "Blastoma", "score": 0.009523809523809525, "content": "Mortality during the first few years after diagnosis is around 15%, although current therapeutic approaches have reached cure rates of up to 60%. The most common forms of therapy are surgical resection, aided by radiation and chemotherapy (before or after surgery), and the survival rates that this yields are between 50% and 90%, a wide range that is influenced by the age at diagnosis, metastasis and histologic variants of the medulloblastoma of each patient. However, despite the long-term survival achieved with current treatments, the neurologic, endocrinologic and cognitive effects are still a great concern in the treatment of medulloblastoma. Nephroblastoma The most common type of renal cancer in children is nephroblastoma, also known as Wilms tumor. Nephroblastoma is also the fourth most common pediatric cancer form, and the most common pediatric abdominal cancer, typically diagnosed in children from zero to five years old." }, { "id": "pubmed23n0131_14741", "title": "[Treatment of colorectal cancer].", "score": 0.009523809523809525, "content": "The large majority of colorectal cancers are well or moderately differentiated adenocarcinomas. Their biological behavior is not as malignant as that of stomach cancer, with a tendency of slow growth and limited spread. Surgery is therefore the first choice for management of these cancers even in cases where complete removal of the tumor is not expected, surgery is useful for the prolongation or improvement of the quality of life. However, the correct choice of operation for such cases is very important. The extent of resection and dissection must be decided based upon the degree of cancer spread. Both must be sufficient, but not excessive. In cases in the early stage where cancerous growth has not spread beyond the submucosal layer, local or segmental excision may be a good enough treatment. On the other hand, for far advanced rectal cancer involving adjacent organs, combined resection and pelvic evisceration is curatively effective. Several pathological findings of resected specimens influencing prognosis were investigated in the present study. In cases which appeared to be diffuse infiltrative spreading type in macroscopic appearance or poorly differentiated, undifferentiated, or mucinous types of cancer in their histological features, survival rates were low. However, these were uncommon and over half of them were much too far advanced to receive curative resection. Irradiation combined with hyperthermia or heavy chemotherapy were applied, but were mostly ineffective. For these uncommon types of cases as well as far advanced cases, we have no effective treatment other than surgery at this time." }, { "id": "wiki20220301en127_19326", "title": "Mediastinal germ cell tumor", "score": 0.009433962264150943, "content": "Treatment Pure mediastinal seminomas are curable in the large majority of patients, even when metastatic at the time of diagnosis. These tumors are highly sensitive to radiation therapy and to combination chemotherapy. However, the cardiotoxicity of mediastinal radiation is substantial and the standard treatment of mediastinal seminomas is with chemotherapy using bleomycin, etoposide and cisplatin for either three or four 21-day treatment cycles depending on the location of any metastatic disease. Patients with small tumors (usually asymptomatic) that appear resectable usually undergo thoracotomy and attempted complete resection followed by chemotherapy. The treatment for mediastinal nonseminomatous germ cell tumors should follow guidelines for poor-prognosis testicular cancer. Initial treatment with four courses of bleomycin, etoposide, and cisplatin, followed by surgical resection of any residual disease, is considered standard therapy." }, { "id": "pubmed23n0107_2562", "title": "[Natural history of synchronous hepatic metastases from a non-treated colorectal cancer].", "score": 0.009433962264150943, "content": "The authors present a retrospective study concerning 135 cases of untreated synchronous metastases from colorectal cancer. The median survival is 5.5 months and the natural history is depending on the percentage of liver replacement, on the \"performance status\" of each patient and on the stage of primary tumors classified according to Dukes. The seric levels of Alkaline Phosphatase and CEA are other useful prognostic factors. The age of patients and systemic chemotherapy (5-Fluorouracil) are not able to influence the evolution of the disease. At last different techniques, both curative and palliative, used in the current treatment of liver metastases from colorectal cancer are discussed and the reported survival improvements reaching with these forms of treatment are compared to the natural history of the disease." }, { "id": "wiki20220301en136_14056", "title": "Adamantinoma", "score": 0.009379993608181527, "content": "Diagnosis Diagnosis is on plain radiography, or CT scan Treatment Treatment consists of wide resection or amputation. Metastases are rare at presentation but may occur in up to 30% of patients during the disease course. Prognosis is excellent, with overall survival of 85% at 10 years, but is lower when wide surgical margins cannot be obtained. This tumor is insensitive to radiation so chemotherapy is not typically used unless the cancer has metastasized to the lungs or other organs. History The typically benign odontogenic tumor known as ameloblastoma was first recognized in 1827 by Cusack but did not yet have any designation. In 1885, this kind of odontogenic neoplasm was designated as an adamantinoma by Malassez and was finally renamed to the modern name ameloblastoma in 1930 by Ivey and Churchill. Some authors still confusingly misuse the term adamantinoma to describe ameloblastomas, although they differ in histology and frequency of malignancy. References External links" }, { "id": "wiki20220301en542_17336", "title": "Ultrasonography of liver tumors", "score": 0.009354082998661311, "content": "US examination is required to detect liver metastases in patients with oncologic history. In addition, the method can incidentally detect metastases in asymptomatic patients. Early identification (small sizes, small number) is important to establish an optimal course of treatment which can be complex (chemotherapy, radiofrequency ablation, surgical resection) but welcomed. In addition, discrimination of synchronous lesions that have a different nature is also important knowing that up to 25–50% of liver lesions less than 2 cm detected in cancer patients may be benign . US sensitivity for metastases detection varies depending on the examiner's experience and the equipment used and ranges between 40–80% . Sensitivity is conditioned by the size and acoustic impedance of the nodules. For a lesion diameter below 10 mm US accuracy is greatly reduced, reaching approx. 20%. Other elements contributing to lower US" }, { "id": "wiki20220301en435_25766", "title": "Pulmonary enteric adenocarcinoma", "score": 0.009345794392523364, "content": "Pulmonary enteric adenocarcinoma is rare subtype of pulmonary adenocarcinoma. Presentation The presentation is similar to that of other lung cancers. There is nothing in the radiological appearances that would suggest this particular histology. Two-thirds of reported cases have occurred in the right lung. The reason for this difference is not known and may be due to chance. Histology The typical histological appearance of this tumour of tall columnar cells arranged in an irregular glandular cavity or cribriform pattern with extensive central necrosis. The cells resemble those of the intestinal epithelium and colorectal carcinomas. Diagnosis Diagnosis of this type of lung cancer is by biopsy, histology and special staining. CT and colonoscopy to rule out a colonic primary are recommended. Treatment Optimal treatment for this condition is not known. Surgery to remove the lesion is the usual form of treatment. Whether radiotherapy or chemotherapy can offer any advantage is not known." }, { "id": "pubmed23n0133_12900", "title": "[Evaluation of the number of patients likely to require surgical treatment of hepatic metastases. Based on a series of 180 colorectal cancers].", "score": 0.009345794392523364, "content": "The spontaneous prognosis of patients with hepatic metastases from colo-rectal cancer is poor in the short term: less than 10 p. cent will be alive after 2 years. Over recent years, several teams have obtained encouraging results after surgical resection of hepatic metastases. The aim of the present study was to evaluate the number of patients likely to require resection of hepatic metastases in a serie of 180 cases of colo-rectal cancer. 57 patients (30 p. cent) already had hepatic metastases at the time of the gastro-intestinal resection and only 3 underwent a simultaneous metastasectomy. In the other cases, the extent of the disease or the general condition of the patients contra-indicated a 2-stage resection. Among the 126 patients free of metastases at the time of the operation, 40 p. cent would have been excluded from hepatic resection in the event of secondary development of metastases because of the general clinical state. 75 patients were suitable for post-operative surveillance of hepatic metastases. We calculated that 20 of them might develop a hepatic metastasis without local recurrence of the colo-rectal cancer in the 2 years following the colonic resection, although of course we were unable to predict the type of metastasis or its accessibility to surgery. These figures may be useful as a guide to the development of a surveillance strategy." }, { "id": "pubmed23n1129_16359", "title": "Anal fistula metastasis of rectal cancer after neoadjuvant therapy: a case report.", "score": 0.009259259259259259, "content": "Anal metastasis of colorectal cancer is very rare and may present synchronously or metachronously, regardless of pre-existing anal diseases. We report a case of anal fistula metastasis after completion of neoadjuvant therapy for rectal cancer, followed by surgical resection of the primary tumor and metastatic lesion. A 50-year-old man was diagnosed with rectal cancer located 5 cm from the anal verge, with a clinical stage of cT3N0M0. He denied any medical or surgical history, and physical examination revealed no perianal disease. He underwent preoperative chemoradiation therapy (CRT) consisting of a tegafur/gimeracil/oteracil potassium (S-1)-based regimen with 45 Gy of radiation. After completion of CRT, computed tomography (CT) revealed the primary tumor's partial response, but a liver mass highly suggestive of metastasis was detected. This mass was later diagnosed as cavernous hemangioma 3 months after CRT initiation. He then underwent and completed six cycles of consolidation chemotherapy with a capecitabine-based regimen. Subsequent colonoscopy revealed the complete response of the primary tumor, but CT showed thickening of the edematous rectal wall. Therefore, we planned to perform low anterior resection as a radical surgery. However, he presented with persistent anal pain after the last chemotherapy, and magnetic resonance imaging revealed a high-intensity mass behind the anus, suggestive of an anal fistula. We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula. Fistulectomy was performed, and a pathological diagnosis of tubular adenocarcinoma, suggestive of implantation metastasis, was made. Thereafter, we performed laparoscopic abdominoperineal resection. Histopathological examination revealed well-differentiated adenocarcinoma, ypT2N0, with a grade 2 therapeutic effect. Subsequent immunohistochemistry of the resected anal fistula showed a CDX-2-positive, CK20-positive, CK7-negative, and GCDFP-15 negative tumor, with implantation metastasis. There was no cancer recurrence 21 months after the radical surgery. This is the first report of anal fistula metastasis after neoadjuvant therapy for rectal cancer in a patient without a previous history of anal disease. If an anal fistula is suspected during or after neoadjuvant therapy, physical and radiological assessment, differential diagnosis, and surgical intervention timing for fistula must be carefully discussed." }, { "id": "pubmed23n0070_17554", "title": "[Yield of diagnostic tests in neoplasms of unknown origin. A retrospective study].", "score": 0.009259259259259259, "content": "A retrospective analysis of 54 patients diagnosed of neoplasia of unknown origin between January 1983 and December 1987 are presented. The patients's characteristics, histologic type, localization of metastasis, diagnostic procedures used and their cost-effectiveness, treatment, survival, and percentage of diagnosis of primary disease, are studied by clinical follow-up o necropsy studies. Our results are compared with those described in the literature. Adenocarcinoma was the predominant histologic type (48%). The cost-effectiveness of diagnostic tests was practically none in those performed without a clear clinical sign of suspicion, and very low in those performed with a clinical suspicion. The over all survival was 13 months with an actuarial survival probability at 24 months of 34%. We highlight the importance of an organized and predetermined clinical approach in this kind of patients, performing complementary tests only under the suspicion of a sign, or if a disease has to be discarded before initiating active oncologic treatment." }, { "id": "wiki20220301en132_46510", "title": "Chondroblastoma", "score": 0.009174311926605505, "content": "Rarely, more aggressive chondroblastomas can metastasize. The most common location for metastases is the lung, with some cases also involving secondary bone sites, soft tissue, skin, or the liver. The prevalence of metastatic chondroblastoma, however, is quite low and is believed to be less than 1%. There is no relationship established between metastasis and previous surgery, non-surgical treatment, anatomical location, or patient age. Survival of patients with metastatic lesions is better when the metastases are surgically resectable, as chemotherapy has been shown to have little to no benefit. Prognosis is bleak for patients with malignant chondroblastomas that are resistant to surgery, radiation, and chemotherapy. However, patients with resectable metastases have survived for several years following diagnosis." }, { "id": "pubmed23n0731_13315", "title": "[Not Available].", "score": 0.009174311926605505, "content": "F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the \"Will Rogers Phenomenon.\" Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice." }, { "id": "pubmed23n0731_13346", "title": "[Not Available].", "score": 0.00909090909090909, "content": "F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the \"Will Rogers Phenomenon.\" Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice." }, { "id": "wiki20220301en012_125066", "title": "Krukenberg tumor", "score": 0.009035515320334262, "content": "Treatment and prognosis Since Krukenberg tumors are secondary (metastatic), management might logically be driven by identifying and treating the primary cancer. The optimal treatment of Krukenberg tumors is unclear. The role of surgical resection has not been adequately addressed but if metastasis is limited to the ovaries, surgery may improve survival. The role of chemotherapy and/or radiotherapy is uncertain but may sometimes be beneficial. History Krukenberg tumors are named after Friedrich Ernst Krukenberg (1871–1946), who reported what he thought was a new type of primary ovarian malignancy in 1896; six years later these were shown to be of metastatic gastrointestinal tract origin. However, Paget had described the process in 1854. References External links Gastrointestinal cancer Ovarian cancer" }, { "id": "pubmed23n0551_9237", "title": "Sister Mary Joseph's nodule as a presenting sign of internal malignancy.", "score": 0.009009009009009009, "content": "CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I." }, { "id": "pubmed23n0074_8054", "title": "[Pulmonary metastases of colorectal origin].", "score": 0.009009009009009009, "content": "From January 1979 to December 1988, 18 patients with pulmonary metastases from colorectal cancers were operated in our division. This series included 11 men and 7 women (average age 57 years). The primary cancer was colic in 6 cases and rectal in 12. In 3 cases, the metastases were synchronous and discovered during the initial assessment. In 15 cases, they were metachronous, without symptoms in 12 cases and symptomatic in 3. These metastases were single in 14 cases, multiple in 3, bilateral in 1. They were peripheral in 15 cases. The histological diagnosis was obtained preoperatively in 5 cases (27.7%). The procedures uses were lobectomy for 11 patients, segmentectomy for 1, wedge resection for 10. Postoperative chemotherapy was given to 7 patients. Benign complications occurred in 2 cases during the postoperative period. No perioperative death was noted. One patient was lost to follow-up without recurrence after 1 year, 6 patients died from neoplastic evolution 4, 8, 15, 17, 22 and 28 months after being operated. In May 1989, 11 patients were still living: -2 scheduled for the excision of a contralateral lesion, -2 with pulmonary recurrence. 7 patients were alive without recurrence 12, 14, 17, 46, 52, 68 and 108 months after being operated. The probability of occurrence of pulmonary metastases in the evolution of colorectal cancer is estimated between 20 and 50%. Only 1% of the patients can be treated surgically. When screening these lesions, one must bear in mind that their appearance is sometimes quite delayed, and often asymptomatic. The repeated use of tracers is necessary but not sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0840_555", "title": "Intestinal intussusception in a young women: unusual cause and specific management.", "score": 0.008928571428571428, "content": "Intussusception in adults is a rare cause of abdominal pain that is often associated with organic pathology. We describe a case of ileocolic intussusception revealing a cecal adenocarcinoma in a young woman successfully managed by laparoscopic-assisted surgery adhering to oncological principles. A 30-year-old woman with a family history of colon adenocarcinoma in a young brother presented to our emergency department with a 2-month history of intermittent colicky abdominal pain accompanied by nausea and vomiting. Physical examination showed a palpable mass in the right lower quadrant of the abdomen. Computed tomography showed a 3-layered structure giving the characteristic target-shaped appearance in the ascending colon, highly suggestive for an ileocolic intussusception associated with right colic parietal thickening and an adjacent lymphadenopathy. Patient was planned for laparoscopic exploration and eventually definitive surgery. Intra-operatively, we found an ileocolic intussusception with thickening of the colic wall and slight proximal intestinal dilation. Multiple lymphadenopathies along the ileocecal artery were observed. Laparoscopic right hemicolectomy was performed following strict oncologic principles with \"en bloc resection\" and lymphadenectomy given the risk of an underlying malignancy. Considering this risk, previous reduction of the invaginated segments was not attempted and primary extracorporeal anastomosis was performed using manual sutures. Macroscopic examination of the resected specimen revealed a tumor mass of the caecal wall .The histological analysis identified a moderately differentiated tubular adenocarcinoma invading the serosa (T3) without permeation of the lymphatic or venous capillaries. No lymphatic metastasis of 28 nodes removed was seen. Postoperative course was uneventful and patient was discharged 5 days after surgery. Postoperative chest, abdomen, and pelvis CT scan were normal. Therefore, tumor is classified as stage II A (T3N0 M0).There was loss of MLH2 and MSH6 protein expression on immunohistochemistry findings reflecting a microsatellite instability phenotype, and the patient was followed up without adjuvant chemotherapy. Ileocolic intussusception rarely revealed a cancer in young adults. Laparoscopic surgery has a special interest in the diagnosis and treatment in this pathology. Oncogenetic consultation should be required in malignant lesion." }, { "id": "pubmed23n0309_13344", "title": "[Preoperative evaluation of cancers of the rectum].", "score": 0.008928571428571428, "content": "The diagnosis of colorectal cancer must be considered in the presence of suggestive symptoms and must be endoscopy. Assessment of operability, including chest x-ray, is completed by CEA determination and x-rays of the colon, looking for a synchronous lesion. Complementary assessments must answer 3 questions: what operation needs to be performed, is any preoperative adjuvant treatment indicated, do any prognostic factors need to be identified before the operation. The treatment of cancer of the colon is now clearly defined; intraoperative hepatic ultrasonography and histological examination of the resection specimen provide all of the necessary data in the majority of the cases. In the presence of a cancer of the rectum, various therapeutic alternatives are available according to the site and stage of the tumour. The complementary assessment includes biopsy to confirm the malignant nature of the lesion, and measurement of the distance of the lower pole from the anal margin (digital rectal examination, endoscopy). A more precise preoperative staging by ultrasonography, computed axial tomography or magnetic resonance is required when the clinician considers that the invasive nature of the lesion justifies preoperative radiotherapy. This precise staging is fully justified in the presence of a small rectal tumour amenable to local resection. Although infiltration of the rectal wall is now very clearly defined, formal identification of metastatic lymphadenopathy still remains hazardous. Finally, the search for distant metastases by invasive and/or expensive techniques is indicated when looking for contraindications to surgery (high-risk patients, surgery for recurrence and metastases). In other cases, the presence of metastases does not contraindicate a palliative colonic resection and intraoperative exploration allows reliable identification of any liver metastasis." }, { "id": "wiki20220301en065_5822", "title": "Oligoastrocytoma", "score": 0.008849557522123894, "content": "Treatment If resected, the surgeon will remove as much of this tumor as possible, without disturbing eloquent regions of the brain (speech/motor cortex) and other critical brain structure. Thereafter, treatment may include chemotherapy and radiation therapy of doses and types ranging based upon the patient's needs. Subsequent MRI examination are often necessary to monitor the resection cavity. Prognosis Even after surgery, an oligoastrocytoma will often recur. The treatment for a recurring brain tumor may include surgical resection, chemotherapy and radiation therapy. Survival time of this brain tumor varies; younger age and low-grade initial diagnosis are factors in improved survival time. References External links Brain and Spinal Tumors: Hope Through Research from the U.S. (National Institute of Neurological Disorders and Stroke) Brain tumor" }, { "id": "pubmed23n0062_12339", "title": "[Patient selection and efficacy of tumor after-care in surgically treated colorectal carcinoma].", "score": 0.008849557522123894, "content": "Scheduled follow-up after surgically treated colorectal cancer remains controversial because eventually only about 5% of patients profit from it. Careful selection should therefore spare those patients unnecessary investigations who are least likely to benefit from follow-up. Only patients should be considered whose tumor was completely resected and who were found free of distant metastases. These patients should be fully informed about their disease and accept scheduled investigation even if asymptomatic. A questionable operability with regard to a second surgical intervention forbids formal entry into a follow-up program as well as a decreased life expectancy due to other disease. The family physician is most qualified to carry out or coordinate these investigations. For the first two postoperative years intervals of three and for the further three years of six months are recommended. Physical examination and determination of CEA titers are the essential measures; colonoscopy, sonography, CT scans, chest X-ray, and for rectal cancer, endoluminal sonography are undertaken periodically. In such a selected cohort one can expect a resectable recurrence in 25% of patients, of which 20% can be cured." }, { "id": "wiki20220301en304_18849", "title": "HOHMS", "score": 0.008771929824561403, "content": "During this period, all malignant lung tumors were considered equivalent for treatment purposes. In the early 1960s, small cell lung carcinoma (SCLC) was recognized for its unique biological behavior, including a much higher frequency of widespread metastasis at diagnosis, and a higher frequency of sensitivity to chemotherapy and radiation therapy. Early studies suggested that patients with SCLC fared better when treated with chemotherapy and/or radiation than when treated surgically, while non-small cell lung carcinoma (NSCLC) patients generally did better after surgery, and usually did not respond well to chemoradiation. This \"traditional\" paradigm, wherein treatment options for lung cancer patients were based on histological stratification into two highly heterogeneous groups (i.e. SCLC vs. NSCLC), remained the standard for approximately 30–40 years." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 186 ] ], "word_ranges": [ [ 0, 33 ] ], "text": "In ANCA vasculitis, whatever it is, these antibodies have been shown to be related to the activity of the disease, but at no time are changes in treatment obligatory due to their levels." }, "2": { "exist": true, "char_ranges": [ [ 0, 186 ] ], "word_ranges": [ [ 0, 33 ] ], "text": "In ANCA vasculitis, whatever it is, these antibodies have been shown to be related to the activity of the disease, but at no time are changes in treatment obligatory due to their levels." }, "3": { "exist": true, "char_ranges": [ [ 0, 186 ] ], "word_ranges": [ [ 0, 33 ] ], "text": "In ANCA vasculitis, whatever it is, these antibodies have been shown to be related to the activity of the disease, but at no time are changes in treatment obligatory due to their levels." }, "4": { "exist": true, "char_ranges": [ [ 201, 364 ] ], "word_ranges": [ [ 36, 59 ] ], "text": "with the patient being asymptomatic and with objective evidence of lack of activity, close follow-up should be performed without restarting or modifying treatment." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Start treatment with corticosteroids.", "2": "Initiate treatment with cyclophosphamide.", "3": "Initiate treatment with mycophenolate mofetil.", "4": "Watchful waiting.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0906_12578", "title": "A case of (double) ANCA-negative granulomatosis with polyangiitis (Wegener's).", "score": 0.018042071197411004, "content": "A 60-year-old man had experienced cough, bloody sputum, and a 38 °C fever for 1.5 months. He visited an outpatient clinic and received antibiotics and nonsteroidal anti-inflammatory drugs. However, because the symptoms continued, he visited our hospital. The past medical history included chronic sinusitis, hypertension, and diabetes mellitus. A chest x-ray film and computed tomography showed multiple pulmonary nodules with cavities. Macrohematuria had developed 3 days before admission, and renal function had deteriorated (creatinine, 2.45 mg/dL) in 2 weeks. He was admitted to our hospital because of rapidly progressive glomerulonephritis (RPGN) and multiple pulmonary nodules. On admission, the clinical diagnosis was suspected to be granulomatosis with polyangiitis (Wegener's) (GPA), although tests for proteinase-3 anti-neutrophil cytoplasmic antibody (PR3-ANCA) were negative. Antibiotics were administered for 5 days. After renal biopsy, methylprednisolone pulse therapy and cyclophosphamide pulse therapy were performed. The pathological diagnosis on the basis of the renal biopsy was glomerular and interstitial hemorrhage, possibly associated with vasculitis. After the treatment, the pulmonary symptoms, multiple pulmonary nodules, and severe inflammatory reactions in the peripheral blood were resolved. However, renal dysfunction progressed to end-stage renal disease 1 month after renal biopsy. Hemodialysis was started, and the steroid therapy was continued. During hemodialysis, a second renal biopsy was performed and led to a diagnosis of pauci-immune focal segmental crescentic glomerulonephritis. Renal function gradually recovered, and hemodialysis was discontinued. This case was (double) ANCA-negative GPA which presented prominent glomerular and interstitial hemorrhage, may be associated with small vessel vasculitis, but without active necrotizing and crescentic glomerular lesions, in the rapidly progressive glomerulonephritis." }, { "id": "pubmed23n1047_6840", "title": "Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome).", "score": 0.01738934056007227, "content": "Churg-Strauss syndrome, Eosinophilic granulomatosis with polyangiitis (EGPA), is a systemic vasculitis that affects small- to medium-sized vessels. It is rare and part of the Anti-neutrophil cytoplasm antibody-associated vasculitis (ANCA) group. We present a 37-year-old man, with a previous history of asthma, that was sent to the ED due to 2 weeks of productive cough, occasional dyspnea on exertion, fever (one week), asthenia, and anorexia. Upon physical examination, he was subfebrile and tachycardic. He had leukocytosis (17.00 x10^9/L) and eosinophilia of 20.0 % (3.4 X10^9/L), creatinine level of 1.5 mg/dL, subtle elevation on liver function tests and CRP of 10.82mg/dL. On Chest X-Ray, there was infiltrate on the right pulmonary base. Due to a strong suspicion of EGPA, he was started on 80mg of prednisolone from admission. ANCA MPO was positive, with the remaining auto-immune study negative. He underwent Thorax CT (under corticotherapy) without relevant changes, as well as bronchoalveolar lavage, without macroscopic signs of alveolar hemorrhage. Because of active urinary sediment, nephrotic proteinuria (6.5g/24h), and acute renal failure he underwent a renal biopsy, which revealed pauci-immune crescentic glomerulonephritis, with predominantly acute findings (in the context of ANCA-MPO Vasculitis - EGPA). After the biopsy, he received three 1g methylprednisolone pulses and was started on Cyclophosphamide. He remained asymptomatic and renal function was restored. This case highlights the importance of integrating all findings in one clinical scenario to prevent a more complex disease diagnosis, with a specific treatment, from being missed." }, { "id": "pubmed23n1016_9206", "title": "A Case of Granulomatosis with Polyangiitis: Consequences of Delayed Diagnosis in a Life-threatening Malady.", "score": 0.016233766233766232, "content": "Granulomatosis with polyangiitis (GPA) is one of three described anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Early diagnosis and treatment of GPA is paramount, as it may help prevent irreversible end-organ damage, especially renal and pulmonary failure. A 72-year-old male with a past medical history of lung adenocarcinoma in remission, chronic sinusitis status-post multiple sinus surgeries, and coronary artery disease presented with shortness of breath, dark urine, and asymmetric polyarthralgias. He had an acute kidney injury, leukocytosis, with urinalysis demonstrating pyuria and hematuria, without casts. Chest imaging showed cavitary nodular opacities in addition to interval increase of existing nodules compared to the most recent scan one month prior. His acute kidney injury progressed to renal failure requiring hemodialysis, and he developed an inflammatory polyarthritis. GPA was suspected clinically so he was started on high-dose intravenous corticosteroids, and subsequently plasmapheresis and rituximab. Serology returned with highly positive proteinase-3 antibodies, and cytoplasmic ANCA positivity on immunofluorescence. Renal biopsy demonstrated severely active pauci-immune glomerulonephritis. Several months after discharge, the patient passed away from gram positive bacteremia. This patient's recurrent sinusitis, pulmonary nodules, and subsequent renal failure were highly suggestive of GPA. A biopsy is recommended to confirm the diagnosis of GPA, but treatment should not be delayed if there is a high index of suspicion for the disease. Induction therapy with corticosteroids combined with rituximab or cyclophosphamide has significantly decreased the mortality of patients with GPA. Patients with GPA often have preceding history of nasopharyngeal and upper airway disease, and can present with fluctuating pulmonary infiltrates. Early recognition and treatment of patients with GPA can prevent life-threatening complications and reduce mortality." }, { "id": "pubmed23n0304_14690", "title": "Systemic vasculitis in a kidney transplant population.", "score": 0.015518633898696203, "content": "Systemic vasculitis as original disease might adversely influence the result of kidney transplantation. The clinical course after 32 transplantations to 26 patients with microscopic polyangiitis, Wegener's granulomatosis, Henoch-Schonlein purpura, thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, or Goodpasture's disease was evaluated. The median follow-up time was 82 months (range, 4-132 months). Frozen sera from 25 transplantations were analyzed for Goodpasture antibodies, myeloperoxidase antineutrophil cytoplasmic antibodies (ANCA), and proteinase 3 ANCA. Survival of patients and grafts did not differ between patients and matched controls. Recurrent vasculitis occurred with seven grafts (four patients with microscopic polyangiitis or Wegener's granulomatosis, two patients with Henoch-Schonlein purpura, and one patient thrombotic thrombocytopenic purpura). New-onset hematuria was the initial renal symptom in five patients. Treatment with corticosteroids, cyclophosphamide, and/or plasma exchange was most often effective, but two grafts were lost. Proteinase 3 ANCA titers were increased to 12-738 U/ml before seven transplants. The patient with the lowest titer lost his graft due to recurrence, two other patients had reversible recurrence after 1 year and 5 years, two patients lost their grafts due to unknown/unrelated causes, and two patients' grafts remain without recurrence. Myeloperoxidase ANCA were increased to 22-39 U/ml before two transplants, which have been uneventful for 4 years. An awareness of the small but perpetual risk of recurrence facilitates early treatment that may save the transplant. Testing for hematuria and early transplant biopsies, and possibly monitoring of ANCA titers, are essential, but pretransplant ANCA titers have no predictive value in asymptomatic patients. Results of kidney transplantation in patients with vasculitis are as good as in other patients." }, { "id": "pubmed23n0565_16371", "title": "[Acute onset Wegener's granulomatosis presenting as otitis media; a case report].", "score": 0.014901349948078919, "content": "We report the case of a 57-year-old woman with Wegener's granulomatosis who presented with otitis media. The patient presented with a 2-month history of bilateral hearing loss and dizziness. Antibiotic treatment was not effective, and the patient was confirmed to have bilateral sensorineural hearing loss. Serum was positive for cytoplasmic anti-neutrophil cytoplasmic antibody [C (PR3)-ANCA] but negative for P(MPO)-ANCA (perinuclear ANCA). While the test results were pending, the patients' general condition worsened ; in particular, signs of active inflammation, cardiorespiratory failure and scleritis developed suddenly. Emergency chest computed tomography revealed evidence of lung involvement and hydrothorax; thus, the patient was diagnosed to have the generalized form of Wegener's granulomatosis. The patient was started on pulse methylprednisolone therapy at 1000mg/day for 3 days, which resulted in marked clinical improvement, and then, the drug therapy was switched to prednisolone 60mg/day and cyclophosphamide 50mg/day and gradually tapered. Early diagnosis of Wegener's granulomatosis is often difficult because of atypical manifestations of the disease; particular attention must be paid to acute onset of the disease, such as in our case. ANCA is a very useful marker for early diagnosis, but about one week is needed to obtain the test results. We believe that early steroid and cyclophosphamide therapy is an effective therapeutic option for patients with signs of severe inflammation and generalized involvement." }, { "id": "pubmed23n0762_21420", "title": "Double-positive Goodpasture's syndrome with concomitant active pulmonary tuberculosis.", "score": 0.01488095238095238, "content": "Anti-glomerular basement membrane (anti-GBM) disease usually presents as rapidly progressive glomerulonephritis, and, when accompanied with pulmonary hemorrhage, it is called Goodpasture's syndrome. Anti-neutrophilic cytoplasmic antibodies (ANCA) may co-exist with anti-GBM antibodies. In most of these \"double positive\" cases, ANCA is specific for myeloperoxidase (p-ANCA). We report a rare case of a critically ill patient c-ANCA-associated double-positive Goodpasture's syndrome with concomitant tuberculosis that was successfully treated with immunosuppression, plasmapheresis and anti-tuberculous therapy (ATT). A 32-year-old gentleman with a 15 pack-year smoking history presented with massive hemoptysis, respiratory failure and oliguria. Laboratory investigation revealed anemia, elevated creatinine and active urinary sediment. Chest X-ray revealed bilateral pulmonary infiltrates. Broad-spectrum antibiotics and intravenous corticosteroids were started. Bronchoscopy showed alveolar hemorrhage and smears from bronchial lavage from both lungs were positive for acid fast bacillus (AFB). Vasculitis work-up revealed high titers of c-ANCA and anti-GBM antibodies. Kidney biopsy revealed crescents in &gt;50% glomeruli on light microscopy. Immunofluorescence showed linear deposition of IgG and C3. The patient received pulse methylprednisone for three days followed by oral prednisone and ATT. In addition, he also underwent nine sessions of plasmapheresis. Oral Cyclophosphamide was added on Day 10. The patient showed remarkable recovery as his lung fields cleared and his kidney function got stabilized. Cyclophosphamide was continued for three months and then switched to azathioprine. At six months, the creatinine is 1.2 mg/dL, with minimal proteinuria and a normal chest X-ray. To the best of our knowledge, this is the only reported case of double-positive Goodpasture's syndrome (c-ANCA and anti GBM) with active tuberculosis treated successfully. " }, { "id": "pubmed23n1120_20589", "title": "A clinical case of recurrent episcleritis as the initial manifestation of granulomatosis with polyangiitis.", "score": 0.014581694204038816, "content": "Granulomatosis with polyangiitis (GPA) is a type of small-sized blood vessel vasculitis that predominantly affects the upper airways, lungs and kidneys and associates with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). Nevertheless, any organ of the body can be affected by GPA, including the eye. Occasionally, ocular involvement can be the initial manifestation, thus representing an essential clue for the physician in the early diagnosis of the disease. We present the case of a 53-year-old woman in whom recurrent episcleritis was the first sign of a multisystem disease. All further investigations led to the final diagnosis of GPA. The remission induction therapy chosen by the rheumatologist consisted of intravenous cyclophosphamide (CP) and methylprednisolone pulse-therapy, followed by oral glucocorticoids (GC). Based on the favorable clinical and paraclinical evolution, induction therapy was replaced by remission maintenance therapy. Azathioprine (AZA) was initiated and oral GC were continued, with dose tapering. Complete remission of episcleritis was observed. <bAbbreviations:</b GPA = granulomatosis with polyangiitis, EGPA = eosinophilic granulomatosis with polyangiitis, MPA = Microscopic polyangiitis, ANCA = Anti-neutrophil cytoplasmic antibodies, c-ANCA = ANCA to proteinase-3, p-ANCA = ANCA to myeloperoxidase, ELISAs = antigen-specific enzyme-linked immunosorbent assays, ENT = ear, nose, throat, CP = cyclophosphamide, NSAIDs = nonsteroidal anti-inflammatory drugs, AZA = azathioprine, GC = glucocorticoids." }, { "id": "wiki20220301en027_70641", "title": "Granulomatosis with polyangiitis", "score": 0.014573887295271582, "content": "Diagnosis Granulomatosis with polyangiitis is usually suspected only when a person has had unexplained symptoms for a long period of time. Determination of anti-neutrophil cytoplasmic antibodies (ANCAs) can aid in the diagnosis, but positivity is not conclusive and negative ANCAs are not sufficient to reject the diagnosis. More than 90% of people who have GPA test positive for ANCA. Cytoplasmic-staining ANCAs that react with the enzyme proteinase 3 (cANCA) in neutrophils (a type of white blood cell) are associated with GPA. Involvement of the ears, nose, and throat is more common in granulomatosis with polyangiitis than in the similar condition microscopic polyangiitis." }, { "id": "wiki20220301en027_70649", "title": "Granulomatosis with polyangiitis", "score": 0.014493433395872422, "content": "Trimethoprim/sulfamethoxazole has been proposed to help prevent relapse though a 2015 Cochrane review did not confirm fewer relapses with trimethoprim/sulfamethoxazole treatment. Prognosis Before modern treatments, the 2-year survival was under 10% and average survival five months. Death usually resulted from uremia or respiratory failure. The revised Five-factor score is associated with 5-year mortality from GPA and is based on the following criteria: age greater than 65 years, cardiac symptoms, gastrointestinal involvement, chronic kidney disease, and the absence of ears, nose, and throat symptoms. With corticosteroids and cyclophosphamide, 5-year survival is over 80%. Long-term complications are common (86%), mainly chronic kidney failure, hearing loss, and deafness. The risk of relapse is increased in people with GPA who test positive for anti-PR3 ANCA antibodies and is higher than the relapse risk for microscopic polyangiitis." }, { "id": "pubmed23n1127_5966", "title": "Granulomatosis with polyangiitis: An atypical initial presentation.", "score": 0.013970409895707008, "content": "Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitis of small and medium vessels with involvement of the upper and lower respiratory tract and necrotizing pauci-immune glomerulonephritis [1]. This vasculitis has a higher incidence in men in the sixth decade of life and more than 80% of patients have positive anti-neutrophil cytoplasm (ANCA) antibodies [1,2]. We present the case of a 23-year-old man with two weeks of evolution with polyarthralgia, asthenia, and cough with hemoptoic sputum. He did a chest radiography that showed diffuse bilateral alveolar infiltrates, on the second stage. The patient presented a rapid clinical worsening, with moderate hemoptysis and severe respiratory failure requiring invasive mechanical ventilation. The autoimmune study revealed positivity for ANCA PR3 in titer &gt;200, having started pulses of methylprednisolone, plasmapheresis and later cyclophosphamide, with clinical improvement. His high-resolution chest computed tomography (CT) showed areas of diffuse ground glass densification suggesting capillaritis/alveolar hemorrhage and two subpleural nodular areas suggestive of granulomatous vasculitis. CT of the nasal sinuses showing findings compatible with acute inflammatory changes, with histology of the nasal mucosa inconclusive. Thus, this case shows an exuberant and potentially fatal form of diffuse alveolar hemorrhage that culminated in the initial diagnosis of granulomatous vasculitis in a young adult." }, { "id": "wiki20220301en146_15457", "title": "Rapidly progressive glomerulonephritis", "score": 0.013868962219033956, "content": "Type III Also known as pauci-immune RPGN, type III RPGN accounts for 55% of RPGN and features neither immune complex deposition nor anti-GBM antibodies. Instead, the glomeruli are damaged in an undefined manner, perhaps through the activation of neutrophils in response to ANCA. Type III RPGN may be isolated to the glomerulus (primary, or idiopathic) or associated with a systemic disease (secondary). In most cases of the latter, the systemic disease is an ANCA-associated vasculitis such as granulomatosis with polyangiitis, microscopic polyangiitis or eosinophilic granulomatosis with polyangiitis. Treatment Therapy consists of a combination of rituximab, corticosteroids, and cyclophosphamide, with a substitution of azathioprine for cyclophosphamide after a ninety-day initial period being another option. When remission is achieved, immunosuppressants are still used, usually corticosteroids with azathioprine or rituximab infusions." }, { "id": "pubmed23n0262_8757", "title": "Relationship between disease activity and anti-neutrophil cytoplasmic antibody concentration in long-term management of systemic vasculitis.", "score": 0.012955974842767295, "content": "Autoantibodies directed against neutrophil cytoplasmic antigens (ANCA) are valuable in the diagnosis of primary systemic vasculitis, and immunofluorescence studies suggest that changes in ANCA concentration reflect changes in disease activity. We used enzyme-linked immunosorbent assays to examine retrospectively the relationship between ANCA concentration and disease activity in 56 patients with systemic vasculitis. We included patients with Wegener's granulomatosis, microscopic polyangiitis, idiopathic rapidly progressive glomerulonephritis, and Churg-Strauss syndrome, and examined separately the initial treatment period (mean length of follow-up, 26 months) and long-term management (mean length of follow-up, 59 months). Levels of ANCA decreased during induction therapy with prednisolone and cyclophosphamide, with or without plasma exchange. During follow-up, 27 relapses were documented in 20 patients (10 with Wegener's granulomatosis, nine with microscopic polyangiitis, and one with Churg-Strauss syndrome), occurring between 4 and 183 months (mean, 62 months) after initial presentation. Patients in whom ANCA were detectable 1 year or more after treatment were at particular risk of clinical relapse. Proteinase 3-directed ANCA appeared to be associated with a higher rate of relapse (44% of patients relapsed) than myeloperoxidase-directed ANCA (13% of patients relapsed). Twenty-four of the 27 relapses occurred in the presence of detectable ANCA; in 21 of these, ANCA concentration was high or rising. The temporal relationship between changes in ANCA concentration and clinical relapse varied considerably between patients; in seven patients, ANCA remained at high levels for many months (range, 14 to 67 months) before eventual relapse. One patient showed high concentrations of ANCA over a period of 11 years without relapse. In five patients, increases in the ANCA level were not temporally associated with relapse (although four of these patients relapsed on other occasions.) We conclude that monitoring ANCA by enzyme-linked immunosorbent assays is of value in the long-term management of patients with Wegener's granulomatosis, microscopic polyangiitis, idiopathic rapidly progressive glomerulonephritis, and Churg-Strauss syndrome. Increases in ANCA and persistently high levels point to the risk of relapse and indicate the need for frequent clinical review and continuing maintenance immunosuppression. However, our results suggest that ANCA assays should always be used in conjunction with other indices of disease activity and should not be the sole basis for changing therapy." }, { "id": "pubmed23n0753_13933", "title": "Pulmonary renal syndrome in a child with coexistence of anti-neutrophil cytoplasmic antibodies and anti-glomerular basement membrane disease: case report and literature review.", "score": 0.012727062362605577, "content": "Pulmonary renal syndrome (PRS), denoting the presence of diffuse alveolar hemorrhage and glomerulonephritis as manifestations of systemic autoimmune disease, is very rare in childhood. The coexistence of circulating anti-neutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane (GBM) disease in children affected by this syndrome is exceptional, with unfavorable outcome in five out of seven patients reported to date. We describe a child with PRS associated with both circulating anti-myeloperoxidase (anti-MPO) ANCA and anti-GBM disease on renal biopsy who was successfully treated with immunosuppressive therapy. A 10-year old girl presented with fever, fatigue, malaise, and pallor followed by hemoptysis and severe anemia. Diffuse alveolar hemorrhage was revealed on fiberoptic bronchoscopy. Renal findings consisted of microscopic hematuria, moderate proteinuria, and anti-GBM disease on renal biopsy. ANCA with anti-MPO specificity were present whereas anti-GBM antibodies were on borderline for positivity. Methyl-prednisolone pulses followed by prednisone led to cessation of hemoptysis, marked improvement of lung fuction, and normal finding on chest x-ray within 10 days. An immunosuppressive regimen was then given consisting of prednisone daily for 4 weeks with subsequent taper on alternate day, i.v. cyclophosphamide pulses monthly for 6 doses, followed by mycophenolate mofetil that resulted in normal lung function tests, hemoglobin concentration, and anti-MPO level within four subsequent weeks. During 10-months of follow-up she remained well, her blood pressure and renal function tests were normal, and proteinuria and hematuria gradually resolved. We report a child with an exceptionally rare coexistence of circulating ANCA and anti-GBM disease manifesting as PRS in whom renal disease was not the prominent part of clinical presentation, contrary to other reported pediatric patients. A review of literature on disease with double positive antibodies is also presented. Evaluation of a patient with PRS should include testing for presence of different antibodies. An early diagnosis and rapid institution of aggressive immunosuppressive therapy can induce remission and preserve renal function. Renal prognosis depends on the extent of kidney injury at diagnosis and appropriate treatment." }, { "id": "pubmed23n0348_22463", "title": "[An old man presenting with fluctuating bilateral multiple cranial nerve palsies and positive test for perinuclear antineutrophil cytoplasmic antibody].", "score": 0.01229260935143288, "content": "A 70-year-old man admitted to a local hospital because of facial muscle weakness, tinnitus and facial pain in left side, was then given corticosteroid with a tentative diagnosis of Bell's palsy and his symptoms gradually improved. Since these symptoms recurred six months later, he was referred to our neurological service. As his brain CT revealed diffuse thickening and enhancement of the dura mater, he was thought to have hypertrophic pachymeningitis (HP). Intravenous antibiotics were started for aspiration pneumonia and his neurological symptoms gradually improved. HP caused by bacterial infection was thus likely and antibiotics, rifampicin and metronidazole, were administered orally as an outpatient. However, one month later, these symptoms were worsened with headache and double vision. He was then rehospitalized. MR imagings of the head with gadolinium disclosed diffuse meningeal thickening and enhancement, especially of the left-sided cerebellar tentorium. Erythrocyte sedimentation rate and C-reactive protein were moderately elevated. Serum angiotensin converting enzyme was within normal range. The test for cytoplasmic antineutrohil cytoplasmic antibody (ANCA) in the serum was negative, however, that for perinuclear ANCA was positive at a titer of 99 EU. Lumbar puncture showed normal findings and negative culture results for bacteria, fungi or mycobacteria. Dural biopsy specimens showed non-specific granulomatous inflammation of the dura with epithelioid histiocytes and Langerhans type multinuclear giant cells with caseous necrosis, however, with no presence of fungi or tubercle bacilli. After the oral administration of cyclophosphamide (100 mg, daily) and prednisolone (40 mg, daily), his neurological symptoms and laboratory findings have been gradually improved and he is well one year after discharge. This case together with previous reports suggests that ANCA positive HP without evidence of other organ involvements may belong to the limited form Wegener's granulomatosis. In the literatures of idiopathic HP, the treatment effect with corticosteroid alone is initially favorable, but transient. On the other hand, using the combined therapy of cyclophosphamide and prednisolone, the remission has been achieved in more than 90% of patients with WG. These data suggest that P-ANCA positive HP should be treated with a combination of corticosteroid and cyclophosphamide." }, { "id": "pubmed23n0898_11147", "title": "Granulomatosis with Polyangiitis (Wegener Granulomatosis) with Unusual Presentation.", "score": 0.011849255039439089, "content": "We came across a 32 years old male admitted in our hospital with prolonged low-grade fever, haemoptysis, leg swelling, weight loss, purpuric rashes and malaena. He received anti-TB treatment at another hospital without any improvement. He was pale with bullous and purpuric lesions over legs and feet. He also had features of consolidation over both lung fields. His CRP was 312mg/L, Urine R/M/E showed 40-50 RBC/HPF, Chest X-ray showed features of bilateral consolidation, c-ANCA-10U/L (positive); Tracheal aspirate for AFB was found to be negative. We diagnosed the case as Granulomatosis with Polyangitis (WG) and started treatment with steroid and cyclophosphamide. But the patient could not be saved probably due to delay in starting management." }, { "id": "pubmed23n0343_3522", "title": "Serial measurements of antineutrophil cytoplasmic autoantibodies in patients with systemic vasculitis.", "score": 0.011634199134199134, "content": "To assess the value of serial determinations of antineutrophil cytoplasmic autoantibodies (ANCA) for monitoring disease activity in patients with systemic vasculitis. Forty-three patients with histologically proven vasculitis (21 with Wegener's granulomatosis, 17 with microscopic polyangiitis, and 5 with renal-limited vasculitis) were studied for a median follow-up of 22 months. Disease activity was prospectively assessed and quantified by the Birmingham Vasculitis Activity Score. A total of 347 sera were analyzed for ANCA determination. Relapses occurred in 23 (54%) of 43 patients. Diagnostic category (Wegener's granulomatosis vs micropolyangiitis and renal-limited vasculitis), severity of initial symptoms (mean vasculitis activity score, mean number of organs involved), and ANCA pattern [cytoplasmic-ANCA (c-ANCA) vs perinuclear-ANCA (p-ANCA)] did not significantly differ between relapsers and nonrelapsers. Lung involvement was more frequent at onset among relapsers [16 of 23 (70%) vs 6 of 20 (30%); P = 0.02]. Relapses were slightly, but not significantly, more frequent in patients with Wegener's granulomatosis or a c-ANCA pattern. The percentage of relapsers was greater in patients with persistently positive ANCA than in patients with negative or decreasing ANCA titers (86% vs 20%, P = 0.0001). However, the predictive value of an increase in ANCA titers for the occurrence of a subsequent relapse was only 28% (4 of 14) for c-ANCA, 12% (2 of 17) for anti-proteinase 3-ANCA, and 43% (6 of 14) for anti-myeloperoxidase-ANCA. An increase in ANCA occurred before or during relapse in 33% (10 of 30) of cases for c-ANCA/anti-proteinase 3 antibodies, and 73% (11 of 15) of cases for anti-myeloperoxidase antibodies. The persistence of ANCA positivity is strongly associated with relapses. However, an increase in ANCA titers has a poor value for the early prediction of a subsequent relapse and should not be used as a sole parameter for therapeutic intervention. In addition, our results suggest that serial anti-myeloperoxidase determination may be useful as a prognostic marker in patients who are p-ANCA positive." }, { "id": "wiki20220301en111_47244", "title": "C-ANCA", "score": 0.011441994392664998, "content": "c-ANCAs, or PR3-ANCA, or antineutrophil cytoplasmic antibodies, are a type of autoantibody, an antibody produced by the body that acts against one of its own proteins. These antibodies show a diffusely granular, cytoplasmic staining pattern under microscopy. This pattern results from binding of ANCAs to antigen targets throughout the neutrophil cytoplasm, the most common protein target being proteinase 3 (PR3). For example, PR3 is the most common antigen target of ANCA in patients with granulomatosis with polyangiitis. In active granulomatosis with polyangiitis, c-ANCA is found over 90% of the time. Other antigens may also occasionally result in a c-ANCA pattern. See also P-ANCA Anti-Neutrophil Cytoplasmic Antibody (ANCA) References Autoantibodies" }, { "id": "pubmed23n0710_17093", "title": "[Granulomatosis with polyangiitis (Wegener). Description of 15 cases].", "score": 0.011253358621779674, "content": "Granulomatosis with polyangiitis (GP) is a necrotizing vasculitis of unknown etiology that involves small and medium caliber vessels. It is associated with anti neutrophil cytoplasm antibodies (ANCA). It most often affects the respiratory tract and the kidneys and its most important pathologic feature is the presence of necrotizing granulomas. To detail the features of 15 patients with GP diagnosed in a university referral center. Retrospective study: between 1984 and 2009, 15 patients with GP were diagnosed in our center. Epidemiological, clinical, laboratory test as well as pathologic studies and treatment were retrospectively analyzed. Biopsy diagnosis of GP was considered as an inclusion criterion. Fifteen patients were diagnosed: 12 men and 3 women. Mean age at diagnosis: 52.2 years (14-78). 12 patients had a history of smoking. A biopsy was diagnostic in all patients. ANCA were positive in 11 cases, 6 had a cytoplasmic c-ANCA pattern. All patients had pulmonary involvement and seven (40%) had renal involvement. All patients received intravenous glucocorticoids and cyclophosphamide as induction therapy. During the disease progression 5 patients died. The clinical features of this series do not differ from those described by other authors. However, a history of smoking is more common than expected. Frequently used drugs were glucocorticoids and cyclophosphamide (oral and pulse therapy). The course was usually unfavorable, with outbreaks or complications due to immunosuppression, except for those with limited forms. Immunosuppressive therapy should be maintained indefinitely in most cases." }, { "id": "InternalMed_Harrison_21888", "title": "InternalMed_Harrison", "score": 0.010946826163409862, "content": "Patients with any of these three diseases can have any combination of the above serum antibodies, but anti-PR3 antibodies are more common in granulomatosis with polyangiitis and anti-MPO antibodies are more common in microscopic polyangiitis or Churg-Strauss. Although each of these diseases has some unique clinical features, most features do not predict relapse or progression, and as a group, they are generally treated in the same way. Since mortality is high without treatment, virtually all patients receive urgent treatment. Induction therapy usually includes some combination of plasmapheresis, methylprednisolone, and cyclophosphamide. Monthly “pulse” IV cyclophosphamide to induce remission of ANCA-associated vasculitis is as effective as daily oral cyclophosphamide but may be associated with increased relapses. Steroids are tapered soon after acute inflammation subsides, and patients are maintained on cyclophosphamide or azathioprine for up to a year to minimize the risk of relapse." }, { "id": "pubmed23n0909_2321", "title": "Negative anti-neutrophil cytoplasm antibody at switch to maintenance therapy is associated with a reduced risk of relapse.", "score": 0.010126647182484745, "content": "Relapse of disease is frequent in anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). It is unclear whether persistent ANCA when starting maintenance therapy increases the risk of relapse. We examined the association between ANCA status and relapse in two randomised controlled trials. ANCA-positive patients in two trials, CYCLOPS and IMPROVE, were switched from cyclophosphamide to maintenance therapy after achieving clinical remission. We classified patients as being either ANCA-positive or ANCA-negative at the time they started maintenance therapy. We compared the risk of relapse in ANCA-positive and ANCA-negative patients. Of 252 patients included, 102 (40%) experienced at least one relapse during the follow-up period. At the time of the switch from induction to maintenance therapy, 111 were ANCA-positive, of whom 55 (50%) relapsed, compared to 141 patients who were ANCA-negative, of whom 47 (33%) relapsed. In multivariable time-to-event analysis, a reduced risk of relapse was associated with having become ANCA-negative at the time of switching to maintenance therapy (hazard ratio 0.63, 95% confidence interval 0.42-0.95; p = 0.026). In addition, initial proteinase 3 (PR3)-ANCA, younger age, lower serum creatinine, pulsed cyclophosphamide for remission induction, and mycophenolate mofetil for remission maintenance were all associated with an increased risk of relapse. Becoming ANCA-negative before the switch to maintenance is associated with a reduced risk of relapse. CYCLOPS: ClinicalTrials.gov, NCT00430105 . Registered retrospectively on 31 January 2007. ClinicalTrials.gov, NCT00307645 . Registered retrospectively on 27 March 2006." }, { "id": "pubmed23n0646_1198", "title": "[Case of microscopic polyangiitis presenting initially as prostatic vasculitis].", "score": 0.009900990099009901, "content": "A 79-year-old man was admitted to our hospital to evaluate prostatic vasculitis that was diagnosed on a prostatic biopsy performed due to an elevated prostate-specific antigen (PSA)level. He complained of general malaise and had hematuria, proteinuria, and interstitial pneumonitis in the lower lung field on admission. A renal biopsy showed necrotizing crescentic glomerulonephritis. He was diagnosed as having microscopic polyangiitis (MPA) based on the presence of small-vessel vasculitis and positivity for myeloperoxidase-anti-neutrophil cytoplasmic antibody (MPO-ANCA) (465 EU). He was effectively managed with methylprednisolone pulse therapy (500 mg/day x 3 days) followed by progressive dosage tapering. In the present case, the identification of prostatic vasculitis led to the early detection of MPA, which resulted in an excellent clinical course. Prostatic involvement has been also reported in patients with Wegener's granulomatosis or Churg-Strauss syndrome. Thus, physicians should be aware of the potential for the involvement of various organs, including the prostate, in patients with ANCA-associated vasculitis." }, { "id": "pubmed23n0726_17916", "title": "Diagnostics and therapy of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides.", "score": 0.00980392156862745, "content": "Granulumatosis with polyangiitis (wegener's)/GPA microscopic polyangiitis (MPA) and Churg Strauss syndrome (CSS) are primary systemic vasculitides which predominantly affect small vessels, showing a high association with a positive C/PR3-ANCA in GPA and P/MPO-ANCA in MPA, so called ANCA-associated vasculitides (AAV). The diagnostic work-up relies on an interdisciplinary approach including imaging techniques and laboratory tests in order to assess disease stage and extent. The golden standard remains the histological proof of a necrotizing, pauci-immune small vessel vasculitis, in GPA additionally non-caseating granuloma is found mainly in the respiratory tract. Treatment is adapted to disease stage and extent and relies on a combination of a cytotoxic plus a tapering regimen of glucocorticosteroids. Induction of remission in \"early systemic\" disease without organ- and life-threatening organ manifestations and a near normal kidney function can be achieved with methotrexate. In the generalized phase with significant renal dysfunction cyclophosphamide is the mainstay of therapy, in rapidly progressive glomerulonephritis with an imminent dialysis indication plasmapheresis is performed additionally. When remission is achieved, usually after 3-6 months of induction treatment, cyclophosphamide is switched to azathioprine as maintenance of remission drug. Alternative therapies are methotrexate provided the kidney function is normal or Leflunomide in the long-term follow-up the relapse rate in ANCA-associated vasculitis is approximately 50% in 5 years, irrespective of the drug used for maintenance treatment. The relapse rate is significantly higher in GPA than in MPA and CSS." }, { "id": "pubmed23n0319_2602", "title": "Clinical course and symptomatic prediagnostic period of patients with Wegener's granulomatosis and microscopic polyangiitis.", "score": 0.009708737864077669, "content": "The clinical course of 15 patients with Wegener's granulomatosis (WG) and eight patients with microscopic polyangiitis (MPA) from one nephrological clinical center is presented for the period from 1984 to 1993, when testing for antineutrophil cytoplasmic antibodies (ANCA) was gradually introduced into routine clinical practice. We found a high degree of prolonged time periods with symptoms attributable to WG or MPA until the specific diagnosis was made. Nine patients with WG and one patient with MPA had symptomatic prediagnostic periods of more than three years, which extended in one case up to twenty years. In these prediagnostic periods, often even severe flares of vasculitic activity resulted in spontaneous remission without immunosuppressive therapy. One patient on chronic dialysis for four months because of rapidly progressive glomerulonephritis, experienced sufficient spontaneous regain of residual renal function to stay off dialysis for 6 years. Despite a high amount of spontaneous recovery, recurrent flares of disease eventually led to death in those cases without sufficient immunosuppressive therapy. Contrary to long courses of disease, one patient with WG had a fulminate exacerbation of disease with lethal hemoptysis after a prediagnostic period of only three months. Renal disease, respiratory and other symptoms did not occur sequentially, but each could precede the other. We conclude in agreement with published former experience, that WG and MPA show a highly variable spontaneous disease course, that requires extended observational periods for evaluating maintenance therapies." }, { "id": "pubmed23n0373_2921", "title": "Are antineutrophil cytoplasmic antibodies a marker predictive of relapse in Wegener's granulomatosis? A prospective study.", "score": 0.009615384615384616, "content": "To investigate the predictive value of testing for antineutrophil cytoplasmic antibodies (ANCA) in 55 patients with systemic Wegener's granulomatosis (WG) included in a randomized, prospective trial comparing corticosteroids and oral or pulse cyclophosphamide. All 55 patients received corticosteroids. A cyclophosphamide pulse of 0.7 g/m2 was given at the time of diagnosis. After the first pulse, the patients were assigned at random to receive either pulse or oral cyclophosphamide (2 mg/kg/day), independently of ANCA results. ANCA were sought using an immunofluorescence assay and an attempt was made to correlate them with relapse of WG. ANCA were monitored throughout the study. At the time of diagnosis, ANCA were detected in 48 (87%) patients, with a cytoplasmic labelling pattern in 44 and a perinuclear pattern in four. ANCA follow-up was available for 50 patients. ANCA disappeared in 34 patients and persisted in nine. For 79% of the patients, the clinical course improved with the disappearance of ANCA and deteriorated with their persistence or increased titre. Among the patients who were initially ANCA-positive, 23 relapses occurred. Relapses were more frequent when ANCA remained positive or reappeared [13/19 ANCA-positive patients vs 3/29 ANCA-negative patients (P&lt;0.01)]. Nine relapses (39%) occurred in patients with persistent ANCA, and ANCA reappearance preceded relapse in eight (35%). The mean time between inclusion and relapse did not differ between the patients who became ANCA-negative and those who were persistently ANCA-positive (14.6+/-13.2 vs 14.4+/-8.2 months). The mean time to ANCA disappearance was similar for the patients who relapsed and those who did not. Corticosteroids and pulse or oral cyclophosphamide did not significantly modify the time to ANCA disappearance. Throughout the study, seven patients were ANCA-negative. Although ANCA positivity was associated with relapse, discordance between cytoplasmic ANCA and disease activity was not unusual. In the absence of clinical manifestations, ANCA titres alone can serve as a warning signal but not indicate whether to adjust or initiate treatment." }, { "id": "pubmed23n0347_15032", "title": "Treatment of acute c-ANCA-positive vasculitis with mycophenolate mofetil.", "score": 0.009523809523809525, "content": "Acute cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA)-positive vasculitis is usually treated with cyclophosphamide and corticosteroids. The incidence of cyclophosphamide-induced lung injury, a potentially life-threatening event, is about 1%. We report on a patient with a history of cyclophosphamide-induced lung injury 2 months after initial treatment of systemic c-ANCA-positive vasculitis. Six months later, the patient presented with acute renal failure caused by an acute relapse of vasculitis. Mycophenolate mofetil (MMF) is a potent immunosuppressive drug that recently has been shown to be effective in the maintenance therapy of c-ANCA-positive systemic vasculitis. With the patient's informed consent, we started treatment with MMF in combination with corticosteroids. Subsequently, anti-proteinase-3-titer (anti-Pr3-titer) returned to normal and renal function improved. In conclusion, MMF in combination with corticosteroids may be useful in the treatment of acute c-ANCA-positive vasculitis." }, { "id": "pubmed23n0525_10859", "title": "Immunosuppressive therapy and clinical evolution in forty-nine patients with antineutrophil cytoplasmic antibody-associated glomerulonephritis.", "score": 0.009523809523809525, "content": "Immunosuppressive therapy and clinical evolution were studied in 49 patients (29 females) with antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis. The mean age of patients at presentation was 55 years, and the mean (+/-SD) follow-up was 43 months (+/-33) (range, 3-140). Among the 49 patients, 10 had biopsy-proven Wegener's granulomatosis, 33 microscopic polyangiitis, 2 Churg-Strauss syndrome, and 4 idiopathic crescentic glomerulonephritis. IgG ANCA autoantibodies were detected in all patients. Induction therapy included pulses and oral administration of methylprednisolone (MP) with oral administration of cyclophosphamide (CP) and plasma exchange in patients with alveolar hemorrhage and serum creatinine (SCr) levels &gt;/= 6 mg/dL. CP was converted to azathioprine (AZA) or mycophenolate mofetil (MMF) after 3-6 months of therapy. Low doses of MP with or without AZA or MMF were administered until the end of follow-up. Therapy institution resulted in remission of disease in all patients. The mean SCr levels decreased from 4.9 mg/dL (+/-2.5) at the onset of the disease to 2.8 mg/dL (+/-1.7) (P &gt; 0.0001), and 3.2 mg/dL (+/-2.3) (P &gt; 0.0001) after 3 and 6 months, respectively. At the end of follow-up, 17 (35%) patients progressed to end-stage renal disease after 34 months (+/-29) (range, 3-98), and 30 (61%) patients maintained sufficient renal function. Two patient deaths were attributed to immunosuppression. Patients with high SCr levels at diagnosis and severe interstitial fibrosis found in renal biopsy had poor renal outcome (P &gt; 0.01 and P &gt; 0.02, respectively). Induction therapy with MP and CP seems to be the regimen of choice in patients with ANCA-associated glomerulonephritis. Early diagnosis and therapy institution as well as long-term treatment lead to acceptable renal survival." }, { "id": "pubmed23n0293_10005", "title": "Treatment response and relapse in antineutrophil cytoplasmic autoantibody-associated microscopic polyangiitis and glomerulonephritis.", "score": 0.009433962264150943, "content": "In this study, the rate of remission, relapse, and treatment resistance in 107 patients with microscopic polyangiitis and necrotizing and crescentic glomerulonephritis associated with antineutrophil cytoplasmic autoantibodies were assessed. Patients with Wegener's granulomatosis were excluded. Prospective criteria were identified to assess remission, relapse, and resistant disease. Ninety-seven of the 107 patients received treatment with corticosteroids (N = 25) or with cyclophosphamide and corticosteroids (N = 72). Of these patients, 75 (77.3%) went into remission (complete remission, N = 61; remission on therapy, N = 14). Of the 75 responders, 32 patients (43%) remained in long-term remission, for a mean follow-up of 44 +/- 29 months; 15 patients (20%) progressed to ESRD without signs of relapse, for a mean of 21.4 +/- 22.8 months after the end of treatment; 6 patients died. Twenty-two of the 75 patients who initially responded to treatment (29%) suffered a relapse that occurred within 18 months of the end of therapy and usually affected the same organ systems as on initial presentation. There was a significant difference in the remission rate between the corticosteroid-treated patients and the cyclophosphamide-treated patients (56% versus 84.7%, P = 0.003), and the cyclophosphamide-treated patients had three times less risk of experiencing a relapse than did corticosteroid-treated patients (0.31, 95% Cl = (0.12, 0.84)). Seventy-seven percent (17 of 22 patients) of treatment resistance occurred in patients who presented with fulminant disease or advanced and severe renal disease. It was concluded that most patients with microscopic polyangiitis or necrotizing and crescentic glomerulonephritis achieve remission with therapy. Relapses occur in 29% of patients and generally respond to retreatment. Initial treatment with cyclophosphamide and corticosteroids rather than corticosteroids alone results in a lower frequency of relapse. Even patients who require dialysis at presentation may benefit from treatment, however, patients who are not treated until the disease process is life-threatening may die before induction therapy is complete, indicating the continued need for early diagnosis and therapy." }, { "id": "pubmed23n0668_198", "title": "Does a gating policy for ANCA overlook patients with ANCA associated vasculitis? An audit of 263 patients.", "score": 0.009259259259259259, "content": "Antineutrophil cytoplasm antibodies (ANCA) are used as diagnostic markers for small-vessel vasculitis of the Wegener Granulomatosis-microscopic polyangiitis (WG-MPA) spectrum, but if testing is applied indiscriminately, its value is diminished. The authors measured the effect of a targeted ANCA testing policy introduced in our institution in an attempt to improve the diagnostic value of testing in patients with suspected vasculitis. The authors measured the rate of ANCA requests at a single regional centre in the year prior to and following the introduction of clinical guidelines to ensure appropriate test usage. The authors also audited clinical outcomes in patients in whom ANCA testing was declined. Following implementation of the antineutrophil cytoplasm antibodies (ANCA) gating policy, the number of monthly ANCA tests carried out fell from 287+/-30 to 143+/-18 (p&lt;0.0001) and was associated with an increased rate of positivity, from 18.5% (95% CI 17.0 to 20.1%) to 30.3% (27.5 to 33.1%; p&lt;0.0001). The authors undertook a careful review of the case records from 263 patients in whom testing was declined according to the gating policy over an 8-month period. After 6 months' follow-up, no diagnoses of small-vessel vasculitis of the WG-MPA spectrum were reached. The rational use of ANCA testing to aid in the diagnosis of vasculitis should include a clinical gating policy to improve diagnostic performance. Adherence to a gating policy for ANCA testing coupled with close liaison between clinician and laboratory does not result in either a missed or delayed diagnosis of small-vessel vasculitis belonging to the WG-MPA spectrum." }, { "id": "pubmed23n0601_3861", "title": "[ANCA(antineutrophil cytoplasmic antibodies)-associated vasculitis in a man with extreme fatigue, fever and progressive renal dysfunction].", "score": 0.009174311926605505, "content": "A 55-year-old man, with no previous history, presented with extreme fatigue and fever and was admitted to hospital. He had progressive renal dysfunction and his serum anti-neutrophil cytoplasmic antibodies (ANCA) were markedly elevated. Renal histology was consistent with ANCA-associated vasculitis. The patient was successfully treated with cyclophosphamide and prednisolone. The classification and management of the ANCA-associated vasculitides are described. The classification was guided by the clinical presentation, serology and results of tissue biopsies. The ANCA inflammation had affected the middle sized and small vessels of especially the upper and lower airways, and the kidneys. The antibodies were directed at proteinase-3 (PR3) or myeloperoxidase (MPO). PR3-ANCA is predominantly found in Wegener's granulomatosis, while MPO-ANCA is related to microscopic polyangiitis. Tissue studies showed granulomatous inflammation of the airways which is typical of Wegener's disease. This type of inflammation is absent in microscopic polyangiitis. The initial treatment schedule consists of prednisone 1 mg/kg daily and oral cyclophosphamide 2 mg/kg daily. In the remission phase, the cyclophosphamide is replaced by azathioprine. It is not yet known how long maintenance treatment should be continued and which parameters have prognostic value." }, { "id": "pubmed23n0828_24507", "title": "[Use of rituximab in the induction of remission of severe, resistant and recurrent form of polyangiitis associated with c-ANCA antibodies - case report].", "score": 0.009174311926605505, "content": "Indications for rituximab (RTX) have recently widened. We present a case of 25-years old patient with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis of high disease activity. The patient in severe condition, massive changes of nasal sinuses, with destruction of the orbit bones, with inflammatory infiltrations of the optical nerves and end stage renal disease was admitted to Nephrology Clinic to begin renal replacement therapy (RRT). Chest HRCT reveled changes of \"frosted glass\", enlarged mediastinal lymphatic nodes and fluid in pleural cavities. C-ANCA antibodies was 23 IU/ml (norm: &lt;2IU/ml). Due to the lack of therapeutic possibilities (exceeded cumulative dose of cyclophosfamide, recurrence of the disease during treatment with mycophenolate mofetil) rituximab was introduced. After proving high expression of CD 20 antigen on the surface of B lymphocytes, two doses of rituximab were administrated (1,0g every two weeks). 8 weeks after the second dose remission of lungs disorders was observed, c- ANCA level decreased to 3,7IU/ml and the granulomatous mass around the optical nerve was stable. 12 months later another supporting dose of rituximab was administrated. Now, 18 months after relapse of the disease patient is in good condition waiting for kidney transplantation. Rituximab is save, well tolerated and effective. Particularly high efficiency of RTX have been observed against lung disorders. No significant remission of granuloma infiltration in the orbits has been noted. Better evaluation of efficiency and safety of rituximab needs further evaluation. " }, { "id": "pubmed23n0664_4232", "title": "Plasma exchange for induction and cyclosporine A for maintenance of remission in Wegener's granulomatosis--a clinical randomized controlled trial.", "score": 0.00909090909090909, "content": "The use of plasma exchange (PE) for induction treatment of anti-neutrophil cytoplasm autoantibody (ANCA)-associated vasculitis (AAV), including Wegener's granulomatosis (WG), is still controversial. The use of PE in AAV is not commonly accepted in patients with a plasma creatinine &lt;500 μmol/L (5.7 mg/dL) despite experimental support for involvement of ANCA in the pathogenesis of vasculitis. In a single-centre study from a tertiary referral centre, 32 patients with ANCA-positive WG were treated with standard immunosuppressive therapy, prednisolone and cyclophosphamide (CYC). In addition, they were randomized to treatment with or without initial PE. After 3 months, they were further randomized in a Latin square design to continue CYC or to change to cyclosporine A (CyA) for 9 months. The renal follow-up was at least 5 years. Renal survival after 1, 3 and 12 months, and 5 years was significantly better in the PE groups. For all groups, the kidney/patient survival was 87.5%/93.7% at 1 year and 72%/56% at 5 years. All patients who were on dialysis when recruited were dialysis dependent 5 years later. There was no difference in morbidity or mortality between PE and control groups. Multivariate analysis demonstrated that PE improved renal survival (P &lt; 0.01) at initial plasma creatinine levels &gt;250 µmol/L (2.85 mg/dL). Change from CYC to CyA did not influence rate of relapses or time to relapse. PE is recommended for induction therapy in WG patients at creatinine levels &gt;250 µmol/L (2.85 mg/dL), whereas previous randomized studies have limited PE to patients with creatinine &gt;500 µmol/L (5.65 mg/dL)." }, { "id": "pubmed23n0745_21769", "title": "Culture-negative subacute bacterial endocarditis masquerades as granulomatosis with polyangiitis (Wegener's granulomatosis) involving both the kidney and lung.", "score": 0.009009009009009009, "content": "Subacute bacterial endocarditis (SBE) occasionally exhibits positive cytoplasmic anti-neutrophil cytoplasmic antibody (c-ANCA) of the anti-proteinase-3 (PR-3) type. Clinically, it mimics ANCA-associated vasculitis, such as Wegener's disease with glomerulonephritis. Lung abscesses are the most common manifestation of lung involvement. We herein report a case of culture-negative SBE strongly c-ANCA/PR3-positive accompanied by pulmonary involvement and glomerulonephritis. In this case, we took biopsies of both the lung and kidney, although renal biopsy is usually preferred over lung biopsy. The lung biopsy showed severe alveolar capillaritis, suggesting vasculitis consistent with polyangiitis. The renal biopsy revealed glomerulonephritis with a membranoproliferative pattern. To our knowledge, this is the first such reported case. A 68-year-old Chinese male patient presented to our hospital with a fever, cough, chest pain, and recurrent peripheral edema. He had a past medical history significant for treated schistosomiasis 20 years previously. Physical examination revealed palpable purpura, mild hypertension, hepatosplenomegaly, and a holosystolic cardiac murmur (Levine 2/6). Echocardiography showed tricuspid valve vegetations with moderate to severe regurgitation. Serum c-ANCA/PR3 and cryoglobulin were strongly positive. Renal biopsy results indicated membranoproliferative glomerulonephritis with several crescents. Chest CT revealed multiple intraparenchymal and subpleural nodules, and lung biopsy showed polyangiitis. The patient's ANCA titers, glomerulonephritis, and pulmonary injury all resolved after antibiotic therapy. SBE may present with positive c-ANCA/PR3, multiple pulmonary nodules, pulmonary polyangiitis, and glomerulonephritis clinically mimicking granulomatosis with polyangiitis (Wegener's granulomatosis)." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 130, 306 ] ], "word_ranges": [ [ 21, 48 ] ], "text": "although there is no history of intoxication, we have to go to the most frequent and that we can antagonize with antidotes: benzodiazepines (flumazenil) and opiates (naloxone)." }, "4": { "exist": true, "char_ranges": [ [ 307, 422 ] ], "word_ranges": [ [ 48, 67 ] ], "text": "If we suspect ethylene glycol intoxication, we would administer thiamine, but there are no data to make us suspect." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Administer naloxone, flumazenil and thiamine.", "2": "Administer naloxone, flumazenil and hypertonic glucose.", "3": "Administer naloxone and flumazenil.", "4": "Administer thiamine and hypertonic glucose.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en258_12063", "title": "Coma cocktail", "score": 0.019704911667637354, "content": "A coma cocktail is a combination of substances administered in an emergency to comatose individuals when the cause of the coma has not yet been determined. The intention is to work against various causes of a coma seen in an emergency setting including drug overdoses and hypoglycemia. A standard combination included dextrose (1 Amp D50W IV), flumazenil (0.2 mg IV), naloxone (2 mg IV), and thiamine (100 mg IV). It has been suggested that the use of naloxone and flumazenil be administered more selectively than glucose and thiamine. Some have proposed that the concept be abandoned completely because modern EMS providers should be able to determine the likely etiology of the change in mental status. At a minimum, the clinical presentation of the patient should rule in or out some portions of the coma cocktail. For example, with the advent and widespread implementation of glucometers, the indications for administering glucose can be more narrowly defined and its use more regimented." }, { "id": "wiki20220301en000_202449", "title": "Hypoglycemia", "score": 0.01779500158177792, "content": "Treatment After hypoglycemia in a person is identified, rapid treatment is necessary and can be life-saving. The main goal of treatment is to raise blood glucose back to normal levels, which is done through various ways of administering glucose, depending on the severity of the hypoglycemia, what is on-hand to treat, and who is administering the treatment. A general rule used by the American Diabetes Association is the \"15-15 Rule,\" which suggests consuming or administering 15 grams of a carbohydrate, followed by a 15-minute wait and re-measurement of blood glucose level to assess if blood glucose has returned to normal levels. Self-treatment If an individual recognizes the symptoms of hypoglycemia coming on, blood sugar should promptly be measured, and a sugary food or drink should be consumed. The person must be conscious and able to swallow. The goal is to consume 10-20 grams of a carbohydrate to raise blood glucose levels to a minimum of 70 mg/dL (3.9 mmol/L)." }, { "id": "pubmed23n0409_14168", "title": "No more coma cocktails. Using science to dispel myths &amp; improve patient care.", "score": 0.017073525138041265, "content": "It should be clear from this discussion that coma cocktails are a bad idea and should be immediately abandoned. In fact, the indiscriminate use of the coma cocktail may indeed harm patients, EMS has evolved to a point where any EMS provider should be able to reasonably determine the most likely cause of coma, or, in a worst-case scenario, narrow the cause to but a few possibilities. Certainly, patients with bona fide hypoglycemia should receive IV glucose. Because the consequences of prolonged hypoglycemia are severe, if there's a doubt about whether hypoglycemia is present, then glucose should be empirically administered. Naloxone should be used only for those cases in which a narcotic overdose appears likely. Similarly thiamine administration should be limited to patients suspected of chronic alcohol abuse and who exhibit at least one of the three symptoms of WE described above. Flumazenil has no role in the routine treatment of coma unless the patient is known to not be benzodiazepine dependent and the overdose is known to result only from benzos--two very difficult requirements to verify in the back of an ambulance at 2 a.m. Coma cocktails are bad medicine. Let's banish them from our EMS armamentarium." }, { "id": "wiki20220301en258_12065", "title": "Coma cocktail", "score": 0.016242346116661296, "content": "Dextrose If the blood glucose concentration of the patient is alternating consciousness or at least contributing to the alteration, said patient likely needs hypertonic dextrose. Another indicator is seizures. Hypertonic dextrose is effective in treating hypoglycemia, and one in twelve patients administered for altered mental status suffer from it. This statistic may be sufficient evidence for doctors to support the routine of administering the drug. Dextrose contributes to the controversy of coma cocktails by inducing Wernicke–Korsakoff syndrome in patients that are deficient in thiamine. Patients that are specifically at risk of being impacted this way are those with alcoholic tendencies or malnourishment." }, { "id": "Neurology_Adams_2942", "title": "Neurology_Adams", "score": 0.013443359677669301, "content": "2. The management of shock, if present, takes precedence over all other diagnostic and therapeutic measures. 3. Concurrently, an intravenous line is established and blood samples are drawn for determination of glucose, intoxicating drugs, and electrolytes and for tests of liver and kidney function. Naloxone, 0.5 mg, should be given intravenously if a narcotic overdose is a possibility. Hypoglycemia that has produced stupor or coma requires the infusion of glucose, usually 25 to 50 mL of a 50 percent solution followed by a 5 percent infusion; this must be supplemented with thiamine. A urine sample is obtained for drug and glucose testing. If the diagnosis is uncertain, both naloxone and the glucose-thiamine combination should be administered." }, { "id": "Neurology_Adams_2873", "title": "Neurology_Adams", "score": 0.01207059003285034, "content": "Many times the primary disorder underlying coma is perfectly obvious, as with severe cranial trauma or a known drug overdose. All too often, however, the comatose patient is brought to the hospital and little pertinent medical information is available. The need for efficiency in reaching a diagnosis and providing appropriate acute care demands that the physician have a methodical approach that first addresses the common and treatable causes of coma. When the comatose patient is first seen, the patient’s airway is cleared and blood pressure is restored; if trauma has occurred, one must check for bleeding from a wound or ruptured organ (e.g., spleen or liver). With hypotension, placement of a central venous line and administration of fluids and pressor agents, oxygen, blood, or glucose solutions (preferably after blood is drawn for glucose determinations and thiamine is administered) take precedence over diagnostic procedures. If respirations are shallow or labored, or if there is" }, { "id": "article-30759_38", "title": "Unconscious Patient -- Treatment / Management", "score": 0.011952981164141056, "content": "Circulation: A mean arterial blood pressure below 70 mm Hg should be treated with fluids or vasopressors. Mean arterial pressures exceeding 130 mm Hg may require administering intravenous (IV) labetalol at a dose of 5 to 20 mg or as necessary. Vital Signs: The vital signs of an unconscious patient should be obtained if this task has not yet been completed. Glucose Administration: If the cause of the coma is unknown, 25 g of dextrose should be administered while awaiting the results of laboratory tests. Thiamine Administration: In cases of malnourishment, a 100 mg dose of thiamine should be administered alongside or before administering glucose to the patient." }, { "id": "Pharmacology_Katzung_1490", "title": "Pharmacology_Katzung", "score": 0.011945532754322037, "content": "Ramin Sam, MD, Harlan E. Ives, MD, PhD, & David Pearce, MD A 65-year-old man has a history of diabetes and chronic kidney disease with baseline creatinine of 2.2 mg/dL. Despite five different antihypertensive drugs, his clinic blood pres-sure is 176/92 mm Hg; he has mild dyspnea on exertion and 2–3+ edema on exam. He has been taking furosemide 80 mg twice a day for 1 year now. At the clinic visit, hydrochlorothi-azide 25 mg daily is added for better blood pressure control and also to treat symptoms and signs of fluid overload. Two weeks later, the patient presents to the emergency depart-ment with symptoms of weakness, anorexia, and generalized malaise. His blood pressure is now 91/58 mm Hg, and he has lost 15 kg in 2 weeks. His laboratory tests are signifi-cant for a serum creatinine of 10.8 mg/dL. What has led to the acute kidney injury? What is the reason for the weight loss? What precautions could have been taken to avoid this hospitalization?" }, { "id": "pubmed23n1010_24763", "title": "Just the Facts: Diagnosis and treatment of diabetic ketoacidosis in the emergency department.", "score": 0.011383647798742139, "content": "A 21-year-old male with known type 1 diabetes mellitus presented to the emergency department (ED) with two days of vomiting, polyuria, and polydipsia after several days of viral upper respiratory tract infection symptoms. Since his symptom onset, his home capillary blood glucose readings have been higher than usual. On the day of presentation, his glucometer read \"high,\" and he could not tolerate oral fluids. On examination, his pulse was 110 beats/minute, and his respiratory rate was 24 breaths/minute. He was afebrile, and the remaining vital signs were normal. Other than dry mucous membranes, his cardiopulmonary, abdominal, and neurologic exams were unremarkable. Venous blood gas demonstrated a pH of 7.25 mm Hg, pCO2 of 31 mm Hg, HCO3 of 13 mm Hg, anion gap of 18 mmol/L, and laboratory blood glucose of 40 mmol/L, as well as serum ketones measuring \"large.\"" }, { "id": "wiki20220301en160_41779", "title": "R v Quick", "score": 0.009900990099009901, "content": "Such malfunctioning of his mind as there was, was caused by an external factor and not by a bodily disorder in the nature of a disease which disturbed the working of his mind. It follows in our judgment that Quick was entitled to have his defence of automatism left to the jury and that Mr. Justice Bridge's ruling as to the effect of the medical evidence called by him was wrong. Had the defence of automatism been left to the jury, a number of questions of fact would have had to be answered. If he was in a confused mental condition, was it due to a hypoglycaemic episode or to too much alcohol? If the former, to what extent had he brought about his condition by not following his doctor's instructions about taking regular meals? Did he know that he was getting into a hypoglycaemic episode? If yes, why did he not use the antidote of eating a lump of sugar as he had been advised to do? On the evidence which was before the jury Quick might have had difficulty in answering these questions in" }, { "id": "article-26221_18", "title": "Opioid Toxicity -- Differential Diagnosis", "score": 0.009869126796824716, "content": "If the classic signs of opioid toxicity are present in a comatose patient, such as constricted pupils and slow respiratory rate, assumptions are often that there is nothing else this patient could have. If after naloxone reversal, the patient appears to have normalized, this assumption can be justified. However, undifferentiated comatose patients are often seen in the emergency setting and can be challenging to evaluate and treat. Traditionally, a \"coma cocktail\" of 4 medications (dextrose/thiamine/naloxone/flumazenil) was used, but only one of the components of the original cocktail (naloxone) remains in use in emergency care as of early 2019. [26] Sometimes an unforeseen consequence of injecting a robust dose of naloxone into the undifferentiated comatose patient is subsequent agitation, which can at times severely limit the team's efforts to evaluate for potentially severe underlying disease unrelated to opioid toxicity. It is often best to consider a very small test dose of naloxone such as 0.4 mg intravenous in the adult patient if that medication is to be given diagnostically and to keep the differential broad regarding potential etiologies of unresponsiveness until the history and physical findings narrow that differential." }, { "id": "Neurology_Adams_2689", "title": "Neurology_Adams", "score": 0.009817647567193846, "content": "We have had the success with the following program, which reflects several published approaches. When the patient is first seen, an initial assessment of cardiorespiratory function is made and an oral airway established. As summarized by Bleck, a large-bore intravenous line is inserted; blood is drawn for glucose, BUN, electrolytes, and a metabolic and drug screen. A normal saline infusion is begun and a bolus of glucose is given (with thiamine if malnutrition and alcoholism are potential factors). To rapidly suppress the seizures, we generally use diazepam intravenously at a rate of about 2 mg/min until the seizures stop or a total of 20 mg has been given; alternatively, lorazepam, 0.1 mg/kg given by intravenous push at a rate not to exceed 2 mg/min, is now favored, being marginally more effective than diazepam because of its clinically longer duration of action (see Table 15-8)." }, { "id": "wiki20220301en069_15245", "title": "Central nervous system depression", "score": 0.00980392156862745, "content": "There are two antidotes that are frequently used in the hospital setting and these are naloxone and flumazenil. Naloxone is an opioid antagonist and reverses the central nervous depressive effects seen in opioid overdose. In the setting of a colonoscopy, naloxone is rarely administered but when it is administered, its half-life is shorter than some common opioid agonists. Therefore, the patient may still exhibit central nervous system depression after the naloxone has been cleared. Naloxone is typically administered in short intervals with relatively small doses in order to prevent the occurrence of withdrawal, pain, and sympathetic nervous system activation. Flumazenil is a benzodiazepine antagonist and blocks the binding of benzodiazepines to gamma-aminobutyric acid receptors. Similarly to naloxone, flumazenil has a short half-life, and this needs to be taken into account because the patient may exhibit central nervous depression after the antidote has been cleared. Benzodiazepines" }, { "id": "wiki20220301en258_12066", "title": "Coma cocktail", "score": 0.009708737864077669, "content": "Naloxone Naloxone effectively treats CNS and respiratory depression caused by opiate/opioid overdose. It allows adequate ventilation for impacted patients, and health professionals administer it intravenously. Naloxone has well-documented effectiveness; as a matter of fact, 575/609 patients (mainly with heroin overdose) showed improved consciousness and respiration within five minutes of treatment. The major downsides to naloxone are the hypersensitivity from the patient and its reaction with substances contaminating opioids/opiates. In terms of hypersensitivity, the patient may subsequently suffer from restlessness, headache, and vomiting. Opiates/opioids, such as heroin, can be contaminated with scopolamine, and if it is present, the patient may face an anticholinergic crisis. Flumazenil Flumazenil is an imidazobenzodiazepine that can help mediate and antagonize the effects of benzodiazepines. It can be used in anaesthesia as well as intensive care." }, { "id": "pubmed23n0110_11168", "title": "Demystifying hypoglycemia. When is it real and how can you tell?", "score": 0.009708737864077669, "content": "Contrary to popular belief, hypoglycemia is an infrequently encountered condition and its presence is questionable until confirmed by appropriate tests. In ambulatory patients, blood glucose levels obtained during intake of a normal diet are more reliable than those obtained during a glucose tolerance test. If the blood glucose is actually abnormally low and the other two criteria of hypoglycemia are also satisfied, a search for the cause is in order. In hospitalized patients, excessive doses of insulin or oral hypoglycemic agents, the effect of drugs, or chronic renal failure are the most common causes of hypoglycemia. If these factors are absent, another chronic illness known to cause hypoglycemia may be the source. If the cause is still obscure, a thorough evaluation of the endocrine status is warranted." }, { "id": "pubmed23n0646_18186", "title": "A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning.", "score": 0.009615384615384616, "content": "ABSTRACT Body packers are people who illegally carry drugs, mostly cocaine as well as opium and/or heroin, concealed within their bodies. The packets are inserted in the mouth, rectum, or vagina in order to get across borders without being detected. In this presentation we report a case of an opium body packer and review the available scientific literature by focusing on mechanisms of toxicity and treatment approach. The patient was a 35-year-old man who had lethargy, respiratory depression, tachycardia, normal blood pressure, hyperthermia, and pinpoint pupils on presentation. No past medical history was obtained and the only positive history was his travel from Afghanistan 2 days earlier, which he had given to emergency personnel before arriving at our hospital. Complete blood cells and kidney and liver tests were all in normal range. In the emergency department, the patient was treated with oxygen, naloxone, and hypertonic glucose. One dose of activated charcoal (1 g/kg) was administered orally. After intravenous injection of naloxone (4 mg), the lethargy, respiratory depression, and miosis were resolved. The patient was admitted to the intensive care unit and 90 min after admission, the patient redeveloped respiratory distress and lost consciousness. He was intubated and mechanically ventilated due to the suspicious of body packing. Plain abdominal x-ray showed multiple packets throughout the gastrointestinal tract; 81 packets were removed by surgery and three of them were left due to leaking. After removing the packets, the patient was treated conservatively. He suffered a pulmonary infection (aspiration pneumonia) and he regained consciousness after 4 days. Upon recovery the patient was seen by a psychiatrist prior to going to prison. Surgery is recommended for body packers who have significant signs or symptoms." }, { "id": "pubmed23n0421_5516", "title": "[What lies under the glass on the medical professional's table?].", "score": 0.009615384615384616, "content": "Normal values are intervals covering the majority of cases detected in healthy individuals. They are gradually replaced by diagnostic criteria based on probability of differentiation between the healthy and ill (prognostic intervals). In 1970-ies, \"recommended for health promotion\" intervals appeared. The physician must know the origin of the criteria recommended for assessment of the results of the laboratory test or another measurement, in diagnosis, only diagnostic criteria must be used but not criteria designed for prophylactic programs. In the context of each disease diagnostic criteria should account for possible sequelae. Such criteria are multiple: for one test (e.g. plasma glucose concentration) there are different criteria for diagnosis of different diseases (diabetes type 1 or 2, hypothyroidism). Only such criteria should be included in recommendations (standards) on diagnosis and treatment of certain diseases. Conventional \"normal values\" should be used only in assessment of the results of prophylactic surveys and in search for explanation for the obscure states." }, { "id": "pubmed23n1056_6772", "title": "Unconscious man in his fifties with elevated anion gap.", "score": 0.009523809523809525, "content": "The use of GHB is still widespread with many hospitalised overdose cases. A man in his fifties was found unconscious in the street and brought to our Acute Admissions. When first examined he was still unconscious, hypothermic, had snoring respiration and smelled of alcohol. He was otherwise haemodynamically stable. Blood samples showed elevated osmolal and anion gaps. The increase in the osmol gap could be explained by the ethanol level of 210 mg/dL (46 mmol/L), but the reason for the increased anion gap was unknown. Flumazenil and naloxone were administered without effect. As the ethanol concentration alone was unlikely to explain the clinical picture, extended toxicological tests were performed. GHB in plasma was very high (5.0 mmol/L; 520 mg/L) even though the sample was taken almost 4 hours after admission. The GHB concentration (present as an anion) corresponded to the increased anion gap. The patient was comatose for approximately 12 hours, which is unusually long in GHB poisoning. Intoxication with GHB is important to consider in comatose patients where other causes are excluded. Prolonged clinical course may be due to a saturation of the GHB metabolism after a large dose or ingestion of GBL or 1,4-butanediol, both of which are precursors to GHB." }, { "id": "pubmed23n1117_8254", "title": "[CME/Answers: Metformin - Dos and Don'ts].", "score": 0.009523809523809525, "content": "CME/Answers: Metformin - Dos and Don'ts <bAbstract.</b CME/Answers: Metformin - Dos and Don'ts In the absence of contraindications metformin is still considered the initial medication in patients with diabetes mellitus type 2, although diabetes therapy is rapidly changing. Metformin is used both as monotherapy and in combination with any other diabetic medication. As a biguanide metformin improves glycemic control by inhibiting gluconeogenesis and increasing insulin-mediated glucose utilization in peripheral tissues. Metformin promotes modest weight reduction and provides several other advantages: no risk of hypoglycemia, excellent general tolerability, well-known long-term safety profile and low-cost. The most common gastrointestinal side effects are usually mild and transient, but vitamin B12 deficiency may develop. Metformin-associated lactic acidosis (MALA) is a rare, but relevant and life-threatening complication. The risk increases with renal impairment; therefore the metformin dose must be adjusted to the eGFR. The use of metformin is contraindicated with an eGFR &lt;30 ml/min/1.73 m2. There are other contraindications: concurrent active or progressive severe liver disease, active alcohol abuse, unstable or acute heart failure, hypoperfusion and hemodynamic instability, as well as a past history of lactic acidosis. Since metformin remains a modern therapy, it is important to be aware of its indications and contraindications." }, { "id": "Neurology_Adams_9574", "title": "Neurology_Adams", "score": 0.009482676186529818, "content": "It must be emphasized, as it was in Chap. 40, that a special danger attends the use of glucose solutions in alcoholic patients. The administration of intravenous glucose may serve to consume the last available reserves of thiamine and precipitate Wernicke disease. Typically, these patients have subsisted on a diet disproportionately high in carbohydrate (in addition to alcohol, which is metabolized entirely as carbohydrate) and low in thiamine, and their body stores of B vitamins may have been further reduced by gastroenteritis and diarrhea. For this reason it is good practice to add B vitamins, specifically thiamine (which may also be supplemented by intramuscular injection), in all cases requiring parenterally administered glucose—even though the alcoholic disorder under treatment, for example, delirium tremens, is not primarily caused by vitamin deficiency." }, { "id": "pubmed23n0254_7155", "title": "The poisoned patient with altered consciousness. Controversies in the use of a 'coma cocktail'.", "score": 0.009433962264150943, "content": "In the assessment and management of the potentially poisoned patient with altered consciousness, the most consequential and controversial interventions occur during the first 5 minutes of care. In this review article, the risks and benefits of standard diagnostic and therapeutic interventions are presented to guide clinicians through this critical period of decision making. Data for discussion were obtained from a search of English-language publications referenced on MEDLINE for the years 1966 to 1994. Older literature was included when pertinent. Search terms included poisoning, overdose, toxicity, naloxone, glucose, thiamine, and flumazenil. Only large trials were used for determinations of diagnostic utility and efficacy. Small trials, case series, and case reports were reviewed extensively for adverse effects. Trials were reviewed for overall methodology, inclusion and exclusion criteria, sources of bias, and outcome. Analysis favors empirical administration of hypertonic dextrose and thiamine hydrochloride to patients with altered consciousness. Although rapid reagent test strips can be used to guide this therapy, they are not infallible, and they fail to recognize clinical hypoglycemia that may occur without numerical hypoglycemia. Administration of naloxone hydrochloride should be reserved for patients with signs and symptoms of opioid intoxication. Flumazenil is best left for reversal of therapeutic conscious sedation and rare select cases of benzodiazepine overdose." }, { "id": "wiki20220301en069_6117", "title": "21 grams experiment", "score": 0.009433962264150943, "content": "Experiment In 1901, Duncan MacDougall, a physician from Haverhill, Massachusetts, who wished to scientifically determine if a soul had weight, identified six patients in nursing homes whose deaths were imminent. Four were suffering from tuberculosis, one from diabetes, and one from unspecified causes. MacDougall specifically chose people who were suffering from conditions that caused physical exhaustion, as he needed the patients to remain still when they died to measure them accurately. When the patients looked like they were close to death, their entire bed was placed on an industrial sized scale that was sensitive within two tenths of an ounce (5.6 grams). On the belief that humans have souls and that animals do not, MacDougall later measured the changes in weight from fifteen dogs after death. MacDougall said he wished to use dogs that were sick or dying for his experiment, though was unable to find any. It is therefore presumed he poisoned healthy dogs." }, { "id": "pubmed23n0609_14980", "title": "Case files of the University of Massachusetts fellowship in medical toxicology: lethal dose of opioids contained in an elastomeric capsule labeled as vancomycin.", "score": 0.009259259259259259, "content": "A 67 year-old male presented to the emergency department with alteration in mental status. On arrival he had vital signs: pulse 110, BP 173/83, respiratory rate 4, oxygen saturation 57% and temperature 36.1 degrees Celsius. His past medical history included hypertension, vitamin B12 deficiency, hyperlipidemia, and recurrent cellulitis treated with vancomycin. The patient had no response to noxious stimuli, pinpoint pupils, and agonal respirations. Secondary to his wife's vehement denial that he had access to or history of using any narcotics, he was intubated after 2.2mg IV naloxone failed to reverse respiratory depression. Thirty minutes before presentation, however, he had received an intravenous infusion of vancomycin administered by his wife at home. The vancomycin, obtained from a home infusion medication supply company, was contained in one of five sealed elastomeric capsules delivered earlier that day. A qualitative comprehensive toxicology screen of urine for 1043 substances identified morphine, codeine, naloxone, lidocaine and caffeine. The original elastomeric container was not available for testing, but another container from the same delivery was submitted for testing to the state forensic laboratory. This intact container was labeled as Vancomycin 1g in 240mL of normal saline. The forensic laboratory confirmed that the alkaloidal contents of the elastomeric capsule were 10% codeine, 4.4% 6-monoacetyl morphine, and 84% morphine. No vancomycin was identified in the infusion bottles. The case was referred to the local police department and the state department of health drug control board. The home infusion company was also immediately notified to prevent similar occurrence. We are reporting the first known case of opioid overdose from an adulterated elastomeric capsule that was labeled as containing an antimicrobial agent." }, { "id": "pubmed23n0318_16753", "title": "[The effects of flumazenil or bicuculline on the respiratory depression by morphine].", "score": 0.009174311926605505, "content": "The effects of intravenous administration of flumazenil (n = 6) or bicuculline (n = 6) on the discharge of the phrenic nerve were studied following vagotomy in pentobarbital anesthetized mechanically ventilated rats. Morphine (0.4 mg.kg-1.min-1) was administrated until the respiratory rate decreased to about a half of the baseline respiratory rate. In this state, we first administered flumazenil (0.25 mg.kg-1) or bicuculline (0.4 mg.kg-1), intravenously and then administered naloxone (0.02 mg) intravenously in the two groups. The increase of inspiratory time from 0.7 +/- 0.1 to 2.0 +/- 0.5 s by morphine recovered to 0.8 +/- 0.2 s by bicuculline and to 0.6 +/- 0.1 s by naloxone. The increase of inspiratory time from 0.7 +/- 0.1 to 1.7 +/- 0.3 s by morphine, and to 2.1 +/- 0.5 s by flumazenil recovered to 0.6 +/- 0.1 s by naloxone. Expiratory time did not change during each drug administration in the two groups. The decrease of respiratory rate from 44 to 23 +/- 4 breaths.min-1 by morphine recovered to 37 +/- 5 breaths.min-1 by bicuculline and to 42 +/- 2 breaths.min-1 by naloxone. The decrease of respiratory rate from 45 +/- 3 to 22 +/- 6 breaths.min-1 by morphine, and to 18 +/- 4 breaths.min-1 by flumazenil recovered to 46 +/- 3 breaths.min-1 by naloxone. Amplitude of integrated phrenic nerve discharge increased to 125 +/- 42% by bicuculline and to 175 +/- 93% by naloxone compared to the baseline values. The decrease of amplitude to 54 +/- 18% by flumazenil recovered to 125 +/- 42% by naloxone. These results suggest that bicuculline not flumazenil antagonizes the respiratory depression of morphine by increasing the respiratory rate and respiratory movement." }, { "id": "pubmed23n0831_3762", "title": "[Non-fatal hyperkalemia in lactic acidosis due to metformin overdose. Report of one case].", "score": 0.00909090909090909, "content": "We report a 74-year-old man with diabetes mellitus type 2 and hypertension, who recently underwent coronary bypass surgery due to severe triple vessel disease receiving cardiological and combined antidiabetic therapy, including metformin 4 g/day. He was admitted with abdominal pain, nausea, vomiting, diarrhea and loss of consciousness. At admission, he was disoriented and agitated with signs of poor perfusion. His blood pressure was 80/70 mmHg, pulse rate 40 beats/min, respiratory rate 20-breaths/min, and axillary temperature 35 °C. Biochemical profile revealed an extreme hyperkalemia of 15.4 mEq/L (double checked), elevated creatinine, uremia and brain natriuretic peptide; hypoglycemia (blood glucose 68 mg/dl) and normal C Reactive Protein. Arterial blood gases revealed severe lactic acidemia. The electrocardiogram showed sinus bradycardia, simple AV block, widened QRS with prominent T wave and prolonged QT. He was admitted to the Intensive Care Unit (ICU) with the suspicion of lactic acidosis associated with metformin, receiving fluid management, intravenous hypertonic glucose plus insulin and sodium bicarbonate, mechanical ventilation, vasopressor therapy, a temporary pacemaker lead, in addition to continuous venovenous hemodiafiltration. Two days later, the patient experienced a significant clinical improvement with normalization of the acid-base status, plasma lactate and potassium levels. On day 9, diuresis was recovered, creatinine and uremia returned to normal levels and the patient was discharged from the ICU." }, { "id": "pubmed23n0423_18527", "title": "[On proportionate medical actions and extraordinary methods of treatment].", "score": 0.00909090909090909, "content": "As a general rule, any medical action should be proportionated. That is, the expected benefit of the treatment provided must be commensurate to the diagnosis and prognosis, the therapeutic efforts the suffering caused to the patient, and the eventual risks. Inversely a disproportionate or excessive medical action that will result in no benefit to the patient is technically incorrect and ethically reprebensible. As opposed to ordinary methods of treatment (basic nursing, feeding, hydration, drugs and regular clinical procedures), we reserve the name of \"extraordinary methods of treatment\" to those medical actions using complex and invasive highcost procedures and equipment that should be urgently indicated in any critically ill patient with a potentially reversible disease. These do not have any indication in terminally ill patients, except in the case of concomitant potentially reversible acute complications. When a DNR (do not resuscitate) order is adopted it should be reassessed periodically. The use, withholding and withdrawal of these extraordinary measures of treatment are subject to a series of medical and ethical requirements, which receive full discussion in this paper." }, { "id": "pubmed23n0070_8657", "title": "[Antagonism of flunitrazepam and fentanyl by flumazenil, naloxone or nalbuphine].", "score": 0.009009009009009009, "content": "The new benzodiazepine antagonist flumazenil represents another approach to the ever-present problem of recurring respiratory depression after anesthesia with flunitrazepam and fentanyl. Objective and subjective side effects of flumazenil were studied in comparison with the opiate antagonists naloxone and nalbuphine. METHODS. One hundred fifty surgical patients, ASA I or II, aged 18-65 years were studied. After premedication with atropine 0.5 mg and flunitrazepam 0.5 mg anesthesia was induced with flunitrazepam 0.5 mg, fentanyl 0.1 mg and etomidate 10 mg and maintained with N2O/O2 2:1 and additional increments of 0.1 mg fentanyl as required. Relaxation for intubation and surgery was obtained with non depolarizing muscle relaxants. After the operation the patients were extubated and then flumazenil 0.4 mg, naloxone 0.05 mg, or nalbuphine 20 mg was given i.v. (randomized and double-blind). In 15 patients blood pressure and heart rate were monitored. In all patients postoperative pain was assessed by the time interval between administration of the antagonist and need for the first analgesic medication. On the 1st postoperative day recall of postoperative events and of pictures shown 5, 30, 60, 120, and 240 min after administration of the antagonist was tested. The patients were interviewed a second time for side effects on day 3-6 after the operation. RESULTS. The three antagonists produced no significant effects on arterial pressure and heart rate. There were no differences between the antagonists in the incidence of postoperative nausea and/or vomiting or postoperative pain. After flumazenil, a significant transient increase in vigilance and better recall of postoperative events was noted within 5 and 30 min after administration of the drug. CONCLUSION. On the basis of the objective clinical findings, there is no reason to prefer either benzodiazepine or opiate antagonists after flunitrazepam and fentanyl. However, postoperative amnesia can be reduced by flumazenil if this is desirable." }, { "id": "pubmed23n0494_18463", "title": "Metformin-associated respiratory alkalosis.", "score": 0.008928571428571428, "content": "We present an 84-year-old man with a history of chronic obstructive pulmonary disease, type 2 diabetes, hypertension, glaucoma, and bladder cancer who presented to the emergency department after the police found him disoriented and confused. Metformin therapy began 3 days before, and he denied any overdose or suicidal ideation. Other daily medications included glipizide, fluticasone, prednisone, aspirin, furosemide, insulin, and potassium supplements. In the emergency department, his vital signs were significant for hypertension (168/90), tachycardia (120 bpm), and Kussmaul respirations at 24 breaths per minute. Oxygen saturation was 99% on room air, and a fingerstick glucose was 307 mg/dL. He was disoriented to time and answered questions slowly. Metformin was discontinued, and by day 3, the patient's vital signs and laboratory test results normalized. He has been asymptomatic at subsequent follow-up visits. Metformin-associated lactic acidosis is a well-known phenomenon. Respiratory alkalosis may be an early adverse event induced by metformin prior to the development of lactic acidosis." }, { "id": "pubmed23n0769_8716", "title": "[Management of the drunken patient].", "score": 0.008928571428571428, "content": "Acute ethanol intoxication is frequent in emergency departments. The clinical presentation is highly variable and ranges from an inebriety to a coma and sometimes an agitated patient. You have to examine completely the patient and to do complementary exams with a capillary glycemia as the minimal standard. We must keep in mind that an acute ethanol intoxication is a diagnosis of exclusion. With trauma patients, we have to keep a low threshold for asking radiological advanced imaging, like cerebro-cervical CT scan. The patient should be reexamined frequently. The treatment is a supportive one. If the patient is agitated, you can give him haloperidol or a benzodiazepine. Before discharge, the patient should see the alcohologic team." }, { "id": "pubmed23n0573_10269", "title": "Octreotide therapy for recurrent refractory hypoglycemia due to sulfonylurea in diabetes-related kidney failure.", "score": 0.008849557522123894, "content": "To describe a patient with kidney insufficiency from diabetes treated with glyburide, who presented with prolonged and recurrent hypoglycemia unresponsive to large intravenous doses of glucose, which was treated successfully with intravenously administered octreotide, and to review the therapeutic options for hypoglycemia. We present a case report of a 66-year-old man with diabetes causing chronic kidney disease, who was treated with orally administered glyburide, 7.5 mg twice a day. He initially presented to another hospital because of hypoglycemia and was treated with intravenously administered glucose and discharged. The next day, his family brought him to our emergency department because of recurring low blood glucose levels and symptoms of sweating, fever, and nightmares. Laboratory tests revealed a blood glucose level of 33 mg/dL and a creatinine concentration of 6.2 mg/dL. The patient was treated with a 5% dextrose and, subsequently, a 10% dextrose infusion without any sustained improvement. The blood glucose level remained low despite the additional administration of 3 ampules of 50% dextrose in water. The patient was given a bolus of octreotide (50 mug subcutaneously) 14 hours after his second presentation. He received another 50-mug dose of octreotide 6 hours later. After this bolus, the hypoglycemia resolved, and he no longer required intravenous administration of glucose to maintain euglycemia. Patients with diabetes and kidney disease frequently have persistent and difficult-to-treat hypoglycemia, unresponsive to conventional therapy. Octreotide is an effective and safe treatment for patients with refractory hypoglycemia attributable to sulfonylureas." }, { "id": "pubmed23n0267_21361", "title": "Effect of flumazenil on basal and naloxone-stimulated ACTH and cortisol release in humans.", "score": 0.008771929824561403, "content": "1. Endogenous benzodiazepine receptor ligands are thought to influence the human hypothalamic-pituitary-adrenal (HPA) axis and naloxone, a known stimulator of adrenocorticotropic hormone (ACTH) release, is thought to act via release of hypothalamic corticotropin-releasing hormone. 2. The aim of the present study was to assess the influence of endogenous benzodiazepine-receptor ligands by administering flumazenil (Ro15-1788), a benzodiazepine antagonist, and measuring ACTH and cortisol release, both basal and during naloxone-stimulation. 3. Nine normal volunteers in a placebo-controlled double-blind design were studied. Flumazenil (0.5 mg, i.v. bolus) was given 2 min before naloxone (125 micrograms/kg bodyweight, i.v. bolus) immunoreactive-adrenocorticotropic hormone (IR-ACTH) and cortisol levels were measured at frequent intervals from 60 min before to 120 min after naloxone injection. 4. Flumazenil had no effect on ACTH and cortisol release when given alone; flumazenil area under the ACTH/time curve (pmol/L.min) = -36.5 +/- 63.5 compared with placebo = -53.5 +/- 31.8, flumazenil area under the cortisol/time curve (nmol/L.min x 10(-3)) = - 2.4 +/- 2.4 compared with placebo -0.56 +/- 1.4. Flumazenil did not change the ACTH and cortisol release achieved with naloxone; naloxone area under the ACTH/time curve (pmol/L.min) = 327.8 +/- 61.7 compared with flumazenil/naloxone = 366.3 +/- 88.1, naloxone area under the cortisol/time curve (nmol/L. min x 10(-3) = 12.2 +/- 3.4 compared with naloxone/flumazenil = 10.5 +/- 2.1. 5. The authors conclude that flumazenil dose not modify basal or stimulated ACTH and cortisol release in healthy humans. This would suggest that endogenous benzodiazepine-like ligands and the benzodiazepine/gamma-aminobutyric acid receptor complex do not tonically influence the hypothalamic-pituitary-adrenal axis." }, { "id": "wiki20220301en296_22508", "title": "Altered level of consciousness", "score": 0.008771929824561403, "content": "Treatment Treatment depends on the degree of decrease in consciousness and its underlying cause. Initial treatment often involves the administration of dextrose if the blood sugar is low as well as the administration of oxygen, naloxone and thiamine. See also Altered state of consciousness Disorders of consciousness Level of consciousness (esotericism) Cognitive deficit References External links Neuroscience Intensive care medicine Emergency medicine Central nervous system disorders Symptoms and signs of mental disorders Consciousness" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 103, 170 ] ], "word_ranges": [ [ 18, 26 ] ], "text": "the clinical description is textbook hypertrophic pyloric stenosis." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Simple abdominal X-ray.", "2": "pHmetry.", "3": "Abdominal ultrasound.", "4": "Determination of electrolytes in sweat.", "5": "Esophagogastroscopy." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0269_12339", "title": "[Cystic fibrosis revealed by dehydration with hypochloronatremic alkalosis in 3 infants and a neonate].", "score": 0.012991943307883749, "content": "BACKGROUND--Acute dehydration with hypochloronatremic metabolic alkalosis is a classical complication of cystic fibrosis of the pancreas. Its progressive development as a revealing manifestation of the disease is rare as is its appearance in newborns. Case n. 1.--A 13 month-old girl was admitted because of status epilepticus. She was severely dehydrated (20% weight loss) but had normal diuresis. Investigations showed metabolic alkalosis, hypochloronatremia and hypokalemia. All the manifestations disappeared within 5 days with treatment but three sweat tests were abnormal. Case n. 2.--A 7 month-old girl was admitted because she suffered from progressive loss of weight (10%); she was dehydrated and had metabolic alkalosis plus hypochloronatremia, but her diuresis was normal. Two sweat tests were abnormal. Case n. 3.--A 4.5 month-old boy was admitted because he suffered from severe (12%) weight loss. His diuresis was normal despite dehydration; metabolic alkalosis and hypochloronatremia were found. Two subsequent sweat tests were abnormal. Case n. 4.--A 3 day-old girl was admitted suffering from meconium ileus. Two initial mechanism analysis for protein were abnormal. She had a cardiorespiratory arrest on the 13th day of life, when she had lost 14% of her birth weight; investigations showed metabolic alkalosis, hyponatremia (83 mEq/l), hypochloremia (45 mEq/l); kalemia was 5.9 mEq/l. Peritoneal dialysis was needed to correct hydroelectrolytic changes. A sweat test performed on the 26th day of life was also abnormal. Investigations performed during the periods of dehydration, and repeated later, showed transient functional kidney failure. None of the four patients had any respiratory or gastrointestinal clinical manifestations of cystic fibrosis. CONCLUSION--Metabolic alkalosis with hypochloronatremia plus progressive, severe dehydration in infants whose diuresis is paradoxically normal must be followed by examination for cystic fibrosis." }, { "id": "pubmed23n0475_11480", "title": "Association of Bartter's syndrome and empty sella.", "score": 0.01105276013678554, "content": "Bartter's syndrome is characterized by hypochloremia, hypokalemia, metabolic alkalosis associated with renal potassium leakage, and normal blood pressure despite increased plasma renin activity. Although association of empty sella with Gitelman syndrome has been reported, no association has been reported with Bartter's syndrome. Here we report a patient with Bartter's syndrome and empty sella. A 12 month-old male patient presented with a history of nausea, vomiting, abdominal distension, constipation, and edema in the lower extremities that had begun in the early postnatal period. The patient was born at 32 weeks gestation by operative delivery for polyhydramnios. Blood pressure was normal. Serum sodium, potassium, calcium, phosphate, chloride, albumin and alkaline phosphatase levels were 129 mEq/l, 2.5 mEq/l, 9 mg/dl, 3.8 mg/dl, 72 mg/dl, 4.2 g/dl and 1285 IU/l, respectively. Serum magnesium level was normal. Arterial blood gas levels revealed pH 7.55 (normal, 7.35-7.45), PCO2 33.6 mm/Hg (36-46), base excess +7.1 (+/- 2.3), and total CO2 33.6 mmol/l (23-27). Renin and aldosterone levels were elevated. Urine had pH 8.0 and specific gravity 1.010. Urinary calcium excretion was 22.8 kg/day (urine calcium/creatinine ratio 0.46). Urinary potassium and chloride levels were elevated. MRI of the brain was normal except for partially empty sella. We present the first pediatric patient with the association of Bartter's syndrome and empty sella." }, { "id": "wiki20220301en053_51835", "title": "Ringer's lactate solution", "score": 0.009900990099009901, "content": "In a large-volume resuscitation over several hours, LRS maintains a more stable blood pH than normal saline. Chemistry One liter of Ringer's lactate solution contains: 130–131 mEq of sodium ion = 130 mmol L−1 109–111 mEq of chloride ion = 109 mmol L−1 28–29 mEq of lactate ion = 28 mmol L−1 4–5 mEq of potassium ion = 4 mmol L−1 2–3 mEq of calcium ion = 1.5 mmol L−1 Ringer's lactate has an osmolarity of 273 mOsm L−1 and a pH of 6.5. The lactate is metabolized into bicarbonate by the liver, which can help correct metabolic acidosis. Ringer's lactate solution alkalinizes via its consumption in the citric acid cycle, the generation of a molecule of carbon dioxide which is then excreted by the lungs. They increase the strong ion difference in solution, leading to proton consumption and an overall alkalinizing effect." }, { "id": "pubmed23n0587_553", "title": "The diagnosis of intestinal obstruction in the newborn; a review of the literature with a report of eight additional cases.", "score": 0.009900990099009901, "content": "Because the clinical appearance of newborn infants having intestinal obstruction is disarmingly normal, vomiting is reason for immediate search for the cause. To this end the character of stools and meconium that are passed should be carefully observed, lest valuable time elapse before correct diagnosis is made. In three cases of volvulus observed by the authors, there was moderate to pronounced distention of the abdomen at birth-a sign which may be helpful in diagnosis. Roentgenograms are the most helpful diagnostic aid. Since the roentgenographic appearance of the normal infant abdomen differs from that of the adult, interpretations should be made with that in mind. In this connection the absence of gas shadows is significant. Although there are dangers in the use of barium in infants, early diagnosis is so important that use of the substance is justifiable if it will help in correct appraisal. The treatment is always surgical, and the procedure of choice is primary anastomosis. Proper preoperative and postoperative care and treatment, including maintenance of fluid and electrolyte balance and blood volume, are of great importance." }, { "id": "wiki20220301en063_63363", "title": "Anion gap", "score": 0.00980392156862745, "content": "Sample calculations Given the following data from a patient with severe hypoalbuminemia suffering from postoperative multiple organ failure, calculate the anion gap and the albumin-corrected anion gap. Data: [Na+] = 137 mEq/L; [Cl−] = 102 mEq/L; [HCO] = 24 mEq/L; [Normal Albumin] = 4.4 g/dL; [Observed Albumin] = 0.6 g/dL. Calculations: Anion Gap = [Na+] - ([Cl−] + [HCO]) = 137 - (102 + 24) = 11 mEq/L. Albumin-Corrected Anion Gap = Anion Gap + 2.5 x ([Normal Albumin] - [Observed Albumin]) = 11 + 2.5 x (4.4 - 0.6) = 20.5 mEq/L. In this example, the albumin-corrected anion gap reveals the presence of a significant quantity of unmeasured anions. See also Osmol gap Delta ratio References External links Clinical Physiology of Acid-Base and Electrolyte Disorders Anion Gap Calculator (includes a correction for the albumin concentration) Metabolic acidosis by Merck More information about the Figge-Jabor-Kazda-Fencl equation" }, { "id": "pubmed23n0278_7682", "title": "[Acute pancreatitis in pregnancy].", "score": 0.00980392156862745, "content": "This paper describes a case of acute pancreatitis occurring in a patient immediately after delivery and in primigravida. The patient had a family case history of dyslipidemia (Type IV). The pregnancy had been complicated by preeclampsia treated at home with nifedipine tablets (one tablet three times a day) with good results on pressure values; lipidic values were high despite dietary measures taken. The baby at birth weighed 3830 g after physiologic labour and a natural delivery. Acute pancreatitis was diagnosed after observation of epigastralgia with irradiation on the left shoulder, vomiting, symptoms of acute abdomen such as sweating, increased pulse rate, hypotension, abdominal pain on palpation, and absence of peristalsis. An analysis of the blood showed high levels of amylase and hyperglycemia, an increase in XDP, and leucocytosis. Instrumental tests such as pancreatic echography revealed an increase in pancreatic volume, uneven structure of the parenchyma and higher levels of liquid in the peritoneum. The patient was moved to intensive-care, a nasal gastric probe inserted, hydroelectrolytic treatment was begun, vital functions monitored, pain kept under control by medical therapy, and antibiotics administered. Subsequent tests showed an improvement in the parameters of pancreatic functions (amylase, lipase, calcium hematic) and their gradual return to normal values. The computerized tomography of abdomen additionally revealed the presence of pancreatic pseudo-cysts and effusion of peritoneal liquid near the right kidney. The patient was discharged after two weeks in the surgical ward. There are many caused of acute abdomen during and immediately after pregnancy, and one of these is acute pancreatitis, though rare (occurring between 1:3800 and 11.467 according to Rabkin).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0854_16987", "title": "Transient symptomatic hyperglycaemia secondary to inhaled fluticasone propionate in a young child.", "score": 0.009708737864077669, "content": "Inhaled corticosteroids (ICSs) are currently used to prevent and treat asthma and recurrent wheezing attacks in children. Fluticasone propionate (FP) is one of the most commonly prescribed ICSs because it is considered effective and well tolerated. A male infant of approximately 1 year of age, who was born to parents without relevant clinical problems or family histories including diabetes, was brought to our attention for recurrent wheezing. When he was approximately 2 years old, a regular daily inhaled treatment with FP given using a spacer was prescribed. With this therapy, the child obtained good control of his symptoms with no further recurrences, but after approximately 2 months of treatment he was admitted to the emergency room because he was whining and agitated and exhibited increased diuresis and water intake. Laboratory tests revealed hyperglycaemia (181 mg/dL), mild glycosuria, blood alkalosis (pH 7.49), a bicarbonate level of 31 mmol/L, a pCO2 level of 39 mmHg, a serum sodium level of 135 mEq/L and a serum potassium level of 3.5 mEq/L. The parents confirmed that the recommended dose of FP had been administered with no increase in the amount of drug. The child was immediately treated with endovenous infusion of physiological saline for 24 h, and his glycaemic levels as well as venous blood gas analysis returned to normal, with an absence of glucose in the urine. Oral glucose tolerance test results and glycated haemoglobin levels were normal. Monitoring of blood glucose levels before and after meals for three consecutive days did not reveal any further increase above normal levels. He was discharged with a diagnosis of transient symptomatic hyperglycaemia during ICS therapy and the suggestion to replace his inhaled FP therapy with oral montelukast. Montelukast was continued for 6 months; during this time, the child did not present any other hyperglycaemia episodes. Although there is no evidence of causation, this case report represents an interesting and unusual description of paediatric transient symptomatic hyperglycaemia after treatment with inhaled FP and highlights the importance of considering this potential adverse event and the necessity of informing parents of the possible clinically relevant risks associated with this drug." }, { "id": "pubmed23n0235_12890", "title": "[Infant esophageal pH monitoring (author's transl)].", "score": 0.009708737864077669, "content": "The authors expound their experience of the infant esophageal pH monitoring from a 100 cases statistic. The digestive radiography is necessary for the vomiting infants but the efficiency of radiology is inadequate to diagnose the reflux and particularly to give a sufficient assessment of its intensity. The esophageal pH monitoring performed during a period of 3 hours is a tremendous learning experience; is allows the clinician to take mild reflux and severe reflux into account; performed in several positions, it shows interesting variations that we can turn to account by giving the therapeutic advices. That test is innocuous, easy, little costly, easily repeated; it must have its place beside other investigations and make us advance in the knowledge of a so often found disorder development." }, { "id": "wiki20220301en013_157309", "title": "Arterial blood gas test", "score": 0.009615384615384616, "content": "Guidelines A 1 mmHg change in PaCO2 above or below 40 mmHg results in 0.008 unit change in pH in the opposite direction. The PaCO2 will decrease by about 1 mmHg for every 1 mEq/L reduction in [] below 24 mEq/L A change in [] of 10 mEq/L will result in a change in pH of approximately 0.15 pH units in the same direction. Assess relation of pCO2 with pH: If pCO2 & pH are moving in opposite directions i.e., pCO2 ↑ when pH is <7.4 or pCO2 ↓ when pH > 7.4, it is a primary respiratory disorder. If pCO2 & pH are moving in same direction i.e., pCO2 ↑when pH is >7.4 or pCO2 ↓ when pH < 7.4, it is a primary metabolic disorder. Parameters and reference ranges These are typical reference ranges, although various analysers and laboratories may employ different ranges." }, { "id": "pubmed23n0784_18692", "title": "[Congenital chloride diarrhea mimicking meconium ileus in newborn].", "score": 0.009615384615384616, "content": "Congenital chloride diarrhoea is a rare autosomal recessive disease and the diagnosis is frequently delayed. The disease is most common in Saudi Arabia and Kuwait 1:3200-13 000 births, Finland - 1:30 000-40 000, and in Poland - 1:200 000. Congenital chloride diarrhoea begins in fetal life. The main clinical sign is watery diarrhea that in utero leads to dilated bowel loops, polyhydramnios and often premature birth. Newborns have distended abdomens, absence of meconium, dilated bowel loops in ultrasonography and watery diarrhea which can sometimes be mistaken for urine. The absence of meconium and the distended abdomen suggest meconium ileus or Hirschsprung disease and can lead to unnecessary surgical intervention. The article is a report on a 3-months old boy with the history of dilated bowel loops in prenatal ultrasonograhy, low birth weight and abdominal distention. Because of the suspicion of mechanical bowel obstruction he had laparotomy on the second day of his life. Mechanical obstruction was excluded and enterostomy was performed. Hyponatremia, hypokaliemia and metabolic alkalosis were found in laboratory tests. The electrolyte disturbances were corrected and enterostomy was closed after six weeks. The final diagnosis of congenital chloride diarrhea was established two months later, when the patient was admitted to hospital again with severe watery diarrhea, metabolic alkalosis, hypochloraemia and hypokalemia. The stool chloride concentration was &gt;90 mmol/L. Water and electrolyte deficits had been corrected. The patient was discharged home with supplementation of sodium, potassium and chloride. His follow-up was uneventful. He remains under the care of the pediatric clinic. " }, { "id": "wiki20220301en063_63348", "title": "Anion gap", "score": 0.009523809523809525, "content": "The concentrations are expressed in units of milliequivalents/liter (mEq/L) or in millimoles/litre (mmol/L). With potassium The anion gap is calculated by subtracting the serum concentrations of chloride and bicarbonate (anions) from the concentrations of sodium and potassium (cations): = ([Na+] + [K+]) − ([Cl−] + [HCO]) = 20 mEq/L Without potassium Because potassium concentrations are very low, they usually have little effect on the calculated gap. Therefore, omission of potassium has become widely accepted. This leaves the following equation: = [Na+] - ([Cl−] + [HCO]) Normal AG = 8-16 mEq/L Expressed in words, the equation is: Anion Gap = Sodium - (Chloride + Bicarbonate) which is logically equivalent to: Anion Gap = (the most prevalent cation) minus (the sum of the most prevalent anions) (Bicarbonate may also be referred to as \"total CO2\" or \"carbon dioxide\".)" }, { "id": "pubmed23n0266_5015", "title": "[Gastroesophageal reflux in infants: ultrasonographic reading of pHmetry].", "score": 0.009523809523809525, "content": "pH monitoring of the distal esophagus has proved both sensitive and specific in the detection of reflux but has several limitations due to changes over time in esophageal pH and possibility of alkaline reflux. Simultaneous ultrasonographic monitoring can be helpful when interpreting the results. One thousand infants (80% under 1 year of age) were examined: 500 suffered from vomiting (310 patients), life-threatening events (65 patients) or repeated respiratory diseases (125 patients). Five hundred infants were controls (320 asymptomatic and 180 sibs of patients with SIDS). pHmonitoring and ultrasonography were performed before and after ingestion of milk by vomiting patients and after administration of orange juice in the other symptomatic patients. Control patients were given milk when asymptomatic or orange juice when they belonged to a SIDS sibship. Ultrasonography permitted to interpret the different phases of the pH curves according to the age of patients, the meals and their nature, the events associated with temporary increase in abdominal pressure, the gravity. pH monitoring was able to recognize 1589 acid reflux but failed to recognize 2091 reflux episodes. While pHmonitoring is helpful to demonstrate a relationship between the reflux and such events as apnea, bradycardia, cough, ultrasonography defines a risk based on specificity of reflux and laryngeal or esophageal dysfunction." }, { "id": "pubmed23n0364_22116", "title": "[Electrolyte abnormalities and metabolic acidosis in two Duchenne muscular dystrophy patients with advanced congestive heart failure].", "score": 0.009433962264150943, "content": "We experienced two Duchenne muscular dystrophy patients with advanced congestive heart failure, who showed abrupt severe hyponatremia, hyperkalemia and metabolic acidosis. Two patients received respiratory management, parenteral nutrition, and drugs including angiotensin converting enzyme inhibitors (ACEI). The patient 1 who was 19 years old showed abdominal pain, hematuria, diarrhea and disorientation. Laboratory findings were as follows; Na 120 mEq/L, K 7.3 mEq/L, BUN &gt; 140 mg/dl (scale over), ACTH 20.2 pg/ml, cortisol 25 micrograms/dl, renin 40.7 ng/ml/hr and aldosterone 203 ng/dl. Arterial blood gas analysis (ABG) showed metabolic acidosis (pH 7.232). Combination therapy with hydrocortisone, glucose-insulin therapy (GIT) and NaHCO3 successfully rescued this patient. The patient 2 (28 years of age) was admitted to our hospital because of congestive heart failure. Laboratory findings were as follows; Na 129 mEq/L, K 5.5 mEq/L, BUN 60 mg/dl, cortisol 21 micrograms/dl, renin 36 ng/ml/hr and aldosterone 47 ng/dl. He complained abdominal discomforts from the next day of admission. Ten days after the admission Na, K and BUN were 111 mEq/L, 6.2 mEq/L and 154 mg/dl, respectively. ABG showed compensated metabolic acidosis. He fell into shock during GIT therapy. Laboratory findings at that time were as follows; Na 108 mEq/L, K 3.2 mEq/L, ACTH 77.6 pg/ml, cortisol 24 micrograms/dl, renin 58 ng/ml/hr and aldosterone 24 ng/dl. Although hydrocortisone was introduced, he could not recover and died. There are some reports about life-threatening electrolyte abnormalities and metabolic acidosis in the patients receiving ACEI. These phenomena were more frequent in patients with renal dysfunction and/or congestive heart failure. Hyponatremia, hypovolemia, combination therapy with nonsteroidal anti-inflammatory drugs (NSAID) and/or potassium sparing diuretics were reported as risk factors. We could not prove the correlation between the acute changes in our cases and ACEI. However ACEI is suspicious, because many of these risk factors were observed in our cases. Aldosterone was extremely elevated in the patient 1 when potassium was severely elevated. On the other hand, the patient 2 showed lower aldosterone level after correction of potassium than that on admission. Potassium is regarded as a major secretion factor of aldosterone for patients receiving ACEI. The fact the patient 2 fell into shock during GIT, tells us that we should use steroid simultaneously when we try to correct potassium quickly in severe cases, because acute reduction of potassium may decrease aldosterone. Today, ACEI is a common drug for CHF, so we should pay attentions that ACEI could cause such acute changes. To prevent such acute changes, excessive restriction of water and sodium intake should be avoided. If possible, NSAID and potassium sparing diuretics also should be avoided. Steroid therapy must be introduced rapidly when needed." }, { "id": "pubmed23n0141_573", "title": "Studies on diarrhea in neonatal calves. 3. Acid-base and serum electrolyte values in normal calves from birth to ten days of age.", "score": 0.009433962264150943, "content": "A detailed clinical examination was conducted and blood samples were collected from a total of 151 normal calves as soon as possible after birth and at two to three day intervals until the calves were ten days old. The mean venous pH values for calves from birth to ten days of age was 7.38 +/- 0.05. The mean serum sodium, potassium, magnesium, inorganic phosphate, calcium and chloride ion concentrations in normal calves from birth to ten days of age were 148 +/- 13, 5.4 +/- 0.8, 2.1 +/- 0.4, 4.3 +/- 0.8, 5.6 +/- 0.5, 95 +/-5, mEq/litre respectively. The mean serum osmolality in normal calves from birth to ten days of age was 280 +/- 12 mOsm/litre." }, { "id": "Biochemistry_Lippincott_1929", "title": "Biochemistry_Lippinco", "score": 0.00937827215199478, "content": "Case 8: No Bowel Movement Patient Presentation: DW is a 48-hour-old female who has not yet had a bowel movement. Focused History: DW is the full-term product of a normal pregnancy and delivery. She appeared normal at birth. DW is the first child of parents of Northern European ethnicity. The parents are both in good health, and their family histories are unremarkable. Pertinent Findings: DW has a distended abdomen. She recently vomited small amounts of bilious (green-colored) material. Diagnosis: Meconium ileus (obstruction of the ileum by meconium, the first stool produced by newborns) was confirmed by abdominal x-rays. About 98% of full-term newborns with meconium ileus have cystic fibrosis (CF). Diagnosis of CF was subsequently confirmed with a chloride sweat test. Treatment: The ileus was successfully treated nonsurgically. For management of the CF, the family was referred to the CF center at the regional children’s hospital." }, { "id": "wiki20220301en074_45829", "title": "Base excess", "score": 0.009345794392523364, "content": "Base excess (or deficit) is one of several values typically reported with arterial blood gas analysis that is derived from other measured data. The term and concept of base excess were first introduced by Poul Astrup and Ole Siggaard-Andersen in 1958. Estimation Base excess can be estimated from the bicarbonate concentration ([HCO3−]) and pH by the equation: with units of mEq/L. The same can be alternatively expressed as Calculations are based on the Henderson-Hasselbalch equation: Ultimately the end result is: Interpretation Base excess beyond the reference range indicates metabolic alkalosis if too high (more than +2 mEq/L) metabolic acidosis if too low (less than −2 mEq/L)" }, { "id": "pubmed23n0510_8528", "title": "Clinical presentation of hypernatremic dehydration in exclusively breast-fed neonates.", "score": 0.009345794392523364, "content": "To identify the clinical presentation of dehydration related to failure of lactation in exclusively breast-fed term infants. A prospective study was performed between January 2000 and June 2003 in Al Qassimi Hospital in the Emirate of Sharjah. Enrollment criteria included term neonates whose birth weight of &gt; 2000 g with no underlying organic illness causing poor feeding admitted for clinical manifestations of dehydration with weight loss of &gt; 10% during the first 2 weeks of life. The control group, a non-randomized sample included healthy full term neonates, seen in Sharjah maternal and child health care center at 4-7 days old for their routine Guthrie screening test. For each dehydrated neonate we took two neonates as controls. Mother's age, parity, length of pregnancy, any pathologic conditions, breastfeeding history and her level of knowledge of lactation was recorded. Neonatal information included mode of delivery, percentage of weight loss, clinical examination, and stool and urine output the previous day. Data was analyzed with Student 't' test and chi-square test. Out of 17208 live births, 29 neonates between the ages of 2-13 days were admitted with weight loss of between 12 and 29% (dehydrated group). 27 patients had hypernatremic dehydration with serum sodium level ranging from 150 to 195 mmol/l. Mean age of admission was 4.9 days. Reasons for admission were: signs of dehydration (55%); hyperthermia (55%); hypoglycemia (27%) and jaundice (59%). The control group included 58 healthy neonates. Their birth weight and age were comparable to those in the dehydrated group. In comparison with the control group, delivery by cesarean section (P&lt; 0.0001), lower level of maternal breastfeeding knowledge (P=0.03), transient inadequate breast milk quantity (P=0.005) and nipple anomalies (P=0.001) was significantly more common in the dehydrated group. Fewer voidings of urine (&lt; 6 times /day) and stool (&lt; 3 times/day) in the previous 24 hours before admission was more frequently observed in the dehydrated group (P &lt; 0.0001). Low level of maternal knowledge in lactation, cesarean section and failure of early postnatal follow up was associated with the neonatal dehydration. Decreased urine and stool frequency might be considered as a warning for failure of lactation." }, { "id": "pubmed23n0397_5428", "title": "Changes in oxygen content and acid-base balance in arterial and portal blood in response to the dietary electrolyte balance in pigs during a 9-h period after a meal.", "score": 0.009259259259259259, "content": "The effect of two dietary electrolyte balance (dEB, Na+ + K+ - Cl-) levels on arterial and portal blood oxygen content, blood pH, and acid-base status in pigs was studied during a 9-h period after a meal, using a crossover experimental design. The dEB levels were established by changing the Cl- level in the diets. Four pigs with a mean weight of 45 kg were surgically fitted with catheters in the carotid artery and portal vein. Two dEB levels (-100 and 200 mEq/kg) were evaluated in two periods of 1 wk each. Feed was given at 2.6 times the maintenance requirement for energy in two meals per day. Water was freely available. Blood samples were taken at 0, 0.5, 1, 1.5, 2, 3, 4, 6, and 9 h after feeding. Blood hemoglobin; O2 pressure; O2 saturation; O2 content; pH; PCO2; HCO3-; base excess; and Na+, K+, and Cl- contents were measured. Oxygen contents in arterial and portal blood were lower (P &lt; 0.008) in the -100 mEq/kg group (5.78 and 4.82 mmol/L respectively) compared to the 200 mEq/kg group (6.18 and 4.99 mmol/L respectively). This was related to the lower hemoglobin content in the blood of animals in the -100 mEq/kg group. Arterial and portal blood pH were lower (P &lt; 0.003) at -100 mEq/kg (7.46 and 7.37) than at 200 mEq/kg (7.49 and 7.43). The difference in blood pH between the two groups was sustained throughout the sampling period. The average values of arterial and portal blood for base excess and HCO3- content were higher (P &lt; 0.001) at high dEB (6.96 and 31.0 mmol/L, respectively, for -100 mEq/kg and 12.54 and 35.9 mmol/ L, respectively, for 200 mEq/kg). The Na+ concentration in the blood was increased and K+ and Cl- concentrations were decreased (P &lt; 0.02) by increasing dEB from -100 mEq/kg to 200 mEq/kg. Blood electrolyte balance level was higher (P &lt; 0.001) in the 200 mEq/kg dEB group than in the -100 mEq/kg dEB group. In conclusion, dEB changed blood oxygen content and pH, and influenced the acid-base buffer system in pigs. Also, within each group, pigs maintained a relatively constant blood pH level during the 9-h period after feeding." }, { "id": "pubmed23n0061_8121", "title": "[Evaluation of an insufflatabe abdominal girdle in shortening the second stage of labor].", "score": 0.009259259259259259, "content": "A prospective study to evaluate the role of the insufflatable abdominal girdle (IAG) in shortening the second stage of labor was carried out in 160 consecutive full-term normal primiparas with vertex presentation. The parturients were randomized in order into 2 groups: the study group (using IAG) and the control group, each containing 80 cases. The average duration of second stage of labor was 40'23\" for the cases of the study group and 59'59\" for the controls. The difference was statistically significant (P less than 0.01). The average duration between the appearance of fetal head at the vulva to the complete birth of the baby was 11'56\" and 20'56\" respectively and again the difference was highly significant (P less than 0.01). Vacuum exteractor necessary for the termination of labor was performed in 15 cases of the controls and only 5 cases of the study group. There was no difference of incidence of abnormal fetal heart rate and appearance of meconium-stained aminotic fluid between two groups. The average Apgar score at 1 minute after birth was 9.78 for the study group and 9.88 for the control group (P greater than 0.005). Results of blood gas analysis of umbilical artery and vein immediately after birth, including pH, PO2, PC2 and BE, were all within normal ranges. Maternal blood pressure, pulse, respiratory rate and blood gas analysis were monitored during the second stage of labor and no significant difference was observed between two groups.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0394_8037", "title": "Cardiovascular glycoside-like intoxication following ingestion of Thevetia nereifolia/peruviana seeds: a case report.", "score": 0.009174311926605505, "content": "Some plants contain glycoside compounds which determine cardiovascular symptoms similar to those observed after acute toxic digoxin administration. The present case report involves a patient who showed important cardiovascular symptoms following the ingestion of Thevetia nereifolia/peruviana seeds. About 30 min after ingestion, a 65-year-old man presented with dizziness, giddiness, numbness and a burning sensation, diarrhea, sweating, vomiting and ECG changes. At the time of admission he presented with tremors; his body temperature was 37 degrees C, and blood analysis gave the following results: K 5.6 mEq/l, myoglobin 176 IU, troponin T 0.10 ng/ml, PO2 69 mmHg, PCO2 37.4 mmHg, pH 7.33, HCO3- 19.9 mEq/l, hemoglobin 14.8 g/dl, saturation 92.5%. Echocardiography showed a left ventricle with normal global and segmentary contractility. The following days, the patient showed a reduction, until total resolution, of the atrioventricular block and of the alterations of the ST segment. The ectopic beats also resolved; K value before discharge was 4.4 mEq/l. On the third day, the serum levels of digoxin were 0.15 ng/ml. This case report is important because it describes all the cardiovascular and non-cardiovascular signs of glycoside toxicity in an adult patient who accidentally swallowed only two seeds (non-fatal dose) of Thevetia." }, { "id": "InternalMed_Harrison_12823", "title": "InternalMed_Harrison", "score": 0.009174311926605505, "content": "Moderatec,d <4 months (<5 kg) 200–400 mL of ORS 4–11 months (5–<8 kg) 400–600 mL of ORS 12–23 months (8–<11 kg) 600–800 mL of ORS 2–4 years (11–<16 kg) 800–1200 mL of ORS 5–14 years (16–<30 kg) 1200–2200 mL of ORS ≥15 years (≥30 kg) 2200–4000 mL of ORS All ages and weights Undertake IV fluid replacement with Ringer’s lactate (or, if not available, normal saline). Give 100 mL/kg in the first 3-h period (or the first 6-h period for children <12 months old); start rapidly, then slow down. Give a total of 200 mL/ kg in the first 24 h. Continue until the patient is awake, can ingest ORS, and no longer has a weak pulse. aAdapted from World Health Organization: First steps for managing an outbreak of acute diarrhoea. Global Task Force on Cholera Control, 2009 (www.who.int/topics/cholera). bContinue normal feeding during treatment. cReassess regularly; monitor stool and vomit output. dVolumes of ORS listed should be given within the first 4 h. Abbreviation: ORS, oral rehydration solution." }, { "id": "pubmed23n0955_2875", "title": "A challenging coexistence of central diabetes insipidus and cerebral salt wasting syndrome: a case report.", "score": 0.00909090909090909, "content": "Combined central diabetes insipidus and cerebral salt wasting syndrome is a rare clinical finding. However, when this happens, mortality is high due to delayed diagnosis and/or inadequate treatment. A 42-year-old white man was referred to neurosurgery due to a non-functional pituitary macroadenoma. He underwent a partial resection of the tumor on July 2, 2015. On the day following surgery he presented polyuria with sodium 149 mEq/L, plasma osmolality 301 mOsm/kg, and urine osmolality 293 mOsm/kg. He started nasal desmopressin 0.05 mg/day with good response. He was already on dexamethasone 4 mg and levothyroxine 75 mcg due to hypopituitarism after surgery. On July 9 he became confused. Cerebral computed tomography was performed with no significant changes. His natremia dropped to 128 mEq/L with development of polyuria despite maintenance of desmopressin dose. His hemoglobin and hematocrit rose from 9.1 g/L to 11.6 g/L and 27.5 to 32.5, respectively. His thyroid function was normal and he was on hydrocortisone 30 mg/day. At 12 p.m. 150 mg/hydrocortisone infusion was initiated, but sodium did not increase. Plasma and urine osmolality were 264 mOsm/kg and 679 mOsm/kg, respectively. At 4 p.m. hydrocortisone was increased and hypertonic saline replacement started. Two hours later he was dehydrated with polyuria and vomiting, and natremia of 124 mEq/L. Hyponatremia was very resistant to treatment despite hypertonic saline replacement, hence desmopressin was suspended. The following day, urine spot analysis showed that natriuresis was 63 mEq/L with serum sodium 132 mEq/L. This was interpreted as a cerebral salt wasting syndrome and control was achieved with aggressive hypertonic saline replacements and fludrocortisone 0.1 mg/three times a day. We present a rare case of a patient with diabetes insipidus and cerebral salt wasting syndrome, who was successfully treated. Hyponatremia in a patient with diabetes insipidus may erroneously be interpreted as inadequate diabetes insipidus control or as syndrome of inappropriate antidiuretic hormone secretion, leading to therapeutic errors. Thus, all clinical and analytical data should be evaluated together for early and correct diagnosis." }, { "id": "pubmed23n0076_7738", "title": "[Oral rehydration solutions with 60 or 90 nmol/L of sodium for infants with acute diarrhea in accord with their nutritional status].", "score": 0.00909090909090909, "content": "A total of 186 infants suffering from dehydration due to acute diarrhea were studied and divided into two groups: 84 children were placed in group A and received the oral rehydration solution (ORS) recommended by the World Health Organization (WHO), know as ORS-90 and those placed in group B were given an ORS with 60 and 90 mmol/L of sodium and glucose, respectively, with an osmolality of 240 mOsm/kg (ORS-60). Seven patients from group A (8.3%) and two from group B (2.5%) could not be orally rehydrated and required intravenous rehydration. The children were divided according to their weight for their age into eutrophics, grade I malnutrition (10 to 25% deficit), grade II (26 to 40% deficit) and grade III (more than 40% deficit). In those patients who evolved favorably, the average rehydration time was 4.5 to 5.3 hours, independently from their nutritional state. In the same way, no important variations were seen in the average sodium and potassium serum levels once the dehydration was corrected, in either of the groups. Yet, both groups showed a persistence in hypokalemia and hyperkalemia seen when admitted, once the dehydration was corrected, demonstrating that the short time needed for the correction of the dehydration was insufficient to completely corrected the changes in serum potassium. Closer studies must be conducted on the hydric balance to adequately demonstrate if the new ORS-60 induces lesser losses through vomiting and feces when compared to the ORS-90 recommended by the WHO." }, { "id": "pubmed23n0634_595", "title": "Periodic paralysis: rare presenting symptom of thyrotoxicosis.", "score": 0.009009009009009009, "content": "Paralysis due to hypokalemia results from an acute shift of potassium into cells or excessive potassium deficit. In the absence of potassium deficit, it is observed in Familial Hypokalemic Periodic Paralysis and in Thyrotoxic Hypokalemic Periodic Paralysis (TPP). This report describes the initial presentation of hyperthyroidism as sudden quadriplegia associated with hypokalemia. A healthy 25-year-old Puerto Rican policeman came to the emergency room with sudden paralysis in the four extremities of five hours evolution. He woke up in the morning and could not get up. The day before admission his legs felt weak, and it was hard to get out of bed. He arrived home at 7:00 PM, ate pasta and vegetables, and went to sleep at 10:00 PM. He had no diarrhea or weight loss, no history of medications or illicit drugs. He has a cousin and an aunt with the diagnosis of hypo-thyroidism. The admission temperature was 36.0 degrees C, pulse 96 per minute, respiratory rate 18 per minute, blood pressure 160/70 mmHg. He was alert and oriented as to time, place and person. He could talk properly and was in no respiratory distress. He had no exophtalmos or lid lag. The thyroid was not enlarged or tender. No pseudoclubbing or pretibial edema was found. There was flaccid paralysis of all extremities, 0/5 legs and 1/5 arms. Deep tendon reflexes could not be elicited. The cranial nerves and sensory examination were normal. The hemogram was within normal limits as were the renal and liver functions. Serum sodium was 140 mEq/L, potassium 1.48 mEq/L, phosphorus 1.4 mEq/L. A random glucose was 155 mg/dl and the arterial Ph was 7.41. The urine potassium was 7.04 mEq/L, sodium 60.8 mg/dl. TSH levelwas &lt; 0.03 ug/d], TUP 50.69% (24-40%), T4 17.6 ug/dl (4.7-11.4 ug/dl) Free T4 Index 28.23. He was managed with intravenous potassium chloride, 80 mEq in a period of seven hours with cardiac monitor. The serum potassium level, after the infusion was completed, was 6.70 mEq/L. No cardiac arrhythmia was documented. Muscle strength recovery was gradual and it was complete 4 hours after the infusion was initiated. The next day the potassium level was within normal limits but a wide pulse pressure and tachycardia still persisted." }, { "id": "pubmed23n0831_1371", "title": "Meconium ileus in newborns with cystic fibrosis - results of treatment in the group of patients operated on in the years 2000-2014.", "score": 0.009009009009009009, "content": "Evaluation of diagnostic and treatment procedures in children with cystic fibrosis (CF) operated on because of meconium ileus (MI). The authors retrospectively reviewed the documentation of 10 CF newborn patients operated on in the years 2000-2014 because of MI. In prenatal ultrasound (US) examinations, suspicion of bowel abnormalities was raised in 2 cases, even though all the 10 mothers had a minimum of 3 US examinations during pregnancy. The mean gestational age of the newborns was 39.2 weeks - 36-41 weeks), their mean birth weight 3472g (2560-4550 g). Family history of CF was positive in two patients. Genetic testing was performed in all the children operated on. In all the children operated on, mutations in both alleles of the CFTR gene were found. Five patients were F508del homozygotic, 4 were heterozygotic for this mutation, one had another mutation. Sweat tests were positive in all the children. Abdominal distention was observed in 9 patients, vomiting and retention of gastric contents in 5. In 8 children meconium was not passed at all. 2 children passed a small amount of viscid meconium. Before the operation, rectal saline washouts were done in 5 newborns. Five patients were operated on during the first day of life, four on the second day and one on the third day of life. Intra-operatively a simple form of MI was diagnosed in 8 cases, a complicated form in 2 cases. In patients with the simple form of MI, a Bishop-Koop stoma was created after the evacuation of meconium. Two of these children needed a resection of some centimetres of dilated terminal ileum with doubtful viability. In newborns with the complicated form of MI, the treatment was individualized, always with stoma formation. The time of postoperative meconium evacuation through enterostomy ranged from 6 to 15 days. Enteral feeding was started on average on the 9th day postoperatively. The mean hospital stay was 22.9 days. In 8 children the stoma was taken out at the mean age of 19.4 months, in one patient the stoma closed spontaneously. No disturbances in electrolyte balance or excessive fluid loss, nor any body weight deficits connected with the stoma were observed. There were no complications during stoma closure. All the patients are alive. The time of observation ranges from 7 to 146 months (average 95 months). All the patients currently present respiratory symptoms, have pancreatic insufficiency and need pancreatic enzyme supplementation. Seven do not, however, have body weight and height deficits. All the children with weight and height deficits have abnormal liver function tests. During observation two patients had MI equivalent symptoms, which was resolved by conservative treatment. 1. In every case of intra-operative diagnosis of MI, it is necessary to perform genetic testing and sweat tests to confirm or exclude CF. 2. Mechanical intra-operative decompression of the bowel from inspissated meconium with a temporary stoma, which makes the continuation of bowel decompression possible in the postoperative period, is an effective treatment in children with MI. 3. The Bishop-Koop stoma, permitting the passage through the whole gastrointestinal tract, is a safe option. In our material, no complications of this stoma, such as stoma care problems or dyselectrolithemia were observed. 4. The decision of stoma closure in children with MI and CF should be delayed until the moment of introducing a broadened diet and should be undertaken together with a pediatrician who is a specialist in CF therapy. ." }, { "id": "wiki20220301en040_1095", "title": "Metabolic acidosis", "score": 0.008928571428571428, "content": "Diagnostic approach and causes Metabolic Acidosis is defined as a reduced serum pH, and an abnormal serum bicarbonate concentration of <22 mEq/L, below the normal range of 22 to 29 mEq/L. However, if a patient has other coexisting acid-base disorders, the pH level may be low, normal or high in the setting of metabolic acidosis. In the absence of chronic respiratory alkalosis, metabolic acidosis can be clinically diagnosed by measuring serum bicarbonate levels in the blood, which is generally a standard component of blood panels. Imperatively, when weighing a metabolic acidosis diagnosis, the change in serum bicarbonate levels over time should be considered; if baseline bicarbonate results are unknown, a single set of values may be misinterpreted. Causes Generally, metabolic acidosis occurs when the body produces too much acid (e.g., lactic acidosis, see below section), there is a loss of bicarbonate from the blood, or when the kidneys are not removing enough acid from the body." }, { "id": "pubmed23n0022_10501", "title": "[Acute abdomen in pediatric roentgenology (author's transl)].", "score": 0.008928571428571428, "content": "In vue of the successes of modern surgery, correct roentgenology in acute abdominal conditions of the infant and child is of utmost importance. History is very incomplete in children so that the most crucial question is when and how should X-ray investigation start? The answer is difficult to provide because of the necessity of early surgery which, in addition can be hindered by an unnecessary roentgenography. Often this cannot be repeated because of worsening in the patient's condition. Knowledge of specific pathology and of congenital malformations is necessary. One must be careful in using contrast medium in acute abdomens as it may worsen the situation. Hypertonic solutions can heavily modifie the fluid and electrolyte balance, especially in dehydrated children. Technical aspects deserve attention, for instance for treatment of invagination, or in congenital megacolon. The authors illustrate these problems with a few cases." }, { "id": "pubmed23n0697_18552", "title": "Cutaneous manifestations of Strongyloides stercoralis hyperinfection in an HIV-seropositive patient.", "score": 0.008849557522123894, "content": "A 41-year-old human immunodeficiency virus (HIV)-positive man was hospitalized with complaints of a 4-week history of nausea and vomiting, associated with decreased oral intake, and a 4-day history of frontal headache and fever. His medical history was significant for a gunshot wound to the head 3 years prior, with a residual seizure disorder. He also had two previous hospitalizations, both for culture-negative bacterial meningitis; the first episode occurred 12 months before admission and the second episode occurred 5 months later. At that time, he was found to be positive for serum antibodies against HIV and a CD4+ T-lymphocyte count of 126/mm3. He had no known drug allergies and was not receiving any medication. On admission, the patient was febrile (104.0 degrees F) and hypotensive (blood pressure, 92/40 mm Hg). Pertinent physical examination findings included cachexia with bitemporal wasting, dry mucus membranes, adherent white patches on the oral mucosa, and negative Kernig's and Brudzinski's signs. His laboratory results revealed macrocytic anemia, a decreased serum sodium of 125 mEq/L, and a normal total leukocyte count with a CD4+ T-lymphocyte count &lt; 50/mm3. Lumbar puncture opening pressure was elevated at 160 mm Hg, and cerebrospinal fluid analysis showed an increased white cell count of 97/microL (84% lymphocytes), a decreased glucose level of 26 mg/dL, and a decreased protein level of 42 mg/dL. The patient was started on empiric therapy that included intravenous ampicillin and cefotaxime, oral Bactrim, and clotrimazole lozenges for thrush. Cerebrospinal fluid culture was positive for Escherichia coli, sensitive to cefotaxime. Two days later, the patient developed fine, erythematous, nonblanchable macules primarily on his abdomen, with minimal involvement of his thorax and back. His skin lesions remained unchanged for the next 2 weeks. Repeat lumbar puncture was performed after 14 days of cefotaxime. The cerebrospinal fluid analysis showed an elevated white cell count of 7/microL (100% lymphocytes), a decreased glucose level of 53 mg/dL, and a decreased protein level of 33 mg/dL. The cerebrospinal fluid culture was now positive for Pseudomonas aeruginosa resistant to cefotaxime. The patient was started on imipenem. On day 34 of his admission, the patient became tachypneic with complaints of dyspnea. A chest roentgenogram revealed bilateral patchy infiltrates. He was transferred to the intensive care unit and intubated for hypoxemic respiratory failure (arterial blood gas values on 6 L of oxygen: pH, 7.46; bicarbonate, 23; and oxygen saturation, 37). That evening, the patient was also noted to have diffuse petechiae and purpura in a reticulated pattern over his abdomen (Figure 1A and 1B), most heavily concentrated in the periumbilical region, extending to the axillae and upper thighs. A 3x3-mm punch biopsy from abdominal skin demonstrated Strongyloides stercoralis larvae in the dermis (Figure 2A and 2B). His sputum specimen was teeming with adult S stercoralis worms (Figure 3) and, subsequently, numerous S stercoralis larvae were observed not only from the bronchoalveolar lavage but also from the nasogastric fluid specimen. These findings confirmed the diagnosis of disseminated strongyloidiasis. On hospital day 35, the patient was doing poorly and was started on thiabendazole (1250 mg twice daily for 28 days). Nine days later, ivermectin (4.5 mg once daily for 3 days for 2 courses) was also added. He continued to clinically deteriorate. The patient died 31 days after systemic antihelminthic treatment was initiated." }, { "id": "pubmed23n0068_1282", "title": "[Bulimia, induced vomiting, hypochloremic-hypokalemic alkalosis and fetal distress in the 33rd week of pregnancy. Obstetric and anesthesiologic management].", "score": 0.008849557522123894, "content": "A 39-year-old primigravida was admitted to the hospital in the 33rd week of pregnancy due to fetal retardation and placental insufficiency, malnutrition, decreased cutaneous turgor, and cardiotocographic (CTG) fetal distress. Body weight had increased subnormally through the 29th week of gestation and had since decreased by 2.5 kg. The following laboratory tests were obtained (normal values for pregnant women in parentheses): serum bicarbonate 50.9 (20-24) mmol/l, pH 7.61 (7.4), PCO2 52.4 (31) mmHg, SaO2 89-91 (greater than 95%); serum sodium 125 (137-145), potassium 1.8 (3.6-5.5), chloride 55 (94-111) mmol/l; colloid osmotic pressure 20.7 (19-22) mmHg. A decompensated hypochloremic-hypokalemic acidosis together with hypovolemic, isotonic hyponatremia was diagnosed and bulimic vomiting that had existed for two decades was discovered as the underlying cause. The acute therapy was aimed at normalization of the fluid-electrolyte status, oxygenation, utero-placental perfusion, and placental-fetal O2 transfer and was carried out under close clinical, biochemical, and CTG surveillance. In addition to the basic measures (lateral tilt position, nasal O2 application, isotonic electrolyte solutions, parenteral nutrition), 158 mmol H+, 240 mmol K+, and 414 mmol Na+ ions were administered. This therapy improved the maternal and fetal parameters continuously (Table 3, Fig. 1). Twenty-six hours following the initiation of treatment, a cesarean section was performed after induction of catheter-epidural anesthesia." }, { "id": "Obstentrics_Williams_4132", "title": "Obstentrics_Williams", "score": 0.008779264214046822, "content": "TABLE 32-3. Umbilical Cord Blood pH and Blood Gas Values in Normal Term Newborns Ramin, 1989a Riley, 1993b Kotaska, 201 Ob Kotaska, 2010e pH 7.28 (0.07) 7.27 (0.069) 7.26 (7.01n-7.39) 7.3 (7.05-7.39) Pco2 (mm Hg) 49.9 (14.2) 50.3(11n.1) 51 (30.9-85.8) 54 (37.5-79.5) HC03 -(mEq/L) 23.1 (2.8) 22.0 (3.6) Base excess (mEq/L) -3.6 (2.8) -2.7 (2.8) pH 7.34 (0.063) 7.31 (7.06-7.44) 7.34 (7.10-7.42) PC02 (mm Hg) 40.7 (7.9) 41 (24.9-70.9) 44 (29.1n-70.2) HC03 -(mEq/L) 21.4 (2.5) Base excess (mEq/L) -2.4 (2) aNewborns of selected women with uncomplicated vaginal deliveries. bNewborns of unselected women with vaginal deliveries. (Data shown as mean (SO). dOata shown as range with 2.5 or 97.5 percentile. eCesarean delivery-labor not stated. From Centers for Disease Control and Prevention, 201n2; Watson, 2006." }, { "id": "wiki20220301en053_51834", "title": "Ringer's lactate solution", "score": 0.008771929824561403, "content": "Ringer's lactate solution is used because the byproducts of lactate metabolism in the liver counteract acidosis, which is a chemical imbalance that occurs with acute fluid loss or kidney failure. The IV dose of Ringer's lactate solution is usually calculated by estimated fluid loss and presumed fluid deficit. For fluid resuscitation the usual rate of administration is 20 to 30 mL/kg body weight/hour. RL is not suitable for maintenance therapy (i.e., maintenance fluids) because the sodium content (130 mEq/L) is considered too low, particularly for children, and the potassium content (4 mEq/L) is too low, in view of electrolyte daily requirement. Moreover, since the lactate is converted into bicarbonate, long-term use will cause patients to become alkalotic. Ringer's lactate and other crystalloids are also used as vehicles for the IV delivery of medications. In a large-volume resuscitation over several hours, LRS maintains a more stable blood pH than normal saline." }, { "id": "pubmed23n0810_7618", "title": "[Assessment of the natural history and clinical presentation of acetonemic vomiting].", "score": 0.008771929824561403, "content": "Ketosis in children may result from physiological adaptation to situations like fasting, fat-rich diet, straining physical activity, as well as from serious endocrine or metabolic disorders. The most frequently diagnosed cause of ketoacidosis are states of acetonemia and acetonuria with vomiting, during airways infections. Assessment of the natural history and clinical presentation of acetonemic vomiting in children. 85 children from 18 months to 12 years of age with acetonemic vomiting were incorporated in this study. Detailed anamnesis, clinical examination, and chosen laboratory parameters were analyzed. In 18% of the children a familial pattern of the disease was observed, 75% of the parents declared that their children had fat-rich meals on a regular basis, in 47% there was a tendency to recurrent respiratory tract. The most frequently observed symptoms were incoercible vomiting with nausea (100%), abdominal pain (87%), headaches (35%) and febrile states (62%). Ketosis triggers were: infections with insufficient fluid and food intake (68%), and child overfeeding with fat-rich products (23%). Observed biochemical disturbances were ketosis (mean J3-hydroxybutyric acid serum concentration--1.03 mmol/l, SD +/- 0.83), acetonuria, hypoglycemia (15%), metabolic acidosis (17%) and dyselectrolytemia (14%). The treatment of the children consisted in intravenous and oral rehydration, managing acid-base and electrolyte disturbances. In some children acetonemic vomiting is recurrent, and thus prophylactic management is im- portant in children who are at risk." } ] } } }

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{ "1": "Debut of type 2 diabetes mellitus, with dyspnea probably due to pneumonia or thromboembolism, since she is taking anovulatory drugs.", "2": "It is a diabetic ketoacidosis. It must be treated with intravenous insulin, serum therapy, general measures and search for precipitating cause.", "3": "Debut of type 1 diabetes with ketoacidosis. Treat with bicarbonate and after correction of acidosis, add intravenous insulin.", "4": "It looks like diabetic ketoacidosis, but it could be alcoholic. BAC should be determined before starting insulin therapy.", "5": "Treat with rapid subcutaneous insulin, serum therapy and ask him to drink plenty of fluids." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0754_13149", "title": "Diabetic ketoacidosis: evaluation and treatment.", "score": 0.01873249299719888, "content": "Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration. Insulin deficiency is the main precipitating factor. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to 50 years of age, and 36 percent in persons younger than 30 years. The case fatality rate is 1 to 5 percent. About one-third of all cases are in persons without a history of diabetes mellitus. Common symptoms include polyuria with polydipsia (98 percent), weight loss (81 percent), fatigue (62 percent), dyspnea (57 percent), vomiting (46 percent), preceding febrile illness (40 percent), abdominal pain (32 percent), and polyphagia (23 percent). Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate diabetic ketoacidosis from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, and can assist in diagnosing comorbid conditions. Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels. Cerebral edema is a rare but severe complication that occurs predominantly in children. Physicians should recognize the signs of diabetic ketoacidosis for prompt diagnosis, and identify early symptoms to prevent it. Patient education should include information on how to adjust insulin during times of illness and how to monitor glucose and ketone levels, as well as information on the importance of medication compliance." }, { "id": "wiki20220301en086_256", "title": "Hyperosmolar hyperglycemic state", "score": 0.018614718614718615, "content": "Differential diagnosis The major differential diagnosis is diabetic ketoacidosis (DKA). In contrast to DKA, serum glucose levels in HHS are extremely high, usually greater than 40-50 mmol/L (600 mg/dL). Metabolic acidosis is absent or mild. A temporary state of confusion (delirium) is also more common in HHS than DKA. HHS also tends to affect older people more. DKA may have fruity breath, and rapid and deep breathing. DKA often has serum glucose level greater than 300 mg/dL (HHS is >600 mg/dL). DKA usually occurs in type 1 diabetics whereas HHS is more common in type 2 diabetics. DKA is characterized by a rapid onset, and HHS occurs gradually over a few days. DKA also is characterized by ketosis due to the breakdown of fat for energy. Both DKA and HHS may show symptoms of dehydration, increased thirst, increased urination, increased hunger, weight loss, nausea, vomiting, abdominal pain, blurred vision, headaches, weakness, and low blood pressure with standing. Management" }, { "id": "wiki20220301en008_125513", "title": "Diabetic coma", "score": 0.017980970811159493, "content": "In the early to middle stages of ketoacidosis, patients are typically flushed and breathing rapidly and deeply, but visible dehydration, pale appearance from diminished perfusion, shallower breathing, and a fast heart rate are often present when coma is reached. However these features are variable and not always as described. If the patient is known to have diabetes, the diagnosis of diabetic ketoacidosis is usually suspected from the appearance and a history of 1–2 days of vomiting. The diagnosis is confirmed when the usual blood chemistries in the emergency department reveal a high blood sugar level and severe metabolic acidosis. Treatment of diabetic ketoacidosis consists of isotonic fluids to rapidly stabilize the circulation, continued intravenous saline with potassium and other electrolytes to replace deficits, insulin to reverse the ketoacidosis, and careful monitoring for complications." }, { "id": "wiki20220301en003_162148", "title": "Hyperglycemia", "score": 0.01752123786407767, "content": "Frequent hunger without other symptoms can also indicate that blood sugar levels are too low. This may occur when people who have diabetes take too much oral hypoglycemic medication or insulin for the amount of food they eat. The resulting drop in blood sugar level to below the normal range prompts a hunger response. Polydipsia and polyuria occur when blood glucose levels rise high enough to result in excretion of excess glucose via the kidneys, which leads to the presence of glucose in the urine. This produces an osmotic diuresis. Signs and symptoms of diabetic ketoacidosis may include: Ketoacidosis Kussmaul hyperventilation (deep, rapid breathing) Confusion or a decreased level of consciousness Dehydration due to glycosuria and osmotic diuresis Increased thirst 'Fruity' smelling breath odor Nausea and vomiting Abdominal pain Impairment of cognitive function, along with increased sadness and anxiety Weight loss" }, { "id": "wiki20220301en002_195769", "title": "Diabetic ketoacidosis", "score": 0.01721981014055486, "content": "Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific \"fruity\" smell. Onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom. DKA happens most often in those with type 1 diabetes but can also occur in those with other types of diabetes under certain circumstances. Triggers may include infection, not taking insulin correctly, stroke and certain medications such as steroids. DKA results from a shortage of insulin; in response, the body switches to burning fatty acids, which produces acidic ketone bodies. DKA is typically diagnosed when testing finds high blood sugar, low blood pH and ketoacids in either the blood or urine." }, { "id": "wiki20220301en002_195789", "title": "Diabetic ketoacidosis", "score": 0.014493506493506494, "content": "Fluid replacement The amount of fluid replaced depends on the estimated degree of dehydration. If dehydration is so severe as to cause shock (severely decreased blood pressure with insufficient blood supply to the body's organs), or a depressed level of consciousness, rapid infusion of saline (1 liter for adults, 10 ml/kg in repeated doses for children) is recommended to restore circulating volume. Slower rehydration based on calculated water and sodium shortage may be possible if the dehydration is moderate, and again saline is the recommended fluid. Very mild ketoacidosis with no associated vomiting and mild dehydration may be treated with oral rehydration and subcutaneous rather than intravenous insulin under observation for signs of deterioration. Normal saline (0.9% saline) has generally been the fluid of choice. There have been a few small trials looking at balanced fluids with few differences." }, { "id": "wiki20220301en008_125514", "title": "Diabetic coma", "score": 0.01443089430894309, "content": "Nonketotic hyperosmolar coma Nonketotic hyperosmolar coma usually develops more insidiously than diabetic ketoacidosis because the principal symptom is lethargy progressing to obtundation, rather than vomiting and an obvious illness. Extremely high blood sugar levels are accompanied by dehydration due to inadequate fluid intake. Coma occurs most often in patients who have type 2 or steroid diabetes and have an impaired ability to recognize thirst and drink. It is classically a nursing home condition but can occur in all ages. The diagnosis is usually discovered when a chemistry screen performed because of obtundation reveals an extremely high blood sugar level (often above 1800 mg/dl (100 mM)) and dehydration. The treatment consists of insulin and gradual rehydration with intravenous fluids." }, { "id": "wiki20220301en167_20594", "title": "Diabulimia", "score": 0.013838143953233467, "content": "Signs and symptoms A person with diabulimia, especially if not treated early, can suffer negative effects on the body earlier than one who is managing properly. Of diabetics who have a DEB, some intentionally misuse insulin to control weight. This may also involve irregular eating patterns. Suspension of insulin combined with overeating can result in ketoacidosis. Multiple hospitalizations for ketoacidosis or hyperglycemia are cues to screen for an underlying emotional conflict. Short term The short-term symptoms of diabulimia are: Frequent and excessive urination Frequent and excessive thirst Frequent and excessive hunger High blood glucose levels (often over 600 mg/dL or 33 mmol/L) Weakness Fatigue Large amounts of glucose in the urine (glycosuria) Inability to concentrate Electrolyte disturbance Severe ketonuria, and, in DKA, severe ketonemia Low sodium levels" }, { "id": "wiki20220301en002_195770", "title": "Diabetic ketoacidosis", "score": 0.013591026999378905, "content": "The primary treatment of DKA is with intravenous fluids and insulin. Depending on the severity, insulin may be given intravenously or by injection under the skin. Usually, potassium is also needed to prevent the development of low blood potassium. Throughout treatment, blood sugar and potassium levels should be regularly checked. Underlying causes for the DKA should be identified. In those with severely low blood pH who are critically ill, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended. Rates of DKA vary around the world. In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% of type 1 diabetics a year. DKA was first described in 1886, and until the introduction of insulin therapy in the 1920s, it was almost universally fatal. The risk of death with adequate and timely treatment is between <1% and 5%." }, { "id": "pubmed23n0304_7472", "title": "[Diabetic emergencies].", "score": 0.01349517198588436, "content": "Based on case reports pathogenesis and treatment of the following diabetic emergencies were discussed: 1. The hyperosmolar non-ketotic coma without or with only modest ketosis occurring mainly in type II diabetics and the severe ketoacidosis with or without disturbed consciousness occurring mainly in type I diabetics are the two forms of severe metabolic decompensation of diabetes mellitus. 2. Severe hypoglycaemia may be caused by treatment with sulfonylureas and insulin. 3. The most dangerous life threatening adverse effect of biguanides is lactic acidosis. The incidence of ketoacidosis is about 1-5% in type I diabetics with a mortality of 3-9%. Mortality rates of hyperosmolar non-ketotic comas are much higher, approaching 20-40%, and are explained by severe concomitant complications and older age. The most important triggering factors of diabetic coma are infections, insulin dispensing errors and non-compliance. Carefully instructing patients about the risks of loosing appetite and vomiting as early signs of ketoacidosis is essential. Adequate replacement of fluid, electrolyte and water are the most important therapeutical aspects of ketoacidosis and hyperosmolar non-ketotic coma. Early diagnosis and appropriate treatment of infection by antibiotics are important. Complication of therapy (hypokalemia, hypovolemia and rapid full of oncotic pressure) should be avoided by clinical and laboratory monitoring. Treatment of acidosis with bicarbonate has been found more dangerous than useful. Severe hypoglycaemia is the most important and most dangerous side effect of sulfonylurea and insulin. The incidence of severe hypoglycaemia under glibenclamide ist 3-5 fold higher than under treatment with tolbutamide or glibornurid. Glibenclamide should not be recommended anymore. Longterm experience of the therapeutic security of new sulfonylurea derivates like glimepirid is lacking. Blood-glucose-measurements in the afternoon are important for recognizing disposition to sulfonylurea hypoglycaemia, because at this time the blood-glucose-values tend to be lower than in the morning fasting state. Under insulin treatment the following risk factors for severe hypoglycaemia need to be considered: metabolic control in the near normal range, intensified treatment with rapidly decreasing HbA1c-levels, impaired renal function, unawareness o hypoglycaemia. When the renal function is impaired, biguanide treatment is not indicated because of the risk of lactic acidosis. Most of the diabetic emergency situations are avoidable by proper education of the patients." }, { "id": "pubmed23n0924_22169", "title": "[Opportunities to improve hospital emergency care of patients with diabetic ketoacidosis].", "score": 0.013130881094952952, "content": "To identify opportunities to improve the care of adult patients with diabetic ketoacidosis in the emergency room. Retrospective observational study of records for 2010 to 2013. Searching for International Classification of Diseases discharge codes 250.1–250.3 we identified patients who met the following 3 criteria: ketonuria of 100 mg/dL or more, diagnosed diabetes or glucose concentration of 250 mg/dL or more, and venous blood pH below 7.30 (or venous bicarbonate concentration less than 18 mEq/L). We reviewed the cases to extract patient and clinical characteristics and time from triage until diagnosis and start of treatment. The findings were compared with recommendations in clinical practice guidelines. We identified 49 episodes of diabetic ketoacidosis (4 mild, 32 moderate, and 13 severe) in 43 patients. The median delay between triage until the first blood test results were available was 142 minutes (range, 59-597 minutes). In 50% of the cases fluid therapy was delayed beyond the time recommended in clinical practice guidelines. Intravenous insulin was also delayed (in 66%) and insuficient intravenous potassium was given in 65%. Sodium bicarbonate was overused (in 50%). Half the patients developed hypokalemia in the hospital. Diagnosis and initiation of treatment were often delayed for patients with diabetic ketoacidosis in our emergency department." }, { "id": "pubmed23n0518_8808", "title": "Diabetic ketoacidosis.", "score": 0.012929596262929596, "content": "A diagnosis of diabetic ketoacidosis requires the patient's plasma glucose concentration to be above 250 mg per dL (although it usually is much higher), the pH level to be less than 7.30, and the bicarbonate level to be 18 mEq per L or less. Beta-hydroxybutyrate is a better measurement of the degree of ketosis than serum ketones. Intravenous insulin and fluid replacement are the mainstays of therapy, with careful monitoring of potassium levels. Phosphorous and magnesium also may need to be replaced. Bicarbonate therapy rarely is needed. Infection, insulin omission, and other problems that may have precipitated ketoacidosis should be treated. Myocardial infarction is a precipitating cause of diabetic ketoacidosis that is especially important to look for in older patients with diabetes. Cerebral edema is a major complication that occurs primarily in children. Education to prevent recurrence should be offered to all patients, including how to manage sick days and when to call a physician." }, { "id": "wiki20220301en002_195795", "title": "Diabetic ketoacidosis", "score": 0.012851630570077172, "content": "Resolution Resolution of DKA is defined as general improvement in the symptoms, such as the ability to tolerate oral nutrition and fluids, normalization of blood acidity (pH>7.3), and absence of ketones in blood (<1 mmol/l) or urine. Once this has been achieved, insulin may be switched to the usual subcutaneously administered regimen, one hour after which the intravenous administration can be discontinued. In people with suspected ketosis-prone type 2 diabetes, determination of antibodies against glutamic acid decarboxylase and islet cells may aid in the decision whether to continue insulin administration long-term (if antibodies are detected), or whether to withdraw insulin and attempt treatment with oral medication as in type 2 diabetes. Generally speaking, routine measurement of C-peptide as a measure of insulin production is not recommended unless there is genuine doubt as to whether someone has type 1 or type 2 diabetes." }, { "id": "article-20429_42", "title": "Diabetes -- Complications", "score": 0.012192704203013481, "content": "The most acute complication of DM is diabetic ketoacidosis (DKA), which typically presents in T1DM. This condition is usually either due to inadequate dosing, missed doses, or ongoing infection. [53] In this condition, the lack of insulin means that tissues are unable to obtain glucose from the bloodstream. Compensation for this causes the metabolism of lipids into ketones as a substitute energy source, which causes systemic acidosis, and can be calculated as a high anion-gap metabolic acidosis. The combination of hyperglycemia and ketosis causes diuresis, acidemia, and vomiting leading to dehydration and electrolyte abnormalities, which can be life-threatening. In T2DM, hyperosmolar hyperglycemic syndrome (HHS) is an emergent concern. It presents similarly to DKA with excessive thirst, elevated blood glucose, dry mouth, polyuria, tachypnea, and tachycardia. However, unlike DKA, HHS typically does not present with excessive urinary ketones since insulin still gets produced by pancreatic beta cells. Treatment for DKA or HHS involves insulin administration and aggressive intravenous hydration. Careful management of electrolytes, particularly potassium, is critical in the management of these emergent conditions. [54]" }, { "id": "Neurology_Adams_9113", "title": "Neurology_Adams", "score": 0.011963626030122194, "content": "Two syndromes have been defined, mainly in diabetics: (1) hyperglycemia with ketoacidosis and (2) hyperosmolar nonketotic hyperglycemia. In diabetic acidosis, the familiar picture is one of dehydration, fatigue, weakness, headache, abdominal pain, dryness of the mouth, stupor or coma, and Kussmaul type of breathing. Usually the condition has developed over a period of days in a patient known or proven to be diabetic. Often, the patient had failed to take a regular insulin dose. The blood glucose level is found to be more than 400 mg/dL, the pH of the blood less than 7.20, and the bicarbonate less than 10 mEq/L. Ketone bodies and b-hydroxybutyric acid are elevated in the blood and urine, and there is marked glycosuria. The prompt administration of insulin and repletion of intravascular volume correct the clinical and chemical abnormalities over a period of hours." }, { "id": "wiki20220301en416_22116", "title": "Diabetes", "score": 0.01186100386100386, "content": "Diabetic emergencies People with diabetes (usually but not exclusively in type 1 diabetes) may also experience diabetic ketoacidosis (DKA), a metabolic disturbance characterized by nausea, vomiting and abdominal pain, the smell of acetone on the breath, deep breathing known as Kussmaul breathing, and in severe cases a decreased level of consciousness. DKA requires emergency treatment in hospital. A rarer but more dangerous condition is hyperosmolar hyperglycemic state (HHS), which is more common in type 2 diabetes and is mainly the result of dehydration caused by high blood sugars." }, { "id": "wiki20220301en003_204068", "title": "Ketosis", "score": 0.011846496106785316, "content": "Ketosis is a metabolic state characterized by elevated levels of ketone bodies in the blood or urine. Physiologic ketosis is a normal response to low glucose availability, such as low-carbohydrate diets or fasting, that provides an additional energy source for the brain in the form of ketones. In physiologic ketosis, ketones in the blood are elevated above baseline levels, but the body's acid–base homeostasis is maintained. This contrasts with ketoacidosis, an uncontrolled production of ketones that occurs in pathologic states and causes a metabolic acidosis, which is a medical emergency. Ketoacidosis is most commonly the result of complete insulin deficiency in type 1 diabetes or late-stage type 2 diabetes. Ketone levels can be measured in blood, urine or breath and are generally between 0.5 and 3.0 millimolar (mM) in physiologic ketosis, while ketoacidosis may cause blood concentrations greater than 10 mM." }, { "id": "article-23176_11", "title": "Hyperglycemia -- History and Physical", "score": 0.011843238587424634, "content": "Symptoms of severe hyperglycemia include polyuria, polydipsia, and weight loss. As the patient's blood glucose increases, neurologic symptoms can develop. The patient may experience lethargy, focal neurologic deficits, or altered mental status. The patient can progress to a comatose state. Patients with diabetic ketoacidosis may present with nausea, vomiting, and abdominal pain in addition to the above symptoms. They also may have a fruity odor to their breath and have rapid shallow respirations, reflecting compensatory hyperventilation for the acidosis. The physical examination can reveal signs of hypovolemia like hypotension, tachycardia, and dry mucous membranes." }, { "id": "pubmed23n1143_24573", "title": "A Case of Euglycemic Diabetic Ketoacidosis due to Empagliflozin Use in a Patient with Type 1 Diabetes Mellitus.", "score": 0.01169052488070893, "content": "Euglycemic diabetic ketoacidosis is characterised by serum blood glucose &lt;250 mg/dl, arterial blood pH &lt;7.35, and the presence of ketones in urine or blood. Here, we present a 36-year female with type-1 diabetes mellitus, a case of euglycemic diabetic ketoacidosis, who was admitted to the emergency unit with nausea, vomiting, and confusion after using empagliflozin, which was added to her treatment one month ago. She was followed up in the intensive care unit for four days. Empagliflozin was discontinued. Intravenous fluids and insulin infusions were given. The patient, whose metabolic acidosis regressed, was discharged with the necessary recommendations and training. Euglycemic diabetic ketoacidosis should be kept in mind as a differential diagnosis in patients with type-1 diabetes and type-2 diabetes presenting with acidosis. Attention should be paid to the patients' medications and whether there are SGLT-2 inhibitors among these drugs. Key Words: Diabetes mellitus, Sodium-glucose co-transporter-2 inhibitors, Euglycemic diabetic ketoacidosis, Empagliflozin." }, { "id": "wiki20220301en002_195787", "title": "Diabetic ketoacidosis", "score": 0.011620119215055923, "content": "A 2004 statement by the European Society for Paediatric Endocrinology and the Lawson Wilkins Pediatric Endocrine Society (for children) uses slightly different cutoffs, where mild DKA is defined by pH 7.20–7.30 (bicarbonate 10–15 mmol/l), moderate DKA by pH 7.1–7.2 (bicarbonate 5–10) and severe DKA by pH<7.1 (bicarbonate below 5). Prevention Attacks of DKA can be prevented in those known to have diabetes to an extent by adherence to \"sick day rules\"; these are clear-cut instructions to person on how to treat themselves when unwell. Instructions include advice on how much extra insulin to take when sugar levels appear uncontrolled, an easily digestible diet rich in salt and carbohydrates, means to suppress fever and treat infection, and recommendations when to call for medical help. People with diabetes can monitor their own ketone levels when unwell and seek help if they are elevated." }, { "id": "pubmed23n0272_8222", "title": "[Ketoacidotic diabetic metabolic dysregulation: pathophysiology, clinical aspects, diagnosis and therapy].", "score": 0.01058817438127783, "content": "When glucose utilisation is impaired due to decreased insulin effect, ketones are produced by the liver from free fatty acids to supply an alternate source of energy. This adaptation may be associated with severe metabolic acidosis and tends to occur in patients with type I (insulin-dependent) diabetes mellitus. In addition, hypovolemia is an almost invariable finding with marked hypoglycemia and is primarily induced by the associated glucosuria. Ketoacidosis stimulates both the central and peripheral chemoreceptors controlling respiration, resulting in alveolar hyperventilation (Kussmaul's respiration). With the ensuing fall in pCO2 the patient tries to raise the extracellular pH. A fruity odor of acetone on the patient's breath sometimes suggests that ketoacidosis is present. The classical triad of symptoms associated with hyperglycemia are polyuria, polydipsia, and weight loss. Circulatory insufficiency with hypotension is not uncommon due to the marked fluid loss and acidemia. In more severely affected patients, neurologic abnormalities may be seen, including lethargy, seizures or coma. Some patients also have marked vomiting and abdominal pain. The history and physical examination may provide important clues to the presence of uncontrolled diabetes mellitus. Once suspected, the diagnosis can be easily confirmed by measuring the plasma glucose concentration. Glucosuria and ketonuria can be semiquantitatively detected with reagent sticks. Blood gas analysis and anion gap give objective information as to the severity of the metabolic acidosis. Therapy must be directed toward each of the metabolic disturbances: hyperosmolality, ketoacidosis, hypovolemia and potassium, and phosphate depletion. The mainstays of therapy are the administration of low-dose insulin and volume repletion.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en021_35409", "title": "Ketoacidosis", "score": 0.01057493093922652, "content": "Acetoacetic acid and β-hydroxybutyrate are the most abundant circulating ketone bodies. Ketone bodies are acidic; however, at physiologic concentrations, the body's acid/base buffering system prevents them from changing blood pH. Management Treatment depends on the underlying cause of the ketoacidosis. Diabetic ketoacidosis is resolved with insulin infusion, intravenous fluids, electrolyte replacement and supportive care. Alcoholic ketoacidosis is treated with intravenous dextrose and supportive care and usually does not require insulin. Starvation ketoacidosis can be resolved with intravenous dextrose with attention to electrolyte changes that can occur with refeeding syndrome. Epidemiology Certain populations are predisposed to develop ketoacidosis including people with diabetes, people with a history of prolonged and heavy alcohol use, pregnant women, breastfeeding women, children, and infants." }, { "id": "article-20429_18", "title": "Diabetes -- History and Physical", "score": 0.010557265766832427, "content": "During patient history, questions about family history, autoimmune diseases, and insulin-resistant are critical to making the diagnosis of DM. It often presents asymptomatically, but when symptoms develop, patients usually present with polyuria, polydipsia, and weight loss. On physical examination of someone with hyperglycemia, poor skin turgor (from dehydration) and a distinctive fruity odor of their breath (in patients with ketosis) may be present. In the setting of diabetic ketoacidosis (DKA), clinicians may note Kussmaul respirations, fatigue, nausea, and vomiting. Funduscopic examination in a patient with DM may show hemorrhages or exudates on the macula. In frank diabetic retinopathy, retinal venules may appear dilated or occluded. The proliferation of new blood vessels is also a concern for ophthalmologists and can hasten retinal hemorrhages and macular edema, ultimately resulting in blindness. While T1DM and T2DM can present similarly, they can be distinguished based on clinical history and examination. T2DM patients are typically overweight/obese and present with signs of insulin resistance, including acanthosis nigricans, which are hyperpigmented, velvety patches on the skin of the neck, axillary, or inguinal folds. Patients with a longer course of hyperglycemia may have blurry vision, frequent yeast infections, numbness, or neuropathic pain. The clinicians must ask the patient bout any recent skin changes in their feet during each visit. The diabetic foot exam, including the monofilament test, should be a part of the routine physical exam." }, { "id": "wiki20220301en002_195799", "title": "Diabetic ketoacidosis", "score": 0.010539945028734978, "content": "Numerous research studies since the 1950s have focused on the ideal treatment for diabetic ketoacidosis. A significant proportion of these studies have been conducted at the University of Tennessee Health Science Center and Emory University School of Medicine. Treatment options studied have included high- or low-dose intravenous, subcutaneous or intramuscular (e.g. the \"Alberti regime\") insulin, phosphate supplementation, need for a loading dose of insulin, and appropriateness of using bicarbonate therapy in moderate DKA. Various questions remain unanswered, such as whether bicarbonate administration in severe DKA makes any real difference to the clinical course, and whether an insulin loading dose is needed in adults." }, { "id": "article-74978_18", "title": "Adult Diabetic Ketoacidosis -- Evaluation", "score": 0.010472933128906712, "content": "Commonly accepted criteria for diabetic ketoacidosis are blood glucose greater than 250 mg/dl, arterial pH less than 7.3, serum bicarbonate less than 15 mEq/l, and the presence of ketonemia or ketonuria. The normal anion gap is 12 mEq/l. Anion gap greater than 14-15 mEq/l indicates the presence of an increased anion gap metabolic acidosis. [17] Arterial pH may be normal or even raised if other types of metabolic or respiratory alkalosis coexist. Typical examples are vomiting or diuretic use. [18] Blood glucose may be normal or minimally elevated in patients with DKA (<300 mg/dl), where the underlying risk of hypoglycemia preexists, such as in patients with alcohol use disorder or patients receiving insulin or SGLT2 inhibitors." }, { "id": "InternalMed_Harrison_27964", "title": "InternalMed_Harrison", "score": 0.010230990383662139, "content": "factors, and the management of diabetes during a concurrent illness. During illness or when oral intake is compromised, patients should (1) frequently measure the capillary blood glucose; (2) measure urinary ketones when the serum glucose is >16.5 mmol/L (300 mg/dL); (3) drink fluids to maintain hydration; (4) continue or increase insulin; and (5) seek medical attention if dehydration, persistent vomiting, or uncontrolled hyperglycemia develop. Using these strategies, early DKA can be prevented or detected and treated appropriately on an outpatient basis." }, { "id": "wiki20220301en021_35404", "title": "Ketoacidosis", "score": 0.010101679929266135, "content": "Ketoacidosis is a metabolic state caused by uncontrolled production of ketone bodies that cause a metabolic acidosis. While ketosis refers to any elevation of blood ketones, ketoacidosis is a specific pathologic condition that results in changes in blood pH and requires medical attention. The most common cause of ketoacidosis is diabetic ketoacidosis but can also be caused by alcohol, medications, toxins, and rarely starvation. Signs and symptoms The symptoms of ketoacidosis are variable depending on the underlying cause. The most common symptoms include nausea, vomiting, abdominal pain, and weakness. Breath may also develop the smell of acetone as it is a volatile ketone that can be exhaled. Rapid deep breathing, or Kussmaul breathing, may be present to compensate for the metabolic acidosis. Altered mental status is more common in diabetic than alcoholic ketoacidosis. Causes" }, { "id": "article-23877_23", "title": "Ketoacidosis -- Differential Diagnosis", "score": 0.010038967043127931, "content": "Hyperosmolar hyperglycemic state (HHS) occurs in the setting of insulin resistance and is more typical of type 2 diabetes. There is sufficient insulin in patients with HHS to suppress lipolysis and production of ketone bodies, but inadequate amounts to prevent the hyperglycemia, dehydration, and hyperosmolality, characteristic of HHS. An illness or event that leads to dehydration will often precipitate the hyperglycemia associated with HHS. The development of HHS is less acute than DKA and may take days to weeks to develop. HHS typically presents with more extreme hyperglycemia and mental status changes compared with DKA. HHS typically presents with normal or small amounts of urine or serum ketones. Plasma glucose values in HHS are typically greater than in DKA and can exceed 1200 mg/dL (66.6 mmol/L). The serum osmolality is elevated greater than 320 mOsm/kg H2O. The serum bicarbonate level is greater than 18 mEq/L (18 mmol/L), and the pH remains greater than 7.3." }, { "id": "pubmed23n1010_24763", "title": "Just the Facts: Diagnosis and treatment of diabetic ketoacidosis in the emergency department.", "score": 0.009900990099009901, "content": "A 21-year-old male with known type 1 diabetes mellitus presented to the emergency department (ED) with two days of vomiting, polyuria, and polydipsia after several days of viral upper respiratory tract infection symptoms. Since his symptom onset, his home capillary blood glucose readings have been higher than usual. On the day of presentation, his glucometer read \"high,\" and he could not tolerate oral fluids. On examination, his pulse was 110 beats/minute, and his respiratory rate was 24 breaths/minute. He was afebrile, and the remaining vital signs were normal. Other than dry mucous membranes, his cardiopulmonary, abdominal, and neurologic exams were unremarkable. Venous blood gas demonstrated a pH of 7.25 mm Hg, pCO2 of 31 mm Hg, HCO3 of 13 mm Hg, anion gap of 18 mmol/L, and laboratory blood glucose of 40 mmol/L, as well as serum ketones measuring \"large.\"" }, { "id": "wiki20220301en008_126400", "title": "Type 2 diabetes", "score": 0.009873537566781634, "content": "Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, and unexplained weight loss. Symptoms may also include increased hunger, feeling tired, and sores that do not heal. Often symptoms come on slowly. Long-term complications from high blood sugar include heart disease, strokes, diabetic retinopathy which can result in blindness, kidney failure, and poor blood flow in the limbs which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon. Type 2 diabetes primarily occurs as a result of obesity and lack of exercise. Some people are more genetically at risk than others." }, { "id": "wiki20220301en003_204072", "title": "Ketosis", "score": 0.009867112278188907, "content": "Ketoacidosis Ketoacidosis is a pathological state of uncontrolled production of ketones that results in a metabolic acidosis. Ketoacidosis is most commonly caused by a deficiency of insulin in type 1 diabetes or late stage type 2 diabetes but can also be the result of chronic heavy alcohol use, salicylate poisoning, or isopropyl alcohol ingestion. Ketoacidosis causes significant metabolic derangements and is a life-threatening medical emergency. Ketoacidosis is distinct from physiologic ketosis as it requires failure of the normal regulation of ketone body production. Causes Elevated blood ketone levels are most often caused by accelerated ketone production but may also be caused by consumption of exogenous ketones or precursors." }, { "id": "wiki20220301en343_25815", "title": "Intravenous sodium bicarbonate", "score": 0.00980392156862745, "content": "Commercial production of sodium bicarbonate began between 1791 and 1823. Intravenous medical use began around the 1950s. It is on the World Health Organization's List of Essential Medicines. Sodium bicarbonate is available as a generic medication. Medical uses Intravenous sodium bicarbonate is indicated in the treatment of metabolic acidosis, such as can occur in severe kidney disease, diabetic ketoacidosis, circulatory insufficiency, extracorporeal circulation of blood, in hemolysis requiring alkalinization of the urine to avoid nephrotoxicity of blood pigments, and certain drug intoxications, such as by barbiturate overdose, salicylate poisoning, tricyclic antidepressant overdose or methanol poisoning. In addition, sodium bicarbonate is indicated in severe diarrhea, where large amounts of bicarbonate may be lost. However, overall treatment should also strive to treat the underlying cause of the acidosis, such as giving insulin in case of diabetic ketoacidosis. Dhaka fluid" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 433, 588 ] ], "word_ranges": [ [ 75, 99 ] ], "text": "With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis, so it is clear." }, "2": { "exist": true, "char_ranges": [ [ 433, 588 ] ], "word_ranges": [ [ 75, 99 ] ], "text": "With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis, so it is clear." }, "3": { "exist": true, "char_ranges": [ [ 433, 588 ] ], "word_ranges": [ [ 75, 99 ] ], "text": "With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis, so it is clear." }, "4": { "exist": true, "char_ranges": [ [ 433, 588 ] ], "word_ranges": [ [ 75, 99 ] ], "text": "With the exception of meglumine antimoniate, none of the other treatments proposed in the different options are indicated in leishmaniasis, so it is clear." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Oral isotretinoin.", "2": "Intralesional meglumine antimoniate.", "3": "Systemic corticosteroids.", "4": "Oral amoxicillin.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0715_21227", "title": "Segmental lesions in pityriasis rosea: a rare presentation.", "score": 0.017940466613032984, "content": "A 34-year-old nonpregnant woman noted a mildly pruritic skin lesion on her right breast for 1 week following an episode of coryza, malaise, and low-grade fever of 3 days' duration. The latter symptoms subsided without any treatment. Ketoconazole cream prescribed by her family physician did not resolve the breast eruption after 1 week, so was stopped. A week later, multiple skin lesions erupted suddenly on her right chest wall starting near the herald patch in midaxillary line and spread distally until the midback. She then consulted the authors. She denied a history of abrasion or trauma to the affected areas. Travel, contact, sexual, and drug histories were unremarkable. She categorically denied past or family history of eczema, psoriasis, contact dermatitis, and drug eruptions. On examination, the initial lesion was an annular and well-demarcated erythematous plaque on her right breast in the upper outer quadrant. Multiple small oval scaly plaques were noted, extending distally along the ribs to the midline on her back, not crossing the midline, predominantly over the distribution of right T4 dermatome (Figure 1). Peripheral collarette scaling was noted (Figure 2). A few scattered small lesions were also noted in the vicinity of this dermatome. Three isolated small plaques were also present on the trunk, one in the supramammary area and the other two on the abdomen and back, respectively. Palmoplantar and mucosal surfaces were uninvolved. The rest of the skin and systemic examination revealed no abnormalities. Complete blood cell counts, fasting glucose, and urinalysis were normal. Venereal Disease Research Laboratory (VDRL) results were nonreactive and human immunodeficiency virus (HIV) antibodies were negative. Repeat testing ofVDRL in serial dilutions and HIV antibodies after 3 months were also nonreactive and negative, respectively. Scrapings from the initial large lesion and subsequent smaller eruptions did not show any evidence of fungal infection on potassium hydroxide smear examination. The patient declined skin biopsy; however, we thought that the most diagnostic label for this condition was pityriasis rosea. Hence, we treated her with triamcinolone acetonide ointment 0.025% to be applied twice daily and desloratadine tablet 5 mg daily for 10 days. The patient demonstrated complete resolution, leaving postinflammatory hypopigmentation. There was no recurrence until 1 year after complete remission." }, { "id": "pubmed23n0742_14680", "title": "Two contrasting post-zoster dermatomal phenomena.", "score": 0.017324133793310333, "content": "A 29-year-old, normotensive, nondiabetic man presented with a 9-day history of a scaly, pruritic eruption involving the right chest, axilla, and arm. He had a history of herpes zoster involving the same areas about 4 weeks ago. The present eruption started after the herpetic lesions had healed. Examination revealed scaly, erythematous plaques and papules involving the right side of the chest, axilla, and arm in a dermatomal pattern (figure 1). Removal of the scales revealed underlying bleeding points (positive Auspitz sign). The rest of the body, including scalp, palms, soles, and nails, were normal. There was no history suggestive of psoriasis in any family member. Systemic examination and routine investigations were noncontributory. A clinical diagnosis of psoriasis was made and confirmed by histopathologic examination of a skin biopsy sample. The patient was prescribed a topical clobetasol cream and oral levocetirizine. The eruption resolved completely after 3 weeks. A 43-year-old normotensive, nondiabetic woman presented with a 2-day history of fever, arthalgias, and generalized erythematous dermatitis. Five days ago, the patient had a toothache for which she was prescribed injectable ampicillin. After receiving ampicillin for 3 days, she developed fever, myalgias, and arthalgias, which was followed several hours later by an erythematous eruption. The dermatitis started on the trunk and, over a period of several hours, progressed to involve the face and limbs. The eruption was slightly pruritic. History revealed herpes zoster 7 months ago involving left thoracic dermatomes, for which the patient was treated with valacyclovir (1 g thrice a day x 7 days) and analgesics. There was no history of post-zoster neuralgia. On examination, the patient was febrile (oral temperature 102 degrees F), her heart rate was 118 beats per minute, and her blood pressure was 110/70 mm Hg. Cutaneous examination revealed an erythematous, maculopapular dermatitis involving the face and limbs in a bilaterally symmetrical pattern; the palms and soles were also bilaterally involved. The whole of the trunk was involved with erythematous and, in places, violaceous, maculopapular eruption except for a small area on the left side corresponding to T8 and T9 thoracic dermatomes (Figure 2). Complete blood cell counts revealed eosinophilia (9%) and liver function tests, kidney function tests, random blood sugar, routine urine examination, and blood and urine cultures were noncontributory. Histopathologic examination of lesional skin biopsy revealed an intense mononuclear cell infiltration with many eosinophils and an interface dermatitis with hydropic degeneration of basal keratinocytes, while in the spared area, only slight lymphocytic infiltration was present in a perivascular distribution. Based on the history and examination, a diagnosis of ampicillin-induced drug dermatitis was made. The ampicillin was stopped and the patient was put on a short course of oral prednisolone, antipyretics, and topical calamine. The patient was afebrile in 2 days and the eruption resolved completely in 8 days." }, { "id": "pubmed23n1147_3222", "title": "[Generalized old world leishmaniasis: first Moroccan case in an immunocompetent adult?]", "score": 0.015371127995324372, "content": "Post-kala-azar dermal <iLeishmaniasis</i (PKDL) is a rare skin syndrome observed after treatment of visceral <iLeishmaniasis</i (VL) with pentavalent antimonial organic salts, never described in Morocco before. Here we report a case in an immunocompetent adult. A 36-year-old-man from Tata in southern Morocco, with a history of visceral <iLeishmaniasis</i 2 years before and treated with meglumine antimoniate and amphotericin B with good clinical course, was hospitalized in dermatology for an erythematous papulo-nodular closet of the face. Six months ago, he presented oral mucosa involvement, then 3 months later, cutaneous lesions appeared on the face. The dermatological examination revealed a papulo-nodular erythematous closet extending to the nose and both cheeks, crusty and lupoid lesions on the forehead, around the eyes and chin, associated with an ulcerative and painless lesion on the heeL. The examination of the oral mucosa revealed an ulceration of the posterior third of the tongue and a papillomatous aspect of the soft palate. The skin biopsy and smear found some amastigote forms of <iLeishmania</i bodies. ITS1 PCR was positive (genus <iLeishmania).</i The HIV serology was negative. The diagnosis of PKDL was then evoked. The patient received intra-muscular injections of meglumine antimoniate with good progress. To our knowledge, this is the first case of generalised leishmaniasis suggesting PKDL reported in a Moroccan immunocompetent adult." }, { "id": "pubmed23n0831_23002", "title": "Lesson of the month 2: Chronic erythematous painless plaque on the eyelid co-presenting with multiple ulcerated nodules on the extremities.", "score": 0.012281618635209796, "content": "Cutaneous leishmaniasis is a parasitic disease caused by the Leishmania species, transmitted by the bite of an infected sandfly. The typical cutaneous lesion is a painless ulcer with a raised, indurated margin and often covered with an adherent crust. The lesions are mostly located on exposed sites such as the face and the extremities. Eyelid involvement is rare, making up only 2-5% of cases with facial cutaneous leishmaniasis. Herein, we report a 50-year-old male who presented with an erythematous plaque on the upper eyelid and multiple ulcerated nodules located on the extremities. Following microscopic examination of the lesional smear, a diagnosis of cutaneous leishmaniasis was made, and the patient was successfully treated with intramuscular meglumine antimonate therapy. " }, { "id": "wiki20220301en250_35957", "title": "Generalized pustular psoriasis", "score": 0.012203897187922747, "content": "Case report 3 An eleven-year-old boy had an eight-year history of recurrent GPP. He suffered from \"fever, malaise and pain\". He was treated with acitretin, and improvement was seen in five weeks. Case report 4 In 1991, a case was reported of a man having plaque psoriasis and treating it with UV radiation at a tanning salon. After receiving a partial thickness burn from overexposure, he presented with annular pustular psoriasis, which cleared after 21 days, only to reoccur every 3 to 6 weeks for a year. Case report 5 A case report published in the Journal of Dermatological Treatment documents the successful use of adalimumab to control symptoms and induce relapse for 72 weeks. \"Adalimumab is ... approved for the treatment of moderate to severe rheumatoid arthritis ... and more recently for the treatment of psoriatic arthritis\". See also List of cutaneous conditions Psoriasis References External links Psoriasis" }, { "id": "pubmed23n1004_10312", "title": "An Uncommon Presentation of Erythrodermic Psoriasis in a Patient Without a History of Psoriasis.", "score": 0.011627162075592569, "content": "Erythrodermic psoriasis is a rare and potentially fatal skin condition. We present the case of a 68-year-old woman, with no prior dermatologic history, who was treated with steroid injection for an insect bite one month prior to presentation and subsequently developed a diffuse erythematous rash. She presented to a military medical center in shock, with weeping, coalesced plaques covering the majority of her skin. Skin biopsies revealed pustular psoriasis, and treatment with infliximab was initiated for erythrodermic psoriasis. After six weeks and three infliximab infusions, the cutaneous lesions had nearly completely resolved." }, { "id": "wiki20220301en250_35956", "title": "Generalized pustular psoriasis", "score": 0.010634481344813448, "content": "Case reports Case report 1 Von Zumbusch observed a male patient, who had had classic psoriasis for several years, and who then went through recurrent episodes of bright [erythema] and [edema], which became studded with multiple pustules. Von Zumbusch observed this patient through nine hospital admissions over 10 years. Case report 2 Hazarika gave a report of a 29-year-old woman with no family history of psoriasis, having had a normal first pregnancy, who presented with GPP in the twenty-eighth week of her second pregnancy. Steroid therapy caused a worsening of the symptoms. With cyclosporine the lesions cleared in 10–14 days, but new lesions appeared. The patient gave birth to a healthy baby in the thirty-eighth week of pregnancy. A month and a half after delivery, the woman presented with a psoriatic plaque on her leg." }, { "id": "pubmed23n0530_5789", "title": "Chronic granulomatous disease: two members of a single family with different dermatologic manifestations.", "score": 0.010557691236280572, "content": "Case 1: A 33-year-old man with a 14-year history of localized skin disease on the face and scalp was evaluated at the department of dermatology. The physical examination revealed plaques with papules, pustules, and a golden yellow crusting on the forehead, cheeks, upper lip, and chin (Figure 1). The scalp presented fine, whitish scales. At the beginning of his disease, the patient presented large red and painful purulent boils. The 14-year clinical course of these lesions was characterized by partial remissions and recurrences, but he did not specify any treatment related to improvement. The clinical diagnosis given for the scalp lesions was seborrheic dermatitis. For the facial lesions, many differential diagnoses were considered, among them: seborrheic dermatitis, acneiform dermatitis, impetigo, folliculitis, seborrheic pemphigus, and demodicidosis. The histopathologic study of a biopsy taken from the cheek (Figure 2) showed superficial spongiform dermatitis with neutrophils and folliculitis that are compatible with the diagnosis of seborrheic dermatitis. Both Gram and periodic acid-Schiff stains were negative. Follow-up of the patient was not possible since he did not come back. The disease in this patient initially manifested at age five by the presence of recurrent ganglionic abscesses. At age 15, he presented a pulmonary abscess of a left lobule that was surgically removed; at this point the diagnosis of chronic granulomatous disease was established. At age 28, an exploratory laparotomy was performed due to peritonitis and multiple hepatic abscesses. At that time, he was treated with antibiotics (mainly trimethoprim-sulfamethoxazole) and interferon-g. The patient had two brothers who died due to complications of chronic granulomatous disease. In addition, both his mother and sister presented a history of discoid lupus-like lesions. Case 2: Coincidentally, his 27-year-old sister was seen in our department of dermatology 5 years before, presenting infiltrated and erythematous plaques with fine scales (Figure 3) on the right side of the nose and the left annular finger. No other cutaneous or mucous lesions were seen. She referred onset in childhood with similar lesions on sun-exposed areas that disappeared without scarring. A biopsy was performed and the results were compatible with the diagnosis of discoid lupus erythematosus (Figure 4). Direct immunofluorescence was not available. At that time, she did not mention the family history of chronic granulomatous disease. Clinical follow-up was not possible, but his brother referred that she afforded complete remission only with sun protection." }, { "id": "pubmed23n0731_3980", "title": "Exclusive plaque psoriasis of the lips: efficacy of combination therapy of topical tacrolimus, calcipotriol, and betamethasone dipropionate.", "score": 0.01055475103041105, "content": "A 16-year-old unmarried woman presented with recurrent cracking of the lips indicated by the appearance of grayish white flakes since October 2004, which, in due course, shed off leaving behind an apparently normal mucous membrane. Chewing roasted corn treated with salt and lemon (bhutta) initially caused the lesions. Ever since, it has been a cause of its exacerbation. She never had any relief with either systemic or topical treatment. In fact, an obsession had overtaken her, resulting in a psychological setback. She denied regular drug use for any other ailment. Her menstrual cycle was normal. There was a positive history of psoriasis in her mother. Examination of the lips was conspicuous. It was marked by the presence of a well-circumscribed, moist, raised plaque (Figure 1). Its surface was irregular, with elevation and depression. It was made up of thick, grayish white scales, which were arranged in layers; however, Grattage/Auspitz sign could not be elicited. Fissuring was prominent but the buccal mucosa, surface of the tongue, gingiva, and palate were normal. The clinical examination did not reveal any evidence of skin and/or nail psoriasis/psoriatic arthropathy or any other systemic abnormality. Blood examination including total and differential leukocyte count, complete hemogram, and liver and renal function tests were normal. Biopsy of the representative lesion was subjected to serial sections. They were stained with hematoxylin-eosin to work up microscopic pathology. It revealed the presence of mounds of parakeratosis with numerous neutrophilic Munro microabscesses (Figure 2). Submucosal vessels were dilated and congested. Periodic-acid-Schiff (PAS) stain revealed fungal hyphae and spores within the parakeratotic layer. Colonies of Gram-positive cocci were also demonstrated on the surface of the mucosa. She was administered combination therapy, comprising topical tacrolimus (0.1%) ointment and calcipotirol hydrate (50 microg/g) plus betmethasone dipropionate (0.5 mg/g) twice a day for 7 days. A single bolus dose of fluconazole 450 mg orally was also administered. The response to treatment was favorable and the lesions showed regression (Figure 3)." }, { "id": "pubmed23n1040_24187", "title": "Unusual Case of Granuloma Annulare Associated with Diabetes Mellitus.", "score": 0.009900990099009901, "content": "Dear Editor, Granuloma annulare (GA) is an asymptomatic, chronic, and relatively common granulomatous skin condition which presents with annular papules usually slowly progressing into plaques on the extremities and the trunk. It usually presents with non-scaly, erythematous, annular plaques on the distal extremity (1,2). The pathogenesis of GA is still unknown, although a variety of possible factors contributing the disease have been reported, including drugs (3), insect bites, sun exposure, trauma, vaccinations, and viral infections (e.g. hepatitis B, hepatitis C, HIV, Epstein-Barr virus) (1). Several cases in which GA developed on residual skin changes from herpes zoster have also been reported (4). A 47-year-old woman presented with erythematous-livid plaques on the dorsa of her hands and linear and circular lesions on her neck, gradually spreading for the last 4 months prior to admission at our Department (Figure 1a and Figure 1b). She reported excessive thirst and sweating in the last 30 days, but did not consider it significant since it was summer. The patient was otherwise healthy and was not taking any medications. Mycological swabs taken from the dorsal parts of both hands and the neck were negative. Biopsy of the skin changes was consistent with GA, showing palisading granulomatous inflammation which surrounded degenerated collagen within the dermis. A routine laboratory check revealed increased levels of glucose (23 mmol/L) and HgbA1C, while lipid and thyroid hormone levels were normal. Fasting blood sugar lever was 17 mmol/L. Therapy with topical corticosteroid (betamethasone cream) for skin lesions was initiated and applied two times daily for 2 weeks. The patient was immediately referred to an endocrinologist and insulin therapy was initiated due to diabetes mellitus. Complete remission of the skin changes was observed on the follow-up visit after 3 months. There are many clinical variants of GA such as localized, generalized, disseminated, subcutaneous, arcuate dermal erythema, and perforating GA (1). The localized form of GA is most common with annular plaques on the distal extremities. In addition to the typical lesions on the dorsal side of both hands, our patient also presented with atypical, circular lesions around her neck. The relationship between GA and systemic diseases such as diabetes mellitus, thyroid disorders, dyslipidemia, and malignancies remains unclear (5). It is also uncertain whether genetic factors influence susceptibility to GA. Familial cases have been documented, but studies investigating the association between the disease and human leukocyte antigen (HLA) genes have yielded inconsistent results (6). Increased frequency of HLA-B35 in patients with the generalized form has been reported in a few studies (7). GA mostly affects children and young adults, mostly women. Many cases of GA resolve spontaneously within 2 years, but relapses occur in many patients. Treatment is divided into localized skin therapies and systemic therapies (1). High potency topical corticosteroids along with intralesional corticosteroids are the most common localized treatments (8). Systemic therapy includes corticosteroids, chloroquine, dapsone, and isotretinoin (1,9). Cryotherapy and UV-therapy can also be used, although with limited efficacy (10). GA is a common idiopathic disorder of the dermis and subcutaneous tissue that can be associated with a variety of underlying conditions such as diabetes mellitus. The relationship between GA and diabetes mellitus is still unknown. Since skin lesions preceded the diagnosis of DM in our patient and complete remission of skin changes occurred with induction of insulin therapy, it is important to perform routine laboratory test in every patient." }, { "id": "pubmed23n1060_6600", "title": "Acute Generalized Exanthematous Pustulosis After COVID-19 Infection: A Case Report From Saudi Arabia.", "score": 0.009900990099009901, "content": "There is a dearth of robust evidence regarding coronavirus disease 2019 (COVID-19)-related coetaneous manifestations, complications and adverse treatment events. Upon review of the literature there are only a few cases reported of acute generalized exanthematous pustulosis (AGEP) in COVID-19 patients after treatment. Therefore, we are reporting a case of a 34-year-old male not known to have any chronic illness. His severe COVID-19 infection resolved four days prior to presentation to the Emergency Department with pustular rash on erythematous base over his face, neck, upper limbs, anterior and posterior trunk including oral cavity and tounge. The rash started after he took azithromycin, oseltamivir, ribavirin, lopinavir, hydroxychloroquine, prednisolone, ceftriaxone, clindamycin, interferon (IFN) beta, and ceftazidime for COVID-19. Skin punch biopsy was done and he was diagnosed with AGEP but it was still not known if it was related to COVID-19 or a drug-induced condition. Patient was treated with betamethasone valerate 0.1% ointment and lotion, promethazine hydrochloride 25mg tablet, paracetamol 500mg tablet, calcipotriol 50mcg/g and betamethasone 0.5mg/g gel. He discharged the same day to manage at home despite not improving. In the end, we found only a few studies that describe the cutaneous manifestations of COVID-19 infection, which were mainly case reports. We can't be sure that AGEP is a late and severe complication of COVID-19 infection. However, AGEP could be a rare adverse effect of hydroxychloroquine therapy. Improving the knowledge about a wide range of different signs and symptoms of the disease and its severity in addition to all possible adverse treatment events and complications can improve patient safety, survival rate, and quality of life." }, { "id": "wiki20220301en049_77151", "title": "Adalimumab", "score": 0.00980392156862745, "content": "Ankylosing spondylitis Adalimumab has been shown to reduce the signs and symptoms of, and is approved for treatment of, ankylosing spondylitis in adults. Crohn's disease Adalimumab has been shown to reduce the signs and symptoms of moderate to severe Crohn's disease. It has been approved for that use in the UK since 2009. Ulcerative colitis Adalimumab may be effective and well tolerated in ulcerative colitis. It was approved by the US Food and Drug Administration (FDA) for treatment of moderate to severe cases in adults. Plaque psoriasis Adalimumab has been shown to treat moderate to severe chronic plaque psoriasis in adults who have the condition in many areas of their body and who may benefit from taking injections or pills (systemic therapy) or phototherapy (treatment using ultraviolet light alone or with pills). Adalimumab has been shown to be effective therapy when used either continuously or intermittently in patients with moderate to severe psoriasis." }, { "id": "pubmed23n0050_10351", "title": "Clinical, historic, and therapeutic features of aphthous stomatitis. Literature review and open clinical trial employing steroids.", "score": 0.00980392156862745, "content": "The clinical and historic features of 50 patients with diagnosed aphthous stomatitis and treated with topical triamcinolone acetonide, 0.1% or 0.2% aqueous suspension; alone or in combination with initial burst therapy of 40 to 60 mg of prednisone, are reviewed. The mean age of our patients was 36.6 years (range 6 to 80 years). The duration of the chief complaint, usually oral pain, or more specifically, recurrent oral ulcers, was 11.1 years (range 4 weeks to 40 years). All patients showed a wide range of ulcer sizes when examined initially or at follow-up. Forty were followed up for an average of 22.9 months. Thirty-four reported prompt healing of ulcers identified at the time of initial evaluation, and no or markedly fewer ulcers subsequently if maintenance therapy of prophylactic topical triamcinolone, 0.1% or 0.2% aqueous rinse, was used. Five patients reported partial relief. No systemic side effects were noted even after long-term topical therapy. Local candidosis was a complication encountered in five patients." }, { "id": "pubmed23n1048_8012", "title": "Morbihan Disease - An Old and Rare Entity Still Difficult to Treat.", "score": 0.009708737864077669, "content": "Morbihan disease (MD), also known as Morbihan syndrome, \"solid persistent facial edema and erythema\", \"rosacea lymphedema\", and \"solid facial edema in acne\", is a rare and often unrecognizable entity, that presents with a slow occurrence of persistent lymphoedema of the upper two-thirds of the face (1,2). A 30-year-old woman presented to our Department with persistent, asymptomatic face edema and erythema lasting for 18 months. She was previously treated for rosacea with doxycycline (100 mg/day for four months) without improvement. Dermatological examination revealed erythematous, nonpitting, solid edema located on the mid-forehead, nose, and cheeks with sparse erythematous papules and pustules on the entire face including the chin and comedones, papules, and pustules on the back (Figure 1 and Figure 2). She was otherwise healthy and was not taking any medication. Laboratory tests with immunological tests and Quantiferon test together with MRI of the orbits, chest X-ray, chest high-resolution computed tomography, cranial X-ray, and abdominal ultrasound were all within normal limits. Histopathology revealed dermal edema, perivascular and peri-adnexal lymphohistiocytic infiltrate, and sebaceous gland hyperplasia. Based on the typical clinical picture, histopathological findings, and the exclusion of several differentials the diagnosis of MD was established. The patient was treated with oral isotretinoin (20 mg/day for eight months) without regression of solid edema and erythema on the face but with complete regression of acne on the trunk. She was started on oral corticosteroids (prednisolone, 20 mg/day for two months followed by reduction of the dose over three months), again with only slight short transient improvement and rapid relapse of facial erythema and edema. The patient refused any other suggested treatment. We treated our patient for a total 2 years and followed up for 5 years. The pathogenesis of MD is still unknown. It is considered a clinical variety or a complication of rosacea or acne which does not tend to regress spontaneously. It is believed that chronic inflammation in patients with MD is due to acne or rosacea causing structural damage to blood and lymph vessels (1,3,4). However, cases of MD without previous history of rosacea and acne have been reported supporting the distinct disease theory (3,4). Edema and erythema are localized on the upper half of the face affecting the forehead, glabella, eyelids, nose, and cheeks. Although the symptoms may come and go, MD usually does not improve without treatment (5). Several therapeutic options have been reported, although there is no established standard treatment for MD. Reported therapy includes short-term oral isotretinoin (0.5 mg/kg/day), long-term oral isotretinoin (40-80 mg/day, 10-24 months), long-term doxycycline, combination of systemic corticosteroids and antibiotic (prednisolone 20 mg/day for 2 weeks and doxycycline 200 mg/day for 12 weeks), slow-releasing doxycycline monohydrate (40 mg/day for 6 months), long-term minocycline (50 mg/day for 4 months), and a combination of both oral retinoid and ketotifen (isotretinoin 0.7 mg/kg/day for 4 months, ketotifen 2 mg/day for 4 months) (1,2,6,8). The disease is frequently recalcitrant to therapy, and only several cases of successfully treated patients with MD have been reported (1,2,4, 6-8). We presented a patient with characteristic features of MD, which is a persistent, cosmetically disturbing condition, unfortunately mostly refractory to therapeutic measures." }, { "id": "pubmed23n0551_9235", "title": "Hailey-Hailey.", "score": 0.009708737864077669, "content": "An 18-year-old white man with a \"rash\" on his forehead, neck, and upper part of the back for more than 5 years presented to the dermatology clinic complaining of chronic irritation and burning in these locations. He first became aware of the problem while playing football when he noticed that areas where his shoulder pads and helmet contacted his skin were red and irritated. He was treated by his primary care physician for contact dermatitis, and the areas partially responded to mild topical corticosteroids and emollients. Symptomatic worsening of the lesions, including increasing burning pain and a clear discharge, subsequently led to a primary care diagnosis of impetigo, which was treated with oral antibiotics. Again, there was partial improvement while taking the antibiotics but no resolution, and the areas of involvement continued to expand. Exacerbations over the next few years were diagnosed as tinea, psoriasis, and seborrheic dermatitis, with the patient reporting temporary and incomplete relief following treatment for all of the above diagnoses." }, { "id": "pubmed23n0586_8443", "title": "Nodular lymphangitic subcutaneous dissemination after intralesional antimonial treatment for localized cutaneous leishmaniasis.", "score": 0.009615384615384616, "content": "Human leishmaniases are protozoan diseases with diverse clinical features. They are transmitted by the bites of the Phlebotomus sand fly, and the reservoirs are usually wild and domestic animals, particularly dogs. In Spain, Leishmania infantum is the causative agent of both cutaneous and visceral leishmaniasis. Cutaneous leishmaniasis is a parasitic disease occurring throughout the Americas and in the Old World, particularly the Middle East and North Africa. It is spread by the female sandfly. We report a 33-year-old man who presented with a solitary plaque on the right elbow, which was found to contain Leishmania bodies. He was treated with intralesional meglumine antimoniate, but 2 weeks later, several subcutaneous nodules were noted on the inner right arm. PCR identified the organism as L. infantum. The patient was treated with itraconazole (200 mg/day) for 6 weeks was prescribed, which resulted in marked clinical improvement in the elbow plaque. However, because of the persistence and lack of response of the other lesions, systemic treatment with meglumine antimoniate (20 mg/kg/day) intravenously for 7 days and intramuscularly for 13 days was administered. A progressive improvement in both cutaneous and subcutaneous lesions was achieved, and the lesions resolved completely after 2 months." }, { "id": "pubmed23n0704_24421", "title": "Febrile ulceronecrotic Mucha-Habermann disease in a 34-month-old boy: a case report and review of the literature.", "score": 0.009615384615384616, "content": "We report a case of febrile ulceronecrotic Mucha-Habermann disease (FUMHD) in a 34-month-old boy. Our patient had a history of biopsy-proven pityriasis lichenoides et varioliformis acuta (PLEVA) since age 2. At 34 months, his skin lesions rapidly progressed to ulceration and necrosis in the setting of high fever. Skin biopsy revealed an intense lichenoid infiltrate with parakeratosis at the edges of areas of epidermal necrosis consistent with FUMHD, which is the severe variant of PLEVA. Despite initial treatment with prednisolone, his disease progressed to involve more than 50% of his body surface area. In addition to corticosteroids, he was treated with intravenous immunoglobulin, dapsone, and acyclovir, without complete resolution of disease. Methotrexate successfully cleared his skin disease and systemic symptoms. This patient highlights the exceptional response of FUMHD to methotrexate. Based on our review of the literature, this also represents the youngest reported case of FUMHD." }, { "id": "wiki20220301en250_35955", "title": "Generalized pustular psoriasis", "score": 0.009523809523809525, "content": "See Case Report 4 Treatments Treatments vary widely, and many different drugs have been documented as being successful. Some medications are successful in some patients, while unsuccessful in others. Below is a list of some medications used to treat GPP: Etanercept PUVA Hydroxyurea Dapsone Systemic corticosteroids Cyclosporin A Adalimumab Etretinate Isotretinoin Acitretin Prognosis GPP is a rare and severe type of psoriasis. It in rare cases it is said to be fatal and in some cases has driven patients to intensive burn units. An article published in Pediatric Dermatology said, \"The GPP pattern is as an acute, episodic, and potentially life-threatening form of psoriasis.\" There is no cure-all treatment for GPP, and as such, the mortality rate is high. Ryan and Baker observed 155 patients with GPP, 106 of which were followed up with. 26 of those 106 died as a result of the psoriasis or the treatment. Their data gives a 25% mortality rate. Case reports" }, { "id": "pubmed23n0791_5926", "title": "Self-inflicted herpetic whitlow.", "score": 0.009523809523809525, "content": "A 25-year-old dental radiographer reported to the outpatient department with lesions at the lower and upper lips which had later spread to his finger. On the basis of the given history and clinical features, a diagnosis of primary herpetic infection on the mouth followed by secondary infection on the finger was made and the patient was advised systemic and topical antiviral therapy following which his lesions healed uneventfully. " }, { "id": "wiki20220301en030_5191", "title": "Lichen planus", "score": 0.009433962264150943, "content": "Graft-versus-host disease (GVHD) Lacy, reticulated plaques or erosions that resemble oral LP may occur in GVHD. The histologic findings of these disorders are also similar. The patient history is useful for differentiating chronic GVHD from oral LP. Oral involvement in acute GVHD is less well characterized than chronic GVHD, but has been associated with erythematous, erosive, ulcerative, or lichenoid oral lesions. Leukoplakia Leukoplakia is a manifestation of squamous epithelial hyperplasia that may be a precursor to oral squamous cell carcinoma. White patches or plaques usually appear on the oral mucosa. To rule out malignancy, a biopsy of leukoplakia is indicated. Oral squamous cell carcinoma Oral squamous cell carcinoma (SCC) can present as erythematous or white patches, ulcers, or exophytic masses. The highest risk for oral SCC may occur in patients with erythematous or erosive oral LP. A biopsy is indicated." }, { "id": "pubmed23n0134_5107", "title": "[The natural history of Still's disease. Description of a clinical case with repeated recurrences and long remission periods].", "score": 0.009433962264150943, "content": "A case of Still's disease is presented that demonstrates the uncertain prognosis and the duration of the treatment required to prevent recurrences. The importance of frequent check-ups is also emphasised." }, { "id": "wiki20220301en113_29465", "title": "Alefacept", "score": 0.009345794392523364, "content": "Indications Alefacept is indicated for the management of patients with moderate to severe chronic plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. The concomitant use of low-potency topical corticosteroids was permitted during the treatment phase with alefacept and does not seem to pose any additional risks. The drug was approved based upon studies involving 1,869 patients altogether with plaques covering at least 10% of body surface. Either 7.5 mg IV or 15 mg IM once a week were applied. The long-term results (reduction of at least 75% in pretreatment PASI scores) were 14% and 21%, respectively. Additional improvements ensuing after completion of the 12-week treatment phase or after completion of a second alefacept treatment were also seen. Often the remissions were maintained for 7 to 12 months after end of treatment." }, { "id": "pubmed23n0092_8786", "title": "[Apropos of 45 cases of cutaneous tuberculosis in Tlemcen (western Algeria)].", "score": 0.009345794392523364, "content": "The cutaneous tuberculosis (CTB) is still frequent in Algeria. From March 81 through December 87, forty-five cases were observed in our service of Dermato-Venereology (CHU Tlemcen), something like 6.4 cases per year. The two sexes are equally represented; 66.6% aged under 40; 66.6% are living in cities and have modest social and economical conditions; 20% were inoculated with BCG; previous CTB (personal 8.8% of family 11.1%) were hardly seen. It took some 44% of the patients less than a year to ask for a diagnosis, after receiving several non specific treatments. The rest took longer to come for consultation and in one case, the disease evaluated for 28 years. One explanation is that sometimes the affection causes very little annoyance. The clinical aspects observed were often evocative: Lupus vulgaris, 28.8%, scrofuloderma, 28.8%, specific adenitis, 13.3%, tuberculosis verrucosa cutis, 13.3%, gum, 13.9%, ulcerous CTB, 2.2%. Tuberculin skin test was positive for 86% of the cases and was taken into consideration when it reaches over 15 mm (46%), and with discomfort (4.4%). The treatment was efficient in the large majority of the cases. However, 29.5% of the patients gave up before the end of the cure. We insist upon the priority of the relationship doctor-patient in the case of a chronicle affection, which is less uneasy for some and shameful for a great many." }, { "id": "wiki20220301en256_19705", "title": "Frontal fibrosing alopecia", "score": 0.009259259259259259, "content": "Treatment Improvement or stabilization of the condition has been reported with topical and intralesional corticosteroids, antibiotics, hydroxychloroquine, topical and oral immunomodulators, tacrolimus, and most recently, 5α-reductase inhibitors. In one study, the use of antiandrogens (finasteride or dutasteride) was associated with improvement in 47% and stabilization in 53% of patients Recently, successful treatment of facial papules in patients with frontal fibrosing alopecia was described with oral isotretinoin. See also Skin lesion References External links Conditions of the skin appendages" }, { "id": "InternalMed_Harrison_4055", "title": "InternalMed_Harrison", "score": 0.009259259259259259, "content": "Oral griseofulvin or terbinafine plus 2.5% selenium sulfide or ketoconazole shampoo; examine family members Discontinuation of offending hair style or chemical treatments; diagnosis of trichotillomania may require observation of shaved hairs (for growth) or biopsy, possibly followed by psychotherapy aTo date, Food and Drug Administration–approved for men. bScarring alopecia can occur at sites of kerions. cMay also be scarring, especially late-stage traction alopecia. CAuSES of figuRATE SKin LESionS I. Primary cutaneous disorders A. Tinea B. Urticaria (primary in ≥90% of patients) C. Granuloma annulare D. Erythema annulare centrifugum E. Psoriasis II. A. 1. Erythema migrans (CDC case definition is ≥5 cm in diameter) 2. Urticaria (≤10% of patients) 3. 4. 5. 6. B. Nonmigratory 1. 2. 3. 4. Cutaneous T cell lymphoma (especially mycosis fungoides) aMigratory erythema with erosions; favors lower extremities and girdle area." }, { "id": "pubmed23n0947_16304", "title": "Clindamycin-induced Maculopapular Exanthema with Preferential Involvement of Striae Distensae: A Koebner phenomenon?", "score": 0.009174311926605505, "content": "Clindamycin is a lincomycin-derived antibiotic useful for the treatment of anaerobic and Gram-positive aerobic bacterial infections. Cutaneous adverse reactions are usually maculopapular exanthemas, although hypersensitivity syndrome, acute generalized exanthematous pustulosis, and Stevens-Johnson syndrome have also been reported (1). We report the case of a patient with a maculopapular rash triggered by clindamycin who developed cutaneous lesions on striae distensae (SD). A 47-year-old woman was referred to our clinic for pruritic cutaneous lesions which had started 6 days earlier. Her past clinical history included hypertension, hypothyroidism, hyperuricemia, cholecystectomy, caesarean section, and endometriosis-related abdominal surgery, and she was taking levothyroxine, allopurinol, imidapril, and omeprazole. The skin rash first developed on her neck and back on the 3rd day of clindamycin oral treatment (300 mg every 6 hours), which was prescribed as antibiotic prophylaxis for a tooth implant. General malaise (but not fever) was also reported. Physical examination revealed an erythematous maculopapular eruption symmetrically distributed on the neck, abdomen, and back (Figure 1, A), with isolated lesions involving the proximal upper and lower limbs (Figure 1, B). There was a striking vertical distribution of skin lesions along the SD on the lateral sides of the abdomen (Figure 1, C). No mucosal involvement was found, and laboratory studies showed no abnormalities. Clindamycin withdrawal was followed by prescription of a course of oral deflazacort, starting at 30 mg daily and tapering down during a 9-day period. On the 5th day of treatment, the rash had almost cleared with minimal desquamation (Figure 1, D). Eight weeks after clearance of the skin rash, informed consent was obtained in order to perform an allergological evaluation of clindamycin, including prick and intradermal (ID) tests on the forearm and patch tests on the upper back (2). For patch testing, powder of the commercial capsules (Dalacin®) was diluted in petrolatum (pet.) and water (aq.), resulting in a final 1% clindamycin dilution. Parenteral clindamycin preparations were used in therapeutic concentrations for prick tests (150 mg/mL) and dilutions in saline of 1/100 and 1/10 for the ID test. Other authors have reported that these concentrations do not seem to irritate the skin (3-6). Prick and ID tests were assessed after 20 min and 24 hours, respectively. Patch tests were removed after the 2nd day, and late reactions were evaluated on day 2 and day 4. Prick and ID test results after 20 min were negative. Late results of ID tests with clindamycin (1.5 and 15 mg/mL) were positive: erythematous infiltrated papules about 7×7 mm and 18×15 mm were observed at 24 hours and lasted until the 8th day. Patch tests with clindamycin 1% in pet. and 1% in aq. were also positive (+ on day 2 and day 4). Positive late skin tests suggested delayed-type non-IgE-mediated allergic clindamycin hypersensitivity. Oral challenge tests are considered to be the gold standard to establish or exclude drug hypersensitivity. Due to the positive result of late skin test to clindamycin, oral challenge was not performed in our patient (3,5). The Koebner isomorphic phenomenon has been described in cutaneous reactions induced by drugs, such as antibiotics and chemotherapy. Chronic pressure on the skin is probably involved in the onset of skin lesions in hand-foot eruptions induced by tyrosine kinase inhibitors (sorafenib and sutinib). Solar exposure and cutaneous trauma also seem to play a role in the location of papulopustular eruptions caused by endothelial growth factor receptor inhibitors (erlotinib) (7). More frequent involvement in traumatized skin and surgical scars has been reported in the context of linear IgA bullous dermatosis and leukocytoclastic vasculitis triggered by vancomycin and cefuroxime (8). SD are produced by non-penetrating physical trauma, similar to friction or pressure. Different dermatoses can develop along SD skin lesions (like plaque psoriasis, pustular psoriasis, lichen planus, vitiligo, discoid lupus erythematosus, lupus vasculitis, urticarial vasculitis, or chronic graft-versus-host disease) (9). Bevacizumab, etretinate, and corticosteroid-induced ulcers, hyperpigmentation caused by bleomycin, and urticariform lesions triggered by diclofenac are examples of different type of drug-induced abnormalities involving SD (10). In summary, we identified clindamycin as the cause of the cutaneous reactions that occurred in our patient on the basis of the results of the skin tests and clinical history. Our findings confirmed a delayed-type hypersensitivity reaction, possibly involving a T-cell-mediated immunologic mechanism. Intradermal and patch tests were found to be useful in order to confirm the diagnosis (4,5). We did not find reports in the literature of drug-induced cutaneous eruptions along the SD as a manifestation of a Koebner phenomenon. Clinical underreporting of this phenomenon could explain the scarce literature on this cutaneous adverse reaction." }, { "id": "pubmed23n0747_8257", "title": "A 12-year-old boy with foot lesions.", "score": 0.009174311926605505, "content": "CME EDUCATIONAL OBJECTIVES: 1.Identify the clinical presentation of granuloma annulare.2.Describe the differential diagnosis for granuloma annulare.3.Discuss the appropriate management for granuloma annulare. A 12-year-old healthy male presented to the dermatology clinic for evaluation of lesions on his feet. The lesions were bilateral and had been present for at least 6 months. Multiple topical treatments had been prescribed in the past, including miconazole nitrate 2% cream, oxiconazole 1% cream and alclometasone dipropionate 0.05% ointment. Each had been used for several weeks without improvement. Because of this, the referring doctor prescribed griseofulvin microsize 250 mg twice daily for 4 weeks and referred the patient to dermatology. The patient denied pruritus or pain. Review of systems, medical history, and family history were unremarkable." }, { "id": "pubmed23n1104_10473", "title": "Management of a Unique Presentation of a Common Dermatologic Condition.", "score": 0.00909090909090909, "content": "Skin rashes are a common complaint seen in the primary care setting. There are many dermatologic conditions which a primary care provider (PCP) should be able to recognize and manage. One such condition is granuloma annulare (GA), which commonly presents as smooth, annular plaques on the trunk and/or extremities. Rashes like GA rarely present as unique variants and may be difficult for PCPs to determine from patient history and physical exam alone. Patch granuloma annulare (patch GA) is an example that may clinically mimic a cutaneous lymphoma known as mycosis fungoides (MF). PCPs should ideally be able to recognize the utility of performing a skin biopsy and/or referring the patient to a dermatologist when history and physical exam alone are insufficient. The histologic findings of skin biopsies often become essential in establishing a proper diagnosis and guiding patient management in unique dermatologic variants. The patient in this clinical practice report is a Caucasian female in her late 60s who presented to a dermatology clinic with a two-year history of a worsening widespread eruption on her trunk and extremities. She had been evaluated previously by her PCP about 4 months prior and, without obtaining skin biopsies, treated her with a medium potency topical corticosteroid cream. The eruption had spread over her hips, buttocks, back, thighs, wrists, and elbows. Multiple skin biopsies of affected sites were taken by the second author and revealed findings consistent with patch GA. The patient was started on topical betamethasone dipropionate 0.05% ointment twice daily and noted marked improvement of her symptoms. Although GA is a benign condition of the skin that may be readily detected by PCPs, skin biopsies may be necessary to establish a proper diagnosis when this condition presents as a unique variant (e.g., patch GA). Therapy for patch GA often begins with a trial of high-potency topical steroid therapy in combination with ultraviolet light exposure, depending on disease severity and patient preference. Early evaluation with a skin biopsy by her PCP or an earlier referral to a dermatologist to have skin biopsies performed likely would have helped establish a prompter diagnosis and treatment plan for this patient." }, { "id": "pubmed23n1097_14269", "title": "Chronic unilateral anterior scleritis, think about a herpetic origin: A case report.", "score": 0.009009009009009009, "content": "Scleritis is a very heterogeneous group of diseases responsible for ocular inflammation of varying severity, the evolution and prognosis of which depend on the etiology but also on the appropriate treatment. We report the case of a 15-year-old female patient, without any notable general history, followed in consultation for 3 months for a nodular scleritis not improving under usual treatments. She was reconsulted when her symptoms worsened and the examination revealed a minimal reaction of the anterior chamber, in addition to the nodular scleritis localized in the temporal region, with the notion of a vesicular eruption in the perioral region on the same side of the ocular involvement and preceding the ocular symptoms by one week, consistent with a cutaneous herpes. The patient was put on oral Aciclovir (800 mg, 3 times a day) with a clear improvement marked by a decrease in pain and redness, which improved again after the introduction of oral corticoids. The existence of an extraocular sign of herpes and the good response to antiviral treatment, thus confirming the herpetic etiology of this chronic nodular scleritis. Scleritis is caused by herpes in about 5% of cases. The clinical picture is either ophthalmic herpes zoster with associated scleritis (VZV), or diffuse anterior scleritis, unilateral in 80% of cases, related to herpes simplex. The diagnosis can be confirmed by local swabs, or more often by an antiviral therapeutic test." }, { "id": "pubmed23n0559_8627", "title": "Multiple keratoacanthomas in a young woman: report of a case emphasizing medical management and a review of the spectrum of multiple keratoacanthomas.", "score": 0.008928571428571428, "content": "A 27-year-old white woman was referred for consultation with regard to the presence of extensive multiple keratotic lesions. She began to develop these lesions at the age of 9 years, with healing of the lesions resulting in scar formation. A biopsy was performed at the age of 16 years, but the patient was unsure of the results. Since then, she had not had any treatment or biopsies, and stated that she had not suffered from any health problems during the intervening period. She was most concerned about the tumors on her heels and soles, which caused difficulty with ambulation. The family history was negative for skin diseases, including melanoma, nonmelanoma skin cancer, psoriasis, and eczema, and positive for Type II diabetes mellitus. A relative reported that the patient's grandfather had similar lesions, but the patient's parents and siblings were healthy. She was married and had one child, a 9-year-old daughter. Her child had no skin lesions. The patient's only medication was Ortho-Tricyclene birth control pills. She had no known drug allergies. Physical examination revealed the presence of multiple lesions on her body (Fig. 1). Her left superior helix contained a well-demarcated, dome-shaped nodule with a rolled, mildly erythematous border with a central hyperkeratotic plug. A similar lesion was present in the scaphoid fossa of the left ear and smaller lesions were scattered on her face. Numerous lesions were present on the arms and legs bilaterally, with the majority of lesions being located on the anterior lower legs. There were also lesions present on the palms and soles. The lesions ranged in size from 5 mm to 3 cm, the largest being a verrucous exophytic nodule on the anterior aspect of her left leg. Overall, there appeared to be two distinct types of lesion. One type appeared round, oval, and symmetric with a central keratotic plug, similar to that on the ear. The other type was larger, more exophytic, and verrucous, including the lesions on the volar surfaces. Also present were numerous, irregularly shaped atrophic scars where previous lesions had healed spontaneously. There were no oral lesions or lesions on her fingernails or toenails, and her teeth and hair were normal. A biopsy was obtained from an early lesion on the right dorsal forearm. Histology revealed an exo-/endophytic growth having a central crater containing keratinous material (Fig. 2). The crater was surrounded by markedly hyperplastic squamous epithelium with large squamous epithelial cells having abundant glassy cytoplasm. Some cells were dyskeratotic. Within the dermis was a dense, chiefly mononuclear inflammatory infiltrate. A buttress of epidermis surrounded the crater. The clinical and pathologic data were consistent with keratoacanthomas. Initial laboratory screenings revealed elevated triglycerides and total cholesterol, 537 mg/dL (normal, &lt; 150 mg/dL) and 225 mg/dL (normal, &lt; 200 mg/dL), respectively, with all other laboratory results within normal limits. In anticipation of starting oral retinoid therapy for her multiple keratoacanthomas, she was referred to her primary care physician for control of hyperlipidemia. After her lipids had been controlled, she was placed on isotretinoin (Accutane) 40 mg/day. There was some interval improvement with regression of some lesions leaving atrophic scars. She was also started on topical application of tazarotene (Tazorac) for all nonresolving lesions. Possible side-effects from the isotretinoin occurred, including dry mouth and eyes. After 8 months of isotretinoin, the patient was switched to acitretin (Soriatane) 25 mg to determine whether it might have a more beneficial effect on the resistant lesions. Many of the larger lesions regressed leaving atrophic scars. The dose of acitretin was subsequently increased to 35 mg because the lesions on her heel and the ball of her foot persisted. Almost all of the lesions resolved, except those on her feet, which are slowly regressing. Currently, the patient is on a regimen of acitretin 25 mg once a day with tazarotene 0.1% gel applied directly to the few residual keratoacanthomas on her feet, which are slowly improving." }, { "id": "pubmed23n0691_10650", "title": "Painful ulcers in a 5-year-old girl.", "score": 0.008928571428571428, "content": "A 5-year-old girl was admitted to our clinic with several painful ulcers spreading from the right elbow to the armpit. The right axillary lymph node was palpable. She was previously treated in another service with oral amoxicillin for 10 days due to a diagnosis of impetigo. There was no resolution of the lesion after the treatment, so she looked for another doctor." }, { "id": "pubmed23n1004_25988", "title": "Oral and Vulvar Lichen Sclerosus.", "score": 0.008771929824561403, "content": "Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin (1). Simultaneous involvement of the oral mucosa is extremely rare, but it may be the only affected area (2). A 55-year-old woman was referred to the Department of Oral Medicine, School of Dental Medicine University of Zagreb due to whitish lesions on the right ventrolateral part of the tongue and buccal mucosa with desquamative gingivitis (Figure 1, a-c). The lesions were asymptomatic but indurated on palpation. Histology was conclusive for oral lichen sclerosus (OLS). The lesions on gingiva were successfully treated with betamethasone ointment, three times a day for two weeks. One year earlier, she had been referred to the Department of Dermatology and Venereology with progressive pruritus and dyspareunia, white patches, obliteration of the labia minora, and stenosis of the introitus (Figure 2). Histology was conclusive for vulvar LS (Figure 3, a and b). She was successfully treated for 5 months with clobetasol propionate 0.05% ointment. The patient was taking levothyroxine to treat hypothyroidism associated with Hashimoto's thyroiditis and was otherwise healthy. Oral LS is clinically characterized by the appearance of white macules, papules, or plaques mostly appearing on labial mucosa but also on buccal, palate mucosa and on the lower lip (2,3). On the genitals, it typically manifests as atrophic white plaques, which may be accompanied by purpura or fissuring (1). While vulvar LS is often associated with pruritus, dyspareunia, and dysuria, OLS is often asymptomatic, although pain, soreness, pruritus, and tightness when opening the mouth can be present (1,2). Oral manifestations of LS, as well as association of anogenital and oral LS, are rarely reported in the literature (4-6). Tomo et al. searched the Medline database for papers reporting oral LS cases with histological diagnosis confirmation from 1957 to 2016 and found only 34 cases of oral LS with histopathologic confirmation of the diagnosis (4). Kakko et al. reported 39 histologically proven cases of OLS (2). Attilli et al. (5) reviewed the clinical and histologic features of 72 cases of LS with oral/genital involvement. They reported that LS was diagnosed with exclusive genital lesions in 45, exclusive lip involvement in 20, and orogenital involvement in only 7 cases (5). Some believe that many cases of clinically diagnosed lichen planus may actually be LS and that isolated oral mucosal LS may not be as rare as is generally thought (2). While vulvar LS can occur at any age with increasing incidence with age, the median age of patients with OLS was 34 years and most of the patients were female (1,2,5). Due to the small number of patients in the literature, treatment recommendations for OLS are not available. In case of symptomatic oral lesions, topical or intralesional corticosteroids are considered to be the first-line treatment (2). First-line treatment for anogenital LS is a potent to very potent topical corticosteroid ointment, and second-line therapies include topical calcineurin inhibitors 1% pimecrolimus and 0.1% and 0.03% tacrolimus (1). For treatment-resistant genital LS, oral retinoids, methotrexate, and possibly local steroid injections for single lesions are mainly applicable for women (1). There is limited evidence for systemic treatments for both conditions. If it is not treated, genital LS is associated with a greater degree of scarring and an elevated risk of progression to squamous cell cancer; however, malignant transformation of OLS has not been reported (1-6). Due to the very rare presentation in the oral cavity, it is important to notice these lesions during a dental exam." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 184 ] ], "word_ranges": [ [ 0, 30 ] ], "text": "We present a case of chronic compartment syndrome. For its diagnosis it is necessary to measure the pressure of the affected compartments at rest and after activity (answer 2 correct)." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Positron emission tomography with 18 FDG.", "2": "Determination of posterior compartment pressure immediately after activity.", "3": "Doppler ultrasound to rule out a circulatory disorder of the lower extremity.", "4": "Spectrometry by magnetic resonance.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0608_10255", "title": "[Athletes with exercise-related pain at the medial side of the lower leg].", "score": 0.018070818070818073, "content": "Two patients were diagnosed with exercise-related pain at the medial side of the lower leg. The first patient, an 18-year-old woman who had expanded her athletic activities extensively, had developed pain at the inner side of the distal third portion of the left lower leg. She showed over-pronation of the ankle during running. A 3-phase bone scintigram revealed diffuse uptake of the tracer covering a large portion of the medial tibia margin. Based on this evidence, a diagnosis of periostalgia was made. She recovered after a period of relative calf massages and used insoles. The second patient was a 28-year-old male endurance runner who developed pain at the medial shin after intensifying his training regimen. The periods without pain during running became increasingly shorter, and the medial side of the lower leg became sore and tense. Intracompartmental pressure measurements indicated exercise-related posterior deep compartment syndrome of the calf. The patient recovered after fasciotomy. In athletes, exercise-related symptoms of the medial side of the lower leg can be usually attributed to the tibial periosteum or tendons of the deep calfmusculature, tibial stress reaction or fracture, or a compartment syndrome of the deep calf. Surgery is indicated for chronic compartment syndrome, but conservative therapy provides favourable outcomes in the other types of disorders. The optimal conservative therapeutic approach is unknown, but it is advisable to temporary reduce symptom-provoking athletic activity and modify any risk factors present. Ankle over-pronation during running is considered a very relevant intrinsic risk factor." }, { "id": "pubmed23n0489_6509", "title": "[MR-Imaging of lower leg muscle perfusion].", "score": 0.01747674767476748, "content": "This article describes the potential of dynamic contrast- enhanced magnetic resonance tomography (DCE-MRT) for the visualization and quantification of blood flow of lower leg muscles at rest and after individually adjusted muscular exercise. Five cases were chosen to exemplify the qualitative and semi-quantitative blood flow evaluation in the lower leg muscles. The crural muscle state was determined with an isometric maximal strength measurement from a female patient with peripheral arterial occlusive disease (pAVK), a male patient with coronary heart disease (KHK) without clinical signs of a pAVK, a volunteer with sufficient physical activity in accordance with the Freiburg Questionnaire of Physical Activity and two professional athletes. After calibration of the plantarflexion ergometer MR-PEDALO (Figures 2a and 2b) for the execution of auxotonic muscle work a 1- minute alternating foot extension and flexion exercise on MRPEDALO was performed in the MR machine. Instead of the lower leg splint shown in Figures 2a and 2b the MR coil fits exactly in MR-PEDALO used for DCE-MRT. Mechanical work performed during the 1-minute exercise ranged from 52 watt seconds (Ws) to 244 Ws (0.65 W to 4.07 W), indicating similar interindividual work loads in relation to the individual maximum isometric strength. DCE-MRT was performed at rest and immediately after auxotonic exercise test (T1w 2DFLASH- GE sequence with TR/TE/alpha: 100 ms/6 ms/70 degrees; field of view: 400; matrix: 81 x 256; slice thickness: 10 mm; acquisitions: 73 at 8.3 s each; total examination time: 9.24 min; bolus application of Magnevist, Schering, 0.02 ml/kg kg, 20 ml bolus NaCl, flow 2 ml/s, 22G cannula in a cubital vein). Signal intensity (SI) curves were analyzed with DynaVision (MeVis gGmbH, Bremen, Germany). Measuring peripheral blood flow needs appropriate muscular stress tests. The SI-curves of the region of interest (ROI) representing the peroneus, tibialis anterior and gastrocnemius muscle run almost parallel at rest. Workloads between 52 Ws and 244 Ws (0.65 W and 4.07 W), similar in relation to the individual maximum isometric strength, induce distinctive changes of the upslope, wash-in, peak and washout of SI-curves preferably for the peroneus muscle and less predominant also for the tibialis anterior muscle and gastrocnemius muscle respectively. The first case, a 55-year-old female patient with peripheral arterial occlusive disease (pAVK) stage Fontaine IIb before (Figure 3a) and after (Figure 3b) percutaneous transluminal angioplasty (PTA) of a right femoral artery stenosis shows after interventional treatment a rapid post-exercise SI-increase in the peroneus muscle. The steeper SI-curve indicates a better contrast medium inflow due to an improved perfusion. The second case, a 65-year-old man suffering from coronary heart disease without clinical signs of pAVK (Figure 4) exercised with a workload of 92 Ws. After stress test the ROI for the peroneus muscle shows a clear intensity increase. After exercise the SI-curve for the tibialis anterior muscle shows a similar, but less predominant change while the shape of the SI-curve of the gastrocnemius muscle remains mainly identical. A 23-year-old male person with average physical activity (Figure 5) performed DCE-MRT of the left lower leg after stress test with 172 Ws demonstrating a rapid signal increase in the peroneus muscle while the synergistic tibialis anterior muscle and antagonistic gastrocnemius muscle show a comparatively slow contrast-medium wash-in. A 26-year-old male athlete (Figure 6) exercised with 196 Ws showing a rapid contrast medium inflow in the peroneus muscle and initially also in the synergistic tibialis anterior muscle. A contrast-medium wash-out appears in both muscles, while the shape of the gastrocnemius muscle SI-curve remains substantially unchanged. A 26-year-old female athlete (Figure 7) exercised with 244 Ws. Post exercise SI-curves show a distinctive and rapid increase of contrast medium wash-in with a sharp peak particularly in the peroneus muscle and similarly in the tibialis anterior and gastrocnemius muscle. After exercise all SI-curves show a wash-out phase. SI-curves show relative increase in correlation with Time-to-Peak (TTP) decrease and Mean-Intensity to Time Ratio (MITR) increase indicating blood flow reserve mobilization after exercise. Individual muscle state seems to be linked to muscle recruitment and muscle coordination reflected by post-exercise SI-curves. The gastrocnemius muscle shows comparatively low SI-curve changes after muscular load test. Further methodological standardization and optimization of the stress test is mandatory to assure intra- and interindividual comparisons. Due to direct visualization and quantitative evaluation of the peripheral microcirculation DCE-MRT has a diagnostic potential for monitoring therapeutic response in peripheral circulation disorders and sports medicine." }, { "id": "pubmed23n0909_23174", "title": "Selective Fasciotomy for Chronic Exertional Compartment Syndrome Detected With Exercise Magnetic Resonance Imaging.", "score": 0.015420023014959722, "content": "Chronic exertional compartment syndrome that is refractory to conservative management should be treated with surgical fasciotomy. However, owing to the limitations of intracompartmental needle manometry in reaching a definite diagnosis, the appropriate timing for fasciotomy and on which compartment remain unclear. The authors report the case of a 22-year-old male military cadet who reported pain in his left calf when running or walking for long distances. The pain was located at the lateral aspect of the calf, from the mid-calf level to the ankle. At another hospital, nonenhanced magnetic resonance imaging had been performed, which showed no considerable abnormality. The authors used exercise magnetic resonance imaging to diagnose chronic exertional compartment syndrome. They performed selective fasciotomy on the compartment that showed a high signal intensity. As a military cadet, the patient was required to jog for more than an hour per day and perform strenuous muscle exercises. He reported that he did not have calf pain or discomfort during such activities 13 months postoperatively. The authors obtained a follow-up exercise magnetic resonance image. Compared with the preoperative magnetic resonance image, the follow-up exercise magnetic resonance image did not show high signal intensity at the lateral compartment. Exercise magnetic resonance imaging is useful in confirming the diagnosis of chronic exertional compartment syndrome and enables the performance of selective fasciotomy on the affected compartment. [Orthopedics. 2017; 40(6):e1099-e1102.]." }, { "id": "pubmed23n0962_15295", "title": "Polymyalgia Rheumatica (PMR) with Normal Values of Both Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) Concentration at the Time of Diagnosis in a Centenarian Man: A Case Report.", "score": 0.009900990099009901, "content": "The possibility that polymyalgia rheumatica (PMR) can be diagnosed when both ESR and CRP are normal at the time of diagnosis and before therapy with glucocorticoids, has been often discussed in the literature. We present a case report of a 100-year-old Caucasian man referred to our outpatient clinic, complaining of chronic pain in the shoulder and hip girdle associated with normal values of both ESR (21 mm/1st hour) and CRP (4 mg/dL). In the previous four months, several anti-inflammatory drugs and painkillers associated with physiotherapy treatments gave no significant improvement in pain and self-care. After an ultrasound (US) and an 18-fluorodeoxyglucose positron emission tomography associated with total body computed tomography (18-FDG PET/CT) examination, PMR was diagnosed and he started therapy with 17.5 mg prednisone, obtaining a fast improvement in pain and self-care. After 10 months of tapering, he stopped prednisone without relapse. During a 3-year follow-up, no alternative diagnosis was done. When a patient complains of chronic bilateral shoulder and hip girdle pain associated with normal inflammatory indices, it is reasonable to think in the first instance that this person is not suffering from PMR. Moreover, the possibility that PMR may onset in a centenarian person, is exceptional. In our patient, when we piece the puzzle together, the diagnosis of PMR was the most possible one." }, { "id": "pubmed23n0710_15889", "title": "Can pain influence the severity of findings of an (18)F-FDG PET/CT scan in loosening hip arthroplasty?", "score": 0.00980392156862745, "content": "Pain is a common symptom after loosening and/or after infection of arthroplasty. The aim of the present case report is to indicate that fluorine-18-fluorodeoxy-glucose positron emission tomography/computerized tomography((18)F-FDG PET/CT) scan can be used for the evaluation of pain at the site of arthroplasty with a semi quantitative measurement. An 84 years old male patient, with a history of papillary thyroid cancer was referred to our Nuclear Medicine Department for an (18)F-FDG PET/CT scan for evaluation of his metastatic disease. He reported right hip prosthesis thirty years ago and now suffered from significant pain in the right hip joint which on a scale from 1 to 10 could be rated as grade 8. White blood cell count, sedimentation rate and C-reactive protein were within normal limits. Four years ago he also had severe pain on the right leg that could be rated as grade 8, and underwent an (18)F-FDG PET/CT scan that showed a maximum standardized uptake value (SUV(max)) of 9.8. A year later, at a follow up (18)F-FDG PET/CT scan and under a similar severe pain, SUV(max) was 10. The patient had a hip prosthesis in the left leg 3 years ago, for which he reported pain that could be rated as grade 3 and the SUV(max) was then 3.7. The degree of (18)F-FDG uptake is related to cellular metabolic rate and to the number of glucose transporters. In inflammation, the activated inflammatory cells demonstrate increased expression of glucose transporters and the affinity of glucose transporters for deoxyglucose is increased by various cytokines and growth factors. Furthermore, when the mononuclear cells and the granulocytes are activated by certain infectious humoral stimuli, they use large amounts of glucose by the hexose monophosphate shunt and the rate of oxygen uptake is intensely increased, during the so called \"respiratory burst\". In the present case, it was interesting to note that the degree of (18)F-FDG uptake at the sites of loosening hip arthroplasty was related to the severity of pain. Signs of infection or inflammation although not obvious in our case, could not be excluded because sensitivity, specificity and accuracy of PET for detecting infection associated with hip prostheses has been reported to be, 90%, 89.3% and 89.5%, respectively and sensitivity and specificity for detecting periprosthetic inflammation 100% and 45.5%,respectively. In another study using as a criterion for periprosthetic infection the increased (18)F-FDG activity at the bone-prosthesis interface of the femoral component, sensitivity, specificity, positive and negative predictive values for the (18)F-FDG PET study where 85%, 93%, 80% and 95%, respectively. Inflammation, often intense, may be present in aseptic loosening and characterized by increased periprosthetic (18)F-FDG uptake. In conclusion, in our case the degree of (18)F-FDG uptake in a loosening hip arthroplasty was related to the severity of pain although inflammation or infection could also play some role. Further studies are required to prove this suggestion." }, { "id": "pubmed23n0245_9231", "title": "Exercise hyperemia for the study of peripheral circulation.", "score": 0.00980392156862745, "content": "Blood flow in the calf was measured during postexercise hyperemia in normal subjects and in PAD patients by means of a foot ergometer that gives direct reading of the work performed. In normals, first and peak flow increased with the rise of work load up to 100 KGM. The duration of hyperemia increased with a work load of 30 to 200 KGM. In PAD patients, first flow did not coincide with peak flow. Peak flow was lower and delayed, and the duration of hyperemia was more prolonged than in normal subjects. In patients with intermittent claudication, first flow, peak flow, and work load were higher than in patients with rest pain or impending gangrene. Exercise hyperemia appears as a useful test for screening normal limbs from those with arterial obstruction. Since in PAD patients exercise is interrupted when muscular pain appears, it is evident that the earlier the arrest of work and the appearance of pain, the greater is the involvement in the arterial tree of the leg. Therefore the exercise hyperemia test can be used also as a means of evaluating the different stages of PAD." }, { "id": "pubmed23n0875_23782", "title": "Complex Regional Pain Syndrome Caused by Lumbar Herniated Intervertebral Disc Disease.", "score": 0.009708737864077669, "content": "Most cases of complex regional pain syndrome (CRPS) occur after some inciting injury. There are a few cases of CRPS after an operation for disc disease. CRPS from a mild herniated intervertebral disc (HIVD) without surgical intervention is even rarer than CRPS after an operation for disc disease.A 22-year-old man was transferred to a pain clinic. He had continuously complained about back and right leg pain. He presented with a skin color change in the right lower leg, intermittent resting tremor, stiffness, and swelling in the right leg. He complained of a pulling sensation and numbness in his right buttock, posterior thigh, lateral calf, and ankle. This symptom was in accordance with L4/5 radiculopathy. Magnetic resonance imaging (MRI) also showed L4/5 HIVD that was central to the bilateral subarticular protrusion.He was diagnosed as having CRPS, which fits the revised International Association for the Study of Pain (IASP) criteria. He fulfilled 4 symptom categories (allodynia, temperature asymmetry and skin color change, sweating changes, decreased range of motion and motor dysfunction) and 3 of 4 sign categories (allodynia, temperature asymmetry and skin color changes, decreased range of motion and motor dysfunction). The bone scan and thermography also revealed CRPS.For the past 2 months, we have performed intensive treatments. But, he never became pain-free and walking for 5 minutes led to persistent leg pain. We decided to perform percutaneous nucleoplasty, which can directly decompress a HIVD. On the next day, he achieved dramatic symptom relief. The visual analog scale (VAS) score improved to 3, compared to the VAS score of 9 at the first visit. The skin color change, allodynia, and tremor in the right leg disappeared, and the temperature asymmetry normalized. Motor weakness of the right leg also recovered.We report an unusual case of CRPS that was caused by L4/5 HIVD without a history of trauma or surgery. It has a clear causal relationship between HIVD and CRPS and definitively fits in the newly revised IASP criteria. In conclusion, mild HIVD can cause CRPS without any trauma. And percutaneous nucleoplasty can be considered as a treatment option." }, { "id": "pubmed23n0070_12650", "title": "[Value of transcutaneous staged dynamic oximetry of stage II arteritis of the leg].", "score": 0.009708737864077669, "content": "The clinical and prognostic value of transcutaneous oxygen pressure measurements at rest has been established in Leriche Stage III and IV occlusive peripheral arterial disease but is controversial in Stage II because there is an overlap of transcutaneous pO2 (Tc pO2) values with those of normal subjects. The authors report the results of Tc pO2 measurements during exercise testing in a group of patients with Stage II occlusive arterial disease of the lower limbs. Seventy-eight patients with an average age of 53 years (range 40 to 65 years) whose claudication perimeter and site of pain had been carefully assessed and who had also recently undergone Doppler arterial examination and arteriography and 35 control subjects with an average age of 54 years (range 45 to 70 years) were studied. The Tc pO2 was continuously measured with a multimodular Kontron Supermon at 4 different sites simultaneously: precordium (reference probe), thigh, calf and foot in the dorsal recumbent position after 30 minutes rest, during a standardised exercise stress test at 50 watts and during the recovery phase. The results were expressed as ratio of tissue oxygenation (RTO): thigh, calf or foot Tc pO2/precordial Tc pO2 X 100 in order to take into account the patients cardiorespiratory status and adaptation to exercise. The RTO in normal subjects remained at the upper limits of the resting value throughout exercise and then returned slowly to basal values during the recovery phase.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0629_2565", "title": "Non-invasive neurosensory testing used to diagnose and confirm successful surgical management of lower extremity deep distal posterior compartment syndrome.", "score": 0.009615384615384616, "content": "Chronic exertional compartment syndrome (CECS) is characterized by elevated pressures within a closed space of an extremity muscular compartment, causing pain and/or disability by impairing the neuromuscular function of the involved compartment. The diagnosis of CECS is primarily made on careful history and physical exam. The gold standard test to confirm the diagnosis of CECS is invasive intra-compartmental pressure measurements. Sensory nerve function is often diminished during symptomatic periods of CECS. Sensory nerve function can be documented with the use of non-painful, non-invasive neurosensory testing. Non-painful neurosensory testing of the myelinated large sensory nerve fibers of the lower extremity were obtained with the Pressure Specified Sensory Device in a 25 year old male with history and invasive compartment pressures consistent with CECS both before and after running on a tread mill. After the patient's first operation to release the deep distal posterior compartment, the patient failed to improve. Repeat sensory testing revealed continued change in his function with exercise. He was returned to the operating room where a repeat procedure revealed that the deep posterior compartment was not completely released due to an unusual anatomic variant, and therefore complete release was accomplished. The patient's symptoms numbness in the plantar foot and pain in the distal calf improved after this procedure and his repeat sensory testing performed before and after running on the treadmill documented this improvement. This case report illustrates the principal that non-invasive neurosensory testing can detect reversible changes in sensory nerve function after a provocative test and may be a helpful non-invasive technique to managing difficult cases of persistent lower extremity symptoms after failed decompressive fasciotomies for CECS. It can easily be performed before and after exercise and be repeated at multiple intervals without patient dissatisfaction. It is especially helpful when other traditional testing has failed." }, { "id": "pubmed23n0555_18593", "title": "High-energy phosphate metabolism during calf ergometry in patients with isolated aorto-iliac artery stenoses.", "score": 0.009615384615384616, "content": "Patients with peripheral arterial disease (PAD) and aorto-iliac atherosclerotic lesions suffer from a broad range of complaints, such as pain at the hip, the thigh, and calf claudication. The purpose of this study was to investigate the high-energy metabolism in the calf muscle of patients with PAD with isolated aorto-iliac stenoses during incremental plantar flexion exercise. Using a 1.5 T whole-body magnetic resonance (MR) scanner, 12 patients with PAD with uni- or bilateral aorto-iliac atherosclerotic lesions and 10 healthy male controls underwent serial phosphor-31 MR spectroscopy during incremental exercise at 2, 3, 4, and 5 W. The phosphocreatine (PCr) time constants were calculated for each increment and recovery using a monoexponential model. In the patient group, the run-off resistance was determined on MR angiograms. In both the patients and the controls, the ankle brachial pressure index was measured. The diseased legs exhibited significantly increased PCr time constants during the second and the third workload increment at 3 and 4 W, but not during the first increment at 2 W and recovery compared with normal controls. Only 3 diseased legs succeeded the last increment at 5 W. We detected significant correlations between the ankle brachial pressure index scores and the PCr time constants when including both the diseased and the control legs. The diseased legs showed a significant correlation with the run-off resistance only during the first increment. Our study shows that the impairment of muscle metabolism, expressed by prolonged PCr time constants, occurs with greater work intensities in patients with aorto-iliac disease compared with patients with multisegmental PAD, as recently published, whereas our patients collective exhibited normal PCr recovery time constants. Our findings may help to understand variability of clinical symptoms in aorto-iliac PAD." }, { "id": "pubmed23n0971_19514", "title": "[Contribution of the maximal exercise test to diagnosis the vascular origin of leg pain in athletes].", "score": 0.009523809523809525, "content": "Leg pain is a common debilitating symptom in athletes. Vascular disease is not often proposed as a possible cause. Maximal exercise with measure of the ankle-brachial index after exercise can be an interesting diagnostic test. We report an illustrative case where an athlete presented leg pain revealing arterial disease disclosed by exercise. Interestingly, sub-maximal exercise did not cause pain, causing a delay in diagnosis. The vascular origin of leg pain can be detected with a maximal exercise test that induces the symptomatic pain or at least clinical discomfort." }, { "id": "pubmed23n0505_20608", "title": "Traumatic deep vein thrombosis in a soccer player: A case study.", "score": 0.009433962264150943, "content": "A 42 year-old male former semi-professional soccer player sustained a right lower extremity popliteal contusion during a soccer game. He was clinically diagnosed with a possible traumatic deep vein thrombosis (DVT), and sent for confirmatory tests. A duplex doppler ultrasound was positive for DVT, and the patient was admitted to hospital for anticoagulation (unfractionated heparin, warfarin). Upon discharge from hospital the patient continued oral warfarin anticoagulation (six months), and the use of compression stockings (nine months). He followed up with his family doctor at regular intervals for serial coagulation measurements, and ultrasound examinations. The patient's only identified major thrombotic risk factor was the traumatic injury. One year after the initial deep vein thrombosis (DVT) the patient returned to contact sport, however he continued to have intermittent symptoms of right lower leg pain and right knee effusion.Athletes can develop vascular injuries in a variety of contact and non-contact sports. Trauma is one of the most common causes of lower extremity deep vein thrombosis (DVT), however athletic injuries involving lower extremity traumatic DVT are seldom reported. This diagnosis and the associated risk factors must be considered during the initial physical examination. The primary method of radiological diagnosis of lower extremity DVT is a complete bilateral duplex sonography, which can be augmented by other methods such as evidence-based risk factor analysis. Antithrombotic medication is the current standard of treatment for DVT. Acute thrombolytic treatment has demonstrated an improved therapeutic efficacy, and a decrease in post-DVT symptoms.There is a lack of scientific literature concerning the return to sport protocol following a DVT event. Athletic individuals who desire to return to sport after a DVT need to be fully informed about their treatment and risk of reoccurrence, so that appropriate decisions can be made." }, { "id": "pubmed23n0108_12287", "title": "[Regional blood flow and oxygen consumption in the leg muscles of normal subjects and in those with arterial insufficiency. Study of the distribution of C15O2 and of 15O2 using positron emission tomography].", "score": 0.009433962264150943, "content": "We first studied the distribution of radioactivity during continuous inhalation of C15O2 and 15O2 in traverse tomograms of the greatest diameter of legs, at rest and immediately after exercise (ankle flexions). C15O2 and 15O2 were distributed homogeneously and symmetrically in both legs of normal subjects at rest. The activity accumulated in the anterolateral region after exercise. In patients, this pattern of distribution was similar but asymmetrical, depending on the arterial pathology. No systematic distribution of either C15O2 or 15O2 was observed. In a second step, we studied quantitatively blood flow (F), oxygen uptake (R) and oxygen extraction (E) in 11 subjects: 5 normals (23 +/- 1 years) and 6 patients (60 +/- 11 years) suffering from unilateral intermittent claudication. We used the bolus inhalation technique of C15O2 and 15O2. In the normal leg at rest, ranges were 2.5 to 8.0 ml/min.hg for F, 0.9 to 21.3 mumol/min.hg for R and 3.6 to 33.4% for E. In the pathological leg at rest, ranges were 3.7 to 11.3 ml/min.hg for F, 3.8 to 10.6 mumol/min.hg for R and 7.1 to 24.5% for E. After exercise, ranges were 6.4 to 62.8 ml/min.hg for F, 66.0 to 386.3 mumol/min.hg for R and 29.2 to 89.5% for E in both legs. There was no straight difference between normal and pathological legs soon after exercise. This study allows us to expect that the demonstration of such a difference implies a longer delay of data acquisition following the slow post-ischemia recovery." }, { "id": "pubmed23n0511_11216", "title": "Effect of dry needling of gluteal muscles on straight leg raise: a randomised, placebo controlled, double blind trial.", "score": 0.009345794392523364, "content": "To use a randomised, double blind, placebo controlled trial to establish the effect on straight leg raise, hip internal rotation, and muscle pain of dry needling treatment to the gluteal muscles in athletes with posterior thigh pain referred from gluteal trigger points. A randomised, double blind, placebo controlled trial of 59 male runners was performed during the 2002 Australian Rules football season. Subjects were thoroughly screened and had magnetic resonance imaging of their hamstring muscles to exclude local pathology. The inclusion criterion was reproduction of recognisable posterior thigh pain with the application of digital pressure to the gluteal trigger points. Subjects randomly received either therapeutic or placebo needle treatment on one occasion at their gluteal trigger points. Range of motion and visual analogue scale data were collected immediately before, immediately after, 24 hours after, and 72 hours after the intervention. Range of motion was measured with passive straight leg raise and hip internal rotation. Visual analogue scales were completed for hamstring and gluteal pain and tightness at rest and during a running task. Magnetic resonance imaging scans revealed normal hamstring musculature in most subjects. Straight leg raise and hip internal rotation remained unchanged in both groups at all times. Visual analogue scale assessment of hamstring pain and tightness and gluteal tightness after running showed improvements immediately after the intervention in both groups (p = 0.001), which were maintained at 24 and 72 hours. The magnitude of this improvement was the same for therapeutic and placebo interventions. Resting muscle pain and tightness were unaffected. Neither dry needling nor placebo needling of the gluteal muscles resulted in any change in straight leg raise or hip internal rotation. Both interventions resulted in subjective improvement in activity related muscle pain and tightness. Despite being commonly used clinical tests in this situation, straight leg raise and hip internal rotation are not likely to help the therapist assess response to treatment. Patient reports of response to such treatment are better indicators of its success. The mechanisms by which these responses occur and the reasons for the success of the placebo needling treatment are areas for further investigation." }, { "id": "pubmed23n0542_17919", "title": "High-energy phosphate metabolism during incremental calf exercise in patients with unilaterally symptomatic peripheral arterial disease measured by phosphor 31 magnetic resonance spectroscopy.", "score": 0.009345794392523364, "content": "The treadmill exercise test is the most important examination of the functional ability of patients with intermittent claudication or leg pain during exercise, but it does not provide any metabolic information in the calf muscle. The purpose of this study was to investigate the high-energy metabolism in the calf muscle during incremental progressive plantar flexion exercise of a selected peripheral arterial disease (PAD) patient group. Using a 1.5-T whole-body magnetic resonance scanner, 17 male patients with PAD who had 1 symptomatic and 1 asymptomatic leg and 9 healthy male controls underwent serial phosphor 31 (31P) magnetic resonance spectroscopy during incremental exercise at 2, 3, 4, and 5 W. Furthermore, magnetic resonance angiography was performed, and the ankle-brachial pressure index was determined in the patient group. The runoff resistance (ROR) was separately assessed in each patient's leg. The symptomatic legs exhibited significantly increased phosphocreatine (PCr) time constants during the first three workload increments (2-4 W) and the recovery phase compared with the asymptomatic legs and the normal controls. Only two symptomatic legs reached the last increment at 5 W. Compared with the normal controls, the asymptomatic legs showed significantly increased PCr time constants only at 5 W. In the patient group, we detected significant correlations between the PCr time constants and the ROR, as well as the ankle-brachial pressure index. Moreover, the symptomatic legs presented significantly lower PCr levels and pH values at the end of exercise compared with the asymptomatic and control legs. Our study shows that muscle function in PAD patients can be objectively quantified with the help of 31P magnetic resonance spectroscopy and correlates significantly with hemodynamic parameters such as ROR and ankle-brachial pressure index. Consequently, 31P magnetic resonance spectroscopy seems to be a useful method to monitor the muscle function of PAD patients for evaluation of established therapies or new therapeutic strategies during research trials." }, { "id": "pubmed23n0976_10583", "title": "Superficial peroneal nerve schwannoma presenting as lumbar radicular syndrome in a non-competitive runner.", "score": 0.009259259259259259, "content": "Running is one of the most common sports practices in the world due to the beneficial impact on the health, despite the relatively high risk of getting injuries. In fact, running is one of the most common sports capable to induce overuse injuries of the lower back and leg. In previous studies, the symptoms in the lower limb have been attributed to lumbosacral degenerative pathology. When the symptoms are unclear, they must be studied with great attention by carrying out an accurate process of screening and differential diagnosis. A 42-year-old non-competitive male runner who complained of left leg pain was referred to a physiotherapist. He reported a continuous, deep, sharp, shooting pain of the left leg. The symptoms began one year earlier. Symptoms worsened during prolonged driving and long distance running. The patient had been previously diagnosed with lumbar radicular irradiation in the leg by a general practitioner. Initial management, in another physical therapy outpatient setting, was without any improvement. After surgical excision, symptoms gradually regressed shortly and the patient was referred to a physiotherapist in order to fully recover and restore work and running activities. This case report describes the history, assessment and treatment of a runner with a rare cause of leg pain. After surgery excision, treatment focused on education and loading the tissues over many weeks through a graded program of loaded exercises and running retraining." }, { "id": "pubmed23n0282_2845", "title": "[Quantitative 201Tl-scintigraphy of the lower limb in arterial occlusive disease].", "score": 0.009259259259259259, "content": "201Tl scintigraphy is useful in evaluating the hemodynamic consequences of arterial stenoses in arterial occlusive disease. The aim of the present study was to determine normal values for absolute Tl uptake in the lower leg, for the quotient between left and right lower leg uptake as well as for the redistribution pattern after bicycle exercise. We examined as reference 49 patients without clinical evidence of peripheral or coronary artery disease: absolute Tl uptake in the lower leg in anterior scintigraphy (acquisition time: 120 sec) was 5.02 +/- 1.70 counts/pixel (left) and 5.21 +/- 1.53 counts/pixel (right), the quotient between right and left lower leg was 0.85 +/- 0.09 and the redistribution pattern (quotient of the mean activity exercise/rest) 0.82 +/- 0.17 (left) and 0.83 +/- 0.15 (right). The arithmetic mean minus 2 standard deviations was regarded as the lower limit of normal. In 8 patients with mechanical compression of the left femoral artery before injection at least two scintigraphic parameters were abnormal, in 7 patients with angiographically proven peripheral artery disease at least one scintigraphic parameter was below normal. Quantification of Tl redistribution offers diagnostic advantages in bilateral peripheral artery disease." }, { "id": "pubmed23n0833_7793", "title": "IMPROVED PRESSURE PAIN THRESHOLDS AND FUNCTION FOLLOWING NOXIOUS ELECTRICAL STIMULATION ON A RUNNER WITH CHRONIC ACHILLES TENDINOPATHY: A CASE REPORT.", "score": 0.009174311926605505, "content": "Achilles tendinopathy is a common overuse injury sustained by athletes including runners. The use of noxious electrical stimulation for the treatment of chronic tendinopathies is a novel treatment intervention, which may alter pain perception and serve as adjunct technique in the recovery of painfree function. The purpose of this case report is to demonstrate the use of noxious electrical stimulation for the treatment of chronic, bilateral Achilles tendinopathy that was resistant to conservative treatment using plantarflexor eccentric exercise. A 27-year old male runner was referred to physical therapy with a 7-year history of bilateral Achilles tendinopathy. He scored a 73/80 on the Lower Extremity Functional Scale (LEFS) and a 64% on the Victorian Institute of Sports Assessment-Achilles (VISA-A). Pain pressure threshold testing of the Achilles tendon was performed, followed by a single session of noxious electric stimulation to bilateral Achilles tendons, and the subject was instructed to continue with eccentric gastroc-soleus complex strengthening as previously performed. Pain pressure threshold testing was performed to the mid-portion of the posterior Achilles tendon. The left Achilles tendon mean was 10.50kg and right Achilles tendon was 8.33kg prior to the noxious stimulation intervention. Twenty-four hours after the noxious stimulation treatment, improvements in mean pain threshold testing were found for both the left (16.31kg) and right (12.36kg) Achilles tendons. At one month after the physical therapy noxious stimulation session, the subject was able to progress his workouts to include sprints and interval training. His LEFS improved to 76/80 and his VISA-A improved to 96%. The case illustrates the successful pain reduction and return to progressive sports activity in a runner with chronic Achilles tendinopathy. The utilization of noxious electric stimulation may have altered the pain perception of the nervous system as evidenced by the improvement in pain pressure threshold testing. Future studies on the application of noxious electric stimulation on chronic Achilles tendinopathy may help support the benefit of this intervention on pain and function. Therapy, Level 4." }, { "id": "pubmed23n0276_3583", "title": "99Tcm-sestamibi uptake in the leg muscles and in the myocardium in patients with intermittent claudication.", "score": 0.009174311926605505, "content": "99Tcm-Sestamibi has now replaced 201Tl as a cardiac imaging agent. In addition to the myocardial uptake there is also a considerable uptake in the striated muscle, which may be used for analyzing the muscular perfusion. Sixteen patients with intermittent claudication were investigated with 99Tcm-Sestamibi-SPECT (single photon emission computerized tomography) in order to visualize coronary ischemic disease. After the registration of the myocardial perfusion they were also studied regarding their leg muscle perfusion. This was done at rest and during standardized stress test using a bicycle ergometer. In 10 of the patients there was an increase in the isotope uptake in the myocardium from work to rest &gt; 10% reflecting pronounced myocardial ischemia, which, however, was symptomatic in only 4 of the patients. The muscular uptake in the myocardium of 99Tcm-Sestamibi in the thigh increased significantly from rest to exercise (P &lt; 0.01), while it remained unchanged in the calf muscle. There were no significant correlations at rest between the ratio of the right and left systolic blood pressure in the ankles and the ratio between the right and left isotope uptake in the calves, but the increase in the isotope uptake from rest to work correlated with the blood pressure ratio at r = 0.79, P &lt; 0.01 (anterior projection) and r = 0.71, P &lt; 0.01 (posterior projection)." }, { "id": "pubmed23n0995_9179", "title": "Exercise testing criteria to diagnose lower extremity peripheral artery disease assessed by computed-tomography angiography.", "score": 0.00909090909090909, "content": "The sensitivity and specificity of exercise testing have never been studied simultaneously against an objective quantification of arterial stenosis. Aims were to define the sensitivity and specificity of several exercise tests to detect peripheral artery disease (PAD), and to assess whether or not defined criteria defined in patients suspected of having a PAD show a difference dependent on the resting ABI. In this prospective study, consecutive patients with exertional limb pain referred to our vascular center were included. All patients had an ABI, a treadmill exercise-oximetry test, a second treadmill test (both 10% slope; 3.2km/h speed) with post-exercise pressures, and a computed-tomography-angiography (CTA). The receiver-operating-characteristic curve was used to define a cut-off point corresponding to the best area under the curve (AUC; [CI95%]) to detect arterial stenosis ≥50% as determined by the CTA. Sixty-three patients (61+/-11 years-old) were included. Similar AUCs from 0.72[0.63-0.79] to 0.83[0.75-0.89] were found for the different tests in the overall population. To detect arterial stenosis ≥50%, cut-off values of ABI, post-exercise ABI, post-exercise ABI decrease, post-exercise ankle pressure decrease, and distal delta from rest oxygen pressure (DROP) index were ≤0.91, ≤0.52, ≥43%, ≥20mmHg and ≤-15mmHg, respectively (p&lt;0.01). In the subset of patients with an ABI &gt;0.91, cut-off values of post-exercise ABI decrease (AUC = 0.67[0.53-0.78]), and DROP (AUC = 0.67[0.53-0.78]) were ≥18.5%, and ≤-15mmHg respectively (p&lt;0.05). Resting ABI is as accurate as exercise testing in patients with exertional limb pain. Specific exercise testing cut-off values should be used in patients with normal ABI to diagnose PAD." }, { "id": "pubmed23n0704_22995", "title": "Parents seek early intervention services for a two-year-old without autism.", "score": 0.009009009009009009, "content": "Sam is a 27-month-old boy who you have followed since birth. He lives with his parents in a small resort town approximately 90 miles outside a major city. Both his parents are professionals in their late 30s and have been highly involved in his care since birth. At the 12-month visit, they were concerned about his difficulty regulating. He was not sleeping through the night and had significant difficulty with baths. His physical examination and growth were normal. His eye contact was good, although it was difficult to see him smile. He had 1 or 2 words and was beginning to walk independently.At the 15-month checkup, they continued to be concerned about his poor regulation. He napped sporadically, and he was very difficult to take out on errands as he did not like his car seat. He now had approximately 10 single words, was using his fingers to point, and very clearly waved \"bye bye\" as soon as you entered the room.At the 18-month checkup, they state that he has not yet learned the word \"no.\" He will follow a 1-step command when he wants to but now has 15 single words without any combinations. He points for his needs and to show them something. He has become increasingly \"shy\" around strangers and prefers to play with one other child as opposed to a larger group. He does not like loud noises and prefers to go barefoot constantly. His physical examination was again normal as was his growth. He is referred for a full hearing evaluation, which is also normal. The family was referred to early intervention, and he began receiving speech and language therapy and occupational therapy for his sensory challenges as well as a play group.At the 24-month checkup, his language continued to consist of single words-now approximately 30. When the parents do not understand what he wants, he will often tantrum and has started banging his head on the floor when frustrated. He has no repetitive behaviors and is starting to demonstrate imaginative play. Bath time has becoming increasingly challenging because he does not like the sensation of soap and the water temperature must be \"just right.\" You refer the child to a Developmental and Behavioral Pediatrician for evaluation and at 28 months he is seen. During his testing visit, he had decreased eye contact and followed his own agenda but improved significantly as testing progressed. As he got more comfortable, he began making good eye contact, social referenced, and exhibited joint attention with his parents and the examiner. He did not meet criteria for an autism spectrum disorder or specifically pervasive developmental disorder-not otherwise specified (PDD-NOS). He was given a diagnosis of mixed receptive and expressive language delay and disruptive behavior disorder with sensory processing problems.The parents come to you a month after their evaluation visit asking you to give him a \"listed diagnosis of PDD-NOS\" that could be removed when he turns 3 years so that he may qualify for increased hours of services-up to 15 hours per week-as well as applied behavioral analysis therapy. A behavioral therapist through early intervention has told the family that he would benefit from this increased intervention, specifically applied behavioral analysis but the only way he can receive it is with a \"medical diagnosis\" on the autism spectrum. What do you do next?" }, { "id": "pubmed23n0245_6591", "title": "Simultaneous isotope clearance from the muscles of the calf and thigh.", "score": 0.009009009009009009, "content": "There has been no end to the attempts made to determine the site and severity of arterial lesions in claudicants by the use of non-invasive methods but, so far, their diagnostic value has been limited. A method whose diagnostic accuracy in determining the site and functional severity of the lesions approaches that of arteriography is discussed. The hyperaemic index, which is the ratio of the total excess of blood supply during post-exercise hyperaemia over the maximum hyperaemic flow, has been determined in the thigh and calf simultaneously, by measuring the 99Tcm muscle clearance in 30 limbs of 20 healthy volunteers and 139 limbs of 145 patients with claudication. Lumbar arteriography classified the lesions in all patients as 0-10 per cent, 10-40 per cent, 40-70 per cent and more than 70 per cent stenosis. A bivariate analysis of the hyperamic indices of the thigh and calf determined the site and whether single lesions consisted of a stenosis greater or less than 70 per cent. In limbs with combined aorto-iliac and superficial femoral lesions the values of the hyperaemic indices could determine which of the two lesions was the more severe in addition to whether lesions consisted of a stenosis greater or less than 70 per cent. These findings have been confirmed in a further blind prospective study of 47 limbs in which determination of the site and severity of lesions preceded aortography." }, { "id": "pubmed23n1010_3690", "title": "Unilateral Exertional Compartment Syndrome in a Pediatric Competitive Figure Skater.", "score": 0.008928571428571428, "content": "Chronic exertional compartment syndrome (CECS) occurs when there is an increase in interstitial pressure within a non-compliant fascial compartment during exercise. The hallmark sign of CECS is a consistent onset of symptoms at a specific time, distance or intensity of activity followed by resolution of symptoms when the activity is stopped. Chronic exertional compartment syndrome commonly occurs in the lower legs, is bilateral 85% to 95% of the time and occurs most often in running athletes. The purpose of this case report is to describe the clinical presentation of unilateral chronic exertional compartment syndrome in a pediatric athlete that did not present with the hallmark signs for CECS and additionally participates in a sport where CECS is not common. The subject is a 13 year old female competitive figure skater who presented to physical therapy with right calf pain when figure skating and performing functional tasks. During the initial evaluation the patient had pain at rest as well as with objective testing of the right lower leg. The patient did not progress as expected in physical therapy and therefore the differential diagnosis was re-visited and additional measures were performed. The patient was re-diagnosed with unilateral chronic exertional compartment syndrome. The diagnosis was first clinical and later confirmed by intracompartmental testing. This case report illustrates a patient diagnosed with CECS by intra-compartmental pressure testing that did not present with the standard signs and symptoms; she did not participate in a sport where CECS is typically seen and her symptoms were unilateral. This report represents the importance of consistently including CECS in the differential diagnosis of lower leg pain in athletes regardless of the initial presentation and the sport in which they participate. Additionally, it highlights the importance of a detailed subjective history and the significance of aggravating and alleviating factors in relation to training." }, { "id": "pubmed23n0295_13206", "title": "The quantitation of blood flow/metabolism coupling at rest and after exercise in peripheral arterial insufficiency, using PET and 15-0 labeled tracers.", "score": 0.008928571428571428, "content": "Regional blood flow and oxygen uptake of the lower limbs were studied in 11 patients with arterial insufficiency (10 with severe unilateral, 1 with bilateral intermittent claudication). Regional muscle blood flow (F), oxygen consumption rate (R), and oxygen extraction fraction (E) were evaluated by positron emission tomography (PET) and bolus inhalation of C15O2 and 15O2 by the patient. Tomograms were recorded at the greatest diameter of legs, at rest and ten minutes after a treadmill walk test leading to the development of ischemic pain in the affected leg. In 5 patients, F and E were correlated with the results of occlusive venous strain gauge plethysmography and with the measurements of blood gases in one brachial artery and in the femoral vein of the affected limb. Blood flow values measured at rest and after exercise by PET were poorly correlated with the plethysmographic findings. This may be because PET does not interfere with flow as venous occlusion plethysmography does in low peripheral pressure conditions. The results show that F, R, and E were not significantly different in normal and pathologic legs at rest. The values of F and R were significantly higher in pathologic than in normal lower limbs, ten minutes after exercise, whereas E was not significantly altered by exercise at any side. This suggests that, during the recovery from a walk test, the delayed increase in oxygen uptake is proportional to the delayed hyperemia in the ischemic muscles (\"oxygen debt\") and probably not linked to a luxury perfusion." }, { "id": "wiki20220301en011_137359", "title": "Compartment syndrome", "score": 0.008928216345197852, "content": "Chronic exertional compartment syndrome is usually a diagnosis of exclusion, with the hallmark finding being absence of symptoms at rest. Measurement of intracompartmental pressures during symptom reproduction (usually immediately following running) is the most useful test. Imaging studies (X-ray, CT, MRI) can be useful in ruling out the more common diagnoses. Additionally, MRI has been shown to be effective in diagnosing chronic exertional compartment syndrome. The average duration of symptoms prior to diagnosis is 28 months. Treatment Acute" }, { "id": "wiki20220301en098_6018", "title": "Utilization behavior", "score": 0.008849557522123894, "content": "Diagnosis Quantitative methods of assessing utilization behavior are not available for use and because of this those who notice changes in behavior similar to that of the signs of UB should see a doctor. Many functional disorders can be mistaken for frontal dysfunction as several neurological causes can be attributed to frontal dysfunction. Proper criteria need to be in place for determining UB but because this disorder is in the elementary stage, researchers have not arrived at a full understanding of the disorder. Doctors can test the patient's response, communication and motor skills but the only way to fully diagnose this disorder is to do a scan of the brain to see if the frontal lobe has been damaged. This can be done with the following scan types: CT Scan (X-ray computed tomography) MRI (Magnetic resonance imaging) PET (Positron emission tomography) SPECT (Single-photon emission computed tomography)" }, { "id": "pubmed23n0218_3603", "title": "Leg arteritis exploration by quantitative muscle scintigraphy with 201Tl.", "score": 0.008849557522123894, "content": "Detection and localization of peripheral arterial disease was evaluated by an intravenous injection of 201Tl at peak exercise in 18 subjects and at rest in 6 patients. Images of the skull (S), thighs (T), knees (K), calves (C) and feet (F) were obtained at rest or after exercise and stored in a computer. Intraleg (T/K, T/C, T/F), and left to right interleg (TL/TR,...) count ratios were calculated. In addition, all patients were submitted to routine functional tests (walk perimeter, serial local arterial blood pressure measurement, Strandness test, venous occlusion plethysmography). Correlations between functional tests and the intra and interleg ratios were calculated. After exercise, there is a medium correlation between the tissular blood flow under hyperemia at the calf level and the T/C and C/K ratios. At the calf level a good correlation is obtained for CL/CR and the flux under hyperemia (r = 0.81, P 0.001). A ratio between the counting rates of limb segments after exercise and those of skull was established. The ratios T/S and C/S compared with the systolic pressure index of the most affected limb after a Strandness test give a correlation of 0.72 (P 0.02) for the thigh and of 0.86 (P 0.001) for the calf. For hyperemic flux, the correlation are 0.58 (P 0.005) with T/S and 0.75 (P 0.001) with C/S. In order to find the best quantitative scintigraphic index of the arterial illness, we compared the different ratio values with the distance walked. For T/S we found a relationship very close to a linear one and for C/S a less significant exponential one. Thus, quantitative scintigraphy using 201Tl appears as an accurate method to measure local muscular perfusion deficit in the cases of lower limb arterial disease." }, { "id": "pubmed23n0874_12450", "title": "Accuracy of Palpation-Guided Catheter Placement for Muscle Pressure Measurements in Suspected Deep Posterior Chronic Exertional Compartment Syndrome of the Lower Leg: A Magnetic Resonance Imaging Study.", "score": 0.008771929824561403, "content": "A diagnosis of lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) is made by a dynamic pressure measurement. The insertion of a pressure catheter is guided by anatomic landmarks (freehand) or by ultrasound. The catheter tip is ideally positioned in the tibialis posterior muscle (TP). The accuracy of in vivo catheter placement using lower leg magnetic resonance imaging (MRI) in healthy patients suspected of having dp-CECS has never been studied. To analyze whether a freehand catheter insertion results in accurate positioning in the TP as confirmed by MRI in patients with suspected dp-CECS. Case series; Level of evidence, 4. Catheters were inserted into central portions of the TP using a standard puncturing technique guided by lower leg anatomic landmarks. After timed muscle pressure measurements during a standard provocative treadmill running test, lower leg MRI scans were obtained and evaluated by 2 skilled radiologists. Catheter tip placement was termed accurate (in the TP), suboptimal (in the deep posterior compartment but outside the TP), or inaccurate (outside the deep posterior compartment). Between March 2013 and September 2014, a total of 24 patients (8 male, 16 female; mean age, 30 years [range, 18-54 years]) underwent an intracompartmental pressure (ICP) measurement, followed by MRI. Cardinal symptoms were pain during exertion (20% very severe, 53% severe, and 20% moderate) and tightness (29% very severe, 43% severe). Symptoms were bilateral in 74% of patients. Nine of the 24 patients were diagnosed with dp-CECS based on elevated ICPs. Of the 24 patients, catheter tip placement was accurate in 10 (42%), whereas suboptimal placement was achieved in 9 (38%). Five procedures were inaccurate (transition zone between the deep and superficial compartments, n = 3; in the superficial lower leg compartment, n = 2). Signs of a hematoma were found in 38% of the patients, although there were no associated clinical symptoms. Palpation-guided placement of catheters for TP pressure measurements is suboptimal in more than half of the patients with suspected lower leg dp-CECS. Optimizing the pressure catheter tip positioning technique may improve diagnostic accuracy in dp-CECS." }, { "id": "pubmed23n0284_2419", "title": "[Usefulness of the 201TlCl exercise leg perfusion scintigraphy inarteriosclerosis obliterans (ASO)--with evaluation of leg perfusion comparing before and after PTA].", "score": 0.008771929824561403, "content": "Twenty-eight patients of arteriosclerosis obliterans (ASO) complaining of intermittent claudication or pain at rest underwent symptom limited exercise leg perfusion scintigraphy using 201TlCl (Tl). Regions of interest (ROI) were drawn around each buttocks, thighs, calves and feet in whole body image, and we calculated Lesion/Normal Index (LNI) which was the divided value of the average count per pixel of each ROI of the affected side by that of the normal side. The average LNI of the foot was 0.81 and was smaller than other regions (p &lt; 0.05). Other region except foot showed Tl high uptake in affected side in some cases. Fifteen patients were compared after percutaneous transluminal angioplasty (PTA) with before PTA, and LNI of the foot was statistically improve after PTA (p &lt; 0.005). The period suffer from disease of the group of Tl high uptake in the affected leg was statistically shorter than that of the group of Tl non-high uptake (p &lt; 0.05). We supposed that the Tl uptake of the foot reflects ischemia of the leg sensitively, and high uptake of Tl in affected leg is concerned with compensatory change of microcirculation of ischemic leg in subacute period. This scintigraphy was thought to be useful to detect the ASO and to evaluate the effect of PTA, and was able to avail diagnosis and observation of the course of ASO patient." }, { "id": "pubmed23n1076_13149", "title": "Bilateral Exertional Compartment Syndrome With Endoscopic Fasciotomy Surgical Intervention in a High School Athlete.", "score": 0.008695652173913044, "content": "A 17-year-old female presented to the physical therapy clinic with bilateral lower leg pain that worsened with activity. The patient experienced numbness, tingling, and cramping along the lateral and posterior portions of her legs during basketball practice, and her symptoms had gradually worsened over the past eight months. She obtained minimal relief with conservative treatments such as stretching and rest. X-rays and MRI of the lower limbs were obtained six months after symptoms began and were unremarkable. Further evaluation included compartment pressure testing taken before and after exercise. The patient demonstrated diagnostic pressures indicative of compartment syndrome in two compartments bilaterally. The patient was subsequently diagnosed with exertional compartment syndrome. Exertional compartment syndrome is a cause of muscle pain that occurs due to increased tissue pressure within the confinement of the closed fascial space during exercise. Patients are often misdiagnosed or there is a significant delay in the correct diagnosis. The gold standard for diagnosis is measurement of intracompartmental pressures with the Stryker catheter. Clinicians should consider exertional compartment syndrome in active patients who present with generalized muscle pain or sensation deficits that worsen with activity and are relieved with rest. Surgical intervention is a reasonable intervention and the only definitive option for an athlete with chronic exertional compartment syndrome who wants to continue high-level competition. Endoscopic fasciotomies are the new preferred techniques compared to more invasive open surgeries, which require a full incision. Endoscopic fasciotomy has a quicker healing time and has been shown to be as effective at relieving compartment syndrome symptoms as invasive open techniques. After surgical intervention, the patient reported a 90% reduction in symptoms and had returned to full sport participation within two months." }, { "id": "pubmed23n0844_3063", "title": "Multiprobe devices for exercise transcutaneous oxymetry in patients complaining claudication: interest and limits of unusual probe positions.", "score": 0.008695652173913044, "content": "Exercise transcutaneous oximetry (PtcO2) can argue for a vascular origin of exercise-related pain in atypical unusual localizations, such as lumbar, thigh or foot pain. We used five probes as a standard for treadmill PtcO2 tests. Recent commercially available devices now include up to eight probes. We aimed at analyzing the potential interest of positioning a 6th probe on the area of unusual localization during exercise PtcO2 tests. We retrospectively analyzed our data with a 6-probes device, using as a standard: one probe on the chest, one on each buttock and one on each calf. The sixth probe was positioned either: in the lumbar median position (N.=342), on the anterior lower part of the thigh (N.=391) or on the dorsum of the foot (N.=155) in patients complaining exercise-induced pain including the back, thigh or foot respectively. Results on the sixth probe at the limb were compared to result of the standard adjacent probe. A positive test (abnormal result) was defined as a minimal value of the DROP-index lower than minus 15 mmHg. Prevalence of positive results on the 6th probe with negative results on the adjacent standard probe was 2.3% at the lumbar site, 3.8% at the thigh and 12.3% at the foot level. Atypical localizations are rarely but sometimes associated to isolated positive exercise PtcO2 results and may justify the use of more than five probes in some patients, specifically for foot pain." }, { "id": "pubmed23n1152_1959", "title": "Case report: the role of multimodal imaging to optimize the timing of return to sports in an elite athlete with persistent COVID-19 myocardial inflammation.", "score": 0.008620689655172414, "content": "COVID-19 has been associated with myocardial abnormalities on cardiac magnetic resonance imaging (CMR). We report a case of COVID-19 myocarditis in an elite athlete. A male, 21-year-old elite football player had tested positive for SARS-CoV-2 on a polymerase-chain-reaction test and was referred for cardiac evaluation after experiencing palpitations after returning to sports (RTS). Biochemical evaluation demonstrated elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) and high-sensitive Troponin T. Echocardiography demonstrated left ventricular function within normal ranges for athletes but with diminished basal, posterolateral, and septal strain. Cardiac magnetic resonance imaging (CMR) showed increased T1 values and late gadolinium enhancement (LGE) in the basolateral and mid-ventricular posterior segments. Focal COVID-19 myocarditis was diagnosed and the patient remained restricted from sports, in line with the 2020 ESC sports cardiology guidelines. Two months later, his electrocardiogram (ECG) showed inferoposterolateral T-wave inversion (TWI). Serial imaging studies were performed to optimize RTS timing. Cardiac magnetic resonance imaging showed persistently increased T1/T2 values and persistent LGE at 5 and 7 months. At 9 months, 18 F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)-computerized tomography (CT) demonstrated no pathologically increased cardiac FDG-uptake. Subsequent exercise ECG and Holters demonstrated no complex ventricular arrhythmias. The patient made a complete return to elite competitive sports, without any adverse events at 15 months of follow-up. Cardiac symptoms in athletes post-COVID-19 should prompt cardiac evaluation. As COVID-19 myocarditis inflammation can persist beyond the 3-6 months of recommended sports restriction, a more personalized approach to RTS timing can be warranted. In cases with myocardial oedema without other signs of inflammation, FDG-PET-CT can be of added value to assess active myocardial inflammation." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 309, 431 ] ], "word_ranges": [ [ 40, 58 ] ], "text": "just with the words \"thymic dysfunction\", hypocalcemia and cardiopathy, we would have to go straight to DiGeorge syndrome." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 637, 763 ] ], "word_ranges": [ [ 96, 115 ] ], "text": "can also be associated with cardiopathy, but above all it is characterized by short stature, cardiopathy and bone alterations;" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "22q11 deletion study (Di George or Velo-cardio-facial syndrome).", "2": "Study of FMR1 gene expansion, responsible for Fragile X syndrome.", "3": "Sequencing of genes related to HRAS (Noonan syndrome).", "4": "Genetic study of Williams Beuren syndrome.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0396_14883", "title": "[Congenital cardiopathies and syndromes in adults].", "score": 0.01811772421708477, "content": "Among congenital defects the most common are the congenital heart defects, which constitute a heterogeneous group with a multifactor etiology. A single gene mutation has been identified in some of them, such as in of Williams's syndrome, or they can be due to teratogenic agents. The advance in diagnosis and treatment of congenital heart defects has become very important because mortality has diminished and patients live longer and better, reaching adult hood. Molecular biology offers now opportunities understand the cause of many genetic diseases thanks to molecular studies of chromosomes. Conotruncal malformations are known to be caused by a microdeletion in chromosome 22(22q11), this mutation is also responsible for the DiGeorge and cardiovelofacial syndromes, the most relevant aspects are: congenital heart disease, which is present in 75% of the cases, the leading disorder is Fallot's tetralogy with pulmonary atresia, in second place is interruption of the aortic arch type B, followed by common truncus arteriosus. These patients have other phenotypic features, such as high palate, speech problems, malimplantation of ears, and protuberant nose tip, among others. Diagnosis is made with the FISH (fluorescent in situ hybridization) test that shows a microdeletion in chromosome 22 at the 11.2 region. Another syndrome that has received great attention is the Williams-Beuren syndrome, which courses with mental retardation, hypercalcemia, characteristic facies, and supravalvular aortic and pulmonary stenosis. To day, it is known that its cause is a deletion in chromosome 7(7q11.23), which affects elastin region, in consequence, affecting the vessels." }, { "id": "pubmed23n0709_8599", "title": "[Improvement of genetic diagnostic strategy in velo-cardio-facial syndrome].", "score": 0.015840978593272173, "content": "Velo-Cardio-Facial Syndrome (VCFS) is characterized by congenital heart defects (CHD), palatal abnormalities, facial dysmorphism, neonatal hypocalcemia, immune deficit, speech and learning disabilities. SVCF is caused by microdeletion 22q11.2. Microdeletion is detected by fluorescence in situ hybridization (FISH). The highly variable phenotype makes diagnosis and selection for FISH more difficult. To retrospectively analyze and compare the phenotype of children with a clinical diagnosis of VCFS with/without 22q11 deletion; to verify the validity of literature guidelines and to describe combinations of clinical features that should lead to molecular analysis. The present study was performed in 21 patients with a clinical diagnosis of VCFS. Methaphase chromosome spreads were prepared from phytohaemagglutinin stimulated lymphocyte culture by standard methods before FISH. The patients were divided into two groups according to FISH test: positive and negative. The features commonly noticed in FISH positive patients were: palatal abnormalities/hypernasal speech, learning disabilities, facial dysmorphism, tapered fingers (6/6), CHD (5/6) and recurrent infections (2/6). In FISH negative patients the following were found: learning disabilities, CHD (12/15); facial dysmorphism (10/15), family history of CHD (7/15), short stature (6/15), hypocalcemia, tapered fingers (5/15), recurrent infections (3/15) and palatal cleft (2/15). In both groups, Tobias and McDonald-McGinn guidelines were positive. VCFS has a highly variable phenotype. Our study suggests that 22q11.2 deletion analysis by FISH should be performed in patients who have at least 2 (newborn)/3 (child, adult) specific criteria: CHD, hypocalcemia, palatal abnormalities, facial dysmorphism, learning disabilities, digital anomalies, and immune deficit." }, { "id": "pubmed23n0735_9071", "title": "Williams-Beuren's Syndrome: A Case Report.", "score": 0.014198274132048966, "content": "Williams-Beuren syndrome is a rare familial multisystem disorder occurring in 1 per 20,000 live births. It is characterized by congenital heart defects (CHD), skeletal and renal anomalies, cognitive disorder, social personality disorder and dysmorphic facies. We present a case of Williams syndrome that presented to us with heart murmur and cognitive problem. A 5-year-old girl referred to pediatric cardiologist because of heart murmurs. She had a systolic murmur (2-3/6) in right upper sternal border with radiation to right cervical region. She also had a bulge forehead. Angiography showed mild supra valvular aortic stenosis and mild multiple peripheral pulmonary stenosis. Fluorescent in situ hybridization (FISH) was performed and the result was: 46.XX, ish del (7q11.2) (ELN X1) (7q22 X2) ELN deletion compatible with Williams syndrome. Peripheral pulmonary artery stenosis is associated with Noonan syndrome, Alagille syndrome, Cutis laxa, Ehler-Danlos syndrome, and Silver-Russel syndrome. The patient had peripheral pulmonary artery stenosis, but no other signs of these syndromes were present, and also she had a supravalvular aortic stenosis which was not seen in other syndromes except Williams syndrome. Conclusion. According to primary symptoms, paraclinical and clinical finding such as dysmorphic facies, cognitive disorder and congenital heart defect, Williams syndrome was the first diagnosis. We suggest a more attention for evaluating heart murmur in childhood period, especially when the patient has abnormal facial features or mental problem." }, { "id": "pubmed23n0365_2230", "title": "[22q11.2 chromosome deletion and velo-cardio-facial syndrome in a patient with tetralogy of Fallot].", "score": 0.013646147223417993, "content": "Velo-cardio-facial syndrome includes the following clinical features: congenital heart anomaly, velo-pharyngeal malformations and dysmorphic facial features. In 80% of the patients microdeletion of the long arm of chromosome 22 can be detected. Many patients with DiGeorge syndrome have the same underlying chromosomal etiology, however the same deletion results in severe dysmorphic features, immune defect, hypocalcaemia and in severe mental retardation. In isolated heart defects deletion can be detected in about 15% of the patients. We report the detection of the microdeletion in a patient with tetralogy of Fallot, minimal dysmorphic facial features and normal psychomotor development. Early diagnosis of 22q11.2 chromosomal deletion is important for genetic counseling and further rehabilitation. We emphasize the importance of genetic screening in patients with isolated congenital heart defects." }, { "id": "pubmed23n0346_2859", "title": "[Clinical characterization, molecular and FISH studies in 80 patients with clinical suspicion of Williams-Beuren syndrome].", "score": 0.013485219489690906, "content": "Williams-Beuren syndrome is a developmental disorder affecting vascular and connective tissues and central nervous system. The syndrome is caused by a submicroscopic deletion in the chromosome 7 implicating the 7q11.23 region. Fluorescence in situ hybridization (FISH) and molecular studies allow us to confirm the clinical suspicion of this syndrome. We report clinical evaluation, FISH using Elastin Williams/D7S427 probe and molecular study with markers: D7S672, D7S653, D7S489B, D7S2476, D7S1870 and D7S489A, in 80 patients referred to test for Williams-Beuren syndrome. We found hemizygosity for the critical region in 36 patients. From 69 cases studied by FISH, 28 showed the deletion. Molecular studies in 78 cases showed loss of heterozygosity (LOH) in 26 patients. The patients presented the deletion from the paternal or maternal chromosome at equal frequency. Clinical evaluation of mental retardation, facial features, esotopia dental, malocclusion, hoarse voice, supravalvular aortic stenosis (SVAS), hernias, join limitation, WBS personality and mental retardation from positive and negative patients showed estatistical significant differences for all items except mental retardation and joint limitation. The most significant item was the presence of SVAS. This study confirms the usefulness of genetic studies as a diagnostic tool for William-Beuren Syndrome." }, { "id": "wiki20220301en011_8815", "title": "Williams syndrome", "score": 0.012969571390199915, "content": "If a physician suspects a case of WS, the diagnosis is confirmed using one of two possible genetic tests: Micro-array analysis or the fluorescent in situ hybridization test, which examines chromosome 7 and probes for the existence of two copies of the elastin gene. Since 98-99% of individuals with WS lack half of the 7q11.23 region of chromosome 7, where the elastin gene is located, the presence of only one copy of the gene is a strong sign of WS. This confirmatory genetic test has been validated in epidemiological studies and has been demonstrated to be a more effective method of identifying WS than previous methods, which often relied on the presence of cardiovascular problems and facial features (which, while common, are not always present)." }, { "id": "wiki20220301en074_6079", "title": "Neurodevelopmental disorder", "score": 0.011904761904761904, "content": "Less commonly known genetically determined neurodevelopmental disorders include Fragile X syndrome. Fragile X syndrome was first described in 1943 by Martin and Bell, studying persons with family history of sex-linked \"mental defects\". Rett syndrome, another X-linked disorder, produces severe functional limitations. Williams syndrome is caused by small deletions of genetic material from chromosome 7. The most common recurrent Copy Number Variannt disorder is 22q11.2 deletion syndrome (formerly DiGeorge or velocardiofacial syndrome), followed by Prader-Willi syndrome and Angelman syndrome. Immune dysfunction" }, { "id": "wiki20220301en051_65252", "title": "Ryan Dempster", "score": 0.011781739722916193, "content": "In early June 2009, Dempster released a statement explaining that his daughter, Riley Dempster, had DiGeorge Syndrome, also known as Velo-cardio-facial syndrome (VCFS), 22q11.2 deletion syndrome, and Shprintzen syndrome (after Dr. Robert Shprintzen who identified it in 1978). About 1 baby in 1800 is born with this genetic deletion which ubiquitously affects swallowing, breathing, and speech. Dempster did this because he wanted to help raise awareness of this genetic disease. When asked if she would lead a normal life, he replied, \"Yeah, she will. There can be (problems), but so far all the signs are good. There's a lot of work to do. They say there are 186 symptoms you can have. You just check off ones as you go along.\" After roughly 2 months in the hospital, Riley was able to go home in early June." }, { "id": "wiki20220301en534_1836", "title": "Fryns-Aftimos syndrome", "score": 0.011500708764609912, "content": "Fryns-Aftimos syndrome (also known as Baraitser-Winter Syndrome 1, or BWS1) is a rare chromosomal condition and is associated with pachygyria, severe mental retardation, epilepsy and characteristic facial features. This syndrome is a malformation syndrome, characterized by numerous facial dysmorphias not limited to hypertelorism, iris or retinal coloboma, cleft lip, and congenital heart defects. This syndrome has been seen in 30 unrelated people. Characterized by a de novo mutation located on chromosome 7p22, there is typically no family history prior to onset. The severity of the disorder can be determined by the size of the deletion on 7p22, enveloping the ACTB gene and surrounding genes, which is consistent with a contiguous gene deletion syndrome. Confirming a diagnosis of Fryns-Aftimos syndrome typically consists of serial single-gene testing or multigene panel of genes of interest or exome sequencing." }, { "id": "pubmed23n0515_19423", "title": "[22q11 deletion in conotruncal anomalies].", "score": 0.011238406983087834, "content": "22q11 deletions in conotruncal anomalies. Two children are reported in whom conotruncal anomalies (truncus arteriosus communis, tetralogy of Fallot) were associated with chromosome 22q11 deletion. In both cases, which represent the first published cases in Hungary according to the knowledge of the author, deletions were suspected on the basis of phenotype termed Di George syndrome. Nowadays the role of molecular genetics is growing in the etiology of congenital heart defects and the chromosome 22q11 deletions constitute one of the most frequent genetic mutations associated with congenital heart defects. The author emphasizes that clinicians must know about this disease, and in case of suspicion they should request for molecular genetic investigation. 22q11 deletions have an important roles in the prognosis of congenital heart disease, in counseling and in the prenatal diagnosis as well." }, { "id": "wiki20220301en369_15401", "title": "Floating–Harbor syndrome", "score": 0.010155574762316336, "content": "Diagnosis Until recently, doctors have diagnosed patients with FHS based on clinical observations and how well they fit the disease description, usually occurring in early childhood. Molecular genetic testing is also used now to test for genetic mutations. By performing a sequence analysis test of select exons, mutations can be detected in exon 34 of the SRCAP gene. This mutation has been observed in 19 patients to date. In most cases, if the patient shows classic facial features of FHS, the molecular testing will show a mutation on the SRCAP gene. Differential diagnosis FHS shares some common features with Rubinstein–Taybi (due to overlapping effects of mutations on SRCAP), however cranial and hand anomalies are distinctive: broad thumbs, narrow palate, and microcephaly are absent in Floating-Harbor Syndrome. One child in the UK has a diagnosis of microcephaly alongside Floating–Harbor syndrome." }, { "id": "wiki20220301en002_158032", "title": "Fragile X syndrome", "score": 0.009900990099009901, "content": "This disorder and finding of Fragile X syndrome has an X-linked dominant inheritance. It is typically caused by an expansion of the CGG triplet repeat within the FMR1 (fragile X mental retardation 1) gene on the X chromosome. This results in silencing (methylation) of this part of the gene and a deficiency of the resultant protein (FMRP), which is required for the normal development of connections between neurons. Diagnosis requires genetic testing to determine the number of CGG repeats in the FMR1 gene. Normally, there are between 5 and 40 repeats; fragile X syndrome occurs with more than 200. A premutation is said to be present when the gene has between 40 and 200 repeats; women with a premutation have an increased risk of having an affected child. Testing for premutation carriers may allow for genetic counseling." }, { "id": "pubmed23n0374_7273", "title": "[Microdeletion 22q11: apropos of case of schizophrenia in an adolescent].", "score": 0.00980392156862745, "content": "Deletion of chromosome 22q11 concerns nearly 1/5.000 births, and is the most frequent interstitial microdeletion. The deletion generates various phenotypes which were initially regarded as distinct syndromes. 1) Di George syndrome was described in 1962 by immunologists, and associates thymic and parathyroid hypoplasia, cardiac malformation, and dysmorphic face; the prognosis is severe, as Di George syndrome is a life-threatening condition. 2) The velocardiofacial syndrome was described in 1978 by stomatologists, and associates palate abnormalities, cardiac malformations, dysmorphic faces, and learning disabilities. 3) The Takao syndrome was described in the late seventies by cardiologists as a clinical condition associating cardiac abnormalities and dysmorphic faces. During the nineties, a common molecular etiology was identified, and a new name proposed: CATCH 22, an acronyme for Cardiac abnormalities, Abnormal face, Thymic hypoplasia, Cleft palate, Hypocalcemia, deleted chromosome 22. Furthermore, new phenotypes have been recently recognized, most of them belonging to the psychiatric spectrum. Descriptive studies of large samples of children with 22q11 deletion, conducted, both in the United States and european countries, have shown the following pattern of associated symptoms:--abnormal face (100%), which expression varies with age, and can be discrete;--cardiac abnormalities (84%), including cardiac malformations of conotroncal types;--mouth abnormalities (49%), including cleft palate (14%), and velar dysfunction (20%);--urinary tract abnormalities (36%), including ureteric reflux, lung dysplasia;--transitory hypocalcemia (60%) mostly during infancy, and due to transitory hypoparathyroid dysfunction;--seizures (21%), which are usually a consequence of hypocalcemia;--immunodeficiency (1%), which worsens the prognosis. Deletion of chromosome 22q11 has been also associated with various psychiatric phenotypes, which can be classified into two groups, developmental abnormalities and psychiatric conditions. The great majority of patients with the deletion exhibit impairment of language and motor development, mild mental retardation, persistent coordination deficits, and poor academic performance. The deletion of chromosome 22q11 is also associated with high frequency of behavioral disorder with attention deficit during childhood, and with high frequency of psychotic disorder (bipolar disorder, and schizophrenia) during adolescence and young adulthood. The link between the 22q11 deletion and schizophrenia has been also supported by recent studies showing that the rate of 22q11 deletion in adults with schizophrenia (2%) is higher than it is in the general population. The rate may even be higher (6%) in subjects with childhood onset schizophrenia. The present work reviews the psychiatric literature associated with 22q11 deletion. We also report a case of 22q11 deletion in a 17-year-old girl that was initially diagnosed as paranoid schizophrenia. We will discuss the diagnostic, prognostic, and therapeutic consequences that such a genetic diagnosis implies. In the case reported here, transitory hypocalcemia induced: 1) dystonic symptoms that was believed to be catatonic symptoms or neuroleptic secondary effects, by clinicians; 2) a poor response to neuroleptic medication." }, { "id": "pubmed23n0329_9107", "title": "FISH analysis in both classical and atypical cases of Williams-Beuren syndrome.", "score": 0.00980392156862745, "content": "Williams-Beuren syndrome (WBS) is a rare neurodevelopmental disorder, characterized by distinct facial changes, growth deficiency, mental retardation, supravalvular aortic stenosis (SVAS)/peripheral pulmonary stenosis, and associated at times with infantile hypercalcemia. A pilot study has been carried out to assess the reliability of the detection of hemizygosity at the elastin locus by fluorescence in situ hybridization (FISH) analysis as a diagnostic test in both classical and atypical WBS. Eight subjects with classical WBS and four others in whom a diagnosis could not be confirmed on clinical criteria alone were enrolled. In the classical WBS group, five (5/8) had a visible interstitial 7q11.22-11.23 deletion detected by high-resolution banding, and all (8/8) had a submicroscopic deletion of the elastin locus on chromosome 7 by FISH analysis. In the atypical WBS group, only one (1/4) had elastin deletion. The other three, with isolated SVAS, had normal development and minimal signs of WBS. Furthermore, the patients with microscopic 7q11.22-11.23 deletion have more associated features of WBS than those without visible interstitial deletions by high-resolution banding. These results, therefore, emphasize the importance of a combined high-resolution and molecular cytogenetic (i.e., FISH) approach to diagnosis and suggest that the degree to which microscopic/submicroscopic deletions of chromosome 7 extending in beyond the elastin locus may explain some of the phenotypical variability found in WBS." }, { "id": "wiki20220301en029_13541", "title": "Congenital heart defect", "score": 0.009708737864077669, "content": "which includes electrical conduction defects and abnormalities of the upper limb. The Wnt signaling co-factors BCL9, BCL9L and PYGO might be part of this molecular pathways, as when their genes are mutated, this causes phenotypes similar to the features present in Holt-Oram syndrome. Another T-box gene, TBX1, is involved in velo-cardio-facial syndrome DiGeorge syndrome, the most common deletion which has extensive symptoms including defects of the cardiac outflow tract including tetralogy of Fallot." }, { "id": "pubmed23n0833_20205", "title": "Williams-Beuren Syndrome: A Clinical Study of 55 Brazilian Patients and the Diagnostic Use of MLPA.", "score": 0.009708737864077669, "content": "Williams-Beuren syndrome (WBS) is a genetic disease caused by a microdeletion in the 7q11.23 region. It is characterized by congenital heart disease, mainly supravalvular aortic stenosis, mental retardation, mild short stature, facial dysmorphisms, and variable abnormalities in different systems. Objectives. To report the clinical findings of 55 Brazilian patients confirmed by multiplex ligation-dependent probe amplification (MLPA). Methods. Patients were followed up for 4 years at the Genetics Unit of the Instituto da Criança of the Hospital das Clínicas, FMUSP, Brazil. A kit specific for WBS was used to detect the 7q11.23 microdeletion. Results. Two patients with negative FISH results had positive MLPA results for WBS. The characteristics of the patients with the deletion were as follows: typical WBS facies (98.2%), neuropsychomotor delay (98.2%), hypersocial behavior (94.5%), hyperacusis (94.5%), and congenital heart disease (81.8%). Conclusions. MLPA was effective in detecting the microdeletion in the 7q11.23 region to confirm the diagnosis of WBS. MLPA was also able to confirm the diagnosis of WBS in two patients with typical clinical characteristics but negative FISH results. Thus, MLPA is a promising method in the diagnostic investigation of WBS. WBS is a multisystemic disorder and therefore requires multidisciplinary care and specific follow-up to prevent complications. " }, { "id": "wiki20220301en253_38297", "title": "Fragile X-associated tremor/ataxia syndrome", "score": 0.009615384615384616, "content": "Fragile X-associated tremor/ataxia syndrome (FXTAS) is a late-onset neurodegenerative disorder most frequently seen in male premutation carriers of Fragile X syndrome (FXS) over the age of 50. The main clinical features of FXTAS include problems of movement with cerebellar gait ataxia and action tremor. Associated features include parkinsonism, cognitive decline, and dysfunction of the autonomic nervous system. FXTAS is found in Fragile X \"premutation\" carriers, which is defined as a trinucleotide repeat expansion of 55-200 CGG repeats in the Fragile X mental retardation-1 (FMR1) gene. 4-40 CGG repeats in this gene is considered normal, while individual with >200 repeats have full Fragile X Syndrome." }, { "id": "pubmed23n0968_2465", "title": "22q11.2 deletion detected by <i>in situ</i> hybridization in Mexican patients with velocardiofacial syndrome-like features.", "score": 0.009615384615384616, "content": "Deletion 22q11.2 occurs in 1:4,000-1:6,000 live births while 10p13p14 deletion is found in 1:200,000 newborns. Both deletions have similar clinical features such as congenital heart disease and immunological anomalies. We looked for a 22q11.2 deletion in Mexican patients with craniofacial dysmorphisms suggestive of DiGeorge or velocardiofacial syndromes and at least one major phenotypic feature (cardiac anomaly, immune deficiency, palatal defects or development delay). A prospective study of 39 patients recruited in 2012-2015 at the Instituto Mexicano del Seguro Social at Guadalajara, Mexico. The patients with velocardiofacial syndrome-like features or a confirmed tetralogy of Fallot (TOF) or complex cardiopathy were studied by G-banding and fluorescence <iin situ</i hybridization (FISH) with a dual TUPLE1(HIRA)/ARSA or TUPLE1(22q11)/22q13(SHANK3) probe, six patients without the 22q11.2 deletion (arbitrarily selected) were tested with the dual DiGeorge II (10p14)/D10Z1 probe. Twenty-two patients (7 males and 15 females) had the 22q11.2 deletion and 17/39 did not have it; no patient had a 10p loss. Among the 22 deleted patients, 19 had congenital heart disease (mostly TOF). Twelve patients without deletion had heart defects such as TOF (4/12), isolate ventricular septal defect (2/12) or other disorders (6/12). In our small sample about ~56% of the patients, regardless of the clinical diagnosis, had the expected 22q11.2 deletion. We remark the importance of early cytogenetic diagnosis in order to achieve a proper integral management of the patients and their families." }, { "id": "wiki20220301en012_28081", "title": "Tetralogy of Fallot", "score": 0.009523809523809525, "content": "NOTCH1 is involved in the vascularization of tissues and is the most common site of genetic variations involved with TOF, accounting for 7% of all TOF cases. TBX1 expresses progenitors involved with the development of the right ventricle. Chromosome 22q11 deletions also deleting TBX1 gene have been seen in 17% TOF cases. FLT4 gene expression leads to Vascular endothelial growth factor receptor 3 (VEGFR-3) which helps vascularization. Mutations of this gene have been associated with TOF, accounting for 2.4% of all cases. FOXC2 is another gene involved in embryonic development of the cardiac system. Mutations of this gene have been shown to result in dysfunctional lymphatic syndrome and TOF. GATA4 aids in cardiac development by helping increase the production of cardiomyocytes. Mutations of this gene have been seen in various familial TOF cases often lasting 2-3 generations." }, { "id": "pubmed23n0747_23313", "title": "[Detection of a Williams Beuren syndrome case by MLPA].", "score": 0.009523809523809525, "content": "Williams-Beuren syndrome (WBS) is a rare developmental disorder characterized by distinctive facial, neurobehavioral, and cardiovascular features. WBS is caused by a heterozygous contiguous gene microdeletion of the WBS crítical region on chromosome 7q11.23. Confirmation of clinical suspicion is essential for clinical monitoring of the patient and genetic counseling of the family. Fluorescence in situ hybridization (FISH) is considered the gold standard technique for detecting WBS. Multiplex ligation-dependent probe amplification (MLPA) has been introduced into DNA diagnostic laboratories for the detection of copy number variations in several diseases including WBS. The objective of this study was to confirm, by MLPA, the clinical diagnosis of WBS in a pediatric patient. This technique allowed to detect the deletion of CYLN2, FZD9, STX1A, ELN, LIMK1 and RFC2 genes. In geographic regions were the detection by FISH is not available for this disease, the MLPA methodology allowed to confirm the clinic diagnostic of WBS. To our knowledge this is the first report demonstrating the confirmation of WBS by MLPA in Argentina." }, { "id": "wiki20220301en475_18284", "title": "Nagwa Abdel Meguid", "score": 0.009433962264150943, "content": "Meguid developed a simple molecular screening method to detect premutation carriers of fragile X syndrome. A premutation carrier is an individual who has between 55-200 CGG repeats in the Fragile X (FMR1) gene. The full mutation has over 200 CGG repeats. The procedure included a rapid modified polymerase chain reaction (PCR)-based screening tool for expanded Fragile X Mental Retardation 1 (FMR1) alleles. The results showed that 16 males out of 53 males had the CGG abnormal repeats characteristic of Fragile X gene. 10 of their mothers and 4 of their sisters also had the FMR1 premutation. 66.6% consanguineous marriages were present in the families studied. It was concluded that fragile X syndrome was ruled out of families with consanguineous parents. Instead, fragile X syndrome could be contributed to earlier carrier detection, which may reduce the number of affected children. By isolating the mutation early, the effects of the disease could be reduced in children and in their" }, { "id": "pubmed23n0650_6381", "title": "Williams-Beuren syndrome: diagnosis by polymorphic markers.", "score": 0.009433962264150943, "content": "Williams-Beuren syndrome (WBS) is caused by a 1-2 Mb microdeletion in the region 7q11.23. The clinical presentation may vary and most of the connective tissue abnormalities can be explained by the haploinsufficiency of the ELN gene in this region. The purpose of this study was to determine the value of a polymerase chain reaction assay that uses three polymorphic markers to detect the microdeletion and compare the clinical features. Thirty-two patients with WBS were ascertained accordingly to clinical diagnostic criteria. The markers D7S1870, ELN 17/exon 18, and Hei 1.3/1.4 were designed to detect the heterozygosity in the region 7q11.23. The three markers were informative in 78% and uninformative in 22% of the cases. The most informative marker (69%) was D7S1870, followed by Hei (55%) and ELN 17/exon 18 (44%). The microdeletion was present in 56% and absent in 22% of patients. The craniofacial and cardiovascular abnormalities did not have significant statistical differences in the cases with and without microdeletion. Two of the syndrome characteristics (an overfriendly personality and hyperacusis) were more frequent in the microdeletion group and these differences were statistically significant (p = 0.006 and p = 0.02, respectively). Polymorphic markers might be a good alternative for the molecular diagnosis of WBS in centers where fluorescence in situ hybridization analysis is not available." }, { "id": "wiki20220301en195_12504", "title": "ARVCF", "score": 0.009345794392523364, "content": "Function Armadillo repeat gene deleted in Velo-Cardio-Facial syndrome (ARVCF) is a member of the catenin family which play an important role in the formation of adherens junction complexes, which are thought to facilitate communication between the inside and outside environments of a cell. ARVCF gene was isolated in the search for the genetic defect responsible for the autosomal dominant Velo-Cardio-Facial syndrome (VCFS) a relatively common human disorder with phenotypic features including cleft palate, conotruncal heart defects and facial dysmorphology. ARVCF gene encodes a protein containing two motifs, a coiled coil domain in the N-terminus and a 10 armadillo repeat sequence in the midregion. Since these sequences can facilitate protein-protein interactions ARVCF is thought to function in a protein complex. In addition, ARVCF contains a predicted nuclear-targeting sequence suggesting that it may have a function as a nuclear protein." }, { "id": "wiki20220301en596_25582", "title": "Stephen Warren (geneticist)", "score": 0.009259259259259259, "content": "Research and work His doctoral dissertation was entitled \"Bloom syndrome as a human mutator mutation\". He published 12 manuscripts during his doctoral training. Warren's postdoctoral studies were focused on human molecular genetics and he first began his studies on fragile X syndrome. He made somatic cell hybrids isolating the human fragile X chromosome in rodent cells and devised a strategy to molecular clone the DNA responsible for the syndrome. He began his molecular experiments to implement this strategy in 1985 when he established his own laboratory at Emory University. Using his somatic cells hybrids, Warren led an international group, including his longtime collaborator David L. Nelson at Baylor College of Medicine, that isolated the FMR1 gene responsible for fragile X syndrome in 1991. The cloning of this locus also uncovered, for the first time, a trinucleotide repeat expansion mutation, a mechanism now known to be responsible for dozens of genetic diseases." }, { "id": "pubmed23n0842_168", "title": "Williams-Beuren Syndrome: Experience of 43 Patients and a Report of an Atypical Case from a Tertiary Care Center in India.", "score": 0.009259259259259259, "content": "Williams-Beuren syndrome (WBS) or Williams syndrome (OMIM 194050) is a multisystem disorder manifested by neurodevelopmental delay and is caused by a hemizygous deletion of ∼ 1.5-1.8 Mb in the 7q11.23 region. Clinical features include cardiovascular anomalies (mainly supravalvular aortic stenosis), peripheral pulmonary stenosis, distinctive facies, intellectual disability (usually mild), unique personality characteristics, and growth and endocrine abnormalities. Clinical diagnostic criteria are available for WBS; however, the mainstay of diagnosis is the detection of the contiguous gene deletion. Although FISH remains the most widely used laboratory test, the diagnosis can also be established by means of qPCR, MLPA, microsatellite marker analysis, and chromosomal microarray (CMA). We evaluated the utility of MLPA to detect deletion/duplication in the 7q11.23 region in 43 patients suspected to have WBS using MLPA kits for microdeletion syndromes. A hemizygous deletion in the 7q11.23 region was found in 41 (95.3%) patients using MLPA. One patient had an atypical deletion detected by CMA. During the initial period of this study, the results of 12 patients tested by MLPA were also confirmed by FISH. Compared to FISH and CMA, MLPA is a cheaper, high-throughput, less labor-intensive and less time-consuming technique for the diagnosis of WBS. Although CMA is expensive and labor-intensive, its effectiveness is demonstrated to detect an atypical deletion and to delineate the breakpoints." }, { "id": "wiki20220301en468_29344", "title": "Ying-Hui Fu", "score": 0.009174311926605505, "content": "Neurodegeneration Trinucleotide repeat expansions and neurological diseases When Fu did her post-doctoral work in Baylor College, she was part of the team that was positional cloning the Fragile-X syndrome gene. There, she studied the trinucleotide repeat sequence expansions, the mutations responsible for the Fragile-X Syndrome, and their correlation with disease severity and age of onset. This work led to the discovery of underlying molecular mechanism for genetic anticipation. Following this work, she cloned the gene responsible for Myotonic dystrophy based on the hypothesis that genetic anticipation in Myotonic dystrophy is also caused by trinucleotide repeat expansion on patient DNA. This mutational mechanism is now known to cause not only Fragile X syndrome and Myotonic dystrophy, but also Huntington's disease and many of the spinocerebellar ataxias. Thus, it is a common mutational mechanism in inherited neurological diseases." }, { "id": "wiki20220301en078_61436", "title": "FMR1", "score": 0.00909090909090909, "content": "Fewer than 1% of all cases of fragile X syndrome are caused by mutations that delete part or all of the FMR1 gene, or change a base pair, leading to a change in one of the amino acids in the gene. These mutations disrupt the 3-dimensional shape of FMRP or prevent the protein from being synthesized, leading to the signs and symptoms of fragile X syndrome. A CGG sequence in the FMR1 gene that is repeated between 55 and 200 times is described as a premutation. Although most individuals with the premutation are intellectually normal, some of these individuals have mild versions of the physical features seen in fragile X syndrome (such as prominent ears) and may experience mental health problems such as anxiety or depression. Fragile X-associated tremor/ataxia syndrome" }, { "id": "pubmed23n0981_25646", "title": "[Genetic diagnosis and noninvasive prenatal testing of a family with Williams-Beuren syndrome].", "score": 0.00909090909090909, "content": "To explore the genetic basis of a fetus with ventricular septal defect (VSD) by using modified noninvasive prenatal testing (NIPT) for the detection of microdeletion syndromes. Chromosomal karyotypes of the fetus and its parents were analyzed by G-banding technique. Next generation sequencing (NGS) was used to detect genomic copy number variations (CNVs) in cell-free fetal DNA. The results were verified by fluorescence in situ hybridization (FISH). The fetus and its parents all had a normal karyotype at 320-400 band level. NGS revealed a deletion of 1.30 Mb at 7q11.23 in the fetus, with a 93% overlap with that of Williams-Beuren syndrome (WBS). The father also had a deletion of 1.42 Mb at 7q11.23, with a 99% overlap with that of WBS. Modified NIPT also detected the 1.30 Mb deletion at 7q11.23 in the fetus. The result of FISH has confirmed the above results. It is necessary to carry out genetic testing on fetuses with VSD. NGS can detect fetal microdeletion syndromes and help to trace their parental origin. The modified NIPT for fetal chromosomal microdeletions/microduplication syndromes is highly accurate." }, { "id": "wiki20220301en319_6370", "title": "1q21.1 deletion syndrome", "score": 0.009009009009009009, "content": "GJA5 has been identified as the gene that is responsible for the phenotypes observed with congenital heart diseases on the 1q21.1 location. In case of a duplication of GJA5 tetralogy of Fallot is more common. In case of a deletion other congenital heart diseases than tetralogy of Fallot are more common. References Further reading Genetics of Mental Retardation, Karger. Knight S. (ed) Chapter One: 'A Parent's' Perspective' contains description and photos of female with 1q21.1 microdeletion External links 1q21.1 deletion, GeneReviews NCBI Bookshelf Orpha.net Hematology Congenital disorders Syndromes affecting the nervous system Animal developmental biology Syndromes affecting the heart" }, { "id": "pubmed23n0506_14917", "title": "Accuracy in identification of patients with 22q11.2 deletion by likely care providers using facial photographs.", "score": 0.009009009009009009, "content": "Numerous facial characteristics are associated with velocardiofacial syndrome. Care providers may use these facial characteristics to identify patients who may benefit from fluorescence in situ hybridization genetic testing to determine the presence of the 22q11.2 deletion. The purpose of this study was to test the hypothesis that experienced care providers were able to correctly diagnose the 22q11.2 deletion on the basis of studying frontal facial photographs. After approval was obtained from the human studies committee, patients who had undergone fluorescence in situ hybridization genetics testing for the presence of a 22q11.2 deletion were asked to submit two frontal photographs: one at infancy and one beyond the second birthday. These photographs were randomized, made anonymous, and then placed on a secure Web site. Specialists in the fields of plastic surgery, otolaryngology, genetics, and speech pathology were asked to evaluate their experience and confidence levels in diagnosing a 22q11.2 deletion and were then asked to rate the photographs by likelihood of deletion using a five-point Likert scale. Thirty-two specialists (10 surgeons, nine geneticists, and 13 speech pathologists) participated in the study. On the basis of clear responses, respondents predicted the presence (sensitivity) and absence (specificity) of the 22q11.2 deletion at chance levels. Of the remaining responses, 20 to 25 percent were unsure and 20 to 25 percent were clearly wrong. When an unsure response was treated as a weak positive, the results favored sensitivity slightly, with a sensitivity of 70 percent and a specificity of 50 percent. Sensitivity improved somewhat with experience, as measured by the number of patients seen per year. The prediction of the presence or absence of the 22q11.2 deletion at chance levels suggests that the ability to diagnose on the basis of appearance alone is not a sufficient diagnostic tool. Although the ability does increase with experience, it is of statistical but not clinical significance." }, { "id": "wiki20220301en002_158051", "title": "Fragile X syndrome", "score": 0.008928571428571428, "content": "FMRP is a chromatin-binding protein that functions in the DNA damage response. FMRP also occupies sites on meiotic chromosomes and regulates the dynamics of the DNA damage response machinery during spermatogenesis. Causes Fragile X syndrome is a genetic disorder which occurs as a result of a mutation of the fragile X mental retardation 1 (FMR1) gene on the X chromosome, most commonly an increase in the number of CGG trinucleotide repeats in the 5' untranslated region of FMR1. Mutation at that site is found in 1 out of about every 2000 males and 1 out of about every 259 females. Incidence of the disorder itself is about 1 in every 3600 males and 1 in 4000–6000 females. Although this accounts for over 98% of cases, FXS can also occur as a result of point mutations affecting FMR1." }, { "id": "pubmed23n0690_23900", "title": "Using a combination of MLPA kits to detect chromosomal imbalances in patients with multiple congenital anomalies and mental retardation is a valuable choice for developing countries.", "score": 0.008928571428571428, "content": "Conventional karyotyping detects anomalies in 3-15% of patients with multiple congenital anomalies and mental retardation (MCA/MR). Whole-genome array screening (WGAS) has been consistently suggested as the first choice diagnostic test for this group of patients, but it is very costly for large-scale use in developing countries. We evaluated the use of a combination of Multiplex Ligation-dependent Probe Amplification (MLPA) kits to increase the detection rate of chromosomal abnormalities in MCA/MR patients. We screened 261 MCA/MR patients with two subtelomeric and one microdeletion kits. This would theoretically detect up to 70% of all submicroscopic abnormalities. Additionally we scored the de Vries score for 209 patients in an effort to find a suitable cut-off for MLPA screening. Our results reveal that chromosomal abnormalities were present in 87 (33.3%) patients, but only 57 (21.8%) were considered causative. Karyotyping detected 15 abnormalities (6.9%), while MLPA identified 54 (20.7%). Our combined MLPA screening raised the total detection number of pathogenic imbalances more than three times when compared to conventional karyotyping. We also show that using the de Vries score as a cut-off for this screening would only be suitable under financial restrictions. A decision analytic model was constructed with three possible strategies: karyotype, karyotype + MLPA and karyotype + WGAS. Karyotype + MLPA strategy detected anomalies in 19.8% of cases which account for 76.45% of the expected yield for karyotype + WGAS. Incremental Cost Effectiveness Ratio (ICER) of MLPA is three times lower than that of WGAS, which means that, for the same costs, we have three additional diagnoses with MLPA but only one with WGAS. We list all causative alterations found, including rare findings, such as reciprocal duplications of regions deleted in Sotos and Williams-Beuren syndromes. We also describe imbalances that were considered polymorphisms or rare variants, such as the new SNP that confounded the analysis of the 22q13.3 deletion syndrome." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 339, 434 ] ], "word_ranges": [ [ 50, 66 ] ], "text": "In Behçet's disease oral and genital aphthous ulcers may occur but urethritis is not a feature." }, "2": { "exist": true, "char_ranges": [ [ 208, 338 ] ], "word_ranges": [ [ 31, 50 ] ], "text": "Reiter's syndrome (triad of conjunctivitis, urethritis and arthritis) is one of the forms in which reactive arthritis can present." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Behçet's disease.", "2": "Reactive arthritis syndrome.", "3": "Sweet's syndrome.", "4": "Vitamin A deficiency.", "5": "Gonococcal infection." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en067_58316", "title": "Reactive arthritis", "score": 0.016255534471853256, "content": "Ocular involvement (mild bilateral conjunctivitis) occurs in about 50% of men with urogenital reactive arthritis syndrome and about 75% of men with enteric reactive arthritis syndrome. Conjunctivitis and uveitis can include redness of the eyes, eye pain and irritation, or blurred vision. Eye involvement typically occurs early in the course of reactive arthritis, and symptoms may come and go. Dactylitis, or \"sausage digit\", a diffuse swelling of a solitary finger or toe, is a distinctive feature of reactive arthritis and other peripheral spondylarthritides but can also be seen in polyarticular gout and sarcoidosis. Mucocutaneous lesions can be present. Common findings include oral ulcers that come and go. In some cases, these ulcers are painless and go unnoticed. In the oral cavity, the patients may suffer from recurrent aphthous stomatitis, geographic tongue and migratory stomatitis in higher prevalence than the general population." }, { "id": "pubmed23n0295_11750", "title": "Increased prevalence of joint manifestations in patients with recurrent aphthous stomatitis (RAS)", "score": 0.015617433414043584, "content": "To characterize the systemic manifestations and joint disease in patents with recurrent aphthous stomatitis (RAS). The presence and features of extra-oral manifestations were determined by a rheumatologist, who examined and interviewed 64 patients, referred during 1993 to the oral medicine clinic for treatment of RAS. Controls were 65 medical staff members of a military clinic associated with the hospital. Based on the rheumatologist's findings and published criteria, the patients were diagnosed as suffering from RAS alone (24 patients), Reiter's syndrome (8), Behçet disease (8), familial Mediterranean fever (1), or RAS with undiagnosable extra oral manifestations (23). Thirteen patients in the last group had joint disease (p &lt; 0.01 compared to the controls), characterized by recurrent mono- or oligoarthritis/arthralgia of short duration, affecting mostly the large joints. Conjunctivitis, pustular rash, lower back pain and urethritis/cervicitis were also common in RAS patients, but only the latter was significantly more frequent in RAS patients than in controls (p &lt; 0.02). These findings suggest that patients with RAS have an increased frequency of a palindromic type joint disease." }, { "id": "pubmed23n0479_10051", "title": "[Behçet's disease in childhood].", "score": 0.01550751879699248, "content": "To make Pediatricians aware of the fact that they must investigate Behçet's disease while performing differential diagnosis of recurrent aphthous stomatitis, even though it is a vasculitis of rare occurrence in early life. Between June 1996 and December 2000, we retrospectively evaluated seven patients of our Pediatric Rheumatology Unit. Demographic, clinical, and laboratory data as well as data regarding treatment and follow-up were presented. Five out of seven patients were female (71.4%), four were non-Caucasian (57.1%), the mean age at onset was 8 years and 11 months (variation of 6 months to 13 years and 8 months), the mean period until diagnosis was 2 years and 3 months (variation of 2 months to 8 years) and the mean follow-up period was 4 years and 2 months (three patients without follow-up). The major criteria of diagnosis were: oral ulcers in seven patients (100%), genital ulcers in three patients (42.8%), ophthalmic alterations in four patients (57.1%) cutaneous vasculitis in one patient (14.2%) and positive pathology test in one patient (14.2%). The minor criteria were: arthralgia/arthritis in five patients (71.4%), family history in two patients (28.5%), and sagittal sinus thrombosis in one patient (14.2%). The initial symptoms included recurrent aphthous stomatitis (more than three painful aphthous ulcers episodes in the period of 1 year), genital ulcers, arthralgia, fever and weight loss. The laboratory findings were: mild anemia in 1/6 patients, ESR&gt;25 in 3/6 patients, increased serum gammaglobulin level in 2/4 patients, B5 histocompatibility antigen in 2/7 patients. The treatment included corticosteroids for 5/7 patients (4 oral, 1 intravenous and one local use), thalidomide for 4/7 patients, colchicine for 2/7 patients and dapsone for 1/7 patient. The outcome was favorable in 4/6, and 3/6 patients presented relapse. Our results confirm the importance of considering the diagnosis of Behçet's disease in patients with recurrent oral and genital ulcers." }, { "id": "pubmed23n0069_14828", "title": "[A case of Reiter's disease with severe skin manifestations successfully treated with oral etretinate].", "score": 0.013844367015098724, "content": "A case of Reiter's syndrome with severe keratoderma being successfully treated with oral Etretinate is reported. A 38 year-old man was referred to our hospital in December, 1985 for treatment of refractory skin eruptions and polyarthralgia. He previously experienced urethritis in December, 1983 with subsequent development of high fever, balanitis, skin eruptions and polyarthritis. Treatments with antibiotics, anti-inflammatory drugs and glucocorticoids were ineffective at that time. The patient was diagnosed as Reiter's syndrome based on his clinical symptoms and the presence of HLA-B27. He was treated in our clinic with oral administration of Etretinate, aromatic retinoids, at the initial doses of 40 mg/day with subsequent increase up to 75 mg/day in 2 weeks. This maintenance dose was continued for two months, resulted in improvements of joint pain, skin eruptions and the laboratory abnormalities. The doses of Etretinate was gradually decreased and then was discontinued after 4 months, when approximately 90% of the skin lesion disappeared. No noticeable side-effect was observed except slight stomatitis. The remission continued for about 2 and half years after cessation of Etretinate without any medication. However, evidence of relapse with the same skin lesions and arthralgia was observed in March, 1989. A repeated treatment with oral Etretinate was attempted with similar but slightly delayed effects." }, { "id": "pubmed23n0020_1876", "title": "The clinical features and HLA associations of reactive arthritis associated with non-gonococcal urethritis.", "score": 0.01324644347900162, "content": "Fifty-seven patients with arthritis associated with non-gonococcal genital infection have been studied. Synovitis characteristically affected one or a few joints, expecially the knee, ankle or metatarsophalangeal joints and was accompanied by tenosynovitis and enthesopathies--each in about one third of the patients. A quarter of the patients had ocular, cutaneous, or mucous membrane lesions (Reiter's syndrome). Although six patients developed a chronic or relapsing course, average duration of the acute episode in the majority was three to five months. Available evidence strongly suggests that infection following sexual intercourse, usually but not always with a new partner, was instrumental in the initiation of the disease. We have suggested the term 'sexually acquired reactive arthritis (SARA)' to emphasize the mode of acquisition of the disease, and note that similar syndromes are seen associated with gut infection. We consider that usage of the term Reiter's syndrome is correctly applied to only those cases which exhibited the characteristic triad of urethritis, arthritis and conjunctivitis with or without other cutaneous and mucous membrane lesions. Thirty-six of the 54 patients who were HLA typed (67 per cent) possessed the antigen HLA-B27. Of 30 who presented directly to a rheumatology unit 25 (82 per cent) were HLA-B27 positive. The other 24 patients initially attended a venereology clinic and only 11 (46 per cent) of these bore the antigen. This appears to reflect disease severity, HLA-B27 positive patients having a significantly longer duration of disease symptoms and a higher frequency of extra-articular manifestations, than those lacking this antigen." }, { "id": "wiki20220301en045_32538", "title": "Aphthous stomatitis", "score": 0.013020465772759351, "content": "Behçet's disease is a triad of mouth ulcers, genital ulcers and anterior uveitis. The main feature of Behçet's disease is aphthous-like ulceration, but this is usually more severe than seen in aphthous stomatitis without a systemic cause, and typically resembles major or herpetiforme ulceration or both. Aphthous-like ulceration is the first sign of the disease in 25–75% of cases. Behçet's is more common in individuals whose ethnic origin is from regions along the Silk Road (between the Mediterranean and the Far East). It tends to be rare in other countries such as the United States and the United Kingdom. MAGIC syndrome is a possible variant of Behçet's disease, and is associated with aphthous-like ulceration. The name stands for \"mouth and genital ulcers with inflamed cartilage\" (relapsing polychondritis)." }, { "id": "pubmed23n1155_14837", "title": "Behcet's disease: Diagnosed as isolated recurrent oral aphthae; a case report.", "score": 0.012948987587116994, "content": "Behçet's disease is a multisystem autoimmune disorder of unknown origin, characterized by frequent oral and genital ulcerations, ocular and cutaneous lesions, arthritis, and it may also involve the gastrointestinal, and central nervous system. In this paper we discuss a case of Behcet syndrome presenting with isolated oral aphthous initially and spotlight on the clinical features and treatment. A case of a 32-year-old male with repetitive oral aphthous on the tongue and the inner cheeks for four days with a history of frequent recurrence. The patient responded to topical triamcinolone acetonide and 5-10 mg/day prednisone. Three weeks later, there was a recurrence of oral aphthous, genitalia lesions, and blurred vision with left eye redness. A uveitis diagnosis was made, and the patient was placed on 75mg (1mg/kg) prednisone with a resultant response. There was another recurrence with all the previous symptoms, so the decision with Dopson treatment was made. The patient was placed on Dapsone, resulting in complete resolution of the lesions with no reproduction within and after six months of several recall visits. The diagnosis of Bechet syndrome was made. Aphthous ulcers may be seen in a variety of disorders, while recurrent and persistent &gt;6 weeks, individual non-healing ulcers require a review of the diagnosis. Behcet disease usually appears 2-3 years after oral and genital ulcers, but oral aphthae may be its first manifestation in 10-20% of cases. AS oral ulcers are among the common complaints of the polyclinics-patients, it is recommended to educate the health professionals to diagnose these unusual cases in the first instance, thus avoiding underdiagnosed and the time management to reduce complications and improve the quality of life in these patients. A case of Behçet's disease in a 32-year-old male who presented initially with oral mucosa and later caused uveitis and genitalia aphthae." }, { "id": "pubmed23n0365_12857", "title": "[A case of intestinal Behçet's disease with abnormal ossification complicated by myelodysplastic syndrome, symptoms revealed after the perforation of ileum ulcer].", "score": 0.012651838890945186, "content": "A 39-year-old man, who had been treated with Etretinate for common wart since he was 29 years old, was admitted to Taga General Hospital complaining of gradually deteriorating lumbago and bilateral hip joints pain in September, 1996. His lower vertebrae and bilateral hip joints showed abnormal ossification on X-ray. The bone scintigraphy indicated the existence of sacroiliitis. His platelet counts were fluctuating between 8 x 10(4) and 9 x 10(4)/mm3. During the follow-up in our out-patient clinic, he was suddenly suffered from severe abdominal pain in August, 1997 and admitted to our hospital. An emergency operation revealed multiple ulcers of his ileum with several perforations. Histological findings of the specimen of the ileum showed simple ulcer. After the operation, he had oral and genital ulcers. He did not have any signs or symptoms of ocular involvement. He was diagnosed as intestinal Behçet's disease. Because he showed gradually pancytopenia for several months after the operation, bone marrow aspiration was performed and a diagnosis of refractory anemia, a type of myelodysplastic syndrome (MDS), with trisomy of chromosome 8 was made. Abnormal ossification of his vertebrae and hip joints were considered to be related to Behçet's disease because an coexistence with sacroiliitis. On the other hand, there is no denying the effects of orally Etretinate administration. Several cases have been reported the association of MDS with Behçet's disease. In this case, the existence of MDS or various symptoms in Behçet's disease became apparent after the perforation of ileum ulcer. This paper discusses possible etiology of the relation between Behçet's disease and MDS, or the characteristic clinical course in this case." }, { "id": "wiki20220301en045_32542", "title": "Aphthous stomatitis", "score": 0.012608565438754119, "content": "Other examples of systemic conditions associated with aphthous-like ulceration include reactive arthritis, and recurrent erythema multiforme. Diagnosis Diagnosis is mostly based on the clinical appearance and the medical history. The most important diagnostic feature is a history of recurrent, self healing ulcers at fairly regular intervals. Although there are many causes of oral ulceration, recurrent oral ulceration has relatively few causes, most commonly aphthous stomatitis, but rarely Behçet's disease, erythema multiforme, ulceration associated with gastrointestinal disease, and recurrent intra-oral herpes simplex infection. A systemic cause is more likely in adults who suddenly develop recurrent oral ulceration with no prior history." }, { "id": "wiki20220301en527_15059", "title": "Oral manifestations of systemic disease", "score": 0.012446679824282167, "content": "Oral manifestations of systematic disease are signs and symptoms of disease occurring elsewhere in the body detected in the oral cavity and oral secretions. High blood sugar can be detected by sampling saliva. Saliva sampling may be a non-invasive way to detect changes in the gut microbiome and changes in systemic disease. Another example is tertiary syphilis, where changes to teeth can occur. Syphilis infection can be associated with longitudinal furrows of the tongue. Mineral and vitamin deficiencies can cause the tongue to appear beefy red and feel sore. Those deficiencies are iron, folate, and vitamin B12. A hairy tongue may be an indication of Epstein Barr virus infection and is usually seen in those infected with human immunodeficiency virus. Other systemic diseases that can cause the tongue to form aphthous ulcers are: Crohn's disease and ulcerative colitis, Behcet's Syndrome, pemphigus vulgaris, herpes simplex, histoplasmosis, and reactive arthritis." }, { "id": "pubmed23n0411_6465", "title": "[Recurrent aphthous stomatitis: treatment with colchicine. An open trial of 54 cases].", "score": 0.012362637362637362, "content": "Colchicine is a treatment used for aphthous stomatitis but its efficacy has never been proved. We report the results of an open trial of 54 patients treated with colchicine for aphthous stomatitis. The aim of our study was to assess the long and short term efficacy and tolerance of this molecule in this disease. The case reports of 64 patients presenting with severe, recurrent aphthous stomatitis treated with colchicine between 1986 and 2000 were analyzed retrospectively. Only immunocompetent patients exhibiting idiopathic aphthous stomatitis or Behçet's disease were included. Ten patients were excluded: 4 cases of Behçet's disease treated with colchicine and systemic corticosteroids, 4 cases of aphthous stomatitis secondary to a hematological cause and 2 patients who were lost to follow-up after 3 month's treatment. Colchicine was prescribed at a dose of 1 to 1.5 mg/d for at least 3 months. All the patients were assessed after 3 month's treatment and all were contacted by phone in May 2000. Our end-point criteria were: the frequency and duration of the episodes, intensity of pain and impact on the quality of life of the patients. Fifty-four patients were included: 39 women (mean age=44 +/- 16.8) and 15 men (mean age=49 +/- 13.5). The disease had progressed for a mean of 11.6 +/- 13.5 years. After 3 month's treatment, 12 patients (22 p. 100) no longer had aphta and were in complete remission, 22 patients (41 p. 100) were significantly improved, since the frequency and duration of the lesions had decreased by at least 50 p. 100 and the latter were no longer painful. Treatment failed or tolerance was poor in 20 patients (37 p. 100). Patients were monitored and assessed for a mean of 4.7 years (range: 6 months to 13 years). Six patients were lost to follow-up. Three patients (6 p. 100) were considered as cured, since they were still in complete remission after suspension of colchicine respectively 6, 24 and 72 months later. Fifteen patients (31 p. 100) had still improved. Among the latter, 10 continued colchicine for a mean of 27 months, and 5 patients stopped treatment, which they considered tedious, after a mean of 16 months. These 15 patients noted a significant reduction in the frequency and duration of the lesions. Moreover, the subjective end-point criteria had improved significantly for them not to wish to change treatment. Thirty patients (63 p. 100) were not improved by the treatment. Some benign adverse events were noted in 10 patients (18.5 p. 100) and led to suspension of treatment in 4 cases. This study, which is the first in size (n=54) and duration of follow-up (4.7 years), showed that colchicine is an efficient preventive treatment of severe aphthous stomatitis for 63 p. 100 of patients after 3 month's treatment and that this improvement was lasting in 37 p. 100 of them. Colchicine should therefore be proposed in first intention in severe recurrent aphthous stomatitis, since it is effective, well tolerated and easy to use." }, { "id": "article-40888_2", "title": "Case Study: 24-Year-Old Male Presenting With Polyarthralgias -- Differential Diagnosis", "score": 0.011983300690650449, "content": "The differential diagnosis for a young male (before fourth decade) with polyarthralgia is more inclined towards rheumatologic conditions like SLE, sarcoid arthritis, scleroderma, or gout. If associated with signs and symptoms of infection, gonococcal joint infection is high on the differential. Rheumatoid arthritis and polymyalgia rheumatica usually affect the older population (after the fourth decade). Based on the distribution of the joints, duration of symptoms, and association with other organ systems the classification of polyarthralgia is very broad and makes for a very challenging diagnosis. The most common differentials for a patient presenting with polyarthralgia are Rheumatoid arthritis, Lupus, Lyme, Septic arthritis, Gonorrheal joint arthritis, or Gout." }, { "id": "article-17766_21", "title": "Recurrent Aphthous Stomatitis -- Evaluation", "score": 0.011796835407399064, "content": "Recurrent aphthous stomatitis is a clinical diagnosis. [3] However, excluding other causes of recurrent aphthous ulcers in the mouth is necessary, like Behçet disease, nutritional deficiencies, or inflammatory bowel disease, particularly when RAS develops suddenly in an adult patient. [14] Some RAS patients have anemia, hematinic, or dietary deficiencies; it is common practice to evaluate the complete blood count, red cell folate, and ferritin and vitamin B12 serum levels, which may also reveal gastrointestinal disorders. [3]" }, { "id": "pubmed23n0702_937", "title": "Urban legends: recurrent aphthous stomatitis.", "score": 0.011759234653202232, "content": "Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high." }, { "id": "pubmed23n0052_20672", "title": "Juvenile onset Reiter's syndrome. A retrospective study of 26 patients.", "score": 0.011569448920399614, "content": "Clinical, laboratory and radiological findings were evaluated in 26 children with Reiter's syndrome, all of whom met the 1982 diagnostic criteria of A. Calin. Twenty-two of the patients (85%) were male and 4 were female (15%); the mean age at onset was 10.5 years (range 4-15.5 yrs). Mean follow-up time was 28.6 months. Diarrhea prior to onset was observed in 18 cases (69%), but there was no report of venereal disease. The full classic triad was initially observed in only 9 patients (35%), urethritis alone in 6 (23%) and conjunctivitis alone in 4 (15%). Arthritis was present in all patients, with the lower limb joints involved in 25 cases (96%); the pattern was pauciarticular in 18 (69%), polyarticular in 7 (27%) and monoarticular in one (4%). There was complete remission in 15 out of the 26 patients (58%), while a sustained and fluctuating course was seen in 7 (27%) and 3 (11.5%) patients, respectively; a single patient showed a remitting course. Balanitis was present in 11 out of the 22 male (50%) cases. Twelve out of 18 patients tested (67%) proved to be HLA B27 positive and there was radiological evidence of sacroiliitis in 5 out of 24 patients (21%). Reiter's syndrome should be included in the differential diagnosis of the arthritic child. As a rule, the course of joint involvement is remittent and sequelae affecting functional capacity are indeed exceptional." }, { "id": "wiki20220301en045_32552", "title": "Aphthous stomatitis", "score": 0.011225806451612903, "content": "RAS type ulceration Recurrent oral ulceration associated with systemic conditions is termed \"RAS-type ulceration\", \"RAS-like ulceration\", or \"aphthous-like ulcers\". Aphthous stomatitis occurs in individuals with no associated systemic disease. Persons with certain systemic diseases may be prone to oral ulceration, but this is secondary to the underlying medical condition (see the systemic disease section). This kind of ulceration is considered by some to be separate from true aphthous stomatitis. However, this definition is not strictly applied. For example, many sources refer to oral ulceration caused by anemia and/or nutritional deficiencies as aphthous stomatitis, and some also consider Behçet's disease to be a variant. Treatment" }, { "id": "First_Aid_Step2_1246", "title": "First_Aid_Step2", "score": 0.011049590755897929, "content": "Arthritis, conjunctivitis, and urethritis in young men. Associated organisms? A 55-year-old man has sudden, excruciating first MTP joint pain after a night of drinking red wine. Diagnosis, workup, and chronic treatment? Spinal stenosis. MCP and PIP joints; DIP joints are spared. Osteoarthritis. Osteogenesis imperfecta. Suspect ankylosing spondylitis. Check HLA-B27. Reactive (Reiter’s) arthritis. Associated with Campylobacter, Shigella, Salmonella, Chlamydia, and Ureaplasma. Gout. Needle-shaped, negatively birefringent crystals are seen on joint fluid aspirate. Chronic treatment with allopurinol or probenecid. Rhomboid-shaped, positively birefringent crystals on joint fl uid aspirate. An elderly woman presents with pain and stiffness of the shoulders and hips; she cannot lift her arms above her head. Labs show anemia and ↑ ESR." }, { "id": "article-17766_8", "title": "Recurrent Aphthous Stomatitis -- Etiology -- Systemic", "score": 0.010527544351073764, "content": "Aphthous-like ulcerations may occur in various systemic diseases, including Behçet disease, nutritional deficiencies, gastrointestinal disorders, and primary and secondary immunodeficiencies, including HIV. [3]" }, { "id": "wiki20220301en012_45679", "title": "Mouth ulcer", "score": 0.009900990099009901, "content": "Other causes A wide range of other diseases may cause mouth ulcers. Hematological causes include anemia, hematinic deficiencies, neutropenia, hypereosinophilic syndrome, leukemia, myelodysplastic syndromes, other white cell dyscrasias, and gammopathies. Gastrointestinal causes include celiac disease, Crohn's disease (orofacial granulomatosis), and ulcerative colitis. Dermatological causes include chronic ulcerative stomatitis, erythema multiforme (Stevens-Johnson syndrome), angina bullosa haemorrhagica and lichen planus. Other examples of systemic disease capable of causing mouth ulcers include lupus erythematosus, Sweet syndrome, reactive arthritis, Behçet syndrome, granulomatosis with polyangiitis, periarteritis nodosa, giant cell arteritis, diabetes, glucagonoma, sarcoidosis and periodic fever, aphthous stomatitis, pharyngitis and adenitis. The conditions eosinophilic ulcer and necrotizing sialometaplasia may present as oral ulceration." }, { "id": "pubmed23n0253_15699", "title": "Exacerbation of soft tissue rheumatism by excess vitamin A: case reviews with clinical vignette.", "score": 0.009900990099009901, "content": "In certain situations, health problems can arise if physicians are not aware of over-the-counter medications and vitamins a patient may be taking in addition to their regular prescriptions. Since many people do not consider OTC drugs to be medications, they often do not relay this information while discussing their medical histories. This article describes how the symptoms of soft tissue rheumatism can become worse if patients ingest an excess amount of vitamin A." }, { "id": "pubmed23n0346_8241", "title": "[Adult-onset Still's disease. Differential diagnosis in recurrent pharyngitis, fever of unknown original and excessive hyperferritinemia].", "score": 0.00980392156862745, "content": "Six weeks before admission a 43-year old previously healthy woman got right-sided pharyngitis, accompanied with Herpes labialis and oral candidiasis. Two weeks later she travelled to a holiday in the Caribbean. During the first week of holiday she developed pharyngitis again, this time accompanied with fever and arthralgies. Therapeutic trial with antibiotics, antimalaric drugs and antiamoebics, given at the holiday resort, did not reduce fever. Immediately after return to Germany a therapeutic trial with imipenem was was attempted, without any apparent improvement. At admission, the patient was febrile, had pinky patchy exanthema and arthralgias. At admission, abnormal findings included anaemia (Hb 8.8 mg/dl), severe leukocytosis (35.3/nl), increased ESR (43/89 mm), CRP (24.2 mg/dl) and ferritin (5751 micrograms/l). Ultrasound examination revealed mild splenomegaly. Computed tomography of the abdomen and chest were without apparent abnormalities. Infection, autoimmune diseases and neoplasia were ruled out. The diagnosis of adult onset Still's disease was established on the basis of a typical triad of symptoms (fever, exanthema, arthritis). Treatment with 100 mg/d prednisolon (started intravenously) was beneficial for fever and arthralgia, and resulted in the normalisation of laboratory findings. After gradual reduction in the corticosteroid dosage, maintenance treatment with 20 mg/d prednisolon was continued over following months. Recurrent prodromal pharyngitis and excessive hyperferritinaemia are, in addition to the triad fever-exanthema-arthritis, further important diagnostic criteria of adult onset Still's disease." }, { "id": "wiki20220301en631_2059", "title": "Autoinflammatory diseases", "score": 0.009708737864077669, "content": "Clinical classification 1. Episodic and multisystemic AIDs (NLRP12-associated disease, Mevalonate kinase deficiency, PFAPA (Periodic fever syndrome, aphthous stomatitis, pharyngitis, and cervical adenitis) or TRAPS (tumor necrosis factor (TNF) receptor–associated periodic fever syndrome)) 2. Episodic, affecting the joints (Gout) 3. Episodic, affecting bone (Chronic recurrent multifocal osteomyelitis (CRMO)) 4. Persistent and multisystemic (Schnitzler syndrome, Crohn's disease or DIRA) 5. Persistent, affecting the skin (Interleukin-36-receptor antagonist deficiency (DITRA), Sweet syndrome or Neutrophilic panniculitis) Molecular mechanism of the origin 1. Inflammasome activation (Mevalonate kinase deficiency or Muckle–Wells syndrome) 2. NFκB activation (NLRP12-associated disease, Crohn's disease or Blau syndrome) 3. IL‑1β pathway dysregulation (PFAPA, Schnitzler syndrome, DIRA or DITRA)" }, { "id": "pubmed23n1166_5982", "title": "[Clinical observation of Behçet's disease in a 33-year-old woman].", "score": 0.009708737864077669, "content": "The paper describes a clinical case of Behçet's disease accompanied by oral aphthous elements and external genital sores. The disease occurred after an infectious and inflammatory process in the oropharynx; chronic erythema nodosum and arthritides were successively diagnosed. A set of anamnestic data and clinical and laboratory examinations could establish a correct diagnosis." }, { "id": "wiki20220301en067_58312", "title": "Reactive arthritis", "score": 0.009615384615384616, "content": "The manifestations of reactive arthritis include the following triad of symptoms: an inflammatory arthritis of large joints, inflammation of the eyes in the form of conjunctivitis or uveitis, and urethritis in men or cervicitis in women. Arthritis occurring alone following sexual exposure or enteric infection is also known as reactive arthritis. Patients can also present with mucocutaneous lesions, as well as psoriasis-like skin lesions such as circinate balanitis, and keratoderma blennorrhagicum. Enthesitis can involve the Achilles tendon resulting in heel pain. Not all affected persons have all the manifestations. The clinical pattern of reactive arthritis commonly consists of an inflammation of fewer than five joints which often includes the knee or sacroiliac joint. The arthritis may be \"additive\" (more joints become inflamed in addition to the primarily affected one) or \"migratory\" (new joints become inflamed after the initially inflamed site has already improved)." }, { "id": "pubmed23n0573_12262", "title": "[Nosological diagnosis and outcomes of arthritis associated with streptococcal infection].", "score": 0.009615384615384616, "content": "To specify the course and outcomes of arthritides associated with streptococcal infection (AASI). The trial comprised 60 patients with arthritis (mean age 26.8 +/- 14.0). The patients met the following criteria: arthritis, elevated (&lt; 500 U) titers of antistreptolisin-0 in the absence of heart disorders detected at Doppler-echocardiography (2D-echoCG), urogenital infection, Yersinia infection, psoriasis. In addition to routine clinical tests, the following investigations were made: tests for alloantigen of B-lymphocytes D8/17 and antigen HLA-B27, antibodies to polysaccharide of streptococcus of group A, bacteriological test of laryngeal smears for streptococcal infection, prospective follow-up (mean 31.2 +/- 19.6 mon) with 2D-echoCG. Rheumatic arthritis was rejected in 33.3% patients. Other diseases were diagnosed: early rheumatoid arthritis (10%), seronegative spondylarthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, Still's disease, Konig's disease, sarcoidosis, gout, arthritis on the background of streptococcal nodular erythema. Acute rheumatoid fever (ARF) was diagnosed in 56.7% patients, poststreptococcal arthritis (PSA) in 10%. PSA differed from ARF by onset at the age of 36.0 +/- 10.2 years, short latent period (11.2 +/- 1.3 days), a significantly longer course of arthritis (95.0 +/- 3.9 days), recurrences. Alloantigen of B-lymphocytes was detected in 52.8% AASI patients (the difference from the control is highly significant (p &lt; 0.001). Arthritis development was not associated with carriage of HLA-B27 carriage. In examination of AASI patients for diagnosis of ARV and PSA it is necessary to reject other diseases among which early RA (10%) is most frequent. It is recommended to make diagnosis of ARF in AASI patients with definition of risk factors (age 7-15 years, family history of rheumatic fever, carriage of alloantigen d8/17), 2.5-year and longer follow-up with 2D-echoCG. Diagnosis of PSA is made in rejection of ARF and in the presence of the following characteristics: development of the disease at the age 30-40 years, a short latent period of the infection, long-term persistent course of arthritis, insufficient effect of nonsteroid anti-inflammatory drugs, frequent affection of sacroiliac joints, recurrence, entezopathy." }, { "id": "wiki20220301en045_32541", "title": "Aphthous stomatitis", "score": 0.009523809523809525, "content": "Gastrointestinal disorders are sometimes associated with aphthous-like stomatitis, e.g. most commonly celiac disease, but also inflammatory bowel disease such as Crohn's disease or ulcerative colitis. The link between gastrointestinal disorders and aphthous stomatitis is probably related to nutritional deficiencies caused by malabsorption. Less than 5% of people with RAS have celiac disease, which usually presents with severe malnutrition, anemia, abdominal pain, diarrhea and glossitis (inflammation of the tongue). Sometimes aphthous-like ulcerations can be the only sign of celiac disease. Despite this association, a gluten-free diet does not usually improve the oral ulceration. Other examples of systemic conditions associated with aphthous-like ulceration include reactive arthritis, and recurrent erythema multiforme. Diagnosis" }, { "id": "pubmed23n0005_9527", "title": "Acute venereal arthritis. Comparative study of acute Reiter syndrome and acute gonococcal arthritis.", "score": 0.009523809523809525, "content": "Acute venereal arthritis, a syndrome of fever and inflammatory arthritis following recent sexual intercourse, is a frequently misdiagnosed arthritic presentation. Nearly half of 39 patients admitted with a diagnosis of acute gonococcal arthritis were subsequently recognized as having acute Reiter syndrome. A retrospective study of both diseases revealed differentiating features that, when prospectively applied to 21 consecutive patients, permitted a correct and prompt bedside diagnosis. Acute Reiter syndrome could be differentiated by characteristic mucucutaneous lesions, arthritis/tenosynovitis confined to lower extremities, massive recurrent knee effusions, low back pain, conjunctivitis, and genitourinary inflammation. Gonococcal arthritis could be differentiated by migratory arthralgias, high fevers, arthritis/tenosynovitis initially confined to upper extremities, typical cutaneous lesions, and dramatic defervescence to penicillin therapy. Laboratory data provided support for each diagnosis." }, { "id": "First_Aid_Step2_560", "title": "First_Aid_Step2", "score": 0.009484196355014367, "content": "Typical onset is in the late teens and early 20s. Presents with fatigue, intermittent hip pain, and LBP that worsens with inactivity and in the mornings. ■↓ spine fl exion ( Schober test), loss of lumbar lordosis, hip pain and stiffness, and ↓ chest expansion are seen as the disease progresses. Anterior uveitis and heart block may occur. Other forms of seronegative spondyloarthropathy must be ruled out, including the following: Reactive arthritis (formerly known as Reiter’s syndrome): A disease of young men. The characteristic arthritis, uveitis, conjunctivitis, and urethritis usually follow an infection with Campylobacter, Shigella, Salmonella, Chlamydia, or Ureaplasma. Psoriatic arthritis: An oligoarthritis that can include the DIP joints. TABLE 2.9-3. Gout vs. Pseudogout Associated with psoriatic skin changes and sausage-shaped digits (dactylitis)." }, { "id": "article-17766_32", "title": "Recurrent Aphthous Stomatitis -- Differential Diagnosis", "score": 0.009455240982334578, "content": "Behçet disease: patients also have recurrent ulcerations in the genitalia, skin disorders (usually erythema nodosum or papulopustular lesions), ocular disease (usually posterior uveitis), and a variety of neurological, gastrointestinal, renal, hematological, or joint disorders." }, { "id": "pubmed23n0369_10879", "title": "[Wxanthema and acute polyarthritis in a young patient].", "score": 0.009433962264150943, "content": "A young woman developed acute polysynovitis and vasculitis-like changes to the skin. Her blood cultures were positive for Neisseria meningitidis, enabling us to diagnose chronic meningococcemia. This finding was a surprise; in retrospect this diagnosis would not have been expected in light of the fact that there was no meningism, the patient's general condition was only slightly diminished and the temperatures were subfebrile. Besides an episode of vasculitis, the primary differential diagnosis of acute polysynovitis in young women should include a bacterial infection, for example with Neisseria. Usually, Neisseria gonorrhoeae (gonococci) are involved and, as in the case described, only very rarely Neisseria meningitidis (meningococci). The present case report is given to illustrate new clinical aspects of known, but rare disease, to remind clinicians to consider the differential diagnosis of acute polyarthritis and to generate discussion about the clinical signs and pathogenesis of reactive arthritides, in particular, Neisseria." }, { "id": "wiki20220301en067_58314", "title": "Reactive arthritis", "score": 0.009345794392523364, "content": "Because common systems involved include the eye, the urinary system, and the hands and feet, one clinical mnemonic in reactive arthritis is \"Can't see, can't pee, can't climb a tree.\" The classic triad consists of: Conjunctivitis Nongonococcal urethritis Asymmetric oligoarthritis Symptoms generally appear within 1–3 weeks but can range from 4 to 35 days from the onset of the inciting episode of the disease. The classical presentation of the syndrome starts with urinary symptoms such as burning pain on urination (dysuria) or an increased frequency of urination. Other urogenital problems may arise such as prostatitis in men and cervicitis, salpingitis and/or vulvovaginitis in women. It presents with monoarthritis affecting the large joints such as the knees and sacroiliac spine causing pain and swelling. An asymmetrical inflammatory arthritis of interphalangeal joints may be present but with relative sparing of small joints such as the wrist and hand." }, { "id": "pubmed23n0313_15469", "title": "[Sweet's syndrome: a study of 16 cases].", "score": 0.009345794392523364, "content": "We performed a retrospective analysis of the records of 16 patients diagnosed in our dermatology service as Sweet's syndrome (SS), with the aim of describing their clinical findings and associations, and comparing our results with previous ones. The mean age was 51, and 82% were female. A previous infection was recorded in 5 cases (31%) (gastroenteritis, primary pulmonary tuberculosis, upper airways infection, wound infection, and streptococcal pharyngitis). Two patients (12%) suffered from a malignant neoplasia (acute myeloid leukemia and prostatic neoplasia), another patient had a coincident bout of acute ulcerative colitis with pyoderma gangrenosum, and a third one referred previous ingestion of diclofenac and intense sun exposure. Most patients had their lesions localized on the upper extremities (75%), fever was present in 8 cases (50%), arthralgia in six (37%), and erythema nodosum in five (31%). The most frequent laboratory finding was an elevated sedimentation rate (93% had values over 20 mm/h), and only 44% of patients had leukocyte counts over 10 x 10(9)/l. Urinanalysis was abnormal in one third of the patients, and chest roentgenograms, performed in ten patients, were all normal. Most of the patients were treated with low doses of oral prednisone (30 mg/day) with good results. The disease recurred in 25% of the patients." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 245 ] ], "word_ranges": [ [ 0, 33 ] ], "text": "We are talking about a patient with 3-vessel coronary artery disease and, very importantly, with severe ventricular dysfunction. Under these conditions, the treatment of choice would be surgical (myocardial revascularization surgery or by-pass)." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Percutaneous revascularization.", "2": "Medical treatment.", "3": "Myocardial revascularization surgery.", "4": "Implantation of balloon counterpulsation.", "5": "Cardiac transplantation." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0097_11940", "title": "Complete occlusion of the left main coronary artery: clinical and angiographic observations in five cases.", "score": 0.01598746081504702, "content": "Involvement of the left main coronary artery is observed in approximately 5 to 8% of patients with coronary artery lesions detected by coronary angiography, but occlusion of the left main artery is a very infrequent finding. Out of approximately 4000 patients undergoing coronary angiography, four men and one woman, 37 to 60 years old, showed total occlusion of this vessel. Four of them had angina pectoris and three had had a myocardial infarction. All five showed deep ST depression in V 2(or 3)-6 during bicycle exercise testing. Apart from the left main artery occlusion, all had significant obstructive lesions in other coronary vessels, including the right coronary artery or its major branches. There was collateral circulation from the right coronary artery in all patients. Left ventricular function was well preserved in three patients and markedly impaired in two. Four patients underwent bypass surgery and they have been followed for 10 to 28 months. Three are free of angina and one has only minimal angina. One patient refused surgery and he continued to have severe angina despite intense medical treatment. He died suddenly after 30 months follow-up. In patients with complete occlusion of the left main coronary artery, development of adequate collateral flow seems important in preserving left ventricular function, but collaterals are usually insufficient to prevent angina. Moreover, associated obstructive lesions in other coronary arteries constitute a potential threat to the collateral circulation. Effective symptomatic relief is obtained by coronary bypass grafting, and revascularization may also improve prognosis in this subset of patients with coronary heart disease." }, { "id": "pubmed23n0254_15995", "title": "[Results of coronary surgery in mildly symptomatic patients with left ventricular dysfunction, multivessel disease and stenotic single residual patent vessel].", "score": 0.015067079463364292, "content": "While efficacy of coronary artery bypass surgery in patients with depressed left ventricular function and myocardial ischemia is widely recognized, its results in patients in the absence of clinical evidence of myocardial ischemia remain uncertain. The purpose of this study was to evaluate the effects of coronary revascularization in comparison with conventional medical therapy in subjects with ischemic cardiomyopathy and myocardial ischemia presumed on the basis of angiographic anatomy but not demonstrated by functional testings. We selected retrospectively patients who underwent coronary angiography from 1986 trough 1993 and met the following criteria: presence of three-vessel coronary artery disease, occlusion of two and significant luminal narrowing (&gt; or = 50%) of the third major epicardial artery, left ventricular dysfunction (ejection fraction &lt; or = 40%), no angina or presence of mild angina, absence of inducible ischemia on exercise test and, when performed, of redistribution in the vascular territory of the patent vessel. Thirty-one consecutive patients underwent isolated surgical revascularization treatment, while thirty medically treated patients with matched clinical characteristics were selected. Age (61 +/- 10 vs 62 +/- 9), gender (M/F 27/3 vs 24/7), NYHA class I-II (53 vs 62%) or NYHA III-IV (47 vs 38%), incidence of previous infarction (87 vs 94%), number of reversible defects in the vascular territory of the patient vessel on stress scintigraphy (0.6 vs 0.5), patent vessel (right coronary artery 7 vs 10; left circumflex 14 vs 12; left anterior descending 9 vs 9) and left ventricular ejection fraction (28 +/- 8 vs 31 +/- 7), were similar in the two groups (medical vs surgical). Surgically treated patients exhibited a lower proportion of overall cardiac deaths (7/31, 23% vs 19/30, 63%; p &lt; 0.001), and more prolonged survival (67 +/- 9.3 vs 34 +/- 2.5 months; p = 0.04, Mantel and Cox test) than medically treated patients, respectively. The incidence of perioperative myocardial infarction was 10% (3/31). Causes of cardiac death were myocardial ischemia (9/19; 47%), sudden death (5/19; 26%) and heart failure (5/19; 26%) in medical patients, while were surgery (3 cases) and surgery related infection (1 case) (total 4/7; 57%), myocardial ischemia (1/7; 14%), sudden death (1/7; 14%) and heart failure (1/7; 14%) in surgical patients. Cox proportional hazard regression analysis with survival as the dependent variable, identified treatment, surgical or medical, as the best predictor of cardiac events (chi square improvement 9.36, p = 0.002). The next most powerful predictors were NYHA class and ACE-inhibitors treatment (chi square improvement 4.47 and 2.79, respectively). In patients with left ventricular dysfunction, multivessel coronary artery disease and single patent but stenotic residual vessel, coronary artery bypass grafting appear to offer a better survival than medical therapy, even in the absence of clinically evident myocardial ischemia." }, { "id": "pubmed23n0608_8239", "title": "[\"Needle-to-scalpel\"--the benefit of urgent CABG in significant left main coronary artery stenosis].", "score": 0.011666666666666665, "content": "Left main coronary artery (LMCA) stenosis is a relatively infrequent but important cause of symptomatic coronary artery disease. The diagnosis of left main coronary artery disease is made by coronary angiography. Coronary artery bypass grafting is the first-line therapy, the standard treatment for LMCA stenosis, which improves the likelihood of survival, while percutaneous coronary intervention (PCI) is emerging as a possible alternative to surgery. We present the case of a patient with history and symptoms of stable angina pectoris, especially associated with exercise, variable threshold, since four years, and who describes a worsening of symptoms in the last month; the angina had become more frequent, more prolonged and occurred at a lower threshold. At about 20 hours from getting admitted to our hospital, the patient had severe and prolonged rest angina, associated with important changes on ECG, which led to the indication of emergency coronary angiography. This investigation showed severe left main coronary artery stenosis and significant lesions in other important vessels (three-vessel disease), in a patient with normal left ventricular function. The recurrence and the intensity of prolonged angina of our patient have necessitated urgent myocardial revascularization surgery with quadruple coronary-artery bypass grafting. After surgery, the patient was asymptomatic and he was discharged 8 days after in a good clinical state. The advantage of coronary artery bypass grafting performed as urgent surgery for the treatment of our patient with left main coronary artery stenosis and concomitant acute coronary syndrome, shortly after coronary angiography, was obvious, significantly improved the clinical outcome, without postoperative ischemic complications." }, { "id": "wiki20220301en359_24609", "title": "Hybrid cardiac surgery", "score": 0.009900990099009901, "content": "Clinical applications Hybrid revascularization approach for coronary artery disease Surgical bypass grafting and percutaneous coronary artery revascularization are traditionally considered isolated options. A simultaneous hybrid approach may allow an opportunity to match the best strategy for a particular anatomic lesion. Thus hybrid coronary revascularization and MIDCAB (minimally invasive direct coronary artery bypass surgery) have been developed. Revascularization of the left anterior descending artery with the left internal mammary artery is by far the best treatment option in terms of long-term results. Integrating this therapy with percutaneous coronary angioplasty (hybrid procedure) offers multi-vessel revascularization through a mini-thoracotomy. Particularly in high risk patients, morbidity and mortality decreases in comparison to conventional surgery. Completion angiography" }, { "id": "pubmed23n0083_1882", "title": "[Indication for coronary revascularization for angina pectoris: correlation with prognosis of medically-treated patients].", "score": 0.009900990099009901, "content": "To assess the indication for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), we studied 93 patients with angina pectoris but without myocardial infarction. All patients had significant stenosis (greater than 50%) in at least one coronary artery, including the left anterior descending artery. Fifty-eight patients received medical treatment (Group I), 12 had PTCA (Group II) and 23 had CABG (Group III). Findings of coronary angiography, treadmill exercise tests and dipyridamole perfusion scintigraphy as well as the frequency of cardiac events during follow-up were assessed in each group. 1. Coronary angiography revealed 1 vessel disease in 38% of the patients in Group I, 58% in Group II, and 13% in Group III; 2 vessel disease in 33%, 25% and 61%; and 3 vessel disease in 29%, 17% and 26%, respectively. 2. Exercise duration with the treadmill test was 4.7 min in Group I, 4.0 min in Group II and 3.7 min in Group III. ST depression (greater than or equal to 1 mm) was induced in 75%, 83% and 95%, respectively. Exercise duration improved from 4.0 to 6.0 min after PTCA and from 3.7 to 4.5 min after CABG. Exercise-induced ST depression also became less frequent; from 83% to 25% after PTCA and from 95% to 32% after CABG. Dipyridamole perfusion scintigraphy showed reversible defects in 86% of the patients in Group I and in all patients in Groups II and III. Reversible defects were observed in 17% of the patients after PTCA and in 21% after CABG. 3. During a mean follow-up period of 26 months, cardiac deaths occurred in one patient (2%) in Group I and 2 (7%) in Group III. Nonfatal cardiac events (myocardial infarction and unstable angina or those necessitating revascularization--late PTCA or CABG) were observed in 12 patients (21%) in Group I, 4 (24%) in Group II and 10 (36%) in Group III. Anginal attacks at least once weekly remained in 12% of the patients in Group I, 19% in Group II and 14% in Group III at the last follow-up. In conclusion, PTCA and CABG appear to be effective methods for improving ischemia and exercise tolerance. However, preventive PTCA and CABG may not be indicated in patients with mild angina, because the prognosis is also excellent in medically-treated patients with angina but without myocardial infarction or left main coronary artery disease." }, { "id": "wiki20220301en048_43632", "title": "Revascularization", "score": 0.00980392156862745, "content": "Applications For coronary artery disease (ischemic heart disease), coronary artery bypass surgery and percutaneous coronary intervention (coronary balloon angioplasty) are the two primary means of revascularization. When those cannot be done, transmyocardial revascularization or percutaneous myocardial revascularization, done with a laser, may be an option. Treatment for gangrene often requires revascularization, if possible. The surgery is also indicated to treat ischemic wounds (inadequate tissue perfusion) in some forms of chronic wounds, such as diabetic ulcers. References Vascular surgery" }, { "id": "wiki20220301en099_51261", "title": "List of MeSH codes (E04)", "score": 0.009708737864077669, "content": "– cardiovascular surgical procedures – cardiac surgical procedures – cardiomyoplasty – heart arrest, induced – circulatory arrest, deep hypothermia induced – heart bypass, right – fontan procedure – heart massage – heart transplantation – heart-lung transplantation – heart valve prosthesis implantation – myocardial revascularization – angioplasty, transluminal, percutaneous coronary – atherectomy, coronary – coronary artery bypass – coronary artery bypass, off-pump – internal mammary-coronary artery anastomosis – pericardial window techniques – pericardiectomy – pericardiocentesis – reperfusion – myocardial reperfusion – vascular surgical procedures – angioplasty – angioplasty, balloon – angioplasty, balloon, laser-assisted – angioplasty, transluminal, percutaneous coronary – angioplasty, laser – angioplasty, balloon, laser-assisted – atherectomy – atherectomy, coronary – angioscopy – arteriovenous shunt, surgical" }, { "id": "pubmed23n0334_16706", "title": "[Surgical revascularization of the myocardium in patients with chronic coronary disease and depressed left ventricular function: 1-year observation].", "score": 0.009708737864077669, "content": "Many reports confirm the importance and benefit of the surgical revascularization (CABG) in patients with ischemic heart disease and severely depressed left ventricular (LV) systolic function. This mode of treatment is better than medical therapy in patients with very low LV ejection fraction (LVEF) and can prolong the life. However, the effect of CABG on LV hemodynamics is still unclear. The aim of the study was: 1) to assess the effect of CABG on LV hemodynamics in patients with low LVEF and 2) to examine the influence of two types of cardioplegia-crystalloid (CC) and blood (BC) cardioplegia--on LV function during 1 year follow-up. 122 patients with stable angina pectoris qualified for CABG were included in the study. Patients were divided into two groups: group I-47 pts with LVEF &lt; or = 40% and group II--75 pts with LVEF &gt; 40% and then patients were randomized for two types of antegrade-retrograde cardioplegia (CC--subgroups Ia, IIa and BC--subgroups Ib, IIb). Before operation and 4 times after CABG (after 2-6 weeks, 3 months, 6 months and 1 year) echocardiographic examination was performed. Diameters of left atrium and ventricle, LVEF and wall motion score index (WMSI) were calculated. During 1 year 8 patients died (5 of them during perioperative period and 3 patients during follow-up). Patients in group I before operation were in higher NYHA and CCS class and had more often myocardial infarction. During each of the five echocardiographic examination the values of LVEF and WMSI did not differ between subgroups Ia vs Ib and IIa vs IIb. In group I, especially in patients with very low LVEF &lt; or = 30%, the values of LVEF and WMSI improved significantly (p &lt; 0.001) during 1 year of follow-up. But in group II a transient deterioration of LVEF (p &lt; 0.05) 2-6 weeks after CABG was noted. We conclude that surgical revascularization in patients with severe depressed hemodynamics improves LV systolic function during 1 year follow-up. The use of CC or BC did not seem to make any difference to the early and long-term hemodynamic effect of the revascularization." }, { "id": "wiki20220301en082_56744", "title": "Intra-aortic balloon pump", "score": 0.009615384615384616, "content": "Indications The following situations may benefit from this device. Cardiogenic shock when used alone as treatment for myocardial infarction. 9–22% survive the first year. Reversible intracardial mechanical defects complicating infarction, i.e. acute mitral regurgitation and septal perforation. Unstable angina pectoris benefits from counterpulsation. Post cardiothoracic surgery—most common and useful is counterpulsation in weaning patients from cardiopulmonary bypass after continued perioperative injury to myocardial tissue. Preoperative use is suggested for high-risk patients such as those with unstable angina with stenosis greater than 70% of main coronary artery, in ventricular dysfunction with an ejection fraction less than 35%. Percutaneous coronary angioplasty In high risk coronary artery bypass graft surgery where cardiopulmonary bypass time was shortened, as well as during intubation period and hospital stay. Thrombolytic therapy of acute myocardial infarction." }, { "id": "pubmed23n0083_7830", "title": "[Results of coronary surgery in patients over 70 years of age].", "score": 0.009615384615384616, "content": "Among the 628 consecutive patients who underwent coronary bypasses performed by the same surgical group between January 1, 1982 and December 31, 1987, 71 (11 p. 100) were aged 70 years or more (mean: 72.5 years; range: 70-83 years). 99 p. 100 of the patients had a history of severe, disabling exertional angina (46 p. 100) or unstable angina (52 p. 100) of 55 months' duration on average; 35 patients (49 p. 100) had already experienced myocardial infarction. Coronary angiography showed a one-vessel disease in 1 case, a two-vessel disease in 1 case, a two-vessel disease in 31 cases and a three-vessel disease in 39 cases; 11 patients (15 p. 100) had stenosis of the left main coronary artery. The ventricular function was considered unaltered in 59 cases (83 p. 100). Altogether, 155 bypasses, including 25 internal mammary grafts, were performed, i.e. an average of 2.2 bypasses per patient. There was only one early (21st day) post-operative death. The post-operative period was uneventful in 57 patients (60 p. 100); 9 developed peri-operative necrosis. Seventy patients have been followed up for a mean period of 24 months: there were 3 late deaths of non-cardiac origin; 60 patients (84.5 p. 100) are now asymptomatic and 3 (4.5 p. 100) are suffering from residual angina. Early mortality excluded, the cumulative probability of survival at 5 years is 94 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0328_5582", "title": "Coronary angioplasty, bypass surgery, and retransplantation in cardiac transplant patients with graft coronary disease.", "score": 0.009523809523809525, "content": "Graft coronary disease (GCD) remains the single greatest limitation to long-term survival of heart transplant recipients. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited; palliative coronary revascularization has been attempted. Because of the high mortality rate associated with advanced forms of GCD our institution offers the option of retransplantation in selected cases. The aim of this study was by analyzing retrospectively the outcomes of angioplasty, coronary bypass grafting, and retransplantation in cardiac transplant patients to attempt to identify subgroups of transplant recipients with graft coronary disease who may profit from myocardial revascularization. Of the 989 patients undergoing 1016 heart transplantations (HTx) at our institution between 10/86 and 12/97, all were screened for the development of GCD. Analyzing routinely annual angiography, intracoronary ultrasound in defined study patients, and autopsy findings, GCD was diagnosed in 124 patients (110 male, 14 female) 2 to 107 months after HTx (mean 30 months). PTCA: Fourty-six out of 124 patients underwent 76 angioplasties at a mean of 50 +/- 30 months (range 4-91 mo) following cardiac transplantation. The primary success rate was 96% (73/76). The reason for the unsuccessful angioplasty attempts (n = 3) was failure to completely penetrate a stenosis of LAD in 2 patients and severe dissection of RCA, which required emergency surgery, in one. Angiographic restenosis occurred in 42% (31 of 76 lesions) and was diagnosed 11 +/- 11 months after the first angioplasty. There was no procedure-related death. CABG: Seven patients underwent bypass surgery at a mean of 67 months (range 6-128 months) after HTx. Elective surgery was performed in 2 patients with proximal severe triple-vessel disease (Type A lesion) and in 1 patient with severe tricuspid regurgitation who received a tricuspid valve replacement and concomitant single-vessel bypass surgery for proximal GCD (Type A lesion). One patient with combined Type A and B/C lesions required emergency surgery for dissection of RCA after an angioplasty procedure. Three patients with post-infarction unstable angina developed worsening congestive heart failure which required emergency surgery. Angiographically all these patients showed diffuse, distal arteriopathy (combined Type B/C lesions). The electively operated patients and the patient with dissection of RCA were successfully treated and survived beyond hospital discharge (overall survival for CABG in GCD patients 4/7 = 57%). After a mean follow-up of 10 months (range 2-32 months) all are in good clinical condition. All 3 patients with distal arteriopathy and emergency surgery died in hospital of left-ventricular failure (43%). Retransplantation: Eight patients underwent retransplantation at a mean of 54 months (range 6-96 months) after HTx. Six of 8 patients had successful operations and survived beyond hospital discharge with a one-year-survival rate of 75%. In a mean follow-up of 31 months (5-68 months) 3 of 6 retransplant recipients developed a recurrence of GCD. The presence of angiographic distal arteriopathy should be considered a significant factor in patient selection for coronary revascularization procedure. Coronary angioplasty is to be considered as a method of treatment for severe, local stenoses (Type A lesion). PTCA may be applied in these selected cardiac transplant recipients with primary success and complication rates comparable to routine angioplasty but with an increased rate of restenosis especially in small vessels (diameter &lt; 2.5 mm). The distinction between Type A lesions in large (diameter &gt; or = 2.5 mm) and small vessels may be important not only with respect to restenosis but also with respect to long-term benefit. The overall survival did not differ between GCD patients with and without PTCA, suggesting this treatment to be largely palliative. (ABSTR" }, { "id": "pubmed23n0285_2026", "title": "[Symptomatic and silent myocardial ischemia during drug therapy and after aortocoronary bypass].", "score": 0.009523809523809525, "content": "In 53 patients with stable angina pectoris 24-hour ambulatory electrocardiographic monitoring (Holter) and bicycle ergometry were used before and six months after a coronary bypass. The examination before operation was made while anti-ischaemic medication was administered, the examination after revascularization was done without medication. The patients were divided into group A (31 patients where complete revascularization of the myocardium was made) and group B (22 patients with incomplete revascularization) and the results were compared during medication and after aortocoronary bypass. In patients of group A revascularization prolonged significantly the load period during ergometry, as compared with medication (from 7.2 +/- 2.2 min. to 9.1 +/- 2.4 min., p &lt; 0.01), the depression of the ST segment in lead V5 was reduced (from 1.3 +/- 0.8 mm to 0.8 +/- 1.0 mm, p &lt; 0.05) and the number of painful episodes during Holter monitoring (from 1 +/- 1 to 0, p &lt; 0.01). In patients of group B none these parameters improved. Medicamentous treatment eliminated ischaemia during a load in 16% of patients in group A, while revascularization did so in 61% (p &lt; 0.01). In patients of group B the success rate of medication was 9%, in revascularization 14% (p = n.s.). During Holter monitoring after revascularization no episodes of ST depressions associated with anginous pain were recorded, although the mean number of silent episodes of ST depressions per 24 hours was 6 +/- 8 in patients of group B and 1 +/- 2 in patients of group A. In patients with stable angina pectoris complete revascularization is significantly more effective than anti-ischaemic medication as regards tolerance of loads and suppression of myocardial ischaemia. Silent myocardial ischaemia is frequent after aortocoronary bypasses and its possible occurrence should be taken into account, in particular in patients with incomplete revascularization." }, { "id": "wiki20220301en325_2192", "title": "Management of acute coronary syndrome", "score": 0.009433962264150943, "content": "Patients without ST segment elevation are said to suffer from non-ST-elevation acute coronary syndrome and tend not to have full occlusion of a coronary artery. If there is evidence of myocardial cell death (especially elevated cardiac biomarkers) they are considered to have a non-ST-elevation myocardial infarction (NSTEMI); otherwise they are classified as suffering from unstable angina. Their management is based on the estimation of their risk for adverse events. Patients at low risk can be adequately treated with medical therapy, in many ways similar to the one used for STEMI (but excluding thrombolytics). Those at moderate to high risk benefit from an early invasive strategy, which includes coronary angiography and, if necessary, revascularization with percutaneous coronary intervention or coronary artery bypass surgery." }, { "id": "pubmed23n0232_4988", "title": "[Involvement of the common trunk of the left coronary artery].", "score": 0.009433962264150943, "content": "This work describes the observations made in a group of 32 patients suffering from left main coronary stenosis (narrowing of 70% or more). 28 patients underwent surgical treatment: they represent 14% of 200 consecutive surgical cases. The diagnosis of left main narrowing is not possible on clinical ground only. However, several common features can be noted. Patients without myocardial infarction commemoratives all experienced unstable angina pectoris. When a bicycle ergometric test could be realized, it was positive for a low work load. It showed a mean 3 mm ST depression for a mean charge of 75 watts. The repolarisation disturbance lasted long after interruption of effort (more than 7 minutes). Coronarography very often showed multiple vessel disease. the anterior descending artery was stenosed in 25 patients, the circumflex artery artery in 23 and the right coronary artery in 27 patients out of the 32. In the majority of the patients, an anastomotic circulation was evidenced. The direction of the vicarious flow was determined by the relative degree of stenosis on the arteries implied in this collaterality. The mortality of coronarography was 1/32. Among the 28 operated patients, 1 died shortly after operation, giving an operative mortality of 3.6%. During a mean follow-up of 15 months, 1 death during the first postoperative year, 2 failures, 2 partial successes and 22 clinical recoveries were noted. Out of 18 patients socially susceptible to work again, 12 are effectively working, 3 are retired and 3 are still totally unable to work at the present time." }, { "id": "pubmed23n0988_21770", "title": "Atypical and delayed de Winter electrocardiograph pattern: A case report.", "score": 0.009345794392523364, "content": "de Winter electrocardiograph (ECG) pattern signifies proximal left anterior descending coronary artery (LAD) occlusion and extensive anterior myocardial infarction, and it is found in about 2% of patients with proximal LAD occlusion. However, it is often unrecognized by physicians. In this case report, we present a patient with chest pain but showing an atypical and delayed de Winter ECG pattern. A previously healthy 61-year-old man attended our emergency department with chest pain radiating to the left arm and back for 4 hours, who was without serious cardiovascular risk factors. ECG at emergency department showed no significant changes. High-sensitivity cardiac troponin I (hs-cTnI) was within normal limit. At 5 hours after onset, ECG showed significant upsloping ST depression at J point in precordial leads V3 to V6, slight ST elevation in aVR and depression in inferior leads, and hs-cTnI peaked at 2.610 μg/L. The diagnosis of de Winter ECG pattern was confirmed by coronary angiography with an occlusion of the proximal LAD. A stent was implanted through percutaneous coronary intervention. The patient's chest pain was relieved without further increase of hs-cTnI. ECG after procedure showed ST segment back to baseline in leads V4 to V6, but persistent ST elevation in V1 to V3 with QS or Q wave. Timely diagnosis of de Winter ECG pattern is very important, especially the atypical and delayed ECG changes. It should be treated as ST elevation myocardial infarction equivalent and deserves emergent revascularization therapy." }, { "id": "pubmed23n0043_6822", "title": "[Constriction of the left main coronary artery. Early and long term treatment outcome].", "score": 0.009345794392523364, "content": "Clinical presentation and course were studies in 45 consecutive patients (p)--39 males, 6 females with angiographically proven left main coronary artery stenosis (LMCA) &gt; 50%. Mean age was 54.7 years. Three (6%) had no history of chest pain, 2 p (4%) had atypical chest pain, and the remaining (90%) had typical angina pectoris. 19 p (42%) had unstable angina, 20 p (44%) had suffered a myocardial infarction in the past. Outside an episode of chest pain most of the patients had an abnormal ECG with ST-T segment depression 2 mm or more in leads V3-6 and ST-T elevation in leads V1 and aVR. No significant differences were found when the abnormalities of the ST-T segment were compared to severity of LMCA obstruction. A symptom limited exercise test was performed in 17 (37%) p. It was abnormal in 13 p (29%). Thirty eight patients (85%) underwent bypass surgery and the mean number of bypass graft was 3.3. Seven patients were treated medically. In the surgical group four p (10.5%) died perioperatively. All of them had subtotal occlusion of LMCA, without significant lesions in the remaining coronary arteries, the ejection fraction (EF) was above 66%. Among thirty four living patients thirty have been asymptomatic. In the medically treated group 3 p (42%) died and only two of four survivors were asymptomatic at a mean follow-up 35.7 months. Left ventricle of all died patients were severely damaged (EF mean 28%), right coronary artery (RCA) was totally occluded and all had rythm disturbances. We conclude, that patients with significant LMCA stenosis had a good prognosis when treated surgically.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0253_2984", "title": "The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses.", "score": 0.009259259259259259, "content": "This study sought to evaluate, in a prospective and randomized trial, the relative efficacies of three possible therapeutic strategies for patients with a single severe proximal stenosis of the left anterior descending coronary artery and stable angina. Although percutaneous transluminal coronary angioplasty and coronary artery bypass surgery are often performed in patients with a single proximal stenosis of the left anterior descending coronary artery, it is unclear whether revascularization offers greater clinical benefit than medical therapy alone. At a single center, 214 patients with stable angina, normal ventricular function and a proximal stenosis of the left anterior descending coronary artery &gt; 80% were randomly assigned to undergo mammary bypass surgery (n = 70), balloon angioplasty (n = 72) or medical therapy alone (n = 72). Angioplasty had to be considered technically feasible in every case. The predefined primary study end point was the combined incidence of cardiac death, myocardial infarction or refractory angina requiring revascularization. At an average follow-up period of 3 years, a primary end point had occurred in only 2 patients (3%) assigned to bypass surgery compared with 17 assigned to angioplasty (24%) and 12 assigned to medical therapy (17%) (p = 0.0002, angioplasty vs. bypass surgery; p = 0.006, bypass surgery vs. medical treatment; p = 0.28, angioplasty vs. medical treatment, all by log-rank test). There was no difference in mortality or infarction rates among the groups. However, no patient allocated to bypass surgery needed revascularization, compared with eight and seven patients assigned, respectively, to coronary angioplasty and medical treatment (p = 0.019). Both revascularization techniques resulted in greater symptomatic relief and a lower incidence of ischemia on the treadmill test; however, all three strategies eventually resulted in the abolition of limiting angina. The more aggressive therapeutic approach with initial bypass surgery for patients with a single severe proximal stenosis of the left anterior descending coronary artery is associated with a lower incidence of medium-term adverse events than coronary angioplasty or medical treatment. However, all three strategies resulted in a similar incidence of death and infarction during an average follow-up period of 3 years. This information should be taken into consideration when physicians and patients make therapeutic choices in this setting." }, { "id": "pubmed23n0098_16909", "title": "Percutaneous transluminal coronary angioplasty in patients with silent myocardial ischemia during exercise testing.", "score": 0.009259259259259259, "content": "Silent myocardial ischemia was present in 50 of 507 patients undergoing PTCA. Of these patients, five had type 1 (asymptomatic with no previous myocardial infarction), 27 had type 2 (asymptomatic after myocardial infarction) and 18 had type 3 silent myocardial ischemia (angina present in addition to silent episodes). Ischemia was documented in all patients in the exercise ECG, in 18 patients with thallium scintigraphy and in four with radionuclide ventriculography. The indication for PTCA was considered established in patients with type 1 silent ischemia based on ECG changes in the presence of high grade stenosis of the left anterior descending artery under the assumption of improved prognosis. The fact that patients with myocardial infarction have a poorer prognosis in the presence of ST-segment depression served as the basis for the indication for PTCA in type 2 patients. In type 3 patients, PTCA was carried out to ameliorate the symptomatic as well as asymptomatic episodes of ischemia. The follow-up period averaged 12 +/- 6 months. The primary rate of success was 92% with no differences between the groups. There were no complications in type 1 and type 2 patients; in two patients with type 3 silent ischemia, immediate bypass surgery was carried out due to acute occlusion of the dilated vessel. One patient in the latter group had myocardial infarction in the region perfused by the dilated vessel four months after the procedure. The angiographically-documented rate of restenosis was 33% in type 1 patients, 26% in type 2 and 40% in type 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "InternalMed_Harrison_19431", "title": "InternalMed_Harrison", "score": 0.00918839360807401, "content": "Embolic distal protection devices decrease the risk of distal embolization, as well as the incidence of no-reflow and myocardial infarction associated with saphenous vein graft interventions. CASE 5: UNPROTECTED LEFT MAIN PCI IN A HIGH-RISK PATIENT (Figs. 297e-6 and 297e-7; Videos 297e-27 to 297e-34) An 89-year-old woman presented with a NSTEMI associated with 5-mm ST-segment depression in the apical leads occurring 2 weeks after hospitalization for a NSTEMI that was treated conservatively. Chronic obstructive lung disease, elderly age, and the patient’s refusal to consider cardiac surgery restricted the choice of therapeutic options to medical and/or percutaneous interventions. Diagnostic catheterization revealed a left dominant circulation with a heavily calcified 80% distal left main coronary artery stenosis extending into the LAD and into the proximal LCx coronary arteries. A 70% proximal LAD lesion was also present." }, { "id": "pubmed23n0507_17524", "title": "[Short- and medium-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery disease in patients who are poor candidates for surgical revascularization].", "score": 0.009174311926605505, "content": "Surgical revascularization is the procedure of choice for unprotected left main coronary artery stenosis, but it may be unsuitable in some patients. We report short- and medium-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery stenosis in a series of patients who were poor candidates for surgery. Descriptive study of a historic cohort of consecutive patients with unprotected left main coronary artery stenosis who were not candidates for surgery, treated with percutaneous coronary intervention at a single center between April 1999 and December 2003. A total of 83 patients (mean age 72 [9] years) were included. Twenty patients (24%) were in shock on presentation. Surgery was considered unsuitable because of unacceptable surgical risk, poor condition of the distal vessels or comorbid conditions in 61 (73.5%) patients, or acute myocardial infarction in 22 (27%). An intraaortic balloon pump was used in 34 (40%); abciximab in 30 (36%) and stenting in 79 (95%) procedures. The intervention was considered successful in 76 patients (92%). Total in-hospital mortality was 28.9% (55% in patients with acute myocardial infarction and 20% in those without acute myocardial infarction). Median follow-up was 17 months. Average survival was 19.7 (2) months. Eighteen (22%) patients were hospitalized again for a new ischemic event, and 14 (17%) underwent revascularization. In 9 cases (10.8%) a new angioplasty was performed, and in 5 (6.0%) surgical revascularization was necessary. Percutaneous coronary intervention is an option for revascularization in left main coronary artery stenosis in patients who are poor candidates for surgery, although in-hospital and long-term mortality remain high." }, { "id": "pubmed23n0036_870", "title": "Main left coronary artery disease. Clinical experience from 1964-1974.", "score": 0.009174311926605505, "content": "Obstructive lesions of the main left coronary artery (LCA) were demonstrated angiographically in 73 patients, comprising 4.3% of the total population referred to us for diagnostic evaluation of chest pain. Although there were no specific historical or clinical features which could absolutely distinguish this subgroup from the larger population of coronary artery disease patients, 81% (34/42) of the double Master's exercise tests, in which the patient achieved a heart rate of at least 110 beats/min. demonstrated greater than or equal 2 mm R-ST segmental depression. Of the total group of 73, 32 were evaluated during the six-year period from 1964 to 1971 and a preliminary report made in 1972. The diagnosis in the remaining 41 patients was established in the 1/2 year period from 1971 to 1973. The initial 32 patients were seen before the significance of a main LCA lesion was appreciated. In this subgroup there were five deaths at the time of cardiac catheterization. However, in the more recent group improved recognition of patients with possible main LCA disease prior to catheterization has led to a much lower death rate related to diagnostic catheterization. Only one of the last 41 patients undergoing coronary angiography has died. Nineteen patients were managed medically. Of this group 17 were considered to be under the same risk of death as the surgical candidates. Their mortality rate, as high. The risk of hying was 43.6% after 24 months, 51.1% after 36 months, and 73.6% after 42 months of observation. Although the initial surgical experience, using internal mammary artery implants and saphenous venin bypass grafts, was associated with a high mortality, direct revascularization surgery over the last 2 1/2 years has been accomplished with a perioperative mortality of only 6.2%. All deaths in the group of 40 patients receiving elective revasularization with saphenous vein bypass grafts occurred in the first six months following surgery. The risk of dying was 12.5% after six months of observation and was unchanged for the remainder of the follow-up period. After 21 months the difference in survival between the two groups is statistically significant (P less than 0.05). The one late death among the surgical survivors occurred four months after the operative procedure and was related to noncardiovaxcular surgical complications. The surgical survivors have been followed for an average of 27 months. Thus revascularization surgery has improved the prognosis for patients with main LCA disease. We currently advise prompt evaluation for any patient suspected of having this type of obstruction and urgent idrect revascularization surgery if this lesion is demonstrated angiographically." }, { "id": "wiki20220301en099_51275", "title": "List of MeSH codes (E04)", "score": 0.00909090909090909, "content": "– thoracic surgical procedures – cardiac surgical procedures – cardiomyoplasty – heart arrest, induced – circulatory arrest, deep hypothermia induced – heart bypass, right – fontan procedure – heart massage – heart transplantation – heart-lung transplantation – heart valve prosthesis implantation – myocardial revascularization – angioplasty, transluminal, percutaneous coronary – atherectomy, coronary – coronary artery bypass – coronary artery bypass, off-pump – internal mammary-coronary artery anastomosis – pericardial window techniques – pericardiectomy – pericardiocentesis – mediastinoscopy – pulmonary surgical procedures – bronchoscopy – collapse therapy – pneumonolysis – pneumothorax, artificial – lung transplantation – heart-lung transplantation – pneumonectomy – pneumonolysis – thoracoplasty – thoracoscopy – thoracic surgery, video-assisted – thoracostomy – thoracotomy – thymectomy – tracheostomy" }, { "id": "InternalMed_Harrison_19429", "title": "InternalMed_Harrison", "score": 0.009069413950346225, "content": "CASE 4: SAPHENOUS VEIN GRAFT INTERVENTION WITH DISTAL PROTECTION (Fig. 297e-5; Videos 297e-23 to 297e-26) A 62-year-old male with a history of chronic stable angina. A four-vessel coronary artery bypass grafting (CABG) surgery was performed 17 years earlier with a left internal mammary artery graft to the LAD, a right internal mammary artery graft to the right coronary artery (RCA), a saphenous vein graft to the first obtuse marginal branch, and a saphenous vein graft to the first diagonal branch. The patient had a recent increase in angina with exertion and was found to have lateral ischemia on an exercise technetium-99m scan. Diagnostic cardiac catheterization revealed a significant stenosis in the body of the saphenous vein graft to the first obtuse marginal branch." }, { "id": "pubmed23n0026_2280", "title": "Mechanical and surgical interventions for the reduction of myocardial ischemia.", "score": 0.009009009009009009, "content": "To reduce myocardial ischemia effectively, mechanical or surgical interventions must achieve either augmentation in coronary blood flow, a reduction in myocardial oxygen demand, or a combination of both. Coronary bypass graft procedures can achieve an immediate augmentation in coronary blood flow distally through the involved vessel and thereby improve myocardial perfusion and oxygen delivery and thus have the potential for reversing myocardial ischemia both acutely and for the long term. Although myocardial revascularization may resolve the ventricular functional alterations associated with acute myocardial ischemia it remains uncertain whether revascularization can reverse ischemic myocardial cellular injury and in what time framework, as related to reversible vs. irreversible ischemic cellular changes. Mechanical circulatory assistance (MCA) using diastolic counterpulsation effectively reduces myocardial ischemia by the physiologic mechanisms of 1) decrease in left ventricular after-load and left ventricular wall tension, 2) improvement is cardiac output by diastolic counterpulsation and 3) augmentation of coronary blood flow by diastolic pressure augmentation. The most effective indication for either MCA or myocardial revascularization is for interruption of myocardial ischemia prior to the development of infarction. Clinical sudies have demonstrated that acute myocardial ischemia can be effectively interrupted by intraaortic balloon pumping (IABP) including reversal of left ventricular dysfunction associated with acute myocardial ischemia. In most instances, cessation of IABP resulted in recurrence of myocardial ischemia indicating the need for urgent revascularization surgery. In the management of medically refractory myocardial ischemia. IABP has been effective in complete suppression of ischemia in 80 percent and resulted in marked improvement in all, allowing safe revascularization surgery with an operative mortality in the range of 5% and perioperative myocardial infarction incidence of 2%. In patients with acute myocardial infarction and cardiogenic shock (AMI-CS), IABP can resolve CS in 75 percent. The combination of IABP and surgery has resulted in survival approaching 45 percent indicative of a significant improvement in salvage in this group of patients where expected mortality approaches 100 percent." }, { "id": "pubmed23n0232_11320", "title": "[Improved angina-free work tolerance up to 6 years following bypass operation according to degree of revascularization].", "score": 0.009009009009009009, "content": "Bypass surgery improves exercise performance in a high percentage of patients with effort angina. The influence of the degree of revascularization on the extent and duration of improvement of exercise parameters was evaluated in 415 patients with angiographically determined degrees of revascularization (REV) by serial exercise testing 1-6 years after bypass surgery. Patients with three different degrees of REV are compared. REV I: All vessels up to 50% stenosed have a patent graft. REV II: The main vessel supplying the left ventricle (LV) has a patent graft. REV III: The main vessel supplying the LV has not a patent graft but at least one additional graft is patent. Angina-free exercise tolerance in watts, the maximum double product (HR X BP), and the percentage of patients with angina pectoris and ST-segment depression during exercise were recorded. In patients with REV I and II the angina-free exercise tolerance was improved up to 6 years after bypass surgery but in patients with REV III only 2 years afterwards. Patients with REV I, REV II, and REV III showed improvement of all three parameters for 6 years, 4 years and 1 year respectively. The completeness of revascularization is an important determinant in the longterm improvement of postoperative exercise parameters up to 6 years after surgery." }, { "id": "pubmed23n0597_16024", "title": "Percutaneous unprotected left main angioplasty with drug-eluting stents in a nonagenarian: feasible and safe despite recurrent restenosis.", "score": 0.008928571428571428, "content": "The management of severe coronary artery disease in the very elderly is challenging and the most appropriate revascularization strategy highly debated. To date, coronary artery bypass surgery has been the treatment of choice for significant stenosis of unprotected left main (ULM) coronary. Whether this holds true also in very old patients is unknown. The Authors hereby report the case of a 91-year-old diabetic man who underwent coronary angiography in June 2005 for subacute unstable angina. Angiography disclosed a critical stenoses in the distal unprotected left main, left anterior descending, and distal left circumflex, which were treated with a paclitaxel-eluting stent and a bare-metal stent (BMS), respectively. Four months later, recurrent angina lead to a second angiography which showed critical restenosis in the left anterior descending and significant ostial stenosis in the left circumflex. Another paclitaxel-eluting stent was implanted in the left anterior descending, followed by kissing balloon in the left main, achieving a good angiographic result. Six months later angina recurred again: at angiography diffuse restenosis in the left main, left anterior descending and left circumflex was documented. A crushing technique was thus employed to deliver 2 sirolimus-eluting stents, achieving a satisfactory final result. Since then, and to date for more than 17 months since the last procedure, this nonagenarian has remained free from anginal chest. This case highlights the potentials and drawbacks of percutaneous coronary intervention for unprotected left main disease, suggesting nonetheless, that this revascularization strategy can be safely repeated even in elderly patients." }, { "id": "pubmed23n0204_4089", "title": "Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. European Coronary Surgery Study Group.", "score": 0.008928571428571428, "content": "This report presents the final results (follow-up 5--8 years) of a prospective study in 768 men aged under 65 with mild to moderate angina, 50% or greater stenosis in at least two major coronary arteries, and good left ventricular function. 395 were randomised to coronary artery bypass surgery, 373 to no treatment; 1 patient in the surgery group was lost to follow-up. These original groups were compared, whatever subsequently happened to the patients. Survival was improved significantly by surgery in the total population, in patients with three-vessel disease, and in patients with stenosis in the proximal third of the left anterior descending artery constituting a component of either two or three vessel disease, and non-significantly in patients with left main coronary disease. An abnormal electrocardiogram at rest, ST-segment depression greater than or equal to 1.5 mm during exercise, peripheral arterial disease, and increasing age independently point to a better chance of survival with surgery. In the absence of these prognostic variables in patients with eigher two or three vessel disease the outlook is so good that early surgery is unlikely to increase the prospect of survival. In terms of anginal attacks, use of beta-adrenergic blockers and nitrates, and exercise performance the surgical group did significantly better than the medical group throughout the 5 years of follow-up, but the difference between the two treatments tended to decrease." }, { "id": "pubmed23n0350_2320", "title": "[Reperfusion therapy and mechanical circulatory support in patients in cardiogenic shock].", "score": 0.008849557522123894, "content": "Cardiogenic shock is a state of inadequate tissue perfusion due to cardiac dysfunction, which is most commonly caused by acute myocardial infarction. The pathophysiology of cardiogenic shock is characterized by a downward spiral: ischemia causes myocardial dysfunction, which, in turn, augments the ischemic damage and the energetical imbalance. With conservative therapy, mortality rates for patients with cardiogenic shock are frustratingly high reaching more than 80%. Additional thrombolytic therapy has not been shown to significantly improve survival in such patients. Emergency cardiac catheterization and coronary angioplasty, however, seem to improve the outcome in shock-patients, which most probably is due to rapid and complete revascularization generally reached by angioplasty. In addition to interventional therapy with rapid coronary revascularization, the use of mechanical circulatory support may interrupt the vicious cycle in cardiogenic shock by stabilizing hemodynamics and the metabolic situation. Different cardiac assist devices are available for cardiologists and cardiac surgeons: 1. intraaortic balloon counterpulsation (IABP), 2. implantable turbine-pump (Hemopump), 3. percutaneous cardiopulmonary bypass support (CPS), 4. right heart, left heart, or biventricular assist devices placed by thoracotomy, and 5. intra- and extrathoracic total artificial hearts. Since percutaneous application is possible with IABP, Hemopump and CPS, these devices are currently used in interventional cardiology. The basic goals of the less invasive intraaortic balloon counterpulsation (IABP; Figure 1) are to stabilize circulatory collapse, to increase coronary perfusion and myocardial oxygen supply, and to decrease left ventricular workload and myocardial oxygen demand (Figure 2). Since the advent of percutaneous placement, IABP has been used by an increasing number of institutions (Figure 3). In addition to cardiogenic shock, the system may be of use in a variety of other indications in the catheterization laboratory and intensive care unit, including weaning from percutaneous cardiopulmonary bypass, in ischaemic left ventricular failure, in unstable angina, in high risk PTCA, and in prophylactic support in patients with myocardial infarction and successful revascularization. Animal experimental data showed that IABP may improve success of thrombolysis and recent clinical data suggest that survival is enhanced and transfer for revascularization is facilitated when patients with myocardial infarction and cardiogenic shock undergo thrombolysis and IABP rather than thrombolysis alone. A lot of studies had demonstrated before, that combined use of counterpulsation and revascularization therapy (i.e. coronary bypass surgery or angioplasty) may improve prognosis in patients with myocardial infarction complicated by cardiogenic shock (Table 1). In such patients, early treatment with IABP is most important: Multivariate analysis identified early IABP-support with a duration of shock to IABP-treatment of &gt; or = 4 hours as an independent predictor of a positive short-term outcome. In shock-patients with postinfarction ventricular septal defect, IABP provides a marked hemodynamic improvement, and a significant decrease in shunt-flow (Figure 5). However, despite initial stabilization with IABP, such patients need immediate surgical repair of the septal defect to avoid hemodynamic deterioration. The rate of complications related to percutaneous IABP was significantly attenuated by employing catheters of reduced size. Using 9.5-F catheters, a long duration of counterpulsation emerged as the most significant factor associated with complications. In our hospital, those patients with 9.5-F catheters in whom counterpulsation did not exceed 48 hours had a low complication rate of 3.9%. The Hemopump is a catheter-mounted transvalvular left ventricular assist device intended for surgical placement via the femoral artery (Figures 6 and 7). (ABSTRACT TRUNCATED)" }, { "id": "pubmed23n0232_5748", "title": "[Improved myocardial function after transluminal coronary angioplasty (author's transl)].", "score": 0.008849557522123894, "content": "To assess the results of transluminal coronary angioplasty (TCA), 42 patients (mean age 50 years) with for coronary artery disease were investigated at rest and during exercise with the ECG (n = 40), thallium-201 myocardial scintigraphy (n = 23) and equilibrium-radionuclide ventriculography (n = 32). Each method of stress testing was quantified: the exercise ECG by means of an ischemia score, incremented with increasing ST-segment depression and decremented as a function of duration of exercise and workload in watts; thallium-201 scintigraphy by means of an index for minimal to maximal perfusion region (vitality index) and redistribution factors; equilibrium-radionuclide ventriculography by means of global ejection fraction and maximum systolic volume change with respect to the end-diastolic volume. The patients were divided into three groups: 30 had successful TCA defined as demonstrating at least a 20% reduction in the stenosis; six underwent aortocoronary bypass operation (nine grafts; complete revascularization in four patients); and in six patients TCA was unsuccessful. TCA was successful in 24 LAD stenoses, 5 RCA stenoses, and in one proximal anastomosis of an aortocoronary bypass graft. Dilatation could not be achieved in three LAD stenoses and three stenoses of the RCA. In those in whom it was successful, TCA yielded an average reduction of coronary artery stenosis from 84 to 43%. Both TCA and bypass operation (OP) led to comparable degrees of functional improvement. The ischemia score decreased from 2.8 to 0.9 after TCA and from 1.6 to 0 after OP. The vitality index increased from 67 to 77% and from 74 to 81% after TCA and OP respectively while the corresponding redistribution factors decreased (TCA: at 1 hour from 5 to 1% and at 3.5 hours from 11 to 4%; OP: at 1 hour from 2.2 to 1.4% and at 3.5 hours from 7.6 to 4.1%. The global ejection fractions at rest improved from 46 to 52% and from 38 to 45% and during exercise from 42 to 50% and from 36 to 43% after TCA and OP respectively. The maximum--dV/dt/EDV increased at rest (TCA: from 2.7 to 3.5 per second; OP: from 2.1 to 3.8 per second) and during exercise (TCA: from 3.1 to 4.0 per second; OP: from 2.6 to 3.3 per second). In the group with unsuccessful TCA, no significant differences in the latter parameters were observed. Ten of the 30 patients who had undergone successful dilatation were reinvestigated after three months. Maintenance of good functional results could be documented in eight while deterioration was seen in two patients, one with a significant restenosis and one who developed a new narrowing distal to the successfully dilated stenosis. Thus, the results show that in selected cases, TCA can render improved ventricular function and perfusion comparable to that of aortocoronary artery bypass surgery." }, { "id": "wiki20220301en010_91451", "title": "Coronary artery bypass surgery", "score": 0.008771929824561403, "content": "A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization. The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization. A meta-analysis with over 6000 patients showed that coronary artery bypass was associated with lower risk for major adverse cardiac events compared to drug-eluting stenting. However, patients had a higher risk of stroke events." }, { "id": "pubmed23n0004_6342", "title": "[The fate of patients with stenosis of the trunk of the left coronary artery].", "score": 0.008771929824561403, "content": "We have studied the fate of 49 patients with stenosis of the trunk of the left coronary artery of more than 50%. The follow-up period extends from 1,5 years to 5 years (with a mean of 33.83 +/- 13.55 months). The clinical picture was not characteristic. Unstable angina was found in 59% of cases. The exercice test (29 patients) was positive in 100%, with a mean depression of 3.3 mm. Stenosis of the trunk, which is rarely an isolated condition (8% of cases), is usually associated with disorders of the other main coronary vessels. Twenty six patients underwent surgery. Thirteen patients who were operable were treated medically. The performance of the left ventricle and the degree of involvement of the coronary arteries were comparable in these two groups. Seven inoperable patients were treated medically. Actuarial survival curves show a significant difference (p less than 0.01) in survival after two years between the operated cases (88%), the operable cases treated medically (60%), and the inoperable cases (57%). The decreased mortality of the operated cases corresponds also with a greater functional capacity in the survivors compared with that of the cases treated medically." }, { "id": "wiki20220301en102_4974", "title": "Drug-eluting stent", "score": 0.008695652173913044, "content": "Two major randomized controlled trials comparing CABG and DES are either completed or ongoing, and have published results - Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) and Future Revascularization Evaluation in Patients With Diabetes Mellitus—Optimal Management of Multivessel Disease (FREEDOM). The five-year follow-up results of SYNTAX showed, depending on the complexity of coronary vessel disease, PCI was either equally effective or inferior to CABG. Similarly, results from the FREEDOM trial published after five years showed CABG to be superior to PCI in reducing rates of death and myocardial infarction. Both trials found either increased or insignificantly different rates of stroke with CABG as compared to PCI. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 236, 326 ] ], "word_ranges": [ [ 39, 54 ] ], "text": "If the epidermal detachment is less than 10% then we would be dealing with Stevens-Johnson" }, "4": { "exist": true, "char_ranges": [ [ 0, 235 ] ], "word_ranges": [ [ 0, 39 ] ], "text": "We are dealing with a severe patient, with target lesions and Nikolsky's sign in > 30% of the body surface area. Together with the history of treatment with carbamazepine, the suspicion will be of toxic epidermal necrolysis (answer 4)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Acute urticaria of pharmacological cause.", "2": "Erythema minor exudative secondary to drugs.", "3": "Pharmacological Stevens-Johnson syndrome.", "4": "Epidermal toxic necrolysis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0681_20513", "title": "Toxic epidermal necrolysis and Stevens-Johnson syndrome.", "score": 0.01827436582109479, "content": "Toxic epidermal necrolysis (TEN) and Stevens Johnson Syndrome (SJS) are severe adverse cutaneous drug reactions that predominantly involve the skin and mucous membranes. Both are rare, with TEN and SJS affecting approximately 1or 2/1,000,000 annually, and are considered medical emergencies as they are potentially fatal. They are characterized by mucocutaneous tenderness and typically hemorrhagic erosions, erythema and more or less severe epidermal detachment presenting as blisters and areas of denuded skin. Currently, TEN and SJS are considered to be two ends of a spectrum of severe epidermolytic adverse cutaneous drug reactions, differing only by their extent of skin detachment. Drugs are assumed or identified as the main cause of SJS/TEN in most cases, but Mycoplasma pneumoniae and Herpes simplex virus infections are well documented causes alongside rare cases in which the aetiology remains unknown. Several drugs are at \"high\" risk of inducing TEN/SJS including: Allopurinol, Trimethoprim-sulfamethoxazole and other sulfonamide-antibiotics, aminopenicillins, cephalosporins, quinolones, carbamazepine, phenytoin, phenobarbital and NSAID's of the oxicam-type. Genetic susceptibility to SJS and TEN is likely as exemplified by the strong association observed in Han Chinese between a genetic marker, the human leukocyte antigen HLA-B*1502, and SJS induced by carbamazepine. Diagnosis relies mainly on clinical signs together with the histological analysis of a skin biopsy showing typical full-thickness epidermal necrolysis due to extensive keratinocyte apoptosis. Differential diagnosis includes linear IgA dermatosis and paraneoplastic pemphigus, pemphigus vulgaris and bullous pemphigoid, acute generalized exanthematous pustulosis (AGEP), disseminated fixed bullous drug eruption and staphyloccocal scalded skin syndrome (SSSS). Due to the high risk of mortality, management of patients with SJS/TEN requires rapid diagnosis, evaluation of the prognosis using SCORTEN, identification and interruption of the culprit drug, specialized supportive care ideally in an intensive care unit, and consideration of immunomodulating agents such as high-dose intravenous immunoglobulin therapy. SJS and TEN are severe and life-threatening. The average reported mortality rate of SJS is 1-5%, and of TEN is 25-35%; it can be even higher in elderly patients and those with a large surface area of epidermal detachment. More than 50% of patients surviving TEN suffer from long-term sequelae of the disease." }, { "id": "pubmed23n0666_16732", "title": "Severe carbamazepine-induced cutaneous reaction in the treatment of post-herpetic neuralgia. Case report.", "score": 0.017470247177296307, "content": "Post-herpetic neuralgia (PHN) is the main complication of herpes zoster. Carbamazepine (CBZ), a well-tolerated anticonvulsant, but frequently associated with severe cutaneous reactions, such as the Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is used in the treatment of this complication. The objective of this article was to report a case of SJS/TEN secondary to CBZ in a patient with PHN. This is a female patient with continuous severe, burning, chock-like pain in the thoracic region and dorsum associated with reduced strength in the ipsilateral upper limb and diaphoresis. She had crusty and erythematous lesions in the dorsal region of the thorax with allodynia and dysesthesia in the affected dermatome. She was treated with CBZ 300 mg.day(-1), amitriptyline (AMT) 12.5 mg at bedtime, and infiltration with local anesthetic in the affected region. After 15 days, she developed malaise, fever, muscle pain, and arthralgia with a mild non-specific cutaneous rash. Carbamazepine was discontinued immediately. One week later, she was hospitalized with urticaria, generalized exanthema, erythematous cutaneous eruptions, bullae, and purpuric maculae all over her body. The impression was of carbamazepine-induced SJS/TEN. She evolved with progressive worsening of her symptoms, with increase in the number and size of cutaneous lesions, besides generalized erythematous macular rash, areas of necrosis, and erosions with symmetrical loosening of the epidermis in face, neck, thorax, dorsum, and limbs, affecting more that 50% of her body surface, besides involvement of buccal, conjunctival, and genital mucosa with vesicular erosions. She had progressive functional worsening, evolving to septic shock and multiple organ failure followed by death. Stevens-Johnson syndrome and toxic epidermal necrolysis are severe cutaneous reaction with potential for elevated morbidity and mortality that requires immediate intervention and adequate management. In addition, we would like to alert that the use of Carbamazepine should be supervised, especially in the elderly." }, { "id": "pubmed23n1164_2609", "title": "Toxic Epidermal Necrolysis: A Case Report on a Drug-Induced Phenomenon.", "score": 0.0164021164021164, "content": "Toxic epidermal necrolysis (TEN) is a group of severe forms of several life-threatening conditions. As a co-infection of this group, Stevens-Johnson syndrome (SJS) is a rare though severe disease of the skin and mucous membranes. Intake of some drugs could cause reactions such as SJS and TEN. A form of severe connective tissue disorder, TEN is also known as Lyell's syndrome and is a common cause of significant skin and mucous membrane disintegration. Adverse medication reactions are the most prevalent and contribute highly to the incidence rates of the major etiological variables for TEN. Erythema, epidermal detachment that manifests as blisters, and denuded skin patches are the defining features of this pathology. In the majority of cases, the administration of pharmaceutical drugs is thought to be the primary cause of SJS/TEN. In this article, we report a case of a 33-year-old male patient who presented with complaints of lower left facial pain and thus was prescribed carbamazepine. Following this, the patient presented with an adverse reaction to the administration of carbamazepine and was taken off the drug immediately. The treatment included the administration of hydration therapy and appropriate antibiotics for treating the fluid-filled vesicles. The treatment regimen continued for three weeks and was stopped when the skin lesions were scarce and there was an improvement in the overall health of the patient." }, { "id": "pubmed23n0590_2805", "title": "Fatal toxic epidermal necrolysis induced by carbamazepine treatment in a patient who previously had carbamazepine-induced Stevens-Johnson syndrome.", "score": 0.016373124592302675, "content": "Toxic epidermal necrolysis (TEN) is a rare but life-threatening skin disease that is most commonly drug-induced. It has recently been suggested that Stevens-Johnson syndrome (SJS) belongs to the same group of skin disorders, although it has a lower mortality rate than TEN. We report the case of a 26-year-old male schizophrenic patient with a history of carbamazepine-induced SJS 5 years earlier. At the time of his current admission, he was admitted to our psychiatry department with acute agitation due to schizophrenia. However, the patient and his family denied history of drug allergy. After 3 days of carbamazepine treatment, the patient developed TEN (body surface area &gt; 90%). He was transferred to the burn center, but despite appropriate treatment, including intravenous hydrocortisone 200 mg q6h and being covered with sterile biological material, he died. It is important to note that re-administration of a drug that previously caused SJS may lead to TEN, which has a very high mortality rate." }, { "id": "pubmed23n1136_14948", "title": "Carbamazepine Induced Stevens-Johnson Syndrome That Developed into Toxic Epidermal Necrolysis: Review of the Literature.", "score": 0.01569676181617348, "content": "Stevens-Johnson syndrome and toxic epidermal necrolysis are both skin diseases believed to be following the pattern of a type IV hypersensitivity mechanism, which can be triggered by infectious agents or administration of a variety of drugs as part of the spectrum of severe cutaneous adverse reactions (SCARs). Fever and blisters, that peel forming painful raw areas, are early symptoms of this condition, and complications such as dehydration, sepsis, pneumonia, and multiple organ failure are typically seen during the course of the disease. <iCase Presentation</i. We present a case of a 23-year-old female patient referred to our hospital after taking carbamazepine and developing high-grade fever and ulcers that appeared initially in her mouth and face but then progressed despite treatment, extending all over her body and involving about 90% of her BSA. The use of IVIG and plasmapheresis was a good management for our case, helping in our patient's well-being and recovery. Even if there is no stipulated guideline treatment for cases of SJS and TEN, we think that further investigations about IVIG and plasmapheresis should be investigated as a possible way to treat both conditions." }, { "id": "pubmed23n1007_17859", "title": "[Drug-induced toxic epidermal necrolysis with secondary aspergillus fumigatus infection: a case report].", "score": 0.01521164021164021, "content": "Among the various drug induced dermatological entities toxic epidermalnecrolysis (TEN) and Stevens-Johnson syndrome (SJS) occupy a primary place in terms of mortality. Toxic epidermal necrolysis also known as Lyell's syndrome was first described by Lyell in 1956. Drugs are by far the most common cause of toxic epidermal necrolysis, in which large sheets of skin are lost from the body surface making redundant the barrier function of the skin, with its resultant complications. Drug-induced toxic epidermal necrolysis are severe adverse cutaneous drug reactions to various precipitating agents that predominantly involve the skin and mucous membranes. Toxic epidermal necrolysis is rare but considered medical emergencies as they are potentially fatal. Drugs are the most common cause accounting for about 65%-80% of the cases. The most common offending agents are sulfonamides, NSAIDs, butazones and hydrantoins. An immune mechanism is implicated in the pathogenesis, but its nature is still unclear. There is a prodormal phase in which there is burning sensation all over the skin and conjunctivae, along with skin tenderness, fever, malaise and arthralgias. Early sites of cutaneous involvement are the presternal region of the trunk and the face, but also the palms and soles, rapidly spread to their maximum extent, the oral mucosa and conjunctiva being affected. Initial lesions are macular, followed by desquamateion, or may be from atypical targets with purpuriccenters that coalesce, from bullae, then slough. The earlier a causative agent is withdrawn the better is the prognosis. Several treatment modalities given in addition to supportive care are reported in the literature, such as systemicsteroids, high-dose intravenous immunoglobulins, ciclosporin, TNF antagonists. Recovery is slow over a period of 14-28 days and relapses are frequent. Mortality is 25%-50% and half the deaths occur due to secondary infection. Here we report a 50-year-old female of drug-induced toxic epidermal necrolysis. She was admitted to the dermatology ward with extensive peeling of skin over the trunk and limbs. She had taken alamotrigine for epilepsy. A week after taking the tablets, the patient developed a severe burning sensation all over the body and followed by a polymorphic erythematous dermatitis and widespread peeling of skin. We treated this patient with high dose corticosteroids, high-dose intravenous immunoglobulins and etanercept, but eventually she died of secondary aspergillus fumigatus infection." }, { "id": "pubmed23n0280_14726", "title": "Clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme.", "score": 0.014944339958318507, "content": "To conduct a prospective case-control study about causative factors of severe bullous erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis, we needed to define criteria for classifying the cases and standardize the collection of data so that cases could be reliably diagnosed according to this classification. Based on review of case histories and photographs of patients, a group of experts proposed a classification based on the pattern of erythema multiforme-like lesions (categorized as typical targets, raised or flat atypical targets, and purpuric macules) and on the extent of epidermal detachment. An atlas illustrating this classification that included photographs and schematic drawings was developed. We compared the evaluations of 28 cases by four nonphysicians relying on the atlas with the evaluations of the same cases by five experts not using the atlas to determine the usefulness of this atlas for classifying cases according to our nosologic schema. The following consensus classification in five categories was proposed: bullous erythema multiforme, detachment below 10% of the body surface area plus localized \"typical targets\" or \"raised atypical targets\"; Stevens-Johnson syndrome, detachment below 10% of the body surface area plus widespread erythematous or purpuric macules or flat atypical targets; overlap Stevens-Johnson syndrome-toxic epidermal necrolysis, detachment between 10% and 30% of the body surface area plus widespread purpuric macules or flat atypical targets; toxic epidermal necrolysis with spots, detachment above 30% of the body surface area plus widespread purpuric macules or flat atypical targets; and toxic epidermal necrolysis without spots, detachment above 10% of the body surface area with large epidermal sheets and without any purpuric macule or target. Using the atlas, the nonexperts showed excellent agreement with the experts. This study suggests that an illustrated atlas is a useful tool for standardizing the diagnosis of acute severe bullous disorders that are attributed to drugs or infectious agents. Whether the five categories proposed represent distinct etiopathologic entities will require further epidemiologic and laboratory investigations." }, { "id": "pubmed23n0668_6781", "title": "Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap associated with carbamazepine use.", "score": 0.01466795615731786, "content": "A benign pruritic rash occurs in 10%-15% of persons treated with carbamazepine. A small fraction of them may experience life-threatening dermatological syndromes such as exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). The case of an 18-year-old female suffering from bipolar affective disorder (mania) who was being treated with carbamazepine, lithium, chlorpromazine and benzhexol is presented. After 10 days of treatment, she developed high-grade fever and mucocutaneous manifestations of SJS-TEN overlap. She was treated in hospital with systemic corticosteroids, antibiotics, intravenous fluids and other supportive measures, and recovered after 3 weeks." }, { "id": "pubmed23n1068_23492", "title": "A 51-Year-Old Woman with Drug-Induced Hypersensitivity Syndrome Associated with Carbamazepine, Reactivation of Human Herpesvirus 6, and Acute Liver Failure: A Case Report.", "score": 0.014285714285714285, "content": "BACKGROUND Infection with human herpesvirus 6 (HHV-6) is a recognized risk factor for the development of drug-induced hypersensitivity syndrome (DIHS). DIHS is a systemic autoimmune condition that presents with mucocutaneous lesions of varying severity and comprises 3 subtypes: toxic epidermal necrolysis, Stevens-Johnson syndrome, and drug reaction with eosinophilia and systemic symptoms (DRESS). Here, we describe the case of a 51-year-old woman with a diagnosis of DIHS associated with carbamazepine, reactivation of HHV-6, and acute liver failure, which was consistent with DRESS. CASE REPORT We present the case of a 51-year-old Japanese woman who had been taking carbamazepine for epilepsy for the past 3 weeks. She presented with a fever, liver dysfunction, eosinophilia, and the sudden appearance of a skin rash. Steroid therapy was started for suspected drug-induced liver injury. The skin eruption disappeared, and liver dysfunction showed an improving trend. However, after stopping steroid, the pyrexia and eosinophilia reappeared. Therefore, prednisolone was re-administrated. HHV-6 DNA was detected, so HHV-6 reactivation was confirmed. Carbamazepine was stopped, and the clinical manifestations improved. She was ultimately diagnosed with DIHS, consistent with DRESS, associated with carbamazepine and HHV-6 reactivation, and liver dysfunction was assessed histologically. Therefore, the drug-related hepatotoxicity of carbamazepine played a role in causing liver damage rather than HHV-6 infection at that time. CONCLUSIONS We describe a case of DIHS that was also associated with acute liver failure, consistent with DRESS. The case highlights the importance of making the correct diagnosis, as well as the management of mucocutaneous lesions and other systemic conditions (including acute liver failure)." }, { "id": "pubmed23n0648_2252", "title": "Severe cutaneous reactions caused by barbiturates in seven Iranian children.", "score": 0.013898601398601398, "content": "The severe adverse cutaneous reactions of erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare mucocutaneous diseases associated with significant morbidity and mortality. The most common cause is antiepileptic drugs, particularly carbamazepine and lamotrigine, as well as the barbiturates group (phenobarbital and phenytoin). In this article, we present seven children with severe adverse cutaneous reactions caused by barbiturates. The age of the affected children was between 2 and 11 years and they all had a history of taking barbiturates. Their symptoms started 1-3 weeks after the initiation of barbiturates, including a prodrome characterized by 2-3 days of malaise, fever, cough and anorexia, after which the skin and mucosal lesions appeared and worsened. The skin lesions varied from rash to large bullae, plus different forms of mucous membrane involvement. The offending drugs (barbiturates) were stopped immediately and care was largely supportive. As a result of the morbidity and/or mortality associated with EM, SJS and TEN, physicians should keep in mind their differential diagnosis when cutaneous reactions are observed in patients undergoing barbiturate therapy. Furthermore, although TEN and SJS are life-threatening diseases, early detection and appropriate care can lead to a decrease in the incidence of death. The strategies described here seem to be successful and safe because, despite the serious conditions, our patients responded well. All survived." }, { "id": "pubmed23n1097_18179", "title": "Carbamazepine induced toxic epidermal necrolysis and Stevens-Johnson syndrome overlapping during pregnancy in a South-East Asian patient: A case report.", "score": 0.01387846961740435, "content": "Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare and severe forms of drug-induced skin reaction. Most frequently involved drugs are noted to be non-steroidal anti-inflammatory agents, antibiotics, and anticonvulsants. These have high morbidity and mortality and counts among dermatological emergencies. We report an eventful case of a 22-year-old lady who suffered and recovered from carbamazepine-induced SJS/TEN overlapping during her pregnancy. Our patient had a history of epilepsy for which she was under sodium valproate. Switching to carbamazepine due to its low teratogenicity led our patient to this condition. History of prodromal symptoms and exposure to carbamazepine helped in the diagnosis. Carbamazepine abstinence and a multidisciplinary approach in symptomatic management worked very well for the patient. Carbamazepine-induced TES/SJS manifests multisystem effects and requires a multidisciplinary approach for management. The condition itself is life-threatening and in its addition, their sequelae further threaten the life of the patients. Early intervention is the key. Genetically susceptible are thought to be the ones carrying human leukocyte antigen B*15:02 (HLA-B*15:02) allele and it is most prevalent in South-East Asian populations. Screening of this allele before using carbamazepine prevents the incidence of carbamazepine-induced SJS/TEN. Prodromal symptoms of carbamazepine-induced SJS/TEN constitute flu-like symptoms that should not be missed. Early intervention and multidisciplinary approach prevent secondary infections and complications. Screening for HLA-B*15:02 variant allele and close monitoring of these adverse reactions along with proper counseling to patients goes a long way in preventing the development of this life-threatening condition." }, { "id": "wiki20220301en001_135064", "title": "Stevens–Johnson syndrome", "score": 0.013689281413087114, "content": "Stevens–Johnson syndrome (SJS) is a type of severe skin reaction. Together with toxic epidermal necrolysis (TEN) and Stevens–Johnson/toxic epidermal necrolysis (SJS/TEN), it forms a spectrum of disease, with SJS being less severe. Erythema multiforme (EM) is generally considered a separate condition. Early symptoms of SJS include fever and flu-like symptoms. A few days later, the skin begins to blister and peel, forming painful raw areas. Mucous membranes, such as the mouth, are also typically involved. Complications include dehydration, sepsis, pneumonia and multiple organ failure. The most common cause is certain medications such as lamotrigine, carbamazepine, allopurinol, sulfonamide antibiotics and nevirapine. Other causes can include infections such as Mycoplasma pneumoniae and cytomegalovirus, or the cause may remain unknown. Risk factors include HIV/AIDS and systemic lupus erythematosus." }, { "id": "pubmed23n0353_21079", "title": "[Stevens-Johnson syndrome with transition to toxic epidermal necrolysis after carbamazepine administration, heroin and alcohol abuse].", "score": 0.013597612958226769, "content": "A 28 year old patient developed a severe bullous exanthem and enanthem combined with hepatitis, fever and blood count abnormalities after taking carbamazepine and consumption of heroin and alcohol. After discontinuing carbamazepine, prednisolone was given over a five day period accompanied by intravenous fluid and electrolyte substitution and local therapy which lead to improvement. Severe bullous skin reactions nowadays are classified into erythema exsudativum multiforme majus (EEMM), Stevens-Johnson syndrome (SJS), overlap Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS/TEN), TEN with maculae and TEN on large erythema, and they are most often caused by antibiotics and anticonvulsant drugs. Heroin and alcohol abuse alters host immunity which subsequently may increase susceptibility to allergic reactions. There is a high (40%) mortality rate for TEN, and patients with organ involvement are at increased risk." }, { "id": "pubmed23n0504_7176", "title": "[Severe drug-related skin reaction: toxic epidermal necrolysis caused by carbamazepine].", "score": 0.013559477845192132, "content": "Drug-related skin reactions often present as macular, maculopapular or urticarial rashes. Severe drug eruptions are rare, with life-threatening events occurring in about 4 per one million persons a year. In pediatric patients the estimated incidence of Stevens-Johnsons-syndrome (SJS) and toxic epidermal necrolysis (TEN) is even lower. They are often caused by antiepileptic drugs like carbamazepine. A 10 (5)/ (12) year old boy of dark complexion suddenly developed a severe bullous skin disease six weeks after starting carbamazepine therapy due to focal epilepsy. Within few hours a life-threatening systemic inflammatory reaction occurred with subsequent respiratory failure. The clinical course was complicated by bacterial sepsis, bilateral thrombosis of the external iliacal veins and bilateral ocular symblephara. The skin healed with considerable pigmentary disturbance. We report the differential diagnostic and therapeutical features of toxic epidermal necrolysis and give a review of the literature." }, { "id": "pubmed23n0719_13699", "title": "Drug-induced Stevens-Johnson syndrome: case series from tertiary care centre in Gujarat.", "score": 0.013511266317452399, "content": "The aims of the present article were to study clinical features and to analyse them in different drug class associated with Stevens-Johnson syndrome (SJS) in a tertiary care hospital in Gujarat, India. A prospective hospital-based study was carried out over a period of 3 years (June 2007 to September 2009) at Sheth Vadilal Hospital, Ahmedabad, India. The diagnosis of SJS was made mainly on the basis of the clinical findings, which included extensive erythema multiforme, purpuric lesions with bullae and detachment of skin involving at least two mucous membranes. Further, in each patient suspected with SJS, various laboratory tests such as complete blood count, liver function tests, metabolic panel, chest X-ray and other serological test were carried out. SJS was confirmed on the basis of most widely accepted Bastuji-Garin definition. Causality assessment was performed using the Naranjo scale. Only 'probable' and 'definite' reactions were included. Antibacterials for systemic use, anti-inflammatory and antirheumatic products and antiepileptics were the drug classes most commonly associated (8 of 29 cases, each) with SJS. Individually, ibuprofen was involved in the highest number of cases (five cases, 17.2%), followed by carbamazepine (four cases, 13.8%) . The mean duration of developing SJS symptoms was 15.9 days (SD = 8.7 days) and improvement after treatment was 14.2 days (SD = 4.6 days). The duration of appearing SJS symptoms varied significantly between different classes of drugs (p &lt; 0.001). The appearance of SJS symptom started within 10 days for anti-inflammatory and antibacterial compared with 24 days of antiepileptic agents. All the patients with antiepileptic agent-induced SJS had 7% to 9% of detached body surface area. In two patients, SJS progressed to toxic epidermal necrolysis and of which one led to death and the other developed long-term complication of conjunctival xerosis. A total of six patients developed long-term complications: four patients had conjunctival synechia, one patient had conjunctival xerosis and one patient had urethral stricture. More than 80% of the SJS events were induced by antibacterial, anti-inflammatory and antiepileptic agents with same frequency. The duration of the appearance of SJS symptoms significantly varied between different drug classes and started within 10 days for anti-inflammatory and antibacterial compared with 24 days of antiepileptic agents." }, { "id": "wiki20220301en255_33710", "title": "Erythema multiforme major", "score": 0.012647898816809465, "content": "Erythema multiforme major is a form of rash with skin loss or epidermal detachment. The term \"erythema multiforme majus\" is sometimes used to imply a bullous (blistering) presentation. According to some sources, there are two conditions included on a spectrum of this same disease process: Stevens–Johnson syndrome (SJS) Toxic epidermal necrolysis (TEN) which described by Alan Lyell and previously called Lyell syndrome[5]. In this view, EM major, SJS and TEN are considered a single condition, distinguished by degree of epidermal detachment. However, a consensus classification separates erythema multiforme minor, erythema multiforme major, and SJS/TEN as three separate entities. References 5. Orphanet Journal of Rare Diseases 2010, 5:39 doi:10.1186/1750-1172-5-39 External links Drug eruptions" }, { "id": "pubmed23n1134_8148", "title": "Successful Treatment of Carbamazepine-Induced Toxic Epidermal Necrolysis With Clinical Gastrointestinal Involvement: A Case Report.", "score": 0.012546676624346527, "content": "Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare and life-threatening disease of the skin and mucosal surfaces. Although gastrointestinal manifestations in adults are potential prognostic factors for disease severity, there are limited data on such cases and their standard management in the pediatric population. We herein report the case of an 8-year-old girl with a 1-year history of epilepsy, who presented with bilateral conjunctivitis and progressively widespread bullous, and pruritic eruption based on erythematous skin after administration of carbamazepine. A diagnosis of carbamazepine-induced TEN was made, and the drug was immediately discontinued. The result of genetic screening showed that the patient was positive for the HLA-B<sup*</sup15:02 allele. Then, her condition got worse by developing gastrointestinal involvement, including hematemesis and severe watery bloody diarrhea. A combination of the intravenous immunoglobulin and the appropriate dose of systemic steroids have contributed to a favorable outcome in this case. Multidisciplinary care of mucocutaneous involvement, supplemental nutrition, and fluid replacement was also critically warranted. This report aims to contribute to the current literature on TEN-related gastrointestinal manifestations in pediatrics and highlights the need for further investigations in determining the optimal treatment in such cases. In conclusion, we reported the successful treatment of TEN-related gastrointestinal manifestations in a pediatric patient, which should be critically considered in patients with SJS/TEN. Since it may significantly contribute to the poor prognosis of the illness, further investigations in determining standard management in such cases are necessary." }, { "id": "wiki20220301en001_135087", "title": "Stevens–Johnson syndrome", "score": 0.012348668280871672, "content": "Stevens–Johnson syndrome (SJS) is a milder form of toxic epidermal necrolysis (TEN). These conditions were first recognised in 1922. A classification first published in 1993, that has been adopted as a consensus definition, identifies Stevens–Johnson syndrome, toxic epidermal necrolysis, and SJS/TEN overlap. All three are part of a spectrum of severe cutaneous reactions (SCAR) which affect skin and mucous membranes. The distinction between SJS, SJS/TEN overlap, and TEN is based on the type of lesions and the amount of the body surface area with blisters and erosions. It is agreed that the most reliable method to classify EM, SJS, and TEN is based on lesion morphology and extent of epidermal detachment. Blisters and erosions cover between 3% and 10% of the body in SJS, 11–30% in SJS/TEN overlap, and over 30% in TEN. The skin pattern most commonly associated with SJS is widespread, often joined or touching (confluent), papuric spots (macules) or flat small blisters or large blisters" }, { "id": "First_Aid_Step2_110", "title": "First_Aid_Step2", "score": 0.012299291777044925, "content": "Patients with erythema nodosum may have a falseVDRL (as in SLE). SJS and TEN constitute two different points on the spectrum of life-threatening exfoliative mucocutaneous diseases that are often caused by a drug-induced immunologic reaction. The epidermal separation of SJS involves < 10% of body surface area (BSA), whereas TEN involves > 30% of BSA. Involvement of 10–30% of BSA is often considered SJS/TEN overlap. May be preceded by erythema multiforme, a flulike prodrome, skin tenderness, a maculopapular drug rash, or painful mouth lesions. Often associated with a history of exposure to new drugs, such as penicillin, sulfonamides, seizure medications (e.g., phenytoin, carbamazepine), quinolones, cephalosporins, allopurinol, corticosteroids, or NSAIDs. Exam reveals severe mucosal erosions with widespread erythematous, cutaneous macules or atypical targetoid lesions. The epidermal lesions often become confluent and show a Nikolsky’s sign and epidermal detachment." }, { "id": "wiki20220301en154_45011", "title": "Genital ulcer", "score": 0.012153455681374464, "content": "Causes of drug induced genital ulcers take the form of Stevens–Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, and fixed drug eruptions in response to a diverse list of medications. Stevens–Johnson syndrome and toxic epidermal necrolysis are more likely than erythema multiforme to have genital manifestations although all present with a toxic appearing patient. A fixed drug eruption in comparison does not present as a toxic appearing patient but rather single or multiple erythematous patches that vary in size and shape which eventually turn dark brown in color and become itchy. The defining characteristic is that these drug eruptions appear in the same location each time the offending medication is used, and will resolve on their own." }, { "id": "wiki20220301en218_4109", "title": "List of skin conditions", "score": 0.012074903142488162, "content": "Drug-induced nail changes Drug-induced pigmentation Drug-induced pseudolymphoma Drug-induced urticaria Erythema multiforme major (erythema multiforme minor–erythema multiforme von Hebra) Exudative hyponychial dermatitis Fixed drug reaction Halogenoderma Heparin necrosis HIV disease-related drug reaction Hydroxyurea dermopathy Injection site reaction Iododerma Leukotriene receptor antagonist-associated Churg–Strauss syndrome Linear IgA bullous dermatosis (linear IgA dermatosis) Photosensitive drug reaction Red man syndrome Severe cutaneous adverse reactions (includes DRESS syndrome, Steven Johnson syndrome, Toxic epidermal necrolysis, Stevens-Johnson/toxic epidermal necrolysis overlap syndrome, and Acute generalized exanthematous pustulosis) Scleroderma-like reaction to taxanes Serum sickness-like reaction Steroid acne Steroid folliculitis Stevens–Johnson syndrome Sulfonamide hypersensitivity syndrome Texier's disease Toxic epidermal necrolysis (Lyell's syndrome)" }, { "id": "wiki20220301en031_2586", "title": "Erythema multiforme", "score": 0.011891050583657588, "content": "Erythema multiforme was first described by von Hebra in 1860. Signs and symptoms The condition varies from a mild, self-limited rash (E. multiforme minor) to a severe, life-threatening form known as erythema multiforme major (or erythema multiforme majus) that also involves mucous membranes. Consensus classification: Erythema multiforme minor—typical targets or raised, edematous papules distributed acrally Erythema multiforme major—typical targets or raised, edematous papules distributed acrally with involvement of one or more mucous membranes; epidermal detachment involves less than 10% of total body surface area Stevens–Johnson syndrome and toxic epidermal necrolysis used to be considered part of the erythema multiforme spectrum, but that is no longer the case." }, { "id": "article-30294_3", "title": "Stevens-Johnson Syndrome -- Introduction", "score": 0.011738206275181625, "content": "Stevens-Johnson syndrome/toxic epidermal necrolysis is a rare, acute, serious, and potentially fatal skin reaction in which there are sheet-like skin and mucosal loss accompanied by systemic symptoms. Medications are causative in over 80% of cases. Stevens-Johnson syndrome/toxic epidermal necrolysis is classified by the extent of the detached skin surface area. Stevens-Johnson syndrome: less than 10% body surface area Overlap Stevens-Johnson syndrome/toxic epidermal necrolysis: 10% to 30% body surface area Toxic epidermal necrolysis more than 30% body surface area" }, { "id": "wiki20220301en031_2587", "title": "Erythema multiforme", "score": 0.011559696342305038, "content": "Stevens–Johnson syndrome and toxic epidermal necrolysis used to be considered part of the erythema multiforme spectrum, but that is no longer the case. The mild form usually presents with mildly itchy (but itching can be very severe), pink-red blotches, symmetrically arranged and starting on the extremities. It often takes on the classical \"target lesion\" appearance, with a pink-red ring around a pale center. Resolution within 7–10 days is the norm. Individuals with persistent (chronic) erythema multiforme will often have a lesion form at an injury site, e.g. a minor scratch or abrasion, within a week. Irritation or even pressure from clothing will cause the erythema sore to continue to expand along its margins for weeks or months, long after the original sore at the center heals. Causes" }, { "id": "wiki20220301en253_18595", "title": "Bullous drug reaction", "score": 0.01138888888888889, "content": "Bullous drug reaction most commonly refers to a drug reaction in the erythema multiforme group. These are uncommon reactions to medications, with an incidence of 0.4 to 1.2 per million person-years for toxic epidermal necrolysis and 1.2 to 6.0 per million person-years for Stevens–Johnson syndrome. The primary skin lesions are large erythemas (faintly discernible even after confluence), most often irregularly distributed and of a characteristic purplish-livid color, at times with flaccid blisters. See also Skin lesion List of cutaneous conditions References External links Drug eruptions" }, { "id": "InternalMed_Harrison_4043", "title": "InternalMed_Harrison", "score": 0.010778985507246376, "content": "Drug-induced erythroderma (exfoliative dermatitis) may begin as an exanthematous (morbilliform) eruption (Chap. 74) or may arise as diffuse erythema. A number of drugs can produce an erythroderma, including penicillins, sulfonamides, carbamazepine, phenytoin, and allopurinol. Fever and peripheral eosinophilia often accompany the eruption, and there may also be facial swelling, hepatitis, myocarditis, thyroiditis, and allergic interstitial nephritis; this constellation is frequently referred to as drug reaction with eosinophilia and systemic symptoms (DRESS) or drug-induced hypersensitivity reaction (DIHS). In addition, these reactions, especially to aromatic anticonvulsants, can lead to a pseudolymphoma syndrome (with adenopathy and CAuSES of ERyTHRoDERMA 1. Primary cutaneous disorders a. b. c. 2. 3. a. Cutaneous T cell lymphoma (Sézary syndrome, erythrodermic mycosis fungoides) b. 4. Idiopathic (usually older men) a Discussed in detail in Chap. 71." }, { "id": "pubmed23n0565_20855", "title": "Stevens-Johnson syndrome due to concomitant use of lamotrigine and valproic acid.", "score": 0.010777390169885702, "content": "Stevens-Johnson syndrome (SJS) is a rare but life-threatening acute mucocutaneous hypersensitivity reaction, usually related to drugs. Severe cutaneous adverse effects such as SJS and toxic epidermal necrolysis can arise during treatment with antiepileptic drugs (AEDs). A 23-year-old female patient with idiopathic epilepsy was referred to the emergency service with fever, oral and genital mucosal lesions, generalized rash, and weakness. She had been taking carbamazepine, valproic acid, and lamotrigine until 1 week prior to referral. Following consultations with a range of clinicians, the patient was diagnosed with SJS related to lamotrigine on the basis of her history and physical findings, and on consideration of current consensus definitions of this condition. The patient was followed up and treated in the emergency intensive care unit with intravenous fluids, antibacterial therapy, and methylprednisolone. After 18 days, the patient was considered to have made a sufficient recovery and was discharged. Patients who undergo therapy with AEDs, particularly new users of these agents, should be informed of and monitored for possible systemic and cutaneous adverse effects of AEDs. Polytherapy should be avoided for as long as possible as this increases the frequency of adverse effects, and treatment should be discontinued if any rash appears." }, { "id": "InternalMed_Harrison_4108", "title": "InternalMed_Harrison", "score": 0.010580524344569289, "content": "Induction of SJS is most often due to drugs, especially sulfonamides, phenytoin, barbiturates, lamotrigine, aminopenicillins, nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine), and carbamazepine. Widespread dusky macules and significant mucosal involvement are characteristic of SJS, and the cutaneous lesions may or may not develop epidermal detachment. If the latter occurs, by definition, it is limited to <10% of the body surface area (BSA). Greater involvement leads to the diagnosis of SJS/TEN overlap (10–30% BSA) or TEN (>30% BSA). In addition to primary blistering disorders and hypersensitivity reactions, bacterial and viral infections can lead to vesicles and bullae. The most common infectious agents are HSV (Chap. 216), varicellazoster virus (Chap. 217), and S. aureus (Chap. 172). CHAPTER 72 Skin Manifestations of Internal Disease" }, { "id": "wiki20220301en031_2573", "title": "Toxic epidermal necrolysis", "score": 0.01017170812041365, "content": "Signs and symptoms Prodrome TEN ultimately results in extensive skin involvement with redness, necrosis, and detachment of the top (epidermal) layer of the skin and mucosa. Before these severe findings develop, people often have a flu-like prodrome, with a cough, runny nose, fever, decreased appetite and malaise. A history of drug exposure exists on average 14 days (ranging from 1–4 weeks) prior to the onset of symptoms, but may result as early as 48 hours if it is a reexposure. Skin findings Initial skin findings include red-purple, dusky, flat spots known as macules that start on the trunk and spread out from there. These skin lesions then transform into large blisters. The affected skin can then become necrotic or sag from the body and peel off in great swaths." }, { "id": "article-161219_20", "title": "Adverse Drug Reactions -- Issues of Concern -- Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis", "score": 0.010015520419051314, "content": "Lesions usually start on the face as an erythematous rash and then spread to all other areas. Lesions typically appear as target-like lesions and flaccid bullae at first.  As the condition progresses, sheet-like detachment of the epidermis and erosions occur. The acute, progressive phase of the illness lasts for approximately 7 to 9 days from initial symptoms. Skin reepithelizes over 7 to 21 days after the acute phase ends. Drugs associated with SJS and TEN include carbamazepine, sulfamethoxazole, phenytoin, lamotrigine, and immune checkpoint inhibitors." }, { "id": "pubmed23n1101_15251", "title": "Dual Antiepileptics Induced Stevens-Johnson Syndrome: A Case Report.", "score": 0.009900990099009901, "content": "Stevens-Johnson syndrome and Toxic Epidermal Necrolysis are acute mucocutaneous reactions hallmark of which is widespread necrosis and detachment of epidermis. SJS/TEN fall under the single disease spectrum with an incidence rate of 1.0 to 6.0 per 1000000 and 0.4 to 1.2 per 1000000 respectively. Here, we present a case of a 46 years female who developed a generalized erythematous rash over her body, 26 days after being exposed to phenytoin and sodium valproate. Given the strong association between SJS and antiepileptic drugs, and the usual presentation being within the first eight weeks of exposure to susceptible medications; we diagnosed her with SJS. Phenytoin and sodium valproate was withdrawn and she was managed with antihistamines and corticosteroids. She improved significantly within 15 days of our intervention. The mortality rates for SJS and TEN are up to 10% and 30-50% respectively. Early identification of SJS, discontinuation of triggering medicines, and prompt initiation of supportive therapy improve the prognosis. Keywords: adverse drug reactions;antiepileptic drugs;case report;stevens-johnson syndrome." }, { "id": "pubmed23n0854_16148", "title": "Stevens Johnson syndrome-Toxic Epidermal Necrolysis Overlap induced by sulfasalazine treatment: a case report.", "score": 0.00980392156862745, "content": "Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are life-threatening and severe adverse cutaneous drug reactions characterized by epidermal detachment presenting as blisters and areas of denuded skin. SJS, SJS-TEN overlap and TEN differ only by their extent of skin detachment. We report here the case of a young woman (33- year old) admitted to the dermatological unit for epidermal detachment (at 18% of the body surface area), blisters, red macular and papular lesions, developed 15 days after administration of sulfasalazine. Prior to this, she complained of fever and discomfort upon swallowing. Skin biopsy had shown epidermal necrosis compatible with Stevens Johnson Syndrome and Toxic Epidermal Necrolysis. As the epidermal detachment was between 10% and 30%, she was diagnosed as a Stevens Johnson Syndrome/Toxic Epidermal Necrolysis overlap. The course was favorable 17 days after stopping the drug and starting a symptomatic treatment. Practitioners and patients need to be aware of the initial clinical signs of severe cutaneous adverse drug reactions such as fever, influenza-like symptoms, dysphagia or burning eyes. Early discontinuation of medication remains the best way to improve prognosis of patients with Stevens Johnson's Syndrome and Toxic Epidermal Necrolysis." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 111, 272 ] ], "word_ranges": [ [ 23, 48 ] ], "text": "a patient with advanced renal failure (stage 5) is contraindicated for any imaging study that requires the administration of IV contrast, such as CT angiography." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Disordered echocardiogram.", "2": "Pulmonary scintigraphy.", "3": "Pulmonary angio-CT.", "4": "Electrocardiogram.", "5": "Chest X-ray." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0833_8362", "title": "[What may cause diabetes].", "score": 0.015188470066518847, "content": "The case study describes a case of 49-year-old man with morbid obesity since childhood (BMI 40 kg/m2), arterial hypertension (approx. since aged 15, treated since 2004), dyslipidemia (since 2006), type 2 diabetes mellitus (since 2006, on insulin therapy since 2008) and smoking (until 2011, 20 cigarettes a day). 16 types of medication, 8 for hypertension, statin, therapy for diabetes, aspirin, allopurinol. In 2010 (when aged 45) hospitalized in our clinic with dyspnoea and chest pain with a high pressure reading of 180/110 mm Hg (identified symptoms of heart failure with LV ejection fraction of 33 %, in NYHA II functional class, echocardiographically: left atrium: 46 mm, left ventricular chamber size in diastole: 70 mm, interventricular septum: 12 mm, septal hypokinesis, Doppler ultrasonography of lower limb arteries (calcification, diffuse atherosclerotic changes, absent stenosis), CT coronary angiography (significant stenosis of the left coronary artery). Treatment started with 40 mg oral dose of furosemide daily. In May 2011 he was hospitalized with an acute coronary syndrome: acute NSTEMI of the inferior wall (coronarography: 2-vascular problems, implemented PKI, implanted DES - ramus circumflexus, paroxysmal atrial fibrillation, NYHA III functional class, left ventricular ejection fraction: 30 %, pulmonary hypertension). In 2012 renal denervation for resistant hypertension was carried out, carotid stent implanted for stenosis of the carotid artery, presence of diabetic nephropathy (KDOQI stage 3, GF 40 ml/min). In August 2014 admitted to our clinic with pulmonary oedema, cardiogenic shock, acute ischemia of the right calf with peripheral embolisation, presence of atrial flutter, impairment of renal parameters, echocardiographically: left atrium: 55 mm, left ventricle size: 75 mm, akinesis of the septum and posterior wall, occlusion of the right leg arteries (given the patients serious state angio-surgical intervention was contraindicated, vitally indicated leg amputation considered), the patient died after 4 days of hospitalization in an intensive care unit after unsuccessful treatment. A combination of diabetes, hypertension and ischemic heart disease is frequent and prognostically serious. Diabetes increases cardiovascular morbidity and mortality and therefore we should check for diabetes in all cardiovascular patients." }, { "id": "pubmed23n0387_6127", "title": "Demonstration of pulmonary embolism with gadolinium-enhanced spiral CT.", "score": 0.011061419200954084, "content": "The authors report a case of successful detection of pulmonary embolism using gadolinium-enhanced spiral CT (Gadodiamide, 0.4 mmol/kg, 2 ml/s, delay 18 s) in a 77-year-old woman, with previous allergy to iodinated contrast medium, and renal failure, who presented with pulmonary arterial hypertension. Doppler ultrasound of the lower limbs was first performed and revealed a deep venous thrombosis of the right lower limb. To establish if venous thrombosis was the cause of pulmonary hypertension and to confirm that pulmonary endarterectomy was not indicated in this situation, several imaging modalities were performed. Lung scintigraphy and MRI were non-diagnostic. Gadolinium-enhanced spiral CT demonstrated a large thrombus located proximally and in a segmental artery of the right lower lobe. This case illustrates the potential usefulness of gadolinium as alternative contrast agent with spiral CT to diagnose pulmonary embolism and elucidate the cause of pulmonary arterial hypertension in a patient with some contraindications for iodinated contrast medium injection." }, { "id": "pubmed23n0551_368", "title": "[Thromboembolic events in patients after a negative computed tomography pulmonary angiogram: A retrospective study of 165 patients].", "score": 0.010390589248701176, "content": "To determine the value of computed tomography (CT) angiography of the chest as a diagnostic test to exclude pulmonary embolism and to assess compliance with diagnostic protocols for thromboembolic disease. We retrospectively studied patients who underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. All the patients were followed for 3 months. The percentage of patients diagnosed with a thromboembolic event based on an objective test during the follow-up period was determined. We analyzed the percentage of patients with a negative CT angiogram on whom additional diagnostic tests (ultrasound of the lower limbs and/or ventilation-perfusion lung scintigraphy) were performed. One hundred sixty-five patients underwent CT angiography of the chest because of suspected pulmonary embolism in 2004. Four of the patients were excluded from the study because they were on chronic anticoagulation therapy and a further 2 were excluded because they had a life expectancy of under 3 months. Of the remaining 159 patients, 60 had CT angiograms that were interpreted as high probability for pulmonary embolism (prevalence of 38%). Thirty-nine of the 99 patients with a negative CT angiogram experienced an objectively confirmed thromboembolic event (63% sensitivity; 95% confidence interval, 53%-73%). Other diagnostic tests were not performed in 46% of the cases. In our setting, a negative single-detector helical CT angiogram was not sensitive enough to exclude the diagnosis of pulmonary embolism. Furthermore, compliance with internationally accepted diagnostic protocols was far from optimal." }, { "id": "article-118745_27", "title": "Progestins -- Contraindications -- Combined Estrogen-Progestin Contraception", "score": 0.010246772714052397, "content": "Any factors that increase the risk of cardiovascular disease or thromboembolism are contraindications to COCs due to the procoagulant effects of estrogen and are considered an “unacceptable risk,” as indicated with a Category 4 label. Category 4 denotes unacceptable health risk if the contraceptive is administered to subjects with the existing condition, basically a contraindication. Categories, from 1 to 4, are outlined in detail by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). These include women ≥35 years old who smoke, 2 or more risk factors for cardiovascular disease (older age, smoking, diabetes, and hypertension), hypertension (≥160 mmHg/≥100 mmHg), venous thromboembolism (VTE) unless on anticoagulation, thrombogenic mutations, ischemic heart disease, history of stroke, complicated valvular heart disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis), diabetes mellitus for longer than 20 years or diabetes with nephropathy, retinopathy, or neuropathy. [10] [20]" }, { "id": "First_Aid_Step2_1220", "title": "First_Aid_Step2", "score": 0.00999912899573208, "content": "What is metabolic syndrome? Appropriate diagnostic test? A 50-year-old man with angina can exercise to 85% of maximum predicted heart rate. A 65-year-old woman with left bundle branch block and severe osteoarthritis has unstable angina. Target LDL in a patient with diabetes. Signs of active ischemia during stress testing. ECG findings suggesting MI. Coronary territories in MI. A young patient has angina at rest with ST-segment elevation. Cardiac enzymes are normal. Common symptoms associated with silent Mls. The diagnostic test for pulmonary embolism. An agent that reverses the effects of heparin. The coagulation parameter affected by warfarin. A young patient with a family history of sudden death collapses and dies while exercising. Endocarditis prophylaxis regimens. The 6 P’s of ischemia due to peripheral vascular disease. Virchow’s triad. The most common cause of hypertension in young women. The most common cause of hypertension in young men." }, { "id": "wiki20220301en021_58661", "title": "Chest pain", "score": 0.009900990099009901, "content": "Medical tests On the basis of the above, a number of tests may be ordered: An electrocardiogram (ECG) Chest radiograph or chest x rays are frequently performed Echocardiography can be useful in patients with known cardiac disease or aortic dissection CT scanning is used in the diagnosis of aortic dissection V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is suspected) Blood tests: Troponin I or T (to indicate myocardial damage) Complete blood count Electrolytes and renal function (creatinine) Liver enzymes Creatine kinase (and CK-MB fraction in many hospitals) D-dimer (when suspicion for pulmonary embolism is present but low) serum lipase to exclude acute pancreatitis Management Management of chest pain varies with the underlying cause of the pain and the stage of care." }, { "id": "pubmed23n0506_20393", "title": "[Pulmonary thrombendarterectomy in a patient with chronic thromboembolic pulmonary hypertension (CTEPH) and chronic renal failure due to diabetic nephropathy--case report].", "score": 0.009900990099009901, "content": "A case of 63-years old man suffering from CTEPH and chronic renal failure due to diabetic nephropathy is presented. First diagnosis of pulmonary hypertension was made at the beginning of 2000. Then the secondary anticoagulant prophylaxis were introduced. Despite such treatment there was no improvement and level of pulmonary hypertension increased. Finally, the pulmonary thrombectomy was considered because of proximal location of thromboembolic obstruction in pulmonary artery. Before surgery, the hemodialysis was started. Pulmonary thrombendarterectomy along with right coronary artery bypass grafting were performed in November 2001. The procedure was conducted successfully. The patient's condition improved and pulmonary pressure dropped substantially. During follow-up anticoagulant prophylaxis and hemodialysis are continued. It might be conducted that pulmonary thrombendarterectomy can be successfully performed also in patients with complex coexisting conditions." }, { "id": "wiki20220301en025_8015", "title": "Pulmonary hypertension", "score": 0.00980392156862745, "content": "Exclude other diseases If the echocardiogram is compatible with a diagnosis of pulmonary hypertension, common causes of pulmonary hypertension (left heart disease and lung disease) are considered and further tests are performed accordingly. These tests generally include electrocardiography (ECG), pulmonary function tests including lung diffusion capacity for carbon monoxide and arterial blood gas measurements, X-rays of the chest and high-resolution computed tomography (CT) scanning. Ventilation/perfusion scintigraphy If heart disease and lung disease have been excluded, a ventilation/perfusion scan is performed to rule out CTEPH. If unmatched perfusion defects are found, further evaluation by CT pulmonary angiography, right heart catheterization, and selective pulmonary angiography is performed. CT scan" }, { "id": "article-40870_20", "title": "Case Study: 60-Year-Old Female Presenting With Shortness of Breath -- Diagnosis", "score": 0.00980392156862745, "content": "Myxedema coma or severe hypothyroidism Pericardial effusion secondary to myxedema coma COPD exacerbation Acute on chronic hypoxic respiratory failure Acute respiratory alkalosis Bilateral community-acquired pneumonia Small bilateral pleural effusions Acute mild rhabdomyolysis Acute chronic, stage IV, renal failure Elevated troponin I levels, likely secondary to Renal failure Diabetes mellitus type 2, non-insulin-dependent Extreme obesity Hepatic dysfunction" }, { "id": "wiki20220301en063_67915", "title": "Pneumonitis", "score": 0.009708737864077669, "content": "Difficulty breathing Food aversion Lethargy End-stage fibrosis and respiratory failure eventually lead to death in cases without proper management of chronic pneumonitis. Diagnosis A chest X-ray or CT is necessary to differentiate between pneumonitis and pneumonia of an infectious etiology. Some degree of pulmonary fibrosis may be evident in a CT which is indicative of chronic pulmonary inflammatory processes. Diagnosis of Pneumonitis is often difficult as it depends on a high degree of clinical suspicion when evaluating a patient with a recent onset of a possible interstitial lung disease. In addition, interpreting pathologic and radiographic test results remains a challenge to clinicians. Pneumonitis is often difficult to recognize and discern from other interstitial lung diseases. Diagnostic procedures currently available include:" }, { "id": "pubmed23n1162_1248", "title": "A Rare Case of MRSA Pericarditis with Expanding, Purulent Pericardial Effusion Leading to Uremic Kidney Failure from a Right, Necrotic Toe.", "score": 0.009708737864077669, "content": "Purulent pericarditis is an extremely rare entity with only a few reported cases so far. This condition deserves prompt diagnosis because of its significant mortality rate if left untreated. A 76-year-old man with a past medical history of coronary artery disease (CAD) with percutaneous coronary intervention (PCI) to the left anterior descending artery (LAD) and right circumflex artery (RCA), ischemic cardiomyopathy with moderately reduced ejection fraction (EF 45-50%), peripheral artery disease (PAD), COVID-19 pneumonia complicated by fibrotic lung disease (on 3 liters of home oxygen), type-2 diabetes mellitus (T2DM), hypertension (HTN), hyperlipidemia (HLD), and chronic kidney disease (CKD) stage III presented with complaints of pleuritic chest pain and shortness of breath. On hospital day 1, he was afebrile and hemodynamically stable with physical exam remarkable for bibasilar crackles and dry gangrene of his right first toe. He developed progressive altered mental status, hypotension, oliguric renal failure, and respiratory distress on hospital day 6. On exam at this time, he had an elevated jugular venous distension (JVD) of 12-14 cm water, pericardial friction rub with decreased heart sounds, and orthopnea; all were consistent with cardiac tamponade clinically. An electrocardiogram (EKG) showed new ST elevations in leads I, II, and aVL with ST depression in aVR and V1 with only mild elevation in troponin I to 0.07 ng/mL. A transthoracic echocardiogram (TTE) was done on hospital day 7 and showed a moderate sized pericardial effusion with inferior vena cava (IVC) enlargement but no atrial collapse, ventricular collapse, IVC collapse, or respiratory variation in the mitral and tricuspid inflow velocities. Blood cultures grew methicillin-resistant <iStaphylococcus aureus</i (MRSA) on hospital day 6, and he was started on intravenous (IV) vancomycin. The differential diagnosis for his enlarging pericardial effusion included purulent pericarditis, uremic pericarditis, or hemorrhagic effusion. He had urgent diagnostic and therapeutic pericardiocentesis with removal of 350 milliliters of fluid. The pericardial fluid was cloudy, tan-brown with a gram stain showing gram-positive cocci in clusters and cultures growing MRSA, which confirmed the diagnosis of purulent pericarditis secondary to MRSA infection. After the pericardiocentesis, his blood pressure, respiratory distress, and renal failure improved. The source of the bacteremia was from osteomyelitis of his gangrenous, right toe with bone biopsy growing both MRSA and <iStreptococcus anginosus</i. He underwent toe amputation for definitive source control. He was discharged on hospital day 24 with a plan to complete 6 weeks of IV vancomycin." }, { "id": "wiki20220301en533_8319", "title": "Chronic thromboembolic pulmonary hypertension", "score": 0.009615384615384616, "content": "Diagnosis Early diagnosis still remains a challenge in CTEPH, with a median time of 14 months between symptom onset and diagnosis in expert centres. A suspicion of PH is often raised by echocardiography, but an invasive right heart catheterisation is required to confirm it. Once PH is diagnosed, the presence of thromboembolic disease requires imaging. The recommended diagnostic algorithm stresses the importance of initial investigation using an echocardiogram and V/Q scan and confirmation with right heart catheter and pulmonary angiography (PA)." }, { "id": "pubmed23n0641_14356", "title": "[Prevalence and difficulties in chronic obstructive pulmonary disease diagnosis in patients suffering from severe peripheral arterial disease].", "score": 0.009615384615384616, "content": "Cigarette smoking is the most prominent risk factor for chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD). Prevalence of COPD among cigarette smokers is about 23% in Poland. Effort dyspnea which develops in advanced stage of COPD is the leading cause of seeking medical advice. Physical activity among patients with PAD is reduced due to intermittent claudication. It may cause delayed COPD diagnosis in this group of patients. To estimate the prevalence of COPD among patients suffering from severe PAD who were hospitalized in surgery department due to critical limb ischemia and to evaluate difficulties during COPD diagnosis in this group of patients. We examined 64 patients suffering from severe PAD (at least IIb stage according to Fontaine's scale). Patients were asked about the typical symptoms of COPD: chronic cough, regular sputum production and dyspnea. To evaluate the intensity of dyspnea we used British Medical Research Council scale. Spirometry was performed to every patient. Patients with airways obstruction underwent spirometry after the administration of inhaled bronchodilator. Every patient who had the post-bronchodilator value of FEV,/FVC ratio below the lower limit of normal values was diagnosed with COPD. It was not possible to evaluate the dyspnea intensity using MRC scale in 44% of 34 patients who reported dyspnea. During the study we diagnosed 16 patients with COPD (9 pts had 1st stage of COPD according to GOLD classification, 7 pts--2nd). 9 patients had been formerly diagnosed with COPD (2 pts--1st stage, 5 pts--2nd, and 2 pts--3rd). Spirometry-defined COPD was present in 39% of study group. The analysis of data from patients with PAD coexistent COPD revealed that 60% of them were current cigarette smokers and 28% of them declared passive smoking exposure. The other known negative prognostic factors in patients with COPD such as BMI lower than 21 kg/mr2, FEV1% of predicted value below 65% and X-rays photograph visible emphysema were observed in 40%, 32% and 12% of patients with PAD and coexistent COPD respectively. Hypertension was present in 52% of patients with PAD and coexistent COPD, cardiac arterial disease in 52% and chronic heart failure due to cardiac arterial disease in 36%. Further analysis of laboratory tests revealed dyslipidemia and chronic kidney disease in 52% and 60% of these patients respectively. COPD diagnosis among patients suffering from severe PAD involves several difficulties such as uselessness of MRC dyspnea scale and frequent heart diseases which delay the COPD diagnosis being considered as primary dyspnea reason. Many factors which have been proven to be responsible for worse prognosis due to COPD were observed in patients with PAD and coexistent COPD. High prevalence of COPD among patients suffering from PAD suggests the spirometry as a COPD screening would be justified in that group." }, { "id": "wiki20220301en020_57455", "title": "Pulmonary artery", "score": 0.009523809523809525, "content": "Clinical significance The pulmonary artery is relevant in a number of clinical states. Pulmonary hypertension is used to describe an increase in the pressure of the pulmonary artery, and may be defined as a mean pulmonary artery pressure of greater than 25mmHg. As can be measured on a CT scan, a diameter of more than 29 mm diameter is often used as a cut-off to indicate pulmonary hypertension. In Chest X-rays, diameter of descending pulmonary artery more than 16 mm indicates pulmonary hypertension. This may occur as a result of heart problems such as heart failure, lung or airway disease such as COPD or scleroderma, or thromboembolic disease such as pulmonary embolism or emboli seen in sickle cell anaemia. Most recently, computational fluid based tools (non-invasive) have been proposed to be at par with the current clinical tests (invasive) of pulmonary hypertension." }, { "id": "pubmed23n0982_14517", "title": "", "score": 0.009523809523809525, "content": "A clinical analysis of an elderly patient with medium-high-risk pulmonary thromboembolism and chronic kidney disease is presented. Recommendations on modern principles of diagnosis, choice of treatment tactics in patients with this pathology are given. Much attention is paid to the safety of anticoagulant treatment." }, { "id": "wiki20220301en329_5609", "title": "Rheumatoid lung disease", "score": 0.009433962264150943, "content": "Prognosis is related to the underlying disorder and the type and severity of lung disease. In severe cases, lung transplantation can be considered. This is more common in cases of bronchiolitis obliterans, pulmonary fibrosis, or pulmonary hypertension. Most complications are not fatal, but does reduce life expectancy to an estimated 5 to 10 years. Epidemiology The prevalence of RA is around 0.3–1.2% (0.92% of Americans). Women are 2–3 times more susceptible than men. The prevalence of rheumatoid lung disease in patients with RA depends on the method used for diagnosis: chest X rays (5%), high resolution CT scans (10–40%)." }, { "id": "pubmed23n0764_22729", "title": "Diagnostic yield and renal complications after computed tomography pulmonary angiograms performed in a community-based academic hospital.", "score": 0.009433962264150943, "content": "Venous thromboembolism and pulmonary embolism (VTE/PE) remain a diagnostic challenge. The computed tomography pulmonary angiogram (CTPA) has emerged as a popular diagnostic test for PE. However, there is limited data on diagnostic yield and complications in actual clinical settings. Our goal was to determine the diagnostic yield for PE and rate of renal complications following CTPA in a large community hospital setting. A retrospective chart review of 1,514 patients who underwent CTPA in the emergency department or during the initial 24 hours of admission to a community-based academic hospital. Of 1,514 CTPAs, 125 were positive for VTE/PE yielding a positive diagnosis in 8.2%. Dyspnea was the most common symptom in patients and a normal physical exam was the most common finding. Among the 925 patients with adequate data to calculate the rate of contrast-induced nephropathy (CIN), 25.8% had an increase of at least 25% in serum creatinine following the CTPA. Pre-existing diabetes and age were the most important predictors of CIN. CTPA has a low diagnostic yield for PE in a community setting, and in some patient populations, the rate of contrast-induced nephropathy may be higher than previously reported in the literature. Due to the retrospective nature of this study we were limited in using pre-test scoring systems and in measuring the impact of alternative CT diagnoses on patient management." }, { "id": "wiki20220301en023_6530", "title": "Tuberous sclerosis", "score": 0.009345794392523364, "content": "Scan the abdomen for tumours in various organs, but most importantly angiomyolipomata in the kidneys. MRI is superior to CT or ultrasound. Take blood pressure and test renal function. In adult women, test pulmonary function and perform a high-resolution computed tomography (HRCT) of the chest. Examine the skin under a Wood's lamp (hypomelanotic macules), the fingers and toes (ungual fibroma), the face (angiofibromas), and the mouth (dental pits and gingival fibromas). In infants under three, perform an echocardiogram to spot rhabdomyomas, and electrocardiogram (ECG) for any arrhythmia. Use a fundoscope to spot retinal hamartomas or achromic patches." }, { "id": "pubmed23n0748_19201", "title": "ECG of the month. Electrocardiogram in a man with chronic kidney failure. ECG is abnormal and indicative of heart disease.", "score": 0.009345794392523364, "content": "A 70-year-old man came to the Access to Primary Care Clinic at the Interim LSU Public Hospital because he had been told at another hospital that he needed a kidney doctor. The patient had a history of high blood pressure, type 2 diabetes mellitus, long-standing kidney disease, an above the knee amputation on the left, gout, a possible coronary stent procedure five years ago, and recently poor appetite and inability to care for himself. He had a long history of medical noncompliance and was taking no medications when he came to the hospital. He denied all cardiac symptoms, including chest discomfort. He was admitted to hospital because of a blood pressure of 240/110 mmHg, a serum creatinine of 6.0 mg/dL, and an estimated glomerular filtration rate of 11 mL/min - i.e., chronic kidney disease, stage V. His electrocardiogram was read by the computer as normal (Figure 1)." }, { "id": "wiki20220301en034_5656", "title": "Situs ambiguus", "score": 0.009259259259259259, "content": "In pulmonary valve stenosis, there is a reduction in blood flow to the lungs due to an obstruction of the heart at the pulmonic valve. This contributes to cyanosis and pulmonary hypertension. Diagnosis For proper diagnosis of situs ambiguus, cardiac and non-cardiac features must be evaluated. Diagnostic criteria for atrial isomerism includes observation of symmetry of thoracic visceral organs upon echocardiogram, arrhythmia upon electrocardiogram, and chest x-ray for confirmation of the heart's location across the left-right axis. Additional radiographic and cross-sectional imaging may be obtained to evaluate both cardiac and non-cardiac manifestations of situs ambiguus. In addition, a series of gastrointestinal tests can be conducted for observation of intestinal malrotation, as well as a scan of the liver and spleen for biliary function." }, { "id": "article-40870_14", "title": "Case Study: 60-Year-Old Female Presenting With Shortness of Breath -- Differential Diagnosis", "score": 0.009259259259259259, "content": "Acute on chronic COPD exacerbation Acute on chronic renal failure Bacterial pneumonia Congestive heart failure NSTEMI Pericardial effusion Hypothyroidism Influenza pneumonia Pulmonary edema Pulmonary embolism" }, { "id": "wiki20220301en338_16881", "title": "Heart transplantation", "score": 0.009203552499641885, "content": "Absolute contraindications: Irreversible kidney, lung, or liver disease Active cancer if it is likely to impact the survival of the patient Life-threatening diseases unrelated to the cause of heart failure, including acute infection or systemic disease such as systemic lupus erythematosus, sarcoidosis, or amyloidosis Vascular disease of the neck and leg arteries. High pulmonary vascular resistance – over 5 or 6 Wood units. Relative contraindications: Insulin-dependent diabetes with severe organ dysfunction Recent thromboembolism such as stroke Severe obesity Age over 65 years (some variation between centers) – older patients are usually evaluated on an individual basis. Active substance use disorder, such as alcohol, recreational drugs or tobacco smoking (which increases the chance of lung disease) Patients who are in need of a heart transplant but do not qualify may be candidates for an artificial heart or a left ventricular assist device (LVAD)." }, { "id": "wiki20220301en557_13095", "title": "Stuart W. Jamieson", "score": 0.009174311926605505, "content": "Journal articles \"Cardiac transplantation in 150 patients at Stanford University\", British Medical Journal, No. 1 (1979), pp. 93–95. (With Edward B. Stinson and Norman Shumway) \"Primary Pulmonary Hypertension and Pregnancy\", Chest Journal, Vol. 89, No. 3 (March 1986), pp. 383–388. \"Pulmonary endarterectomy: Experience and lessons learned in 1,500 cases\" The Annals of Thoracic Surgery, Vol. 76, No. 5 (November 2003), pp. 1457–1464. \"Pulmonary endarterectomy\", US Cardiology, Vol 1, No. 1 (2004), pp. 1–3. \"Technical advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension\", Seminars in Thoracic and Cardiovascular Surgery, Vol. 18, Issue 3 (2006), pp. 243–249. (With M. Madani) “Pulmonary endarterectomy: recent changes in a single institution's experience of more than 2,700 patients”, The Annals of Thoracic Surgery, Vol. 94, Issue 1 (July 2012), References" }, { "id": "pubmed23n0116_11711", "title": "[Indications for aortocoronary bypass operation in elderly patients: medical point of view].", "score": 0.009174311926605505, "content": "Aorto-coronary (A-C) bypass operations were performed in 20 patients aged 68 to 78 years, and the indications for this operation were discussed retrospectively. The subjects consisted of 14 patients successfully operated and six patients unsuccessfully operated (death 3, graft occlusion 2, perioperative infarction 1). The results were as follows: Average age: There was no difference between the successful group (71.1 +/- 3.3 years; mean +/- SD) and the unsuccessful group (70.3 +/- 2.9 years). Coronary arteriographic findings: The average number of narrowed branches (greater than or equal to 75% stenosis) was 4.3 +/- 3.0 in the successful group (triple vessel disease in 12 cases and double vessel disease in four) and 2.7 +/- 0.5 in the unsuccessful group (triple vessel disease in four and double vessel disease in two), showing no significant difference between the two groups. Nine patients (64.3%) in the former group and one (16.7%) in the latter group had significant left main coronary artery disease (greater than or equal to 50% stenosis). Hemodynamic findings: Ejection fractions of less than 40% existed in three patients (50%) solely in the unsuccessful group; two of whom died. Left ventricular end-diastolic pressures of 30 mmHg or more existed in two cases (33.3%) only in the latter group. Other cardiac findings: Left ventricular end-diastolic dimension of 55 mm or more was found in one (7.1%) successful case and four (66.7%) unsuccessful cases. 201Tl-scintigrams showed a dilated left ventricular cavity in one case (7.1%) in the former group and two (33.3%) in the latter. Functions of other organs: Forced expiratory volume 1.0% or % vital capacity less than 70% was recognized in two cases (33.3%) only in the latter group. A level of serum creatinine more than 1.5 mg/dl was seen in only one case in the latter group. A case with advanced diabetes mellitus was present in the unsuccessful group, and this patient died of diabetic coma. A-C bypass operations are indicated for elderly patients when they have good cardiac function and have no complications of the kidneys, lungs and other organs. It is presumed that grafting the main coronary branches, thereby shortening the time of cardiopulmonary arrest prevents postoperative complications." }, { "id": "pubmed23n0689_16064", "title": "[Chronic thromboembolic pulmonary hypertension in local hospital].", "score": 0.00909090909090909, "content": "Chronic thromboembolic pulmonary hypertension is a serious consequence of pulmonary embolism associated with considerable morbidity and mortality. It develops in about 0.1-3.8% among patients who survive pulmonary embolism despite adecvate treatment. Retrospectively evaluate incidence, clinical picture and difficulties in diagnostics and treatment of patients, in which the diagnosis was confirmed. In years 1996-2007 there were 33,108 patients hospitalized at 1. Internal Clinic of University hospital in Martin, 267 patients (134 women) had pulmonary embolism, 5 (2 women) of them were diagnosed chronic thromboembolic pulmonary hypertension. 3 of them overcame acute pulmonary embolism and one of them had deep venous thrombosis at the same time. These patients, during acute pulmonary embolism, were administrated trombolytic treatment. Two patients were hospitalized because of progressive dyspnoe, 1 patient as acute myocardial infarction without ST segment elevation, 1 patient as heart failure and 1 patient because of susceptive recommitement of pulmonary embolism with hemoptysis. ECG of right heart owerload were found in 4 patients, in all 5 patients in transthoracic echocardiographic examination a pulmonary hypertension were present, in 3 patients there were CT angiography negative and all 5 patients were positive in perfuse scintigraphy of lungs. This time, 2 of them are after successful operation, pulmonary endarterectomy and 1 patient (woman) died as right heart failure. Rest of the patients (2) are followed up by cardiologist in stadium NYHA II. Time till making definitive diagnosis, in spite of progressive discomfort and approved pulmonary embolism, was relatively long (1-5 years), ECG changes was most of the time diagnosed as ischaemic ones. Negative CT angiography of lungs was another step to long term diagnostics. Exactly right and early diagnosis is conclusive, because pulmonary endarterectomy, if its well indicated, is a treatment method, which makes better quality of life and survivance, as we can see in our 2 patients. On the other hand not indicated operation caused the death in our 1 patient." }, { "id": "wiki20220301en022_69274", "title": "Pulmonology", "score": 0.009009009009009009, "content": "Procedures Clinical procedures Pulmonary clinical procedures include the following pulmonary tests and procedures: Medical laboratory investigation of blood (blood tests). Sometimes arterial blood gas tests are also required. Spirometry the determination of maximum airflow at a given lung volume as measured by breathing into a dedicated machine; this is the key test to diagnose airflow obstruction. Pulmonary function testing including spirometry, as above, plus response to bronchodilators, lung volumes, and diffusion capacity, the latter being a measure of lung oxygen absorptive area Bronchoscopy with bronchoalveolar lavage (BAL), endobronchial and transbronchial biopsy and epithelial brushing Chest X-rays CT scan Scintigraphy and other methods of nuclear medicine Positron emission tomography (especially in lung cancer) Polysomnography (sleep studies) commonly used for the diagnosis of sleep apnea" }, { "id": "pubmed23n0323_18783", "title": "[Renal artery stenosis and chronic renal failure in NIDDM].", "score": 0.009009009009009009, "content": "The NIDDM patient, willingly with high blood pressure and atheroma, has frequently an abnormal renal function. Must a renal artery stenosis (RAS) be searched as a determining or favorising cause? We have searched RAS by color duplex scan, in 60 consecutive NIDDM patients with altered renal function (creatinine clearance &lt; or = 60 mL/min). Metabolic blood pressure (ABPM), cardiovascular and renal investigations have been realised. The population was composed of 22F/38M with middle age: 70.7 +/- 6.2 yrs, diabetic duration: 11.6 +/- 8 yrs, the plasma creatinine was: 161 +/- 78 mumol/L and clearance: 40 +/- 13 mL/min. Thirty eight had albuminuria, 28 had plasma creatinine &gt; or = 150 mumol/L. All patients had high blood pressure. Significative RAS (&gt; or = 70%) was detected in 15 patients (25%) by color duplex scan and proved with arteriography (n = 10) or angio NMR (n = 5). Twelve (80%) had unilateral stenosis (4 thrombosis), 3 (20%) bilateral stenosis. Renal US lead the diagnosis in 10 patients (66%): unilateral or bilateral hypotrophy. Those 15 patients had these following characteristics: 4F/11M (sex R : 0.36), middle age: 70.8 +/- 7.2 yrs, diabetic duration: 14.3 +/- 7.5 yrs, HbA1c was at 8.4 +/- 2%, 8 (53%) patients require insuline and 5 have retinopathy, plasma creatinine was at 169 +/- 6 mumol/L; 32% of patients with plasma creatinine &gt; or = 150 mumol/L had RAS (n = 9/60%), creatinine clearance was at 38 +/- 12 mL/min (7/47% &lt; or = 30 mL/min), 9 (60%) had macroalbuminuria and 5 (33%) microalbuminuria. All hypertensive patients were treated (mean SBP: 148 +/- 16, mean DBP: 82 +/- 7 mmHg) and had 62 +/- 28% SBP escape and 33 +/- 19% DBP escape. Ten had severe hypertension (at least 3 hypotensive drugs), 12 received CEI; 8 (53%) were smokers; 14 (93%) had one or more macroangiopathies (10/66% coronary heart diseases, 7/46% lower limbs arteritis, 6/40% carotid atheroma); 13 of these macroangiopathies are severe. In conclusion, renal failure (especially evolutive and/or treated with CEI) in NIDDM must call up a RAS (25%) specially in elderly males with a long diabetes duration, severe hypertension and macroangiopathies. This patient profile must lead to a color duplex scan to confirm the diagnosis already suspected by the renal echography." }, { "id": "wiki20220301en249_31450", "title": "Pulmonary rehabilitation", "score": 0.008928571428571428, "content": "Guidelines Clinical practice guidelines have been issued by various regulatory authorities. American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation has provided evidence-based guidelines in 1997 and has updated it. British Thoracic Society Standards of Care (BTS) Subcommittee on Pulmonary Rehabilitation has published its guidelines in 2001. Canadian Thoracic Society (CTS) 2010 Guideline: Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease. National Institute for Health and Care Excellence (NICE) Guidelines Contraindications The exclusion criteria for pulmonary rehabilitation consists of the following: Unstable cardiovascular disease Orthopaedic contraindications Neurological contraindication Unstable pulmonary disease" }, { "id": "pubmed23n1010_2617", "title": "A 44-Year-Old Man With Dyspnea and a Pulmonary Artery Filling Defect.", "score": 0.008928571428571428, "content": "A 44-year-old man with a history of coronary artery disease, type 2 diabetes mellitus, and OSA reported progressively worsening dyspnea on exertion over a 6-week period. Outpatient CT angiogram revealed a pulmonary artery filling defect. He was sent to the ED where he was started on a heparin drip for unprovoked pulmonary embolism (PE). Echocardiogram revealed normal cardiac function without evidence of right heart strain. Lower extremity ultrasound was negative for DVT. He improved symptomatically, and no risk factors for PE were identified. He was discharged on apixaban. Five weeks later, the patient returned to the ED with hemoptysis. He reported compliance with anticoagulation and improvement of his dyspnea on exertion. History remained negative for recent travel, trauma, surgery, clotting disorders, thromboembolic disease, and alcohol or drug use. He had a 60 pack-year cigarette smoking history and quit 3 months prior." }, { "id": "wiki20220301en012_28091", "title": "Tetralogy of Fallot", "score": 0.008849557522123894, "content": "Diagnosis There are three different useful diagnostic tests used for the diagnosis of Tetralogy of Fallot. These include a chest radiograph, electrocardiogram, and echocardiogram. The echocardiography determines the final diagnosis and typically offers enough information for surgical treatment planning. About half of all patients are now diagnosed before they are born. Differential diagnosis is when physicians diagnose between two or more conditions for a person's symptoms and this can include primary pulmonary causes of cyanosis, cyanotic heart lesions, pulmonary stenosis and transposed arterial trunks." }, { "id": "pubmed23n0402_3711", "title": "[Early results of aortic valve replacement in patients 65 year and older].", "score": 0.008849557522123894, "content": "30 patients aged 65 years or more, who underwent aortic valve replacement in the Department of Cardiac Surgery, Medical University of Łódź in 2000, were assessed. This group consisted of 19 women (63.3%) and 11 men (36.7%). The mean age of the patients was 71.83 years +/- 3.76, age range from 66 to 78 years. The analysis of preoperative clinical state of the patients revealed prevalence of diabetes mellitus in 23 pts (76.7%), chronic bronchitis in 4 pts (13.3%), arterial hypertension in 8 pts (26.7%), pulmonary hypertension in 8 pts (26.7%), atrial fibrillation in 4 pts (13.3%), ventricular arrhythmia in 13 pts (43.3%) and cigarette smoking in 8 pts (26.7%). The mean left ventricular ejection fraction was 50.8% (+/- 8.12%, from 31% to 64%). All patients before aortic valve replacement procedure underwent coronary angiography. All patients were operated on cardiopulmonary by-pass and myocardial protection was obtained by the use of cold crystalloid cardioplegy solution based on St. Thomas Hospital formula. 7 patients (23.3%) underwent myocardial revascularization procedure simultaneously. In early postoperative period the following complications were observed: death--2 (6.67%), low cardiac output syndrome--4 (13.33%), need of use of intraaortic contrapulsation--3 (10%), need of use of inotropic agents--13 (43.33%), respiratory failure with the need of prolonged intubation--8 (26.67%), acute renal failure--2 (6.67%), stroke--1 (3.33%), need of temporary cardiac pacing--4 (13.33%), need of rethoracotomy--2 (6.67%). The results of aortic valve replacement procedures in patients over 65 years age good, in spite of prevalence of number risk factors in these patients. The high rate (23.3%) of patients requiring simultaneous myocardial revascularization is remarkable. The age of a patient should not be treated as a contradiction to the cardiac surgery." }, { "id": "wiki20220301en272_13070", "title": "2009 swine flu pandemic in Malaysia", "score": 0.008771929824561403, "content": "On 18 August, three more death cases were confirmed and brought the number of death cases in Malaysia to 67. A 33-year-old woman was transferred to ICU after her lungs disease began to deteriorate after 4 days of treatment in a private hospital. She showed symptoms on 31 July and antiviral drugs were started on 7 August. On 12 August, she died due to bronchopneumonia. Her result later came back and was positive for the flu. A 10-year-old school girl, who was diagnosed with Systemic lupus erythematosus was sent to ICU after she had breathing difficulty, chest pain and stomach ache. Antiviral drugs were given since 8 July. Despite on medicine, she died on 13 August due to Systemic lupus erythematous with severe pneumonia with renal impairment. A 71-year-old woman with Chronic obstructive pulmonary disease, hypertension, Ischaemic heart disease and Diabetes mellitus type 2, showed symptoms of the flu and was hospitalised on 12 August. However, on 14 August, she died due to Ischaemic" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 277 ] ], "word_ranges": [ [ 0, 40 ] ], "text": "Vasospasm as a complication of subarachnoid hemorrhage usually occurs early, in the week after the hemorrhage. The progressive deterioration with alteration of the level of consciousness makes us suspect one of the complications that can occur in this condition: hydrocephalus." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "She is in the moment of evolution in which vasospasm is more frequent.", "2": "This progressive deterioration is probably secondary to aneurysm rebleeding.", "3": "Subacute deterioration is most likely due to hydrocephalus.", "4": "The diagnostic technique of choice is cerebral angiography.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0116_3841", "title": "Intracranial hematomas following aneurysmal rupture: experience with 309 cases.", "score": 0.01694324362013666, "content": "Three hundred and nine consecutive cases of intracranial hematomas due to aneurysmal rupture--representing 34% of the total number of patients with aneurysms observed in a 12-year period--were evaluated; of these, 211 were submitted to computed tomography scan. Hematomas were present on admission in 71% of patients and occurred at rebleeding in 29%. Ruptured middle cerebral artery aneurysms caused an intracranial hematoma more frequently than aneurysms in other locations. Ventricular hematomas were frequently observed--especially at rebleeding--in cases with anterior communicating artery aneurysms. Basal ganglia hematomas were detected in eight cases with internal carotid bifurcation aneurysms and in three with middle cerebral artery aneurysms. Subdural hematomas were observed in 32 cases, mainly due to ruptured middle-cerebral-artery and internal-carotid-artery aneurysms. As for clinical evolution, a rapid deterioration was observed in 39% of cases and a chronic course in 46%; a subacute deterioration was far less frequent. Delayed deterioration from vasospasm was observed in 8% of cases, and appeared to be related to the amount of subarachnoid bleeding associated with the hematoma. One hundred and forty-two patients were submitted to surgical treatment (evacuation of hematoma together with exclusion of aneurysm); deep coma, poor medical condition, stabilized neurological disability, or combinations of these factors accounted for the high number of patients not operated upon. Regardless of treatment, 24% of patients showed good results and 58% died. Presence of a large hematoma, ventricular hemorrhage, and shift of the ventricles represented significant risk factors, associated with a poor prognosis. A comparison between two groups of patients admitted within 3 days of hemorrhage--47 operated on early, and 149 with delayed treatment--showed that better results were achieved by early operations, especially for cases in Hunt's grades IV and V." }, { "id": "pubmed23n0076_9758", "title": "[Consequences of meningeal hemorrhage during the first days after its onset].", "score": 0.015813117699910152, "content": "Results of subarachnoid hemorrhage (SAH) in the acute phase are represented by the direct threat of vasospasm. The first step still is to recognise SAH, so that all misleading clinical aspects of arterial aneurysm rupture do not misguide, or even fail to do the right diagnosis. If so, rebleeding still remains a real danger. Among biological patterns, hyponatremia is an important factor of vasospasm. Cardiovascular symptoms are represented by a sudden and transient arterial hypertension which can drive to a diagnostic error and electrocardiographic abnormalities, which are directly related with the degree of vasospasm; their evolution is completely regressive. Main intracranial consequences are early hydrocephalus, worsening of consciousness and progressive ventricular distension on CT scan and vasospasm, which occurs between the 4th and the 12th day, may be asymptomatic or symptomatic, responsive for delayed ischemia, followed by deterioration of consciousness and focal neurological signs. The main factors responsible for the vasospasm are a high amount of blood in basal cisterns on CT scan; an increase of substances released by the lysis of hemoglobin in CSF; hyponatremia, hypovolemia, and decrease in cerebral blood flow. Consequences of these disorders have to be well known in the medical treatment before and after operation." }, { "id": "pubmed23n0310_2182", "title": "[Management of subarachnoid hemorrhages without detectable aneurysm].", "score": 0.01406116844995739, "content": "In this study, 21 patients with subarachnoid hemorrhage (SAH) but negative angiography were evaluated. Angiography was performed twice on each patient, that is, on admission and at 2 weeks following admission. All patients had severe headache of sudden onset, a characteristic manifestation of SAH. Clinical grades on admission (Hunt and Kosnik classification) were generally good: 17 patients were in grade I or II and 4 patients were in grade III. SAH was confirmed by the presence of subarachnoid clot on CT in all cases. Based on the distribution of SAH, CT findings were classified into two patterns, i.e., perimesencephalic and non-perimesencephalic patterns. Four patients showed the perimesencephalic pattern and the remaining 17 the non-perimesencephalic. The period of follow-up ranged from 20 days to 11 years 6 months, with a mean of 6 years 10 months. Except for three recent cases, the mean follow-up period in 8 years 9 months. Exploratory craniotomies probing for aneurysms have been performed in four patients, but no aneurysms have been found in any of these cases. Clinical deterioration associated with vasospasm was observed in one patient. A communicating hydrocephalus requiring a shunting procedure was observed in three patients showing the non-perimesencephalic type CT pattern. Rebleeding occurred in one patient who subsequently died of what may be a dissecting aneurysm of the vertebral artery. One patient who was able to return to full activity experienced symptoms attributable to SAH such as frequent headaches and increased fatigability. Complete recovery was observed in the remaining 19 patients. Two of them, however, later died due to myocardial infarction and aging, respectively. Given these generally positive outcomes, it should be possible to inform such patients of the benignity of their condition. Angiography may not demonstrate a ruptured aneurysm on initial examination in all cases of aneurysmal SAH. Serial angiography, however, can provide a definite diagnosis of the dissecting aneurysm. Therefore, repeat angiography, particularly, when possible, digital subtraction angiography, is necessary to rule out aneurysmal SAH. While small aneurysms or microaneurysms are often found through exploratory craniotomy, we do not agree with the opinion that surgery may be appropriate for certain patients with SAH but with negative angiography. The natural history concerning rebleeding in such cases, as well as morbidity and mortality associated with hemorrhage, remains to be defined. Furthermore, there are reservations regarding whether coagulation of these abnormalities with bipolar cautery constitutes definitive treatment." }, { "id": "pubmed23n0524_10374", "title": "Impact of coil embolization on overall management and outcome of patients with aneurysmal subarachnoid hemorrhage.", "score": 0.0132213608957795, "content": "We report on the consequences of introducing coil embolization for the total management of and outcome in patients with subarachnoid hemorrhage (SAH). In southern Sweden, a prospective analysis of all patients with SAH of verified aneurysmal origin was conducted during the 3 years when coiling was gradually being introduced. The incidence of acute or chronic hydrocephalus, vasospasm, delayed ischemic deterioration, and outcome at 3 to 6 months after bleeding was analyzed. Coiling of aneurysms was used progressively more compared with clipping during the study period. The number of patients subjected to coiling was 26 (36%) of 73 patients during calendar year 1997, 43 (53%) of 81 patients in 1999, and 55 (74%) of 74 patients in 2001 (P &lt; 0.0001). Gradually, more elderly patients were admitted during the study period. Virtually all aneurysms located in the posterior circulation were treated by coil embolization, even at the start of the study, whereas aneurysms at all other locations were progressively more likely to be treated similarly. The incidence of hydrocephalus in the acute (average for all 3 yr, 39%) or chronic (16%) phase, vasospasm as measured by Doppler sonography (33%), and delayed ischemic deterioration (29%), as well as outcome at 3 to 6 months (61% good recovery, 13% deceased), did not change significantly during the study. The main cause of unfavorable outcome was the severity of the SAH. The increasing use of coil embolization for ruptured aneurysms in the anterior circulation did not have any significant impact on the overall incidence of SAH-related complications or outcome. The main determinant for outcome after SAH is still the severity of the SAH." }, { "id": "wiki20220301en170_30306", "title": "Anterior cerebral artery syndrome", "score": 0.012083188102707098, "content": "The crucial step in the evaluation of stroke patients is to obtain brain imaging to ascertain the type and characteristics of the stroke. In this regard, non-contrast CT of the head is the imaging modality of choice. Ischemic changes may classify as acute, subacute, and chronic, depending on the time in which they present after the onset of stroke. CT scan can also rule out intracranial hemorrhage.[18] If an intracranial hemorrhage is present, aneurysmal rupture should be investigated given its association with arterial vasospasm resulting in stroke.[3] Anterior cerebral artery strokes could be missed on imaging studies depending on their location or size. One case series found that 37.5% (6 of 16) of ACA infarcts evaluated by CT were identifiable only after using contrast injection or angiography. If the area of hypodensity is small and localized over a sulcus, the infarct could be overlooked.[1] [13] Noncontrast head CT should be quickly followed by CT angiography of the head and" }, { "id": "wiki20220301en026_4637", "title": "Subarachnoid hemorrhage", "score": 0.010972699772654679, "content": "People with poor clinical grade on admission, acute neurologic deterioration, or progressive enlargement of ventricles on CT scan are, in general, indications for the placement of an external ventricular drain by a neurosurgeon. The external ventricular drain may be inserted at the bedside or in the operating room. In either case, strict aseptic technique must be maintained during insertion. In people with aneurysmal subarachnoid hemorrhage the EVD is used to remove cerebrospinal fluid, blood, and blood byproducts that increase intracranial pressure and may increase the risk for cerebral vasospasm. Preventing rebleeding Efforts to keep a person's systolic blood pressure below somewhere between 140 and 160 mmHg is generally recommended. Medications to achieve this may include labetalol or nicardipine." }, { "id": "pubmed23n0126_6819", "title": "[New clinical grading in ruptured cerebral aneurysm].", "score": 0.009900990099009901, "content": "A new clinical grading of subarachnoid hemorrhage (SAH) due to ruptured aneurysm, classified by the presence or absence of vomiting, and by the duration of initial unconciousness at the time of bleeding, is proposed. Grade I: headache without vomiting, Grade II: headache, vomiting, and/or loss of consciousness lasting less than one hour, Grade III: loss of consciouness for over one hour. Grade IV: permanent unconsciousness or cerebral herniation signs. Based on the clinical records, 142 cases of ruptured cerebral aneurysms directly operated on in phases varying from peracute phase (within 72 hours) to delayed phase (22 days or over) were retrospectively analyzed. They included 99 cases which were operated on under microscope. The Hunt &amp; Hess grading was applied just before surgery. Outcome at the 6 month to 1 year follow-up was rated as good, fair, poor and dead. Correlations between the severity and the outcome were calculated using the chi-square test and the levels of significance were compared with those between the recent Hunt and Hess grading and the outcome. In the total of 142 cases, correlation between the clinical severity and the outcome was significant (P less than 0.0005), whereas correlation between the Hunt &amp; Hess grading and the outcome was not significant. In the analysis of cases classified by the operative timing, the clinical severity showed good correlation in the peracute (within 72 hours after SAH) (P less than 0.05) alone, while Hunt &amp; Hess grading showed correlation in delayed phase alone. Neither of the gradings was significant in the acute phase or subacute phase.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0318_15355", "title": "[Multiple bacterial aneurysms: case report].", "score": 0.00980392156862745, "content": "A 59-year-old man presented with an internal carotid artery (ICA) bacterial aneurysm which ruptured during surgery for treatment of another bacterial aneurysm. He had been admitted to our hospital because of the recurrence of colon cancer. He had undergone aortic and mitral valve replacement because of closure incompetence due to bacterial endocarditis two months previously. Two months after treatment for colon cancer, he developed fever, and arterial blood culture demonstrated. Staphylococcus epidermidis. A few days later, he suddenly suffered severe headache and vomiting, followed by deterioration of consciousness. CT showed subarachnoid hemorrhage and angiography showed a saccular aneurysm at the opercular portion of the left middle cerebral artery (MCA). Immediate clipping of the aneurysm was attempted. The carotid cistern was opened via a left frontotemporal craniotomy, but an ICA aneurysm, which had not been previously recognized, ruptured suddenly. The ICA aneurysm was wrapped with Vascwrap with some difficulty. The MCA aneurysm was then trapped. Postoperatively, the patient continued to be stuporous for a few days. Two weeks later, he died of complications caused by pneumonia. Bacterial aneurysm is more likely to be located in the distribution of the distal arterial tree, mainly in the distribution of the MCA. The difficulty of preoperative diagnosis and the unpredictable clinical course of bacterial aneurysms are emphasized." }, { "id": "pubmed23n0589_8344", "title": "[Spontanious subarachnoidal hemorrhage: report on 67 surgicaly treated patients].", "score": 0.00980392156862745, "content": "The aneurysmal subarachnoid hemorrhage (SAH) is a syndrom with an extremely complex pathophysiological course. Although treatment outcomes in patients with intracranial aneurysms of the circle of Willis and SAH have improved over time, the mortality and morbidity rates remain unacceptably high. The clinical course and the outcome were evaluated in a group of patients who underwent surgery. Patient characteristics, including age, sex, preexisting medical conditions, aneurysm location and size, time to admission, admission neurological status, computerized tomography and angiography findings were analyzed to determine relationship to outcome. A total of 67 patients with the intracranial aneurysms were treated by the microsurgical technique for a direct aneurysm surgery. The data were analyzed in two aspects: the overall management and the surgical results. An occlusion of aneurysm neck was done in 97% and 3% of patients were treated by aneurysm wrapping. There was a significant relationship between the neurological status on admission and the outcome (p &lt; 0.005). Out of 67 patients, 50% had a good result, 16% were moderately disabled, 18% were severely disabled, and 12% were dead at the six month post-SAH evaluation. The results were significantly better according to the better neurological status on admission (p = 0.0001). The disastrous natural history of subarachnoid hemorrhage secondary to ruptured intracranial aneurysm has largely remained unaffected by even the best medical and surgical care because of the natural history of the disease, as well as mistakes in diagnosis and delays in treatment. Among the patients who were underwent surgery, 50% returned to their premorbid state, and 12% died. The factors associated with poor results were direct effects of the initial hemorrhage, vasospasm and rebleeding. Although the results of management of patients with ruptured aneurysms seem to be improved with time, there is opportunity for substantial additional improvement." }, { "id": "pubmed23n0355_19962", "title": "[Postoperative hemorrhage due to normal pressure hyperperfusion breakthrough after a trapping of VA-PICA dissecting aneurysm].", "score": 0.009708737864077669, "content": "We described a case of cerebellar hemorrhage after trapping of a vertebral artery dissecting aneurysm. A forty-eight-year-old man had suffered from severe headache, vomiting and disturbance of consciousness. He was transferred to our hospital in an ambulance. Emergency CT scan showed subarachnoid hemorrhage in the posterior fossa predominantly, intraventricular hemorrhage and hydrocephalus change. Chest X-ray showed radiological evidence of pulmonary edema. The initial blood-gas determinations demonstrated a marked reduction in PaO2 and increased PaCO2. Five days after admission, the patient's condition was improving. Cerebral angiography was performed using the Seldinger method. It revealed a right vertebral artery dissecting aneurysm just distal to the posterior inferior cerebellar artery. We performed an operation to trap the VA dissecting aneurysm. Blood pressure was well controlled under 140 mmHg during the operation and he recovered from anesthesia completely. On the day after the operation, suddenly the patient's consciousness began to deteriorate. Emergency CT scan was performed and it showed SAH, cerebellar hemorrhage and diffuse swelling of the cerebellum on the same side as the operation. We suspected rebleeding of the aneurysm due to a clip's having slipped. Reoperation was performed, but the clip was not displaced and there were no definite bleeding vessels on the operative field. Consequently only external decompression and resection of the right cerebellum were performed. We discuss pathogenesis of the occurrence of hemorrhage in this particular case after trapping. We also review the relevant literature." }, { "id": "pubmed23n0240_10847", "title": "[Natural history and operative treatment of intracranial aneurysms after subarachnoid haemorrhage (author's transl)].", "score": 0.009708737864077669, "content": "This report presents an evaluation of prognosis in 227 patients with subarachnoid haemorrhage caused by intracranial aneurysm, comparing operative treatment in 118 patients with conservative treatment in 109. In all operable cases, the prognosis following early surgery was better than that of conservative treatment. Statistical comparison of patient groups according to the clinical condition allowed the formation of guidelines for the optimal timing of surgery: patients in good clinical condition should be operated on at the earliest possible moment. The overall mortality with such a policy is lower than with a waiting policy, since the majority of recurrences occurred within 2 weeks. Patients with disturbed consciousness and neurological deficit are best operated on either within 24 hours or following stabilization or improvement of the clinical picture -- mostly after 2 weeks. The risk of rebleeding is much lower in these cases, which justifies awaiting optimum clinical conditions. Surgery on comatose patients is contraindicated." }, { "id": "pubmed23n0073_14052", "title": "[The foramen of Monro--blockage caused by a giant aneurysm of the basilar artery. A case report and review of the literature].", "score": 0.009615384615384616, "content": "A case of a giant aneurysma of the basilar artery bifurcation with occlusive hydrocephalus due to bilateral foramen of Monro occlusion is reported. The patient presented with progressive neurological deterioration which led to computerized tomography examination and implantation of a ventricular shunt as an emergency procedure. After the patient had recovered to a certain extent, four-vessel angiography was performed that demonstrated a giant basilar tip aneurysm. As the posterior communicating, the posterior cerebral as well as the superior cerebellar arteries originated from the aneurysm sac direct surgical attack as well as endovascular treatment was considered to be impossible. A permanent biventricular-abdominal shunt system was implanted and the patient was discharged. Three weeks later the patient was readmitted comatose after he had suffered a massive subarachnoid hemorrhage from which he finally died. The clinical and radiological signs, the differential-diagnostic considerations as well as the few cases of foramen of Monro occlusion by a giant basilar artery tip aneurysm, presented in the literature so far, are discussed." }, { "id": "pubmed23n0276_11351", "title": "[Management for subarachnoid hemorrhage with negative initial angiography].", "score": 0.009615384615384616, "content": "Subarachnoid hemorrhage (SAH) is commonly caused by ruptured aneurysm or arteriovenous malformation which is detected by cerebral angiogram. However, since angiograms sometimes cannot show the origin of SAH, we review 12 cases (6.3% of total SAH) to assess the management of these cases. We divided the 12 cases into three groups. Group A (occulted aneurysm group) consisted of six cases of which aneurysms were detected by repeated angiographies in four, and by surgical procedures in two. Group U (unknown etiology group) consisted of five cases. Their follow up periods varied from 7 months to 7 years 11 months, and all of them recovered well and had no episode of rebleeding. Group R (rebleeding group) consisted of one case which fatally re-bled on the second day. Group A tended to be Hunt and Hess grade 3, and Fisher group 3 or 4. In contrast, group U tended to be H and H grade 1 or 2, and Fisher group 2. However by their clinical and neuroradiological findings alone, it was not possible to distinguish the two groups certainly. This means that the patients whose initial angiography does not show the origin of bleeding must be cared for as an occult aneurysm case. Twice repeated angiograms should be programmed. In our cases the first was carried out on the seventh day in the hope that the reason for vasospasm of the parent artery might be shown to be a hidden aneurysm. The second was carried out sometime between the 14th and 21st day because of thrombolysis in the aneurysm, and because it was necessary to relieve vasospasm.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1152_22046", "title": "Relationship of Pressure Reactivity Index and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage.", "score": 0.009523809523809525, "content": "Patients with aneurysmal subarachnoid hemorrhage (SAH) continue to have poor functional outcome due to the occurrence of delayed cerebral ischemia (DCI). Although vasospasm represents the primary therapeutic target for mitigating DCI, DCI occurs through multifocal etiologies that involve impaired cerebral autoregulation. Worse pressure reactivity index (PRx) values, which consists of a moving correlation coefficient between intracranial pressures and mean arterial pressures, have been shown to be associated with DCI in non-randomized clinical trials. We discuss two patients that presented with high-grade SAH and comatose exams. Patient one was a 34-year-old male diagnosed with SAH from a ruptured right middle cerebral artery aneurysm. He had intact PRx values (Mean: -0.07 during hospital days 9-19), while having severe, refractory vasospasm. At the conclusion of his hospitalization, he was functionally independent, had negligible DCI, and was successfully discharged home. Patient two was a 78-year-old female diagnosed with SAH from a ruptured anterior communicating artery aneurysm. She had an improving PRx ranging from -0.1 to 0.1 early in her hospitalization. However, upon developing severe vasospasm, her PRx increased to 0.6 (overall PRx from hospital days 4-16 was 0.3), and she suffered from extensive DCI in bilateral middle cerebral and anterior cerebral artery distributions that ultimately resulted in malignant cerebral edema and brain death. Cerebral autoregulation as measured by PRx may represent a viable target for neuroprognostication by evaluating DCI risk in patients with SAH who develop severe or refractory vasospasm. Further studies evaluating the role of cerebral autoregulation, PRx, and its pathophysiological role in DCI are warranted." }, { "id": "wiki20220301en026_4640", "title": "Subarachnoid hemorrhage", "score": 0.009520599882045665, "content": "In general, the decision between clipping and coiling is made on the basis of the location of the aneurysm, its size and the condition of the person. Aneurysms of the middle cerebral artery and its related vessels are hard to reach with angiography and tend to be amenable to clipping. Those of the basilar artery and posterior cerebral artery are hard to reach surgically and are more accessible for endovascular management. These approaches are based on general experience, and the only randomized controlled trial directly comparing the different modalities was performed in relatively well people with small (less than 10 mm) aneurysms of the anterior cerebral artery and anterior communicating artery (together the \"anterior circulation\"), who constitute about 20 percent of all people with aneurysmal SAH. This trial, the International Subarachnoid Aneurysm Trial (ISAT), showed that in this group the likelihood of death or being dependent on others for activities of daily living was reduced" }, { "id": "pubmed23n0267_3875", "title": "[Ruptured distal anterior cerebral artery aneurysms presenting with acute subdural hematoma: report of two cases].", "score": 0.009433962264150943, "content": "Two cases of ruptured distal anterior cerebral-artery aneurysms presenting with acute subdural hematoma are reported. Case 1 was a 55-year-old male, who showed abrupt disturbance of consciousness. An emergency CT revealed acute subdural hematoma at the right parietal convexity and interhemispheric fissure with moderate midline shift. There was no evidence of subarachnoid hemorrhage. Right carotid angiography showed an aneurysm at the right distal anterior cerebral artery. An emergency external decompression was performed and the aneurysm was clipped successfully through the interhemispheric fissure. In the operative field, subarachnoid hemorrhage could not been seen, and the patient had uneventful recovery. Case 2 was a 66-year-old female, who complained of severe headache. She deteriorated rapidly and become comatous with development of anisocoria. An emergency CT revealed acute subdural hematoma on the bilateral parietal convexities and interhemispheric fissure with severe midline shift. There was no evidence of subarachnoid hemorrhage. Carotid angiography showed right distal anterior cerebral artery aneurysm. An emergency external decompression was performed, then the aneurysm was clipped successfully. She recovered with disorientation and hemiparesis. Ruptured distal anterior cerebral artery aneurysms presenting with acute subdural hematoma without subarachnoid hemorrhage are rare. It is suggested that CT scans and history of patients are most important but an emergency angiography was prerequisite for correct diagnosis. Surgical treatment should be the best management in such cases." }, { "id": "pubmed23n0617_207", "title": "Interdisciplinary treatment selection in admitted patients with acute subarachnoid hemorrhage.", "score": 0.009433962264150943, "content": "To review the angiographic and clinical outcomes from acute (first 6 hours after bleeding) interdisciplinary treated patients with ruptured intracranial aneurysm. An interventional neuroradiologist and a neurosurgeon set the emergent treatment of 100 consecutive patients with subarachnoid hemorrhage (SAH) harboring 111 cerebral aneurysms. Decisions were based on the patient's clinical condition, aneurysm's morphology and location, presence of intracranial mass-occupying process (IMOP), angiographic flow distribution patterns and treatment-related risk profit. The benefits of a joined case assessment were retrospectively analyzed, comparing our clinical and radiological results with those of the averaged literature series. Initially, 39 aneurysms in 34 patients were endovascularly (EV) treated and 68 aneurysms in 66 patients were surgically (S) treated. Four nonruptured aneurysms remain under control. Complete radiological aneurysm occlusion was initially achieved in 35 (89.7%) EV and 62 (95.4%) S treated aneurysms. Twenty-six patients in poor clinical condition with IMOP as well as ten patients with distally located, 18 with EV unfavorable and 12 with highly expected recanalization rate aneurysms required S treatment. Four aneurysm remnants (two EV and two S) remain unchanged. Two EV treated aneurysms grew and were surgically occluded, and another three patients required an additional coiling procedure after recanalization. Favorable evolution was observed in 27 (79.4%) EV and 55 (83.3%) S treated patients. Computed tomography-documented rebleedings (7:1), angiographic vasospasm (3:5) and occlusion of main vessels (2:2) were the method-related complications in the EV and S groups, respectively. After comparing the literature data, acute interdisciplinary treatment of patients with SAH increases the rate of aneurysm occlusion, improves patient's evolution and reduces the number of complications." }, { "id": "pubmed23n0106_16244", "title": "Cerebromeningeal hemorrhage. Analysis of autopsies performed over a 10-year period.", "score": 0.009345794392523364, "content": "A study was conducted on the medical records of 353 patients who died of a subarachnoid hemorrhage (SAH) and who were submitted to autopsy over the last 10 years. SAH was associated with arterial hypertension in 180 (51%) cases, with ruptured aneurysms in 102 (28.9%), and with other pathologies in 71 (20.1%). The patients with hemorrhage associated with arterial hypertension were mostly males, and those with hemorrhage due to aneurysms were mostly females. Of the patients with aneurysms, 36 (35.3%) had aneurysms in the anterior communicating artery, 30 (29.4%) in the internal carotid artery, and 23 (22.6%) in the middle cerebral artery. Among the patients with aneurysms who suffered rebleeding and vasospasm, 59.1% and 61.5%, respectively, were classified as grade I and II upon admission, and all evolved toward grade IV after these complications. Vasospasm predominated from the 3rd to the 10th day after hemorrhage, and rebleeding from the 9 to 16th day and both were most frequent among patients with aneurysms of the anterior communicant artery. Sixty eight percent of the patients with aneurysms died during the first 9 days after hemorrhage. Because of our conduct was to operate systematically late, a considerable number of patients lost the opportunity to be treated surgically with possible favorable evolution due to vasospasm or rebleeding." }, { "id": "pubmed23n0058_17961", "title": "[Value of the measurement of cerebral blood flow before and after diamox injection in predicting clinical vasospasm and final outcome in aneurysmal subarachnoid hemorrhage].", "score": 0.009345794392523364, "content": "The timing for surgery on ruptured intracranial aneurysms remains a difficult question and the choice of the day of operation depends greatly from the occurrence of a vasospasm. On a previous paper, the value of the cerebral blood flow (CBF) measurement by intravenous injection of Xenon 133 was demonstrated to be efficient for the prediction of vasospasm only when done between day 4 and day 8 after bleeding. Moreover the efficiency of the measurement was much greater if the evolution of the CBF values between D0 and D8 was considered, but this method was incompatible with early surgery. It suggested the interest of a dynamic study of the CBF by the same method. On a series of 43 patients, the comparison between basal CBF values and reactivity of CBF values to intravenous injection of 1 gram of acetazolamide for the prediction of clinical vasospasm is presented. The series comprises 32 early admitted patients (74%) and 31 operated patients (16 of them between D0 and D3 after bleeding, 15 others after D4). The efficiency of the CBF reactivity study for the prediction of the clinical vasospasm appears much greater than that of the basal CBF value, even during the first three days after bleeding, but not for the prediction of the final clinical outcome. The method is immediate and compatible with early surgery. What precisely is evaluated by this method on the physiopathology of the vasospasm remains disputable, but the operability of the patients seems to be explored." }, { "id": "article-28680_23", "title": "Saccular Aneurysm -- Treatment / Management -- 3. Surgical Clipping", "score": 0.00928333512410014, "content": "Those patients with a ruptured cerebral aneurysm should be admitted to the intensive care unit for close monitoring. Endovascular coiling or surgical clipping of the ruptured aneurysm should be performed as early as possible in the majority of the cases to reduce the risk of rebleeding. Patients need to be monitored for the signs and symptoms of clinical deterioration due to vasospasm, rebleeding, seizures, cerebral edema, hydrocephalus, and hyponatremia. In the first 48 hours after a SAH, the major cause of morbidity or mortality is rebleeding. Blood pressure should be maintained near 120/80 mmHg before the definite procedure to occlude the aneurysm, but after the treatment, the mean arterial pressure should be maintained above 100 mmHg to reduce ischemic changes secondary to vasospasm. Cerebral vasospasm resulting in cerebral ischemic and neurologic deterioration starts around day 3 to 5 and peaks at day 7. Oral nimodipine at a dose of 60 mg every 4 hours is given for 21 days to improve outcomes. [34] [35] Daily transcranial doppler is recommended to monitor vasospasm. After aneurysm repair, cerebrovascular imaging is generally recommended to look for remnants or recurrence of the aneurysm that may require re-intervention. This can be performed intraoperatively or a few days later." }, { "id": "pubmed23n0019_2937", "title": "[A case of multiple anomalies of cerebral vessels--fenestration of the middle cerebral artery aneurysm of the anterior communicating artery and arteriovenous malformation on the frontopolar region (author's transl)].", "score": 0.009259259259259259, "content": "A case associated with multiple cerebral vascular anomalies, which consisted of fenestration of the middle cerebral artery, arteriovenous malformation and aneurysm of the anterior communicating artery, was reported. A 48 year-old male has been suffering from the left paralysis and mental disorder after the initial attack of subarachnoid hemorrhage, and the second attack resulted in the deterioration of the symptoms. He was admitted to our clinic on October 28, 1974. On neurological examination, mental disorders, such as disorientation, emotional incontinence, amnesia and acalculia, hemiplegia on the left and meningeal irritation signs were observed in admission period. Physical examination was negative. Cerebral angiographic findings were as follows: 1) Moderate vasospasm of the right internal carotid artery at the terminal segment, mild bowing of the anterior cerebral artery and stretching of the frontparietal opercular branches of the middle cerebral artery were observed. 2) Right frontpolar arteriovenous malformation fed by the frontobasal artery and the frontopolar artery, and drained via the aberrant cortical vein into the superior sagittal sinus. 3) Aneurysm of the anterior communicating artery was opacified by left carotid angiography. 4) An abnormal vessel derived from the terminal segment of the right internal carotid artery and terminated at the portion of the sphenoidal segment of the middle cerebral artery. Complete loop was formed between genuine middle cerebral artery and this abnormal artery. He was operated with dissecting microscope on November 11, 1974. The arteriovenous malformation at right frontopolar region was totally removed and aneurysm of the anterior communicating artery was clipped. According to the operative findings, the arachnoid membrane over the right frontopolar region was turbid and adhered to the adjacent tissues. On the contrary, no abnormal findings suggestive of previous subarachnoid hemorrhage were observed around the region of the anterior communicating artery aneurysm. These findings showed that subarachnoidal bleeding was caused by rupture of the arteriovenous malformation of right frontopolar region, but not by the aneurysm on the anterior communicating artery. The postoperative course was uneventful and during the hospitalization the patient starts on rehabilitation therapy. The authors discussed the genesis of fenestration of the middle cerebral artery and relation among these combined vascular anomalies. We inferred that fenestration of the middle cerebral artery arose from the in complete fusion of procursor vascular network in embryonic stage. Additionally, we emphasized that it was necessary to make a distinction between these two terms \"fenestration\" and \"duplication\"." }, { "id": "pubmed23n0288_6800", "title": "[Late complications of subarachnoid hemorrhage from ruptured aneurysms treated with early and delayed surgery].", "score": 0.009259259259259259, "content": "Result of studies on remote sequele of SAH from ruptured brain aneurysms are presented. The investigation have been pointed at the character, range and intensity of some changes in CNS initiated by SAH and resulting from this bleeding. The material comprised of 110 patients: 48 out of this number having been operated on within 72 hours from initial bleed, while 62 have had surgery in delayed term. Three methods of investigations were applied: 1. Angioscintigraphy of the brain. 2. Computerized tomography. 3. Clinical evaluation according to GOS (Glasgow Outcome Scale). The results obtained seem to give reasons to assumption that SAH initiates the gradual process of degradation of the CNS tissues. The blood extravasated to the subarachnoid space following aneurysm burst sets in motion a chain of events leading to: 1) impairment of brain arteries reactivity on elevation of pCO2, 2) intensification of brain atrophy. The intensity of the above mentioned phenomena is proportional to the severity of clinical course of SAH. It came out that timing of surgery has influenced the remote postoperative results less than it had been expected." }, { "id": "pubmed23n0325_7948", "title": "Management of a ruptured cerebral aneurysm in infancy. Report of a case of a ten-month-old boy.", "score": 0.009174311926605505, "content": "A ten month old unconscious boy with hemiplegia (Hunt and Hess IV) was first admitted to a district hospital without a CT scanner or a neurosurgical service (Glasgow-Coma-Score 4, no pathological pupillary signs). Therefore, he was transferred to the Pediatric Department of the University Hospital the same night. An emergency CT scan that night showed intracerebral and subarachnoid hemorrhage with enlarged ventricle (Fisher grade 5). Angiography was not available within reasonable time. Thus in the stage of progressively increasing clinical deterioration, still without pupillary signs, an external ventricular drain-age was placed. Immediately after reduction of the cerebrospinal fluid volume, arterial hypertension was noticed--the right pupil was mydriatic and fixed. Without further apparative diagnosis an emergency craniotomy was performed for decompression under the suspicion of a secondary hemorrhage due to a rerupture of a middle cerebral artery aneurysm. A bleeding aneurysm of the right middle cerebral artery was found and clipped. A mass transfusion was necessary and a pulmonary air embolism occurred. The infant died in tabula. The histological specimens revealed disruption of the internal elastic membrane of both MCA. This emphasizes a congenital nature of the aneurysm. We conclude that cerebral arterial aneurysms have to be considered in the differential diagnosis of stroke-like symptoms in infancy and early childhood, although the incidence of reported cases is less than one case per year. Since no valid screening parameter is available, diagnosis is often made only after rupture of the aneurysm. This causes problems for emergency management. Infants and children with stroke or stroke-like symptoms should immediately be transferred to a hospital with a neurosurgical unit." }, { "id": "pubmed23n0052_5394", "title": "[Ruptured intracranial aneurysm. Modification of the surgical method based on the state of consciousness and age of patients. Personal experience with 468 patients admitted during 2 periods (1972-84 and 1985-89)].", "score": 0.009174311926605505, "content": "The management of the ruptured intracranial aneurysm (clinical grade I to IV only) is studied in a series including 140 patients admitted from 1985 through 1989, in which selected patients were submitted to early surgery and other patients were postponed for delayed surgery. The results are compared to those of an earlier series including 328 patients admitted from 1972 through 1984, for which the general attitude was the delayed surgery: in the later series; the selection for the timing of surgery was based on two main parameters: the clinical status and the patient's age. When we compare both series, the overall management results demonstrate an improvement of 10% of satisfactory results and a decrease of 10% in the death rate in favour of the later series; for the surgical results, the figures are respectively 6% and 5% in favour of the later series. The relationship between age and outcome shows a considerable improvement: over 50 years of age, we observed plus 25% of satisfactory results and minus 22% in death in favour of the later series. Similarly, the relationship between state of consciousness and outcome, demonstrated a great improvement: for drowsy and stuporous patients the figures are respectively plus 22% and minus 21% in favour of the later series. When we consider the later series alone, the patients were admitted at 4 intervals of time from S.A.H. (D0-3, D4-6, D7-15, D16 and over). The most favorable outcome was observed for those patients admitted late (after D7) and already stabilized.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1040_17068", "title": "Delayed cerebral ischemia causing cortical blindness due to repeat cocaine use weeks subsequent to aneurysmal subarachnoid hemorrhage.", "score": 0.00909090909090909, "content": "Cocaine is a known vasoactive drug associated with poor clinical outcomes and high in-hospital mortality related to aneurysmal subarachnoid hemorrhage; however, the association of prior cocaine use with the incidence of vasospasm and delayed cerebral ischemia remains controversial. We report a case of a 42-year-old male with a history of active cocaine use who presented with a severe headache. Imaging demonstrated diffuse cisternal subarachnoid hemorrhage due to a ruptured basilar apex aneurysm, which was successfully treated with endovascular coil embolization. Despite expedited endovascular treatment and an initially benign clinical course, he suffered from delayed cerebral ischemia resulting in cortical blindness due to bilateral posterior cerebral artery vasospasm secondary to repeat cocaine use weeks after his initial ictus. To our knowledge, the present case is the first to describe delayed cerebral ischemia resulting in a severe neurologic deficit due to repeat cocaine use weeks subsequent to aneurysm rupture. We review the current literature on the association of cocaine use with the incidence of vasospasm and delayed cerebral ischemia as well as the effects of cocaine on the cerebrovasculature." }, { "id": "pubmed23n1052_24427", "title": "Rescue endovascular treatment for rapid regrowth of aneurysm remnant on middle cerebral artery trunk after unsuccessful surgical clipping in patients with a ruptured cerebral aneurysm: A report of two cases.", "score": 0.00909090909090909, "content": "We report two rare cases treated with coiling after rapid regrowth (within a month) of an aneurysm remnant on the middle cerebral artery (MCA) trunk after incomplete surgical clipping. The first case, a 47-year-old man with subarachonoid hemorrhage (SAH) (Hunt-Hess grade II, Fisher grade III) underwent clipping of a ruptured saccular aneurysm with a wide neck on the right early frontal branch arising from the MCA trunk. Incomplete clipping with a 1 mm sized remnant neck was performed to avoid sacrificing the lenticulostriate artery. In a follow-up cerebral angiogram on postoperative day 30, a rapid regrowth of the aneurysm remnant was observed, and on that day, complete obliteration was obtained by rescue endovascular treatment. The second case, a 48-year-old healthy woman with SAH (Hunt-Hess grade II, Fisher grade III) underwent clipping of an anteroposteriorly projecting bilobulated aneurysm on the left M1. Incomplete clipping with a minimal remnant neck was performed. In follow-up digital subtraction angiogram on postoperative day 30, a rapid regrowth of an aneurysm remnant involving only a part of the initial aneurysm near the neck was observed, and on that day, complete obliteration was obtained by rescue coiling. These patients were both discharged without any neurological deficits." }, { "id": "pubmed23n0580_21416", "title": "Case of unusual presentation of fusiform aneurysm of the basilar artery.", "score": 0.009009009009009009, "content": "To describe a case of a fusiform aneurysm of the basilar artery presented as a pontine infarct and 2 days later as a subarachnoid hemorrhage caused by the rupture of the same aneurysm. Case report. Tertiary-care hospital. Fusiform aneurysm of cerebral vessels is a rare pathology that presents with ischemic stroke, subarachnoid hemorrhage, or mass effect. Ischemia and subarachnoid hemorrhage in the same patient 2 days apart, to our knowledge, was not reported before. A 55-year-old Hispanic man with history of untreated hypertension and alcohol abuse presented with acute onset of right hemiparesis and dysarthria. On day 2 of his hospital admission, he developed arrhythmia and loss of consciousness. The patient expired from cardiac arrest on day 4 of his hospitalization. Initial head computed tomography scan showed dolichoectatic basilar artery and marked calcification of internal carotid arteries (ICA) and middle cerebral arteries (MCA). Brain magnetic resonance imaging showed left upper pons infarct 2 cm in diameter. Magnetic resonance angiography confirmed presence of a fusiform aneurysm of the basilar artery. Head computed tomography scan at the time of clinical deterioration on day 2 of hospital admission showed subarachnoid bleeding and significant brain edema. Autopsy revealed a ruptured basilar artery aneurysm with thrombus in the lumen and left pontine infarct. Microscopic examination of fusiform aneurysm showed atherosclerosis of the aneurysmal wall and attenuation and inflammation at the rupture site. We hypothesize that in our case, pontine infarct had developed because of occlusion of pontine perforators by a thrombus within an aneurysm, and subarachnoid hemorrhage had developed secondary to a rupture of weakened by inflammatory changes aneurysmal wall. We also hypothesize that in our case, ischemic stroke and subsequent subarachnoid hemorrhage may represent different stages of the same process of atherosclerosis and inflammation in an aneurysmal wall confirmed by autopsy. Origin as well as management of fusiform cerebral aneurysms are unclear. Antiplatelet agents and anticoagulation are recommended by some for stroke prophylaxis in patients with unruptured fusiform cerebral aneurysms. Our case shows that caution should be exercised in prescribing anticoagulants or even antiplatelet agents to a patient with fusiform aneurysm of cerebral arteries due to a possibility of rupture of an aneurysm. Randomized prospective study may be necessary to clarify this issue." }, { "id": "pubmed23n0088_12370", "title": "[Time course of blood velocity changes and clinical symptoms related to cerebral vasospasm and prognosis after aneurysmal surgery].", "score": 0.009009009009009009, "content": "Cerebral vasospasm is a major complication associated with subarachnoid hemorrhage. In spite of extensive research, the pathogenesis of vasospasm remains obscure, and clinical management has so far been extremely difficult. For the evaluation of the efficacy of any treatment and the timing of operation, the development and resolution of the arterial narrowing should be monitored. It is important to know the correlation between the change in flow velocity and the course of clinical symptoms. In this study, the blood flow velocity in the different arteries was measured at short intervals (at least every third day) with transcranial Doppler ultrasonography, in eighteen patients with ruptured cerebral aneurysm. Flow velocity changes began to accelerate from 3 days after surgery, and reached the maximum value between 7 and 10 days, with normalization occurring within the following 2 weeks. The changes showed a significant relationship to the severity of vasospasm, the side of the operative approach, and the administration of calcium antagonist. Based on our results, we categorized the flow velocity changes of vasospasm for clinical practice as follows. (1) A slight acceleration of up to 120 cm/s in MCA and 90 cm/s in ACA was defined as within the normal range. In this state vasospasm was never observed angiographically. (2) Flow velocity changes between 120 and 140 cm/s were a subcritical state. These changes were seen in vasospastic patients who did not develop ischemic deficits. (3) Flow velocity changes of over 140 cm/s in MCA and 100 cm/s in ACA were critical vasospasm, since all of the patients who developed ischemic symptoms were in this group. Velocity changes higher than 170 cm/s in MCA and 130 cm/s in ACA seem to indicate a critical condition with a tendency to develop into brain infarction. The comparison between the time course of the flow velocity changes and clinical status showed that in symptomatic vasospasm the increase in velocity occurred before the manifestation of clinical symptoms. The transcranial Doppler measurements help to identify those patients who have a high risk of developing neurological deficits due to vasospasm, and help to select those who would benefit from preventive treatment in asymptomatic stage." }, { "id": "pubmed23n0316_774", "title": "[Two cases of subarachnoid hemorrhage associated with neurofibromatosis type I: a case of multiple cerebral aneurysms and arteriovenous malformation, and another case of an anterior communicating artery aneurysm].", "score": 0.008928571428571428, "content": "Two cases of subarachnoid hemorrhage associated with neurofibromatosis type I (von Recklinghausen's disease) are reported. A 30-year-old male patient (case 1) had been diagnosed as having neurofibromatosis type I due to neurofibroma and café-au-lait spot. He suffered from subarachnoid hemorrhage and angiography showed multiple aneurysms in the right and left middle cerebral arteries and left internal carotid artery. He also had arteriovenous malformation in the left temporal lobe. Case 2 was that of a 62-year-old female patient with neurofibroma and café-au-lait spot. She suffered from subarachnoid hemorrhage and angiography showed an aneurysm in the anterior communicating artery. Both patients were discharged with no deficits after neck clipping, however they both suffered from large-sized hematoma in the punctured site of the femoral artery after angiography. The cerebral aneurysms associated with neurofibromatosis type I are often multiple and may coexist with arteriovenous malformation." }, { "id": "pubmed23n0237_10832", "title": "[Correlation of vasospasm with operative results in ruptured aneurysms].", "score": 0.008928571428571428, "content": "The present study is a retrospective clinicoradiological correlative investigation of subarachnoid hemorrhage associated with ruptured aneurysms. There were 360 patients in whom the source of subarachnoid hemorrhage was shown by angiography to be a ruptured aneurysm, and 302 of them underwent surgery. Arterial vasospasm was demonstrated in 113 of 360 patients (31%). When the time relationship between the subarachnoid hemorrhage and vasospasm was considered, vasospasms were revealed in 35 patients (31%) to ten days after a hemorrhage. In these cases with preoperative vasospasm, 17 patients were operated within 14 days and 43 patients later than two weeks. On the examination, their clinical state was graded according to Hunt and Hess. The surgical results were also grade in five groups (excellent, good, fair, poor and died) according to the functional results at discharge from the hospital. Of 35 patients of grade I and II at operation, 23 patients (66%) were of excellent or good results. However, of 14 patients of grade IV and V at operation, only on patient took good result. Of 12 patient in whom severe vasospasm was demonstrated and surgery was delayed more than two weeks, 8 patients (66%) had good result. Postoperative vasospasm was recognized in 2 patients, who took poor result. Surgery was carried out in 32 patients on the first or second day after subarachnoid hemorrhage, and 7 patients (22%) of them took good result. The overall mortality was 59% (19 patients). In ten patients, surgery was carried out on the third or fourth day after subarachnoid hemorrhage. Five patients had good result (50%) and four (40%) died. Considering the relationship between the timing and result of surgery, the mortality was 35% in patients operated on in the first week, whereas there were only 38 deaths among the 252 patients operated on after that interval. Among the death patients who were in grade IV or V at admission, intracranial hematoma was seen in 73%. It was concluded that in patients classified as grade I or II, the operation should be performed as soon as possible to prevent another rupture. In grade IV and V patients with severe damage by large hematoma, the mortality and morbidity were high even after evacuation of the hematoma. Patients with marked and diffuse vasospasm should be given conservative treatment at first and then operated on when the patients condition becomes good." }, { "id": "wiki20220301en062_65671", "title": "International Subarachnoid Aneurysm Trial", "score": 0.00891616029230708, "content": "Updated data from the ISAT group in March 2008 shows that the higher aneurysm rate of recurrence is also associated with a higher rebleeding rate, given that the rebleed rate of coiled aneurysms appears to be 8 times higher than that of clipping treated aneurysms in this study. The ISAT authors conclude that \"when treating ruptured cerebral aneurysms, the advantage of coil embolization over clip ligation cannot be assumed for patients < 40 years old.\" Other subsequent studies have questioned the ISAT's conclusions directly. This conclusion is based on a number of methodological assumptions itself and other authors have cautioned about extending it to other patient populations. It appears that although endovascular coiling is associated with a shorter recovery period as compared to surgical clipping, it is also associated with a significantly higher recurrence rate after treatment. The long-term data for unruptured aneurysms are still being gathered." }, { "id": "pubmed23n0112_110", "title": "Early aneurysm surgery: a 7 year clinical practice report.", "score": 0.008849557522123894, "content": "One hundred and fifty patients with intracranial aneurysms, operated on consecutively in the early stage in our department, were re-evaluated retrospectively. Seven surgeons operated on 159 aneurysms in 150 patients. Seventy-nine percent of the patients were in grades I-III (scale of Hunt and Hess), 21% in grades IV-V. Seventy-one percent had a severe haemorrhage (classification of Fisher et al.), 21% had an intracerebral haematoma. Intraoperative CSF drainage was an almost indispensable tool while postoperative external drainage did not prove to be helpful in preventing vasospasm and/or hydrocephalus. Induced hypotension was abandoned in favour of temporary clipping. Thirteen percent of the patients suffered a permanent or fatal immediate postoperative deterioration, while 11% developed delayed neurological deficits. Five percent were related to vasospasms alone, they were all transient. Five percent had vasospasm combined with other complications. One of them had permanent and the other one fatal deficits. One percent deteriorated due to embolism or occluded vessels. The results improved with the introduction of the calcium channel blocker nimodipine, induced hypertension and transcranial Doppler sonographic control of the vasospasm. Patients in good preoperative condition had a good early outcome in 69%. The result was fair in 21% and poor in 4%, while 6% of the patients died. In the poor condition group 22% of the patients made a good, 13% a fair, and 59% a poor recovery, 16% of whom died.(ABSTRACT TRUNCATED AT 250 WORDS)" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 176 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "The key in the question is \"stopping the clinical course\", as Hungtinton's disease, Tourette's and Parkinson's disease do not have treatments that can stop the clinical course." }, "2": { "exist": true, "char_ranges": [ [ 326, 454 ] ], "word_ranges": [ [ 49, 68 ] ], "text": "in clinical cases it is recommended to rule out Wilson's disease in young patients with movement and neuropsychiatric disorders." }, "3": { "exist": true, "char_ranges": [ [ 0, 176 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "The key in the question is \"stopping the clinical course\", as Hungtinton's disease, Tourette's and Parkinson's disease do not have treatments that can stop the clinical course." }, "4": { "exist": true, "char_ranges": [ [ 177, 306 ] ], "word_ranges": [ [ 27, 45 ] ], "text": "Sydenham's chorea is typical of younger children with a history of streptococcal infection and resolution is usually spontaneous." }, "5": { "exist": true, "char_ranges": [ [ 0, 176 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "The key in the question is \"stopping the clinical course\", as Hungtinton's disease, Tourette's and Parkinson's disease do not have treatments that can stop the clinical course." } }

{ "1": "Huntington's disease.", "2": "Wilson's disease.", "3": "Tourette's syndrome.", "4": "Sydenham's chorea.", "5": "Juvenile-onset Parkinson's disease." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0490_14114", "title": "[Tourettism, hemiballism and juvenile Parkinsonism: expanding the clinical spectrum of the neurodegeneration associated to pantothenate kinase deficiency (Hallervorden Spatz syndrome)].", "score": 0.017133275007290755, "content": "Pantothenate kinase deficiency (Hallervorden-Spatz syndrome, HSS) triggers cerebral neurodegeneration with iron deposition in the basal ganglia. The classical form has an early onset in infancy, a progressive course, the presence of extrapyramidal symptoms (dystonia, chorea, rigidity) and pigmentary retinitis. There are atypical late onset forms with predominance of symptoms of Parkinsonism and dementia, which progress slowly and course somewhat less progressively. We describe three patients with HSS and an atypical presentation, with onset during the second decade of life. In all cases magnetic resonance imaging showed areas of hyposignal in T2 sequences in medial globus pallidus, with central hypersignal, which gave rise to a tiger's eye image. Other aetiologies, such as Wilson's disease, gangliosidosis GM1, hypoprebetalipoproteinemia, hexosaminidase A deficiency, aminoacidurias and infantile Huntingdon's chorea, were precluded. In the 20-year-old male the initial manifestations at the age of 17 were superposed over Gilles de la Tourette syndrome, with complex motor and vocal tics, palilalia, behavioural disorders and postural instability. The 13-year-old patient presented symptoms of chorea, hemiballic movements and dystonia in the lower limbs, which limited walking at the age of 12. The 28-year-old female patient presented a progressive rigid akinetic syndrome, with dementia and partial response to levodopa. The clinical spectrum of HSS is broad and its differential diagnosis must include hemiballism, Tourette syndrome and juvenile Parkinsonism." }, { "id": "pubmed23n0467_387", "title": "FINGERPRINT PATTERNS IN HUNTINGTON'S CHOREA AND PARKINSON'S DISEASE.", "score": 0.014565826330532213, "content": "In the course of a continuing search for means of predicting Huntington's chorea before the onset of neurological symptoms, a study of fingerprint patterns was undertaken, using the technique employed by Hodges and Simon in the investigation of patients with Wilson's disease. Fingerprint patterns of 61 patients with Huntington's chorea and 50 with Parkinson's disease were compared with norms established by Scotland Yard. Although an increased incidence of the \"whorl\" pattern was seen in the left second and third fingers in patients with Huntington's chorea, this finding could not be interpreted as having diagnostic or prognostic value as it was found also in some normal subjects and in occasional cases of Parkinson's disease. The pattern supposedly characteristic of Wilson's disease was also seen in persons with Huntington's chorea." }, { "id": "pubmed23n1022_4938", "title": "Nosology and Phenomenology of Psychosis in Movement Disorders.", "score": 0.01436335403726708, "content": "Psychotic symptoms, such as delusions and hallucinations, are part of the clinical picture of several conditions presenting movement disorders. Phenomenology and epidemiology of psychosis in Parkinson's disease have received wide attention; however, the presence of psychosis in other movement disorders is, comparatively, less well known. To review psychotic symptoms present in different movement disorders. A comprehensive and structured literature search was performed to identify and analyze data on patients with movement disorders and comorbid psychosis. In monogenic parkinsonisms, such as PARK-GBA, PARK-LRRK2, and PARK-SNCA, visual hallucinations related to dopamine replacement therapy are frequent as well as are delusions in PARK-LRRK2 and PARK-SNCA, but not in PARK-GBA. Different types of delusions and hallucinations are found in Huntington's disease and other choreic disorders. In Tourette's syndrome, paranoid delusions as well as visual, olfactory, and auditory hallucinations have been described, which usually develop after an average of 10 years of disease. Delusions in ataxias are more frequent in ATX-TBP, ATX-ATN1, and ATX-ATXN3, whereas it is rare in Friedreich's ataxia. Psychosis is also a prominent and frequent clinical feature in Fahr's disease, Wilson's disease, neurodegeneration with brain iron accumulation, and some lysosomal storage disorders, whereas it is uncommon in atypical parkinsonisms and dystonia. Psychosis usually occurs at late disease stages, but may appear as onset symptoms of the disease, especially in Wilson's disease, Huntington's disease, late-onset Tays-Sachs, and Niemann-Pick. Psychosis is a frequent comorbidity in most hyper- and hypokinetic movement disorders. Appropriate recognition is relevant both in the early and late disease stages." }, { "id": "pubmed23n0058_17904", "title": "Profile of patients enrolled in a new movement disorder clinic.", "score": 0.013676991832331637, "content": "To assess the need for a regional expertise in movement disorders, the numbers of patients, clinic visits, and medication changes for a new movement disorder clinic were recorded. During 3 1/2 years, 355 patients were seen, with 1,329 clinic visits. Idiopathic Parkinson's disease was the most common diagnosis, comprising 36% of the population, followed by dystonia (17%), tremor (12%), parkinsonism (i.e., Parkinson's plus syndromes, drug-induced parkinsonism, etc.) (10%), chorea (10%), Tourette's syndrome (6.5%), and tardive dyskinesia (3.4%). Distribution of follow-up visits was similar, with Parkinson's disease (52%) being most frequent and Tourette's syndrome (3.1%) least frequent. The relative utilization of medical care by each patient group was assessed by determining the number of medication changes and the number of clinic visits per follow-up year. No differences in these measures were found using a one-way analysis of variance. Of the Parkinson's disease patients, 67% had Hoehn and Yahr stages III-IV and 77% of the clinic visits were made by this subgroup. When considered in light of the prevalence of each of the diseases, these data show a need for an expertise in movement disorders for a population base of the size we have served." }, { "id": "pubmed23n0776_15334", "title": "Movement disorders in childhood.", "score": 0.01309931506849315, "content": "The aim of this article is to review movement disorders in children. They are common but have etiology and phenomenology different than in adults. Tics are the most common phenomena although in most instances they are mild and have a favorable long-term prognosis. Dystonia is the second most common phenomena but when present it is usually genetic or idiopathic and causes meaningful disability. Sydenham's chorea is the most common cause of chorea in children worldwide. Systemic lupus erythematosus is a much rarer cause of chorea but it is always to be ruled out given the lack of a specific diagnostic marker for Sydenham's chorea. Tremor, usually caused by drugs or essential tremor, is regarded as rather uncommon in children. Arguably, most pediatric patients with tremor do not seek medical attention because of the lack of disability. Stereotypies are relatively uncommon but their recognition is clinically relevant since they are usually associated with severe conditions such as autism and Rett syndrome. Parkinsonism is quite rare in children and either results from encephalitis or is a side effect of medications. Wilson's disease must be ruled out in all children with movement disorders. " }, { "id": "Pharmacology_Katzung_3093", "title": "Pharmacology_Katzung", "score": 0.01282051282051282, "content": "Huster D: Wilson disease. Best Pract Res Clin Gastroenterol 2010;24:531. Jankovic J: Medical treatment of dystonia. Mov Disord 2013;28:1001. Kalia LV, Kalia SK, Lang AE: Disease-modifying strategies for Parkinson’s disease. Mov Disord 2015;30:1442. Kimber TE: An update on Tourette syndrome. Curr Neurol Neurosci Rep 2010;10:286. Kordower JH et al: Transplanted dopaminergic neurons develop PD pathologic changes: A second case report. Mov Disord 2008;23:2303. LeWitt PA et al: AAV2-GAD gene therapy for advanced Parkinson’s disease: A double-blind, sham-surgery controlled, randomised trial. Lancet Neurol 2011;10:309. Lorincz MT: Neurologic Wilson’s disease. Ann N Y Acad Sci 2010;1184:173. Lyons KE, Pahwa R: Outcomes of rotigotine clinical trials: Effects on motor and nonmotor symptoms of Parkinson’s disease. Neurol Clin 2013;31(3 Suppl):S51. Olanow CW et al: A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med 2009;361:1268." }, { "id": "wiki20220301en003_5071", "title": "Wilson's disease", "score": 0.011842269716285464, "content": "Neuropsychiatric symptoms About half of the people with Wilson's disease have neurological or psychiatric symptoms. Most initially have mild cognitive deterioration and clumsiness, as well as changes in behavior. Specific neurological symptoms usually then follow, often in the form of parkinsonism (cogwheel rigidity, bradykinesia or slowed movements and a lack of balance are the most common parkinsonian features) with or without a typical hand tremor, masked facial expressions, slurred speech, ataxia (lack of coordination) or dystonia (twisting and repetitive movements of part of the body). Seizures and migraine appear to be more common in Wilson's disease. A characteristic tremor described as \"wing-beating tremor\" is encountered in many people with Wilson's; this is absent at rest but can be provoked by abducting the arms and flexing the elbows toward the midline." }, { "id": "wiki20220301en002_93716", "title": "Huntington's disease", "score": 0.011826942516342072, "content": "Huntington's disease (HD), also known as Huntington's chorea, is a neurodegenerative disease that is mostly inherited. The earliest symptoms are often subtle problems with mood or mental abilities. A general lack of coordination and an unsteady gait often follow. It is also a basal ganglia disease causing a hyperkinetic movement disorder known as chorea. As the disease advances, uncoordinated, involuntary body movements of chorea become more apparent. Physical abilities gradually worsen until coordinated movement becomes difficult and the person is unable to talk. Mental abilities generally decline into dementia. The specific symptoms vary somewhat between people. Symptoms usually begin between 30 and 50 years of age but can start at any age. The disease may develop earlier in each successive generation. About eight percent of cases start before the age of 20 years, and are known as juvenile HD, which typically present with the slow movement symptoms of Parkinson's disease rather than" }, { "id": "pubmed23n0383_14568", "title": "[Contributions of Charcot and Marsden to the development of movement disorders in the 19th and 20th centuries].", "score": 0.011502318769831585, "content": "Charcot described many neurological diseases in the 19th century, particularly in movement disorders. Charcot contributed in the clinical description of Parkinson's disease, and introduced its first pharmacological treatment. He also studied the hyperkinesias, e.g. of Tourette syndrome, differential diagnosis of tremors, dystonias, choreas and startle disease. Marsden, who died recently, was an exponent in the study of Movement Disorders, with many publications in this field in the 20th century. His most important contributions are definitions and classifications of movement disorders, such as Parkinson's disease, dystonia, myoclonus, essential tremor, the description of the syndromes \"Painful Legs Moving Toes\", \"Gait Ignition Failure\" and \"Primary Writing Tremor\". The contributions of Charcot in the 19th century and Marsden in the 20th century to the movement disorders allow us to conclude that both of them were the most representative icons in this field in the past two centuries." }, { "id": "article-23053_11", "title": "Huntington Disease -- History and Physical", "score": 0.011412855162855163, "content": "Motor disturbances: These include the characteristic unwanted involuntary movements which initially begins in the distal extremities and are of a smaller degree but could go on to affect the facial muscles as well. The movements then spread gradually to the more proximal and axial muscles and are of greater amplitude. Motor symptoms tend to be progressive. Early in the disease, they are mostly hyperkinetic with involuntary chorea. In later stages, however, hypokinesia with bradykinesia and dystonia predominate. The balance between chorea and hypokinesia varies from patient to patient and ranges from overwhelming rigidity in the younger patients, also known as the Westphal variant to older patients being severely affected in the later stages of the disease with rigidity and contractures in the extremities leading them to be bedridden. Dysarthria and dysphagia develop during the course of the disease, which could lead to aspiration in patients, with pneumonia being a common cause of death. Dystonia, characterized by increased muscle tone with slower movements, leads to abnormal posturing such as torticollis and can be the first sign of motor involvement in HD. Other involuntary features include tics and cerebellar signs such as ataxia. Pyramidal signs such as the Babinski sign are present. The motor disturbance on daily activities progresses over time and can lead to difficulties in walking, standing, and frequent falls." }, { "id": "Neurology_Adams_546", "title": "Neurology_Adams", "score": 0.011398552879373575, "content": "In terms of pathologic anatomy and physiology, bradykinesia may be caused by any process or drug that interrupts the cortico-striato-pallido-thalamic circuit. Clinical examples include reduced dopaminergic input from the substantia nigra to the striatum, as in Parkinson disease; dopamine receptor blockade by neuroleptic drugs; extensive degeneration of striatal neurons, as in striatonigral degeneration and the rigid form of Huntington chorea; and destruction of the medial pallidum, as in Wilson disease. As illustrated in Fig. 4-4B, which gives a schematic representation of the hypokinetic state of Parkinson disease, changes in the cortico-striato-pallido-thalamic circuit (in this case mainly the direct striatopallidal pathway) can be interpreted in terms of altered neurochemical and resultant physiologic connectivity within the basal ganglia. The reciprocal situation, enhanced motor activity, is summarized in the analogous diagram for Huntington disease (Fig. 4-4C), in which a" }, { "id": "article-23053_18", "title": "Huntington Disease -- History and Physical -- Clinical course and classification:", "score": 0.011038306451612903, "content": "Overall, the mean age of onset is approximately 45 years. Patients who often present with neurological symptoms also exhibit psychiatric changes. Early in the course of the disease following diagnosis, symptoms such as changes in eye movements, mental planning, depressed or irritable mood as well as mild involuntary movements can be observed. The affected patients are generally able to perform their daily activities. Eventually, chorea progresses, and it becomes increasingly difficult to perform voluntary activities. There are intermittent bursts of aggressive behavior and social disinhibitions. Although patients can maintain some degree of independence, most depend on their caregiver for help. In the later stages of the disease, severe motor disability is noted, and patients are completely dependent on caregivers. The median survival after the onset of the disease is 15 to 18 years. In around 25% of patients, a delayed onset is seen, and these patients exhibit symptoms after the age of 50 and some after the age of 70. Chorea and disturbances in gait are noted on them and often exhibit a benign and more prolonged course than typical patients. [3]" }, { "id": "pubmed23n0265_1526", "title": "Inherited movement disorders.", "score": 0.010324924118027566, "content": "A high proportion of neurological diseases characterized by movement disorders are caused by single genes; in others, such as Parkinson's disease, there appears to be a genetic component. Gene mapping studies have made substantial progress in unravelling the aetiology of dystonias and Huntington's disease, and are underway in other disorders such as essential tremor and Gilles de la Tourette syndrome. These advances are already applicable to clinical practice, particularly in Huntington's disease where identification of the disease mutation has led to the possibility of improved diagnosis and more widespread availability of predictive testing for asymptomatic family members." }, { "id": "wiki20220301en054_23187", "title": "Age of onset", "score": 0.010320300226915692, "content": "The age of onset is the age at which an individual acquires, develops, or first experiences a condition or symptoms of a disease or disorder. For instance, the general age of onset for the spinal disease scoliosis is \"10-15 years old,\" meaning that most people develop scoliosis when they are of an age between ten and fifteen years. Diseases are often categorized by their ages of onset as congenital, infantile, juvenile, or adult. Missed or delayed diagnosis often occurs if a disease that is typically diagnosed in juveniles (such as asthma) is present in adults, and vice versa (such as arthritis). Depending on the disease, ages of onset may impact features such as phenotype, as is the case in Parkinson's and Huntington's diseases. For example, the phenotype for juvenile Huntington's disease clearly differs from adult-onset Huntington's disease and late-onset Parkinson's exhibits more severe motor and non-motor phenotypes." }, { "id": "wiki20220301en219_14751", "title": "Central nervous system disease", "score": 0.010087457761876367, "content": "Tourette's Tourette's syndrome is an inherited neurological disorder. Early onset may be during childhood, and it is characterized by physical and verbal tics. Tourette's often also includes symptoms of both OCD and ADHD indicating a link between the three disorders. The exact cause of Tourette's, other than genetic factors, is unknown. Neurodegenerative disorders Alzheimer’s Alzheimer's is a neurodegenerative disease typically found in people over the age of 65 years. Worldwide, approximately 24 million people have dementia; 60% of these cases are due to Alzheimer's. The ultimate cause is unknown. The clinical sign of Alzheimer's is progressive cognition deterioration. Huntington's disease" }, { "id": "article-143125_4", "title": "Parkinson-Plus Syndrome -- Introduction", "score": 0.010045248868778282, "content": "Less prevalent disorders are frontotemporal dementia, Pick disease, pallidonigral degeneration, parkinsonian-dementia complex of Guam, Wilson disease, and a rigid variant of Huntington disease. [5] [6] This review will discuss the most common PPS conditions, focusing on epidemiology, etiology, pathophysiology, evaluation, and treatment options." }, { "id": "wiki20220301en100_5715", "title": "List of MeSH codes (C10)", "score": 0.009900990099009901, "content": "– high pressure neurological syndrome – meningitis – meningoencephalitis – lupus vasculitis, central nervous system – movement disorders – angelman syndrome – choreatic disorders – chorea gravidarum – huntington disease – dystonic disorders – dystonia musculorum deformans – meige syndrome – torticollis – essential tremor – hallervorden-spatz syndrome – hepatolenticular degeneration – multiple system atrophy – olivopontocerebellar atrophies – shy-drager syndrome – striatonigral degeneration – parkinsonian disorders – lewy body disease – parkinson disease – parkinson disease, secondary – mptp poisoning – parkinson disease, postencephalitic – supranuclear palsy, progressive – Tic disorders – Tourette syndrome – ocular motility disorders – pneumocephalus" }, { "id": "pubmed23n0300_18035", "title": "Tourette's syndrome in the year 2000.", "score": 0.009900990099009901, "content": "To examine the current status of knowledge of Tourette's syndrome (TS) and to highlight those areas of research that are most likely to have the most significant advances in the next few years into the 21st century. Index Medicus was consulted from its beginning in 1885 until 1964 (inclusive), looking initially under the title 'tics' and subsequently under 'Tourette's Disorder'. From 1965 and the advent of MEDLINE, a search was performed looking for 'Tourette's'. A chronological examination of TS in the medical literature is presented. Some issues surrounding Huntington's Disease (HD) research are pertinent to TS and may serve as a guide in the future direction of TS research; these issues have been identified and illustrated in the context of TS. Where relevant, other medical disorders are also commented on. There has been a steady increase in the volume of TS literature since 1885, with a marked increase since 1980, changing in focus from a psychological to a neurobiological viewpoint. Current areas of interest include genetics, comorbid psychopathologies, neuroimaging, treatments, epidemiology and educational considerations. Issues raised by HD and other movement disorders such as Parkinson's Disease (PD) are predictive testing, gene therapy and neural transplants. The year 2000 is likely to herald a significant increase in our knowledge of the genetics and neuroimaging of TS, with new developments in therapy. A broadening of awareness of TS among health workers and teachers in particular is likely to increase the number of diagnosed patients and, hence, new challenges will be posed to existing resources for health and educational provision." }, { "id": "wiki20220301en344_23817", "title": "Joseph Jankovic", "score": 0.009899635036496351, "content": "Past president of the International Parkinson and Movement Disorder Society Past president of the International Neurotoxin Association Honorary Member of the American Neurological Association, Australian Association of Neurologists, French Neurological Society, and the International Parkinson’s Disease and Movement Disorders Society Selected as “Great Teacher” by the National Institute of Health Fellow of the American Academy of Neurology American Academy of Neurology Movement Disorders Research Award First National Parkinson Foundation Distinguished Service Award Huntington’s Disease Society of America Guthrie Family Humanitarian Award Tourette Syndrome Association Lifetime Achievement Award Dystonia Medical Research Foundation Distinguished Service Award Texas Neurological Society Lifetime Achievement Award Baylor College of Medicine Alumni Association Distinguished Faculty Award Baylor College of Medicine Fulbright & Jaworski Faculty Excellence Award" }, { "id": "wiki20220301en262_12883", "title": "Parkinson's disease", "score": 0.00980392156862745, "content": "Multiple causes can occur for parkinsonism or diseases that look similar. Stroke, certain medications, and toxins can cause \"secondary parkinsonism\" and need to be assessed during visit. Parkinson-plus syndromes, such as progressive supranuclear palsy and multiple system atrophy, must also be considered and ruled out appropriately due to different treatment and disease progression (anti-Parkinson's medications are typically less effective at controlling symptoms in Parkinson-plus syndromes). Faster progression rates, early cognitive dysfunction or postural instability, minimal tremor, or symmetry at onset may indicate a Parkinson-plus disease rather than PD itself." }, { "id": "pubmed23n1131_3214", "title": "Eye Movement Disorders in Movement Disorders.", "score": 0.00978047730642307, "content": "Oculomotor assessment is an essential element of the neurological clinical examination and is particularly important when evaluating patients with movements disorders. Most of the brain is involved in oculomotor control, and thus many neurological conditions present with oculomotor abnormalities. Each of the different classes of eye movements and their features can provide important information that can facilitate differential diagnosis. This educational review presents a clinical approach to eye movement abnormalities that are commonly seen in parkinsonism, ataxia, dystonia, myoclonus, tremor, and chorea. In parkinsonism, subtle signs such as prominent square wave jerks, impaired vertical optokinetic nystagmus, and/or the \"round the houses\" sign suggest early progressive supranuclear gaze palsy before vertical gaze is restricted. In ataxia, nystagmus is common, but other findings such as oculomotor apraxia, supranuclear gaze palsy, impaired fixation, or saccadic pursuit can contribute to diagnoses such as ataxia with oculomotor apraxia, Niemann-Pick type C, or ataxia telangiectasia. Opsoclonus myoclonus and oculopalatal myoclonus present with characteristic phenomenology and are usually easy to identify. The oculomotor exam is usually unremarkable in isolated dystonia, but oculogyric crisis is a medical emergency and should be recognized and treated in a timely manner. Gaze impersistence in a patient with chorea suggests Huntington's disease, but in a patient with dystonia or tremor, Wilson's disease is more likely. Finally, functional eye movements can reinforce the clinical impression of a functional movement disorder." }, { "id": "pubmed23n0630_3760", "title": "Wilson's disease: two treatment modalities. Correlations to pretreatment and posttreatment brain MRI.", "score": 0.009764943851572854, "content": "Brain magnetic resonance imaging (MRI) studies on Wilson's disease (WD) show lack of correlations between neurological and neuroimaging features. Long-term follow-up reports with sequential brain MRI in patients with neurological WD comparing different modalities of treatment are scarce. Eighteen patients with neurological WD underwent pretreatment and posttreatment brain MRI scans to evaluate the range of abnormalities and the evolution along these different periods. All patients underwent at least two MRI scans at different intervals, up to 11 years after the beginning of treatment. MRI findings were correlated with clinical picture, clinical severity, duration of neurological symptoms, and treatment with two different drugs. Patients were divided into two groups according to treatment: D: -penicillamine (D-P), zinc (Zn), and Zn after the onset of severe intolerance to D-P. MRI scans before treatment showed, in all patients, hypersignal intensity lesions on T2- and proton-density-weighted images bilaterally and symmetrically at basal nuclei, thalamus, brain stem, cerebellum, brain cortex, and brain white matter. The most common neurological symptoms were: dysarthria, parkinsonism, dystonia, tremor, psychiatric disturbances, dysphagia, risus sardonicus, ataxia, chorea, and athetosis. From the neurological point of view, there was no difference on the evolution between the group treated exclusively with D-P and the one treated with Zn. Analysis of MRI scans with longer intervals after the beginning of treatment depicted a trend for neuroimaging worsening, without neurological correspondence, among patients treated with Zn. Neuroimaging pattern of evolution was more favorable for the group that received exclusively D-P." }, { "id": "wiki20220301en459_21343", "title": "X-linked dystonia parkinsonism", "score": 0.009708737864077669, "content": "X-linked dystonia parkinsonism (XDP), also known as Lubag Syndrome or X-linked Dystonia of Panay, is a rare x-linked progressive movement disorder with high penetrance found almost exclusively in males from Panay, Philippines. It is characterized by dystonic movements first typically occurring in the 3rd and 4th decade of life. The dystonic movements often either coexist or develop into parkinsonism within 10 years of disease onset. Symptoms and signs Symptoms typically present in the 3rd or 4th decade of life, but have been seen as early as the age of 14. It presents with torsion dystonia, particularly when presenting at a younger age, which then progresses to parkinsonism with or without ongoing dystonia. Often the two symptoms coexist. The parkinsonian features of x-linked dystonia parkinsonism include festinating gait, bradykinesia, blepharospasm, and postural instability. It often lacks a resting tremor, helping to differentiate it from Parkinson's disease. Genetics" }, { "id": "wiki20220301en024_61887", "title": "Dystonia", "score": 0.009615384615384616, "content": "An accurate diagnosis may be difficult because of the way the disorder manifests itself. Sufferers may be diagnosed as having similar and perhaps related disorders including Parkinson's disease, essential tremor, carpal tunnel syndrome, temporomandibular joint disorder, Tourette's syndrome, conversion disorder or other neuromuscular movement disorders. It has been found that the prevalence of dystonia is high in individuals with Huntington's disease, where the most common clinical presentations are internal shoulder rotation, sustained fist clenching, knee flexion, and foot inversion. Risk factors for increased dystonia in patients with Huntington's disease include long disease duration and use of antidopaminergic medication." }, { "id": "pubmed23n1067_23822", "title": "Neurological features and outcomes of Wilson's disease: a single-center experience.", "score": 0.00952921157118548, "content": "Wilson's disease (WD) is an autosomal recessive genetic disorder of copper metabolism, and WD patients can present with neurologic symptoms. We aimed to report the general characteristics and prognosis of a Turkish series of WD patients with neurological manifestations. A total of 12,352 patients were screened from the patient database, and 53 WD patients were included. Patients were classified based on the predominant neurological syndrome type including tremor, dystonia, parkinsonism, or discrete neurological signs and were classified as having \"good outcome,\" \"stable,\" and \"poor outcome\" according to their treatment response. There were 32 male and 21 female patients, aged 20-66 years. The mean follow-up was 11.3 ± 4.56 years. Sixty-two percent of patients presented predominantly with neurological symptoms. Neurological WD diagnosis was established after a mean time delay of 2.3 years from the WD diagnosis. The most common neurological manifestation was dystonia, followed by tremor and parkinsonism. Fifteen patients had a family history of WD. Consanguinity was present in 20 patients. Patients were treated with D-penicillamine, trientine, zinc salts, or their combinations. Besides the main treatments, 41 patients were on symptomatic treatment for neurologic symptoms. Thirty-six patients had a \"good outcome,\" five patients were stable, and six patients had \"poor outcome.\" Post-chelation neurological worsening was observed in 11 patients. WD should be considered in differential diagnosis in any patient with unexplained neurologic symptoms. Early diagnosis is important, and appropriate treatment should be promptly initiated to prevent progressive and irreversible damage, with good prognosis and stable disease in the majority of the patients with treatment compliance." }, { "id": "wiki20220301en003_13666", "title": "Tetrahydrocannabinol", "score": 0.009523809523809525, "content": "Neurodegenerative disorders Huntington disease. No reliable conclusions could be drawn regarding the effectiveness of THC or oral cannabis extract in treating the symptoms of Huntington disease as the available trials were too small to reliably detect any difference Parkinson's disease. Based on a single study, oral CBD extract was rated probably ineffective in treating levodopa-induced dyskinesia in Parkinson's disease. Alzheimer's disease. A 2009 Cochrane Review found insufficient evidence to conclude whether cannabis products have any utility in the treatment of Alzheimer's disease. Other neurological disorders Tourette syndrome. The available data was determined to be insufficient to allow reliable conclusions to be drawn regarding the effectiveness of oral cannabis extract or THC in controlling tics. Cervical dystonia. Insufficient data was available to assess the effectiveness of oral cannabis extract of THC in treating cervical dystonia." }, { "id": "pubmed23n0262_8634", "title": "Psychiatric and behavioral abnormalities in Wilson's disease.", "score": 0.009523809523809525, "content": "From the literature and our experience, a relatively consistent picture of psychiatric and behavioral abnormalities in Wilson's disease emerges. The essential elements of this picture are as follows: 1. Psychiatric and behavioral abnormalities are frequent manifestations of WD. The estimates range from 30% (18) to 100% (2) of symptomatic patients. As Wilson himself was the first to state in reference to \"mental change,\" \"its importance should not be underestimated.\" 2. Psychiatric and behavioral abnormalities are often the initial manifestations of WD. Two thirds of our patients first presented with psychiatric symptoms and one third received psychiatric treatment before the diagnosis of WD was made. In the early stages of the disease, when psychiatric and behavioral symptoms predominate, the diagnosis is often missed. Of our 124 patients, WD was diagnosed in only one during this phase. Until the psychiatric presentation of WD is recognized, and the disease is included in the differential diagnosis of psychiatric symptoms, its diagnosis will be missed or delayed. In our patients, and others' (13,15), the delay in diagnosis ranged from 1 to 5 years. Such a delay is particularly tragic as favorable outcome depends upon early discovery. 3. The most common of the psychiatric and behavioral manifestations of WD include: personality changes such as irritability and low threshold to anger, depression sometimes leading to suicidal ideation and attempts, deteriorating academic and work performance that is present in almost all neurologically affected patients. We (1) have also observed, as did Scheinberg and Sternlieb (2) that WD patients exhibit increased sexual preoccupation and reduced sexual inhibition. Finally, cognitive impairment, psychosis, anxiety, and other psychiatric disorders, although less frequent, also occur. 4. Some of the psychiatric and behavioral symptoms are reversible with WD-specific therapy, whereas others are not. We are impressed with the frequency with which the behavioral and \"cognitive\" symptoms are reversed over 1 to 2 years of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en214_28446", "title": "Internal globus pallidus", "score": 0.009433962264150943, "content": "Clinical significance Dysfunction of the internal globus pallidus has been correlated to Parkinson's disease, Tourette syndrome, and tardive dyskinesia. The internal globus pallidus is the target of deep brain stimulation (DBS) for these diseases. Deep brain stimulation sends regulated electrical pulses to the target. In patients with tardive dyskinesia treated with DBS, most people reported more than a 50% improvement in symptoms. Tourette syndrome patients have also benefited from this treatment, showing over 50% improvement in tic severity (compulsive disabling motor tics are symptoms of Tourette patients). The GPi is also considered a \"highly effective target for neuromodulation\" when using deep brain stimulation on Parkinson's disease patients. There is seen to be only some involvement in Huntington's disease with mostly the external globus pallidus being affected. References Basal ganglia" }, { "id": "pubmed23n0730_12170", "title": "The representation of movement disorders in fictional literature.", "score": 0.009433962264150943, "content": "This review considers novels, plays and poems dealing with movement disorders in order to show the relevance in the literary context. The motifs are arranged and compared following a modern neurological nosology according to Parkinson syndromes, dystonia, myoclonus, tics, hemifacial spasm, Tourette syndrome, Huntington's disease and hyperekplexia. There is considerable variety in how movement disorders are depicted and how much influence they have on the plot structures. Their usage ranges from a brief reference in order to accentuate aspects of a character's personality or social position, such as in Shakespeare, Dickens, Tolstoy or Galdós; to truly constituting one of the plot's main themes as, for example, with the representation of Lewy body disease in Franzen's The Corrections and Huntington's disease in Vonnegut's Galápagos, Sawyer's Frameshift or McEwan's Saturday. The symbolic connotation of the disease is of major importance, as is its social and psychological impact. Some 20th century authors transfer rhythm patterns of specific movement disorders into the textual structure, including, among others, Beckett." }, { "id": "wiki20220301en109_4535", "title": "Tourettism", "score": 0.009345794392523364, "content": "Conditions that may manifest tics or stereotyped movements include developmental disorders; autism spectrum disorders and stereotypic movement disorder; Sydenham's chorea; idiopathic dystonia; and genetic conditions such as Huntington's disease, neuroacanthocytosis, pantothenate kinase-associated neurodegeneration, Duchenne muscular dystrophy, Wilson's disease, and tuberous sclerosis. Other possibilities include chromosomal disorders such as Down syndrome, Klinefelter syndrome, XYY syndrome and fragile X syndrome. Acquired causes of tics include drug-induced tics, head trauma, encephalitis, stroke, and carbon monoxide poisoning. The symptoms of Lesch–Nyhan syndrome may also be confused with Tourette syndrome. Tic mimickers Chorea (disease) Myoclonus Dystonia Torsion dystonia Idiopathic dystonia Genetic/chromosomal" }, { "id": "pubmed23n1052_8216", "title": "Juvenile Huntington's disease: two case reports and a review of the literature.", "score": 0.009345794392523364, "content": "Huntington's disease is a rare, autosomal dominant neurodegenerative disease characterized by motor, cognitive, and psychiatric symptoms. Usually, the disease symptoms first appear around the age of 40, but in 5-10% of cases, they manifest before the age of 21. This is then referred to as juvenile Huntington's disease. According to the small number of cases reported in the literature, the course of juvenile Huntington's disease significantly differs from adult onset and shows significant interpatient variability, making every case unique. Our study aims to highlight the complexity and diversity of rare juvenile Huntington's disease. We report cases of two Caucasian patients with chronic tics referred to the Huntington's Disease Competence Center of Vilnius University Hospital Santaros Klinikos with suspicion of juvenile Huntington's disease due to the appearance of chronic motor tics, and behavior problems. The diagnosis of juvenile Huntington's disease was confirmed on both clinical and genetic grounds. In both cases described, the patients developed symptoms in all three main groups: motor, cognitive, and psychiatric. However, the first patient was experiencing more severe psychiatric symptoms; in the second case, motor symptoms (rigidity, tremor) were more prominent. In both cases, apathy was one of the first symptoms and affected patients' motivation to participate in treatment actively. These two case descriptions serve as an important message for clinicians seeing patients with chronic tics and gradually worsening mood and behavior, indicating the need to investigate them for rare genetic disorders. Description of these two clinical cases of juvenile Huntington's disease provides insight into how differently it manifests and progresses in young patients and the difficulties the patients and their families face. There were different but painful ways for families to accept the diagnosis. Because the disease inevitably affects the patient's closest ones, it is crucial to also provide adequate psychological and social support to all the family members. Establishment of multidisciplinary specialist centers for Huntington's disease, as demonstrated by our experience, not only allows timely diagnosis and treatment plans but also ensures thorough disease management and care for patients and systematic support for their families." }, { "id": "pubmed23n0757_16376", "title": "Whose name is it anyway? Varying patterns of possessive usage in eponymous neurodegenerative diseases.", "score": 0.009259259259259259, "content": "There has been long-standing debate over whether use of the possessive form of the names of eponymous neurological disorders should be abandoned. Which view has actually predominated in practice? We empirically assessed current and historical usage in the scientific literature. The PubMed database was queried for the percentage of titles published each year from 1960-2012 which contained the possessive form of Parkinson's (PD), Alzheimer's (AD), Huntington's (HD), Wilson's (WD), and Gaucher's (GD) diseases (e.g. Huntington's disease or chorea vs Huntington disease or chorea). Down syndrome (DS), well known for its changes in terminology, was used as a reference. The possessive form was nearly universal in all conditions from 1960 until the early 1970s. In both DS and GD it then declined at an approximately constant rate of 2 percentage points per year to drop below 15%. The possessive forms of both PD and AD began to decline at the same time but stabilised and have since remained above 80%, with a similar but more volatile pattern in HD. WD, meanwhile, is intermediate between the DS/GD and PD/AD/HD patterns, with a slower decline to its current value of approximately 60%. Declining possessive form usage in GD and DS papers has been remarkably uniform over time and has nearly reached completion. PD and AD appear stable in remaining predominantly possessive. The larger volume of papers published in those fields and their possibly greater public recognition and involvement may make that unlikely to change in the short-term. In a secondary analysis restricted to PD, we found that practices have switched dramatically several times in each of three US-published general neurology journals. Meanwhile, in two UK-published journals, and in the specialist title \"Movement Disorders\", the possessive form has been maintained consistently. The use of eponyms in neurology shows systematic variation across time, disorders, and journals." } ] } } }

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{ "1": "Cardioembolic stroke with complete neurologic dysphagia.", "2": "Cachexia due to chronic empyema in immunocompromised patient.", "3": "Prolonged paralytic syndrome.", "4": "Advanced Alzheimer's disease with severe risk of bronchial aspiration.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0104_14108", "title": "[Percutaneous endoscopic gastrostomy--a possibility for enteral feeding of patients with severe cerebral dysfunctions].", "score": 0.016375404530744337, "content": "Patients who are unable to be adequately nourished owing to cerebral dysfunction do not tolerate nasogastric tubes for enteral nutrition well. They are threatened by active or passive dislocation of the tube into the oesophagus with subsequent aspiration. Although these risks are minimized by percutaneous gastrostomy (PEG), aspiration cannot be completely prevented even when this method of feeding is employed. Enteral nutrition was provided by PEG in 33 patients with different cerebral disorders. PEG was indicated when adequate oral intake of food and fluids proved impossible 8 to 12 days after an acute hypoxaemic cerebrovascular event. 3 of 23 patients who had suffered a stroke, 2 of 8 patients with hypoxaemic brain damage and 3 of 5 patients with decompensated cerebral sclerosis regained the ability to eat between the 21st and 50th day of treatment, so that the gastrostomy could be dispensed with. The other patients died of their severe underlying disease. 6 patients aspirated. In 2 cases this complication occurred during acute aggravation of the underlying disease after several weeks of satisfactory enteral tube feeding. 2 patients aspirated after returning to oral nutrition, whereby feeding was certainly implicated in 1 patient and probable in the other patient. PEG enables adequate enteral nutrition of patients with severe neurological impairment. The advantages of PEG over parenteral nutrition are fewer complications, lower costs and, above all, its superiority in meeting physiological requirements." }, { "id": "pubmed23n1043_5461", "title": "Assessment of the risk of malnutrition due to aspiration pneumonia and oral feeding difficulty.", "score": 0.014827832390576088, "content": "Introduction: many patients with acute-phase swallowing disorders experience malnutrition, which can be caused by oral intake difficulties. Many diseases can cause swallowing difficulties such as aspiration pneumonia, and it is, therefore, necessary to consider the risk of malnutrition during oral feeding therapy in patients with aspiration pneumonia. Objectives: we aimed to evaluate the risk of malnutrition in patients with aspiration pneumonia and other diseases. Methods: the participants comprised 62 patients (45 males, 17 females) with acute-phase swallowing disorders who underwent speech therapy (ST) for swallowing rehabilitation. The patients were divided into four groups: 1) oral feeding with pneumonia, 2) parenteral feeding with pneumonia, 3) oral feeding without pneumonia, and 4) parenteral feeding without pneumonia. The serum albumin and total protein levels were measured to evaluate malnutrition, and swallowing ability was assessed using the Fujishima grade. Results: at the time of ST initiation, serum albumin levels were significantly higher in the oral feeding with pneumonia and oral feeding without pneumonia groups than in the parenteral feeding with pneumonia and parenteral feeding without pneumonia groups. The Fujishima grades differed significantly between the pneumonia/parenteral feeding group and the non-pneumonia/parenteral feeding group. Conclusions: patients with difficulty in swallowing due to aspiration pneumonia were at higher risk of malnutrition than were those without these difficulties. These findings suggest that the nutritional status of parenterally fed patients who developed pneumonia may be inherently poorer than that of orally fed patients." }, { "id": "wiki20220301en045_78674", "title": "Aspiration pneumonia", "score": 0.01326912787586945, "content": "Dysphagia clinicians often recommend alteration of dietary regimens, altered head positioning, or removal of all oral intake. While studies have suggested that thickening liquids can decrease aspiration through slowed pharyngeal transit time, they have also demonstrated increased pharyngeal residues with risk for delayed aspiration. The ability of clinical interventions to reduce pneumonia incidence is relatively unknown. Dietary modifications or nothing-by-mouth status also have no effect on a patient's ability to handle their own secretions. A patient's individual vigor may impact the development of pulmonary infections more than aspiration. Also increased pneumonia risk exists in patients with esophageal dysphagia when compared to stroke patients because patients with stroke will improve as they recover from their acute injury, whereas esophageal dysphagia is likely to worsen with time. In one cohort of aspiration pneumonia patients, overall three-year mortality was 40%." }, { "id": "pubmed23n0412_3907", "title": "Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects.", "score": 0.013182268556412356, "content": "Percutaneous endoscopic gastrostomy (PEG) is a popular technique for long-term enteral nutrition. However it is not beneficial in all cases, and may even prolong the process of dying. The present article discusses the main indications for PEG insertion, and the ethical considerations involved. Three main questions need to be answered: (1) for what purposes should PEG be used; (2) for what type of patients, and (3) when should PEG be inserted in the natural history of the patient's illness? PEG is used in patients unable to maintain sufficient oral intake. It has been found to improve quality of life and/or to increase survival in patients with head and neck cancer, acute stroke, neurogenic and muscle dystrophy syndrome, growth failure (children) and gastric decompression. It led to no improvement in nutritional or functional status in patients with cachexia, anorexia, aspiration (and aspiration pneumonia), and cancer with a short life expectancy. Several court decisions have stipulated that PEG need be offered in patients in a persistent vegetative state or patients with senile dementia who have lost the ability for self-determination. Since the 30-day mortality after PEG insertion is very high for patients hospitalized in a general medical center, a 'cooling off' period of 30-60 days should be scheduled from the time of the PEG request to actual insertion." }, { "id": "pubmed23n0801_25280", "title": "[Nutritional support in stroke patients].", "score": 0.013178428992543782, "content": "Stroke is a public health problem of the first order. In developed countries is one of the leading causes of death, along with cardiovascular disease and cancer. In addition, stroke is the leading cause of permanent disability in adulthood. Many of the patients who survive do so with significant sequelae that limit them in their activities of daily living. Most strokes (80-85%) are due to ischemia, while the rest are hemorrhagic. We have identified many modifiable risk factors, some with an important relationship with dietary factors or comorbidities in wich the diet has a significant impact. The incidence of malnutrition in stroke patients is not well known, but most likely impacts on patient prognosis. Furthermore, the nutritional status of patients admitted for stroke often deteriorates during hospitalization. It is necessary to perform a nutritional assessment of the patient in the early hours of admission, to determine both the nutritional status and the presence of dysphagia. Dysphagia, through alteration of the safety and efficacy of swallowing, is a complication that has an implication for nutritional support, and must be treated to prevent aspiration pneumonia, which is the leading cause of mortality in the stroke patient. Nutritional support should begin in the early hours. In patients with no or mild dysphagia that can be controlled by modifying the texture of the diet, they will start oral diet and oral nutritional supplementation will be used if the patient does not meet their nutritional requirements. There is no evidence to support the use of nutritional supplements routinely. Patients with severe dysphagia, or decreased level of consciousness will require enteral nutrition. Current evidence indicates that early nutrition should be initiated through a nasogastric tube, with any advantages of early feeding gastrostomy. Gastrostomy will be planned when the enteral nutrition support will be expected for long-term (4 weeks). Much evidence points to the importance of glycemic control during hospitalization for stroke. Hyperglycemia at diagnosis and during the first hours of admission impact on patient prognosis. The goal of glycemic control necessary to modify this bad prognosis without adding risk by iatrogenic hypoglycemia is still matter of debate." }, { "id": "pubmed23n0594_2868", "title": "Endoscopic evaluation of neurological dysphagic patients.", "score": 0.01257071024512885, "content": "Dysphagia is a frequent finding in neurological patients and is a symptom related to the severity of the clinical picture. The swallowing impairments, in these patients, increase the risk of aspiration pneumonia, that leads to death, in at least 6% of patients, within the first year. Therefore, evaluation of the swallowing status is essential in patients with dysphagia and videofluoroscopic study of swallowing (VFSS) is the method of choice. It cannot be performed in all patients on account of the complexity of the procedure and since they must be brought to the Radiology Unit. In the 1980, a new bedside method was introduced, namely: fiber-optic endoscopic study of swallow (FESS) which is easy, low-cost, well-tolerated and repeatable. We use this bedside technique to assess swallowing function in patients with dysphagia admitted to acute care units, neurological and internal medicine units. The evaluation aims to indicate the safer nutritional method (oral intake, feeding tube or percutaneous gastrostomy) and, consequently, reducing the risk of aspiration pneumonia during hospitalization. We found that more than 50% of the dysphagic patients present cerebrovascular injuries and in 2% of the population, the first diagnostic hypothesis of Myasthenia Gravis can be made with the FESS technique. In 60%, we indicate a change in nutritional method: in 20% we indicate percutaneous endoscopic gastrostomy (PEG). With these indications, none of those patients had aspiration pneumonia. Our protocol for the bedside fiberoptic study of neurological patients with dysphagia has demonstrated its efectiveness by eliminating the incidence of aspiration pneumonia." }, { "id": "pubmed23n1035_5284", "title": "[Progress Report on Cases of Peripherally Inserted Central Catheter (PICC) Management in Our Hospital, Including Elderly Patients].", "score": 0.012534872167233539, "content": "In our hospital, the number of cases in which peripherally inserted central catheters (PICCs) are used has increased; these patients include elderly people who cannot take medications orally, patients with low levels of awareness, and patients with dysphagia. We report the situation at this time mainly with regard to the number of days on which PICCs were used. Fifteen elderly patients (male, n=7; female, n=8; average age, 89.3±5.3 years) underwent PICC insertion at our hospital from August 2016 to October 2018. Among these patients, 6 had cerebrovascular disorders, 5 had aspiration pneumonia, 2 had Parkinson's syndrome, 1 had consciousness disorder resulting from asphyxia caused by foreign body aspiration, and 1 had interstitial pneumonia. Seven patients received home management. In each patient, we measured the length of time that the PICC was in place. The average duration for which a PICC was in place was 92.9±25.4 days (in cases of home care management, 159.5±48.3 days). The longest duration was 342 days, in a patient with aspiration pneumonia. The endpoints were death and discharge from hospital. Complications/accidents occurred as a result of catheter infection in 2 cases (both patients recovered after catheter removal) and as a result of self-extraction in 1 case. These results suggest that PICC is useful and does not cause serious adverse effects, even in elderly patients who require central parenteral nutrition management." }, { "id": "pubmed23n0537_1919", "title": "Enteral nutrition in patients with chronic neurological diseases.", "score": 0.012327582966888413, "content": "Malnutrition is commonly considered an important risk factor that can produce a negative influence on the prognosis of patients with chronic neurological diseases. The reduced caloric or proteic intake due to the motor or cognitive dysfunction, the hypercatabolic state due to infections, the abnormal gastrointestinal motility are the main mechanisms responsible for a state of malnutrition. Between January and December 1999 fourteen patients with chronic neurological diseases were treated. Ten of them had had a stroke, four due to Amyotrophic Lateral Sclerosis (ALS). After the evaluation of nutritional status the patients received enteral nutrition (EN) by placement of a nasointestinal feeding tube or a Bengmark tube. Glycaemia, blood urea nitrogen, serum creatinine, electrolytes, glycosuria, glutamic-oxalacetic and glutamic pyruvic transaminase were monitored in all patients. Polymeric enteral feeding was administered by an infusion pump. Standard nourished patients (7/14) received a 30 Kcal/kg/day support, the undernourished ones (6 low, 1 moderate malnutrition) received a 35-40 Kcal/kg/day support. The complete caloric supply was reached in three-four days. Both of the groups received continuous feeding infusion during hospitalization. For the patients who continued the nutritional support at home (3/14) refeeding was performed only during night-time. In the patients with stroke the optimal/standard weight was reached within one month. In these patients oral nutrition was started within 45 days of treatment taking into account the restored swallowing function. In the patients with ALS the improvement of nutritional standards was reached within the first month and complete restoration within the second/third month. On the basis of our experience enteral nutrition represents an effective refeeding procedure in patients with chronic neurological diseases." }, { "id": "wiki20220301en045_78676", "title": "Aspiration pneumonia", "score": 0.012116402116402115, "content": "Elderly Aging increases the risk of dysphagia. The prevalence of dysphagia in nursing homes is approximately 50%, and 30% of the elderly with dysphagia develop aspiration. For individuals older than 75, the risk of pneumonia due to dysphagia, is six times greater than those 65. Owing to multiple factors, such as frailty, impaired efficacy of swallowing, decreased cough reflex and neurological complications, dysphagia can be considered as a geriatric syndrome. Atypical presentation is common in the elderly. Older patients may have impaired T cell function and hence, they may be unable to mount a febrile response. The mucociliary clearance of older people is also impaired, resulting in diminished sputum production and cough. Therefore, they can present non-specifically with different geriatric syndromes." }, { "id": "pubmed23n0226_3138", "title": "Nasogastric tube feeding at home: a method for adjunctive nutritional support of malnourished patients.", "score": 0.011530054644808744, "content": "Many patients with chronic diseases develop malnutrition. Force feeding with either enteral tube of parenteral infusions often succeeds in ameliorating this problem in hospitalized patients. However, after discharge many patients are incapable of sustaining adequate dietary intake. As a consequence, malnutrition may persist or recur. The authors' previous experience using nocturnal enteral tube feedings in patients with glycogen storage disease suggested that malnourished patients also might benefit from enteral tube feedings at home. Fourteen undernourished patients selected for domestic enteral tube feedings clearly demonstrated a tolerance, which included adequate gastric emptying, to the infusions during their hospitalization. They ranged in age from 2 months to 68 yr. Infusion pumps delivered the feedings continuously. At home, 12 patients experienced substantial weight gains. Two maintained their weight while they received intensive chemotherapy for malignancies. Except for the two patients with short bowel syndrome, all patients were weaned successfully to oral feedings after 1 to 3 months. The only apparent complication was possible aspiration pneumonia in a patient with neurological dysfunction. This further experience with domestic enteral tube alimentation indicates that selected patients can be managed effectively, safely and economically with nasogastric nutritional support on an outpatient basis." }, { "id": "pubmed23n0814_6542", "title": "A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition.", "score": 0.011243991760128176, "content": "This study aimed to evaluate the survival rate, pneumonia incidence, and hospital admissions among elderly patients with advanced dementia and to compare these outcomes between patients receiving enteral and oral nutrition. An observational, prospective, non-randomized, and unblinded study, with a minimum follow up of 6 months. Inpatient wards as well as ambulatory and emergency units run by a Brazilian university. Dysphagic elderly patients aged ≥ 60 years with advanced dementia (classified as at least 7A according to the Functional Assessment Staging [FAST]). Both patients with gastrostomies and nasogastric feeding tubes were included in the alternative feeding group. Following informed consent, a complete clinical examination was performed upon recruitment, and the primary caregiver was interviewed. Data concerning the major outcomes described above, as well as other demographic and clinical information, were recorded at admission and during follow-up phone calls. Survival analysis was performed using a Kaplan-Meier curve and a stepwise Cox regression analysis. Sixty-seven elderly patients were recruited: 36 (53,7%) for oral feeding and 31 for alternative feeding (n = 28 nasogastric tube). Of these, 57 (85.1%) were classified as at least FAST 7C. They were, on average, 84.79 years old, mostly women (85.1%), and with a low level of education (2.9 years). Mortality at 3 months was 11.1% among the oral feeding group and 41.9% among the alternative feeding group (p = 0.004). At 6 months, the mortality rate increased to 27.8% and 58.1%, respectively (p = 0.012). The following variables persisted in the regression model at the end of the analysis: feeding route (p = .018; RR = 2.33; CI: 1.158-4.667), duration of dementia (p = .014; RR = .88; CI: .786-.974) and number of pressure ulcers (p = .007; RR = 1.250; CI: 1.063-1.470). A higher incidence of aspiration pneumonia was observed in the alternative feeding group (p = 0.006), but no difference in the number of hospital admissions was detected between the groups (p = 0.365). The use of alternative feeding, along with the number of pressure ulcers were associated with an increased risk of death in elderly patients with advanced dementia. A higher incidence of aspiration pneumonia was also observed in the alternative feeding group. The number of hospital admissions was not different between the feeding routes." }, { "id": "wiki20220301en045_78656", "title": "Aspiration pneumonia", "score": 0.010835156897320954, "content": "Risk factors Impaired swallowing: Conditions that cause dysphagia worsen the ability of people to swallow, causing an increased risk of entry of particles from the stomach or mouth into the airways. While swallowing dysfunction is associated with aspiration pneumonia, dysphagia may not be sufficient unless other risk factors are present. Neurologic conditions that can directly impact the nerves involved in the swallow mechanism include stroke, neurodegenerative diseases (such as Parkinson's disease), and multiple sclerosis. Anatomical changes in the chest can also disrupt the swallow mechanism. For example, patients with advanced COPD tend to develop enlarged lungs, resulting in compression of the esophagus and thus regurgitation." }, { "id": "wiki20220301en012_126323", "title": "Parenteral nutrition", "score": 0.01073231205171345, "content": "There are physical, physiological, or mental differences in the geriatric population that could potentially lead to poor nutrient intake that would require them to have nutrition therapy. Geriatric patients are more inclined to have delayed muscle restoration compared to the younger population. Additionally, older patients are observed to have greater cardiac and renal impairment, insulin resistance, and to have deficiencies in vitamins and crucial elements. Patients who require nutrition therapy but have contraindications for or cannot tolerate enteral nutrition are appropriate candidates for parenteral nutrition. In the geriatric population, it is indicated if oral or enteral nutrition is impossible for 3 days or when oral or enteral nutrition is likely insufficient for more than 7 to 10 days. While there are no complications of parenteral nutrition specific to the geriatric population, complications are more prevalent in this population due to increased comorbidities." }, { "id": "pubmed23n0370_21404", "title": "[Two cases of home parenteral nutrition in which home care was difficult].", "score": 0.01063945875163684, "content": "Home parenteral nutrition (HPN) is usually conducted after hospital training and home trials, but in more than a few cases self-care is virtually impossible or the ability of carers is insufficient. We investigated the problem points in the cases of two HPN patients from our hospital. Patient 1 was a 76-year-old man who had undergone surgery for esophageal cancer. He was rehospitalized with passage disorders due to eating difficulties such as dysmasesis and dysphagia and an insufficient ability to comprehend meals. Self-care was virtually impossible owing to his lack of understanding of the disease and his dementia. Even if subcutaneous leakage of the subcutaneously implanted port occurred or the connecting portion became dislocated, the patient would not be able to alert others to this by himself. His wife, the key person in his care, could not undergo hospital training because of her advanced age. She received instruction on the techniques for the completion of IVH for one month from the visiting carer, but handling the syringe and needle and the clamp maneuver were difficult for her, and she later developed an infection and was hospitalized. Upon consultation with the primary physician, a change was made to a Groshong catheter, which reduced the maneuver burden, but the prepared checklist was not used and there were problems in the handling of the catheter and management during the period when the maneuvers were being carried out. In addition, discord arose in the family relations, so a grandchild who was a university student rather than the daughter-in-law received instruction according to the manual in order to care for the patient on the nurse's days off. Currently, HPN is being carried out 3/week with meal instructions adjusted to the patient's dysphagia and contact with the family on the nurse's days off. An issue remaining for the future is the use of informal resources in terms of both micro-intervention, including selection of a catheter with consideration of care ability and meal instruction matched to his eating function, and macro-intervention with consideration of the family environment and interpersonal relationships. Patient 2 was a 41-year-old woman with SLE. She was a former nurse, but self-care was not possible due to steroid myopathy. Her main carer was her mother, but due to Alzheimer's-type dementia her mother had difficulty with sterile maneuvers, and sometime allowed the syringe, needle, and set to get dirty or refused to administer the medication or change the batteries on the pump. A visiting nurse and helper visit twice/week each and another volunteer provides daily support, but to continue home care in the future it will be essential to further train the helper and deepen the cooperation between all related." }, { "id": "wiki20220301en028_93498", "title": "Multiple system atrophy", "score": 0.010549100022784233, "content": "Causes of death The most common causes of death are sudden death and death caused by infections, which include urinary catheterization infections, feeding tube infections, and aspiration pneumonia. Some deaths are caused by cachexia, also known as wasting syndrome. Epidemiology Multiple system atrophy is estimated to affect approximately 5 per 100,000 people. At autopsy, many patients diagnosed during life with Parkinson’s disease are found actually to have MSA, suggesting that the actual incidence of MSA is higher than that estimate. While some suggest that MSA affects slightly more men than women (1.3:1), others suggest that the two sexes are equally likely to be affected. The condition most commonly presents in persons aged 50–60. Research Mesenchymal stem cell therapy may delay the progression of neurological deficits in patients with MSA-cerebellar type." }, { "id": "wiki20220301en012_126324", "title": "Parenteral nutrition", "score": 0.009900990099009901, "content": "In cancer Patients who are diagnosed with cancer, whether as outpatient undergoing treatment or hospitalized, are at a greater risk of malnutrition and cachexia. Cancer-related malnutrition can be attributed to the decrease in food intake, increase in the need for energy, and the alteration of metabolism. Patients should be assessed early on in their cancer treatment for any nutritional risk, such as by taking routine weights and BMI. Parenteral nutrition is indicated in cancer patients when it is not possible to access the digestive tract or if the tract is ineffective. In advanced cancer patients, the use of PN should be discussed in context of the risks and benefits, such as if the approximate survival rate is longer than 3 months and if PN would be expected to greatly improve the patients' quality of life. It is uncertain whether home parenteral nutrition improves survival or quality of life in people with malignant bowel obstruction." }, { "id": "pubmed23n0051_14425", "title": "Risk factors for nosocomial pneumonia in the elderly.", "score": 0.009900990099009901, "content": "Elderly patients have a disproportionate incidence of nosocomial pneumonia (NP) and a higher mortality rate, yet few studies have focused on this high-risk population. We undertook a study to examine risk factors for NP in elderly inpatients and to describe how these patients differ from younger patients with NP. In a public teaching hospital, all cases of NP in patients aged 65+ were ascertained by prospective surveillance during a 2-year period (n = 59). These elderly cases were compared with 59 cases of NP in patients aged 25 to 50 to describe differences in risk factors and outcomes. Elderly cases were then matched to elderly control subjects who were admitted to the same hospital service but did not develop NP. Data were collected on known risk factors and on the potential risk factors of poor nutrition, neuromuscular disease, and dementia. Significant differences in risk factors were analyzed using univariate and multivariate comparisons of cases and controls. Elderly patients had twice the incidence of NP (RR = 2.1) as younger patients. Onset of infection was earlier for young than for older cases (6 versus 11 days, p less than or equal to 0.02), but mortality following NP was equal for the two age groups (42% versus 44%). No significant differences in risk factors were found for old and young cases, although older cases tended to have higher rates of poor nutrition, neuromuscular disease, and aspiration preceding their pneumonias. Comparison of elderly cases and elderly controls revealed significantly increased frequencies of poor nutrition, neuromuscular disease, pharyngeal colonization, aspiration, depressed level of alertness, intubation, intensive care unit admission, nasogastric tube use, and antacid use among cases. Cases were more severely ill on admission and had more pre-existing risk factors (2.8 versus 1.3, p less than or equal to 0.001) and more in-hospital risk factors (4.7 versus 1.6, p less than or equal to 0.001). Logistic regression analysis revealed low albumin, diagnosis of neuromuscular disease, and tracheal intubation to be strong independent predictors of risk for NP among elderly inpatients. We conclude that the specific risk factors of poor nutrition, neuromuscular disease, and tracheal intubation may prove useful to target future clinical interventions to prevent NP in the elderly." }, { "id": "wiki20220301en012_126320", "title": "Parenteral nutrition", "score": 0.00980392156862745, "content": "Medical uses Total parenteral nutrition (TPN) is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity (it is blocked, or has a leak – a fistula) or because its absorptive capacity is impaired. It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications. Parenteral nutrition is used to prevent malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral routes. The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition recommends waiting until the seventh day of hospital care. Absolute indications for TPN Diseases that would require use of TPN include:" }, { "id": "pubmed23n0832_12780", "title": "[Life-threatening airway obstruction accompanied by vocal cord paralysis due to indwelling nasogastric tube in malnourished elderly patients: a report of four cases].", "score": 0.00980392156862745, "content": "We report 4 cases of elderly patients with abrupt onset of serious airway obstruction that is presumed to be due to indwelling nasogastric tube. 2 cases are patients of cerebral infarction and 2 cases are patients of Parkinson disease. The average number of days until NGTS is 17.8 days. In all cases, fiber-optic examination revealed complete loss of adduction in both vocal cords. Infection in the posterior cricoid region caused by ulcerative lesions at the upper end of the esophagus has been implicated as a pathophysiological mechanism of this syndrome, but it was not possible to confirm in the 4 cases. Because it is difficult to exactly diagnose with NGTS in clinical practice, there is a need to consider the inducing factor and response. Body mass index is very low in each of the 4 cases, ranging from 14.2 to 18.0, implying a severely malnourished or immunocompromised state, and may represent a high risk factor for this syndrome. Whenever this life-threatening syndrome is suspected, direct vocal cord examination and removal of the tube are recommended. In addition, the clinicians should not hesitate about doing intubation or tracheotomy in emergency. " }, { "id": "pubmed23n0351_2996", "title": "Prospective audits of quality of PEM recognition and nutritional support in critically ill elderly patients.", "score": 0.009708737864077669, "content": "Undereating is a frequent concern in acute care geriatric settings and is supposed to worsen the outcomes of the underlying diseases, while the quality of nutritional support could be improved. Two consecutive and prospective audits (A and B) with team training over a 1 year period investigated the quality of malnutrition recognition and nutritional support and outcomes in immobilized, critically ill elderly subjects. Audit A included 170 patients (86.3+/-6.1 years old) and audit B, 232 patients (86.3+/-6.3), respectively 20.6% and 31.4% of the hospitalized population. Misclassifications occurred in A in 54.0% compared to 34.05% in B (P &lt; 0.001). 32.6% in A versus 86.9% in B adequately received oral supplements (P = 0.02). Significant risk factors for the adverse outcomes in the combined two audits were: dementia (RR: 1.8, 95%CI: 1.0 to 3.0, P= 0.04) and dehydration (RR: 2.0, 95%CI:1.0 to 4.1, P= 0.05) for pressure ulcer incidence; stroke (RR: 8.8, 95%CI: 4.8 to 16.0, P &lt; 0.001) for pressure ulcer prevalence at discharge; neoplasms (RR: 1.1, 95%CI: 1.0 to 1.2, P = 0.02) for nosocomial infections; bladder indwelling for urinary tract infections (RR: 4.8, 95%CI: 2.9 to 7.7, P&lt;&lt; 0.001); swallowing problems for pulmonary infections (RR: 5.4, 95%CI: 2.8 to 10.5, P &lt; 0.001); venous indwelling for septicaemia (RR: 5.4, 95%CI: 1.3 to 23. 3, P= 0.02). However, after adjustment on significant risk factors, the outcome rate was similar in audit B: death rate: A (15.6%), B (14.2%); length of stay: A (17.3+/-10.4 days), B (17.4+/-10.0); pressure ulcer incidence: A (26.4%), B (20.2%), (83% were erythema); pressure ulcer prevalence at discharge: A (14.7%), B (10.3%), (40% were erythema); nosocomial infections: A (26.4%), B (19.0%). The improvement of malnutrition recognition and nutritional support was not followed by a perceptible decrease in adverse outcome rate, this latter being mainly related to the underlying conditions of these critically ill elderly patients." }, { "id": "pubmed23n0801_25274", "title": "[Role of the nutritional support team in the management of dysphagia].", "score": 0.009660380855302785, "content": "Dysphagia is a highly prevalent symptom, which may be due to multiple disease processes, both structural and functional, and located at the oropharyngeal or esophageal level. Oropharyngeal dysphagia can cause malnutrition even in 1/3 of patients as a result of alterations in the efficiency of swallowing and cause changes in the security of swallowing (penetration and aspiration) in up to 2/3 of the patients who present it, with high risk of aspiration pneumonia and respiratory infections. In neurological, elderly or institutionalized patients its prevalence may range from 30 to 60%, with different degrees of severity that may become necessary artificial nutrition. It is also related to greater disability, prolonged hospital stays and increased mortality. Therefore, early diagnosis is critical and the establishment of an effective treatment that includes postural exercises, nutritional support and rehabilitation. All this wouldn't be possible without a nutritional team that takes part of the multidisciplinary team patients with dysphagia required. It is the only way to ensure a longterm care to these patients in order to decrease the morbidity and mortality." }, { "id": "wiki20220301en527_15064", "title": "Oral manifestations of systemic disease", "score": 0.009615384615384616, "content": "Dysphagia is defined as a difficulty in swallowing. Structurally it worsens when eating solids and neurologically it is worse with fluids. Structural problems may include malignancy, stricture and pharyngeal pouching which can lead to halitosis, regurgitation of undigested food and high feeling of dysphagia. Neurological problems may be related to the patient having multiple sclerosis, motor neuron disease, or having suffered from a stroke. Dysphagia may present as a barrier to care in the dental setting as the patient may require high volume suction in order to maintain patient comfort and reduce the risk of aspiration of dental material/ fluids." }, { "id": "pubmed23n0659_24404", "title": "[Rethinking of about the artificial hydration and nutrition for the end-stage Alzheimer's disease patients from the bioethical point of view--evidence based ethics].", "score": 0.009615384615384616, "content": "Due to an increase in the number of patients suffering from Alzheimer's disease, issues relating to withholding and withdrawing of life-prolonging treatment (artificial hydration and nutrition) are in urgent need of discussion. In the ethical thinking, not only patient's autonomy (Value) but also scientific evidence (Fact) is important (= evidence based ethics). There are evidences in foreign countries that indicate tube feeding does not prevent aspiration pneumonia, does not prolong survival and does not reduce the risk of infection. In Japan, we do not have objective data on the efficacy of tube feeding. Artificial hydration and nutrition is implemented just for improving malnutrition without ethical thinking. To implement tube feeding appropriately for the end-stage Alzheimer's disease patients, an identification of objective evidence and prevalence of advanced directive in Japan are important." }, { "id": "pubmed23n0569_341", "title": "[Clinical features and prognosis of terminally ill patients in a geriatric long-term care hospital with particular regard to the implications of artificial nutrition].", "score": 0.009523809523809525, "content": "To clarify the clinical features of terminally ill patients in our hospital and elucidate the implications of administering artificial nutrition. Between April 2004 and March 2005, we assessed 155 patients who died in Nishimaruyama Hospital--a geriatric long-term care facility in Sapporo. We analyzed their clinical backgrounds on admission, the clinical course up to the terminal stage of the illness, and the outcome of patients who received artificial nutrition. In 95 patients, the main cause of the terminal illness was infection. The symptoms of these patients, such as cerebral infarction and cognitive dysfunction, deteriorated progressively, and eventually, eating became difficult. At this point, alternative methods for providing nutrition were discussed. For 60 patients (41 died of acute disease and 19, of advanced cancers), artificial nutrition was not considered. Artificial nutrition was administered to 63 patients; tube feeding was carried out in 30 patients. Because of repeated aspiration pneumonia, 14 of these 30 patients eventually underwent intravenous hyperalimentation (IVH). Thirty-three patients directly underwent IVH. Thirty-two patients did not undergo any feeding course. The mean survival times of the tube feeding and non-artificial nutrition groups were 827 and 60 days, respectively. The difference in the survival times was statistically significant. The outcome of patients who were placed on tube feeding was good. This may be because we selected those patients considered most suitable for tube feeding or IVH. The criteria that were used to select an appropriate method for providing nutrition varied, although the patients in our hospital requested palliative care." }, { "id": "wiki20220301en306_22389", "title": "Nutritional neuroscience", "score": 0.009433962264150943, "content": "Treatment Prognosis of deficiency is excellent with treatment. Without, pellagra will gradually progress and lead to death within 4–5 years, often a result of malnutrition from prolonged diarrhea, or complications as caused by concurrent infections or neurological symptoms. Symptoms of pellagra can be cured with exogenous administration of nicotinic acid or nicotinamide. Flushing occurs in many patients treated therapeutically with nicotinic acid, and as a result, nicotinamide holds more clinical value as it is not associated with the same uncomfortable flushing. The adult dose of nicotinamide is 100 mg taken orally every 6 hours until resolution of major acute symptoms, followed with oral administration of 50 mg every 8–12 hours until skin lesions heal. For children, treatment involves oral ingestion of 10–15 mg of nicotinamide, depending on weight, every 6 hours until signs and symptoms are resolved. Severe cases require 1 gram every 3–4 hours, administered parenterally." }, { "id": "pubmed23n0081_17004", "title": "The clinical case against tube feeding in palliative care of the elderly.", "score": 0.009433962264150943, "content": "The terminal stages of many neurological illnesses occurring in the elderly produce feeding and swallowing problems. These difficulties lead to ethical, religious, philosophical, and medico-legal conflicts when decisions about starting or stopping tube feedings are considered. We present the case against all forms of tube feeding in a particular subset of elderly palliative patients. These are individuals who are in the end-stage of a progressive neurological disease who are noncommunicative, and spend all or most of their time in a recumbent position. We discuss the physiological phenomena existing in these patients that make the probability of aspiration pneumonia as great or possibly greater than with careful spoon feeding. If tube feeding results in the outcome that it is thought to prevent (ie, aspiration pneumonia) then decisions regarding nutritional support in these patients become clinically clearer." }, { "id": "pubmed23n0490_15187", "title": "Dysphagia following chemoradiation for locally advanced head and neck cancer.", "score": 0.009345794392523364, "content": "To assess the prevalence, severity and morbidity of dysphagia following concurrent chemoradiation for head and neck cancer. Patients who underwent chemotherapy and radiation for head and neck malignancies were evaluated for their ability to resume oral feeding following treatment. Modified barium swallow (MBS) studies were performed if the patients complained of dysphagia or if there was clinical suspicion of aspiration. The severity of dysphagia was graded on a scale of 1-7. If significant abnormalities were found, swallowing studies were repeated until resolution of dysphagia. Between March 1999 and May 2002, 55 patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. Aspiration pneumonia was observed in eight patients, three during treatment and five following treatment. Five patients died from pneumonia. Two patients developed respiratory failure requiring intubation as a complication of pneumonia. At a median follow-up of 17 months (range 6-48 months), 25 patients (45%) developed severe dysphagia requiring prolonged tube feedings for more than 3 months (22 patients) or repeated dilatations (three patients). Among 33 patients who underwent MBS following treatment, 12 patients (36%) had silent aspiration (grade 6-7 dysphagia). Thirteen patients (39%) developed grade 4-5 dysphagia which required prolonged enteral nutritional support to supplement their oral intake. Most patients had severe weight loss (0-21 kg) during treatment, likely due in part to mucositis in the orodigestive tube. Dysphagia is a common, debilitating and potentially life-threatening sequela of concurrent chemoradiation for head and neck malignancy. Physicians should be aware that the clinical manifestations of aspiration may be unreliable and insidious, because of the depressed cough reflex. Modified and traditional barium swallows should be performed following treatment to assess the safety of oral feeding and the structural integrity of the pharynx and esophagus. Patients with severe dysphagia may benefit from rehabilitation. Tube feeding should be continued for those with aspiration." }, { "id": "pubmed23n0046_14784", "title": "[Enteral nutrition in the elderly].", "score": 0.009345794392523364, "content": "Elderly is particularly at risk of malnutrition: he is not able to feed himself adequately, it is then important to attain correct intakes using also artificial enteral nutritional techniques (nasogastric tube, gastrostomy, etc.). These techniques may lead to complications (ab ingestis pneumonia, metabolic complications, alvus disorders): the use of artificially nutrition in the elderly must be carefully evaluated. 257 patients (M = 180, F = 77) aged 65 or more, mainly affected by neoplastic diseases (n 195) and by neurological and vascular diseases (n 62). The feeding route were evaluated in this study: 74% by nasogastric tube, 13% by gastrostomy, 11% by jejunostomy. In a group of 55 patients similar concerning clinical and nutritional conditions we evaluated at the beginning of enteral feeding and four months later, caloric/protein intake, body weight and plasmatic albumin. In patients fed by nasogastric tube a mean intake of 1300 +/- 365 Kcal n.p./die, with a protein rate of 58.5 +/- 16.9 g/die was attained; by gastrostomy 1450 +/- 324 Kcal n.p./die and 65.5 +/- 16 g/die; by jejunostomy 1219 +/- 398 Kcal n.p./die and 53.3 +/- 21 g/die. The compliance to enteral nutrition was well in 37% of patients night administration was performed. Clinical complications: nausea and vomiting were observed in 9 patients with nasogastric tube, in 1 patient with gastrostomy and in 3 patients with jejunostomy; diarrhea has been noticed in 6 patients with nasogastric tube and in 1 patient with jejunostomy. Mechanical complications; nasogastric tube (n 189): 35 displacements, 7 breakages, 4 obstructions; pharyngostomy (n 6): 2 displacements and 1 obstruction; gastrostomy (n 33): 3 displacements; jejunostomy (n 29): 2 misplacements.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0637_10767", "title": "[Is older age a limit factor when considering health resources? The case of home parenteral nutrition].", "score": 0.009259259259259259, "content": "Some bioethicists consider older age as a limiting factor for receiving special medical care. Older adults comprise the majority of home enteral nutrition patients (neoplams of the head, neck, and upper gastrointestinal tract neuromuscular swallowing disorders, dementia, etc) On the contrary, there are very few data on Home Parenteral Nutrition (HPN) in the elderly. We report these of a 75 years old man affected from a severe short bowel syndrome due to mesenteric thrombosis. After a hospital stay of two months he was sent home on HPN. His current caregiver was her wife, a 72 year old woman suffering from incipient Parkinson's disease. HPN lasted for 11 years and was stopped because of clinical deterioration. During this time he presented 5 catheter- related infections (1.3 episodes/1,000 days). 5 catheters were used (average length 788 days). He was hospitalized four times because of HPN complications. Functional status was maintained along almost all the length of HPN. The rate of complications in this patient was similar to other groups of age receiving HPN. The technique was not burdensome for the family. Older age cannot be consider, by itself a limiting factor when receiving long term nutritional support." }, { "id": "wiki20220301en012_126321", "title": "Parenteral nutrition", "score": 0.009174311926605505, "content": "Absolute indications for TPN Diseases that would require use of TPN include: Short bowel syndrome Small bowel obstruction Active gastrointestinal bleeding Pseudo-obstruction with complete intolerance to food High-output (defined as > 500ml/day) enteric-cutaneous fistulas (unless a feeding tube can be passed distal to the fistula) Gastrointestinal disorders TPN may be the only feasible option for providing nutrition to patients who do not have a functioning gastrointestinal tract or who have disorders requiring complete bowel rest, including bowel obstruction, short bowel syndrome, gastroschisis, prolonged diarrhea regardless of its cause, very severe Crohn's disease or ulcerative colitis, and certain pediatric GI disorders including congenital GI anomalies and necrotizing enterocolitis." }, { "id": "pubmed23n0567_22954", "title": "Aspiration syndromes: 10 clinical pearls every physician should know.", "score": 0.009174311926605505, "content": "Aspiration syndromes are clinically and pathologically classified into three sets of disorders: (i) large airway mechanical obstruction caused by foreign bodies; (ii) aspiration pneumonitis; and (iii) aspiration pneumonia. In this article, we discuss the common clinical presentations, risk factors, radiographic features and methods of management of these disorders. We highlight recent recommendations and controversies surrounding the prevention of aspiration pneumonia in the critically ill patient. Finally, we review ethical dilemmas surrounding feeding and aspiration risk concerns in debilitated and demented patients." }, { "id": "wiki20220301en037_67326", "title": "Percutaneous endoscopic gastrostomy", "score": 0.00909090909090909, "content": "PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the stomach in cases of gastric volvulus. Indications Gastrostomy may be indicated in numerous situations, usually those in which normal (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. stroke), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy for tumors in head & neck region)." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 31 ] ], "word_ranges": [ [ 0, 5 ] ], "text": "Chancroid is a solitary lesion." }, "3": { "exist": true, "char_ranges": [ [ 32, 184 ] ], "word_ranges": [ [ 5, 28 ] ], "text": "Secondary syphilis usually occurs as a generalized rash or as characteristic lesions on palms and soles (syphilitic nails) with a longer latency period." }, "4": { "exist": true, "char_ranges": [ [ 185, 286 ] ], "word_ranges": [ [ 28, 43 ] ], "text": "Trichomonas balanitis is always associated with urethritis, which is not referred to in the question." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Genital candidiasis.", "2": "Chancroid.", "3": "Secondary syphilis.", "4": "Trichomonas balanitis.", "5": "Dermatophyte fungal infection." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1157_18552", "title": "Primary syphilis without chancre - A case report of rare syphilitic balanitis of Follmann.", "score": 0.01899189918991899, "content": "Syphilitic balanitis of Follmann (SBF) is a rare condition of primary syphilis which is characterized by any kind of balanitis with or without chancre on the penis combined with the presence of swollen inguinal lymph nodes confirmed by the finding of Treponema pallidum in the lesions or by the positive serological syphilitic testing. Timely identification of the SBF is very important in properly treating the disease stopping the spread of syphilis. A 42year-old heterosexual male patient came to our clinic and complained of a painless, hard erythema nodule with a whitish scale in his coronal sulcus of the penis for about a week. The dermatologic examination revealed an infiltrative, hard erythematous lesion surrounding the coronal sulcus of the patient's penis, with mild erosion and a small amount of exudation. There was a whitish pseudomembrane-like covering on the surface of the erythematous lesion in the coronal sulcus, which is mimicked as candidal balanitis. The result of the fungus microscopic examination was negative, while the laboratory findings showed positive results in serologic syphilitic testing. The patient was diagnosed with primary syphilis and intramuscularly treated with a dose of benzylpenicillin of 2.4 million units. The patient's skin lesions disappeared completely 60 days after penicillin treatment. To our knowledge, this is the first SBF case reported in China. Syphilitic balanitis of Follmann may have variable clinical appearances. We emphasize that when balanitis with risky sexual activities or with sexually transmitted diseases, the diagnosis of SBF should be kept in mind." }, { "id": "wiki20220301en017_7713", "title": "Chancroid", "score": 0.015864527629233512, "content": "Differential diagnosis Despite many distinguishing features, the clinical spectrums of following diseases may overlap with chancroid: Primary syphilis Genital herpes Practical clinical approach for this STI as Genital Ulcer Disease is to rule out top differential diagnosis of Syphilis and Herpes and consider empirical treatment for Chancroid as testing is not commonly done for the latter. Comparison with syphilis There are many differences and similarities between the conditions syphilitic chancre and chancroid: Similarities Both originate as pustules at the site of inoculation, and progress to ulcerated lesions Both lesions are typically 1–2 cm in diameter Both lesions are caused by sexually transmissible organisms Both lesions typically appear on the genitals of infected individuals Both lesions can be present at multiple sites and with multiple lesions" }, { "id": "pubmed23n0401_21378", "title": "Common skin disorders of the penis.", "score": 0.015844218674407353, "content": "Diseases of the male genitalia range from infectious lesions to inflammatory and neoplastic conditions, including many genital manifestations of more general skin diseases. This review highlights the clinical features, diagnosis and treatment of the most common dermatoses of the male genitalia. Herpes genitalis and infections caused by human papillomavirus (HPV) are increasing, particularly in young sexually active people. Herpes simplex virus infection is the commonest infectious cause of genital ulceration, with evidence that many infections are asymptomatic. HPV infection may be latent, subclinical and clinical. The most common causal agents for condyloma acuminatum are low-risk HPV 6 and 11; high-risk HPV types 16 and 18 are associated with premalignant and malignant lesions. Treatment for genital warts remains unsatisfactory; recurrences are common. Imiquimod, a new topical immunotherapeutic agent, which induces interferon and other cytokines, has the potential to be a first-line therapy for genital warts. Scabies and pediculosis are transmitted by skin-to-skin contact and sexual transmission is common, with the penis and scrotum favourite locations for scabious lesions. Oral ivermectin, a highly active antiparasitic drug, is likely to be the treatment of choice, but until approval is granted it should be reserved for special forms of scabies. Common skin diseases, e.g. psoriasis and lichen planus, may have an atypical appearance in the genital area. The typical psoriatic scale is usually not apparent because of moisture and maceration. Allergic contact dermatitis of the genital area may result from condoms, lubricants, feminine hygiene deodorant spray and spermicides. More often, contact dermatitis is irritant, resulting from persistent moisture and maceration. Lichen sclerosus is a chronic inflammatory disease that occurs as atrophic white patches on the glans penis and foreskin. The penile form is a common cause of phimosis in uncircumcised men; involvement of the urethral meatus may lead to progressive meatal stenosis. Plasma cell balanitis is a benign, idiopathic condition presenting as a solitary, smooth, shiny, red-orange plaque of the glans and prepuce of a middle-aged to older man. Squamous cell carcinoma (SCC) in situ, e.g. erythroplasia of Queyrat and Bowen's disease, cannot be excluded clinically; their apparent clinical benignity may lead to lengthy periods of misdiagnosis and biopsy is required to confirm the diagnosis. SCC is the most common malignancy of the penis and the role of oncogenic HPV-types has been also established in SCC of the penis. Prevention of SCC of the penis presupposes an identification of risk factors, early detection of all pre-cancerous lesions and treatment of phimosis." }, { "id": "pubmed23n0665_6370", "title": "[Syphilis in the context of HIV-infection--a complex disease].", "score": 0.01436956081764825, "content": "A 39-year-old man complained about a slightly reddish non-itching rash evolving on his body during the last few weeks without any general symptoms. Physical examination revealed trunk-dominated roseola, papules, a few nodules with haemorrhagic crust on top, and round hyperkeratotic clavus-like lesion on the left plantar foot. In his mouth, he had a few up to 1.5 cm large erosions, and on his capillitium a diffuse alopecia. Serologic testing for syphilis was positive with Treponema-pallidum-particle-agglutination test at 1:163840, VDRL 1:64, positive IgG-FTA-ABS and 19S-IgM-FTA-ABS tests, and a pleocytosis of the liquor. In addition, there were a co-infection with mycoplasma hominis and first diagnosis of HIV infection (CDC-stadium A1). The patient was diagnosed as having secondary syphilis with suspicion of neurologic involvement and was therefore treated with 6x5 Mio. I.E. Penicillin G i.v. per day for 14 days after the initial application of 40 mg methylprednisolone. Under this regimen complete resolution of the skin lesions was noted over a 4 week period as well as slow re-growth of the hair. HIV infection at stadium A1 did not require antiretroviral treatment. A non-pruritic rash should always point to the differential diagnosis of syphilis. If syphilis is diagnosed, any other sexually transmitted disease including HIV should be excluded as possible co-infection. In case of HIV, neurosyphilis can develop at an earlier stage of common syphilis." }, { "id": "wiki20220301en154_45008", "title": "Genital ulcer", "score": 0.013963210702341137, "content": "The most common cause of genital ulcers in the North America and Western Europe are the result of HSV or syphilis infections, while the most common cause in other parts of the world is chancroid. Most sexually active adolescents with genital ulcers have a herpes simplex virus infection, more commonly type 2. Meanwhile, according to 2017 CDC reports, syphilis is more common in men who have sex with men populations although rates of syphilis have been rising in heterosexual men and women in the United States. Following syphilis and genital herpes infections, a chancroid is the third most common cause but tends to occur in focused outbreaks over time. While rates of H. ducreyi infection seem to be declining according to a 2017 report, it is possible this may be due to lack of testing since H. ducreyi requires a very specialized culture medium which is not commonly available. Less common causes include lymphogranuloma venereum, which is more common in men who have sex with men, and" }, { "id": "wiki20220301en154_45002", "title": "Genital ulcer", "score": 0.013850298897027869, "content": "A genital ulcer is an open sore located on the genital area, which includes the vulva, penis, perianal region, or anus. Genital ulcers are most commonly caused by infectious agents (fungal infections, secondary bacterial infections, or sexually transmitted diseases such as genital herpes, syphilis or chancroid). However, this is not always the case, as a genital ulcer may have noninfectious causes as well." }, { "id": "pubmed23n0843_7512", "title": "Pattern of sexually transmitted infections in a Muslim majority region of North India.", "score": 0.013595814033281866, "content": "Changing trends of sexually transmitted infections (STI) and HIV/AIDS has been noted in the literature over years, depending to some extent on the geographical and cultural factors of the region. In Kashmir Valley also, the pattern of STI may be different from the rest of the country. The aim was to present the experience with patterns of STI in Kashmir. Retrospective hospital-based study carried out by detailed analysis of case records of 5-year period. A total of 184 patients, 100 males and 84 females, had specific STI. Genital ulcer disease was the presentation in 54 patients (29.35%), out of which herpes genitalis was found in 27 patients (50%), followed by chancroid in 13 (24.07%) and syphilis in 10 (18.52%) patients. 42 female patients (22.83%) presented with vaginal discharge, out of which, 24 (57.14%) had vaginal candidiasis. 24 males (13.04%) presented with urethral discharge, out of which, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis. Genital molluscum contagiosum (MC) was found in 19 patients (10.33%), and warts in 15 (8.15%). HIV positive serology was detected in 3 patients (1.63%). The most common STI encountered in our study was genital ulcer, followed by vaginal discharge, urethritis, genital MC, and genital warts. Herpes genitalis was the commonest genital ulcer; candidiasis was the most common cause of vaginal discharge and nongonococcal urethritis the most common cause of urethritis. These findings are by and large similar to those noted in other parts of our country." }, { "id": "pubmed23n1005_19541", "title": "[Chancroid].", "score": 0.013566538654199364, "content": "Chancroid (also known as soft chancre and ulcus molle) is a sexually transmitted disease (STD) due to the Ducrey's bacillus (or Haemophilus ducreyi) characterized by chancre at the site of ulcerated inoculation associated with lymphadenopathy. The disease manifests as a small pinkish papule at the site of penetration of the bacterium. After an incubation period ranging from 24 hours to 15 days (on average 5 days). The lesion rapidly evolves into a more or less extended pinkish, painful, deep ulcer with very inflamed and sharp edges and a ragged appearance. The lymphadenopathies usually occur 2-3 weeks after the contact. They are often unilateral and can evolve into ulcers with pus discharge at the level of the skin. Some complications can occur: penile gangrene, extended gangrene of the skin, local superinfection, association with other sexually transmitted diseases. Bacterium can be identified by microscopic examination of a smear of the chancre-like ulcer, more rarely by fine-needle puncture biopsy of a lymphadenopathy. Giemsa or Pappenheim coloration allows identification of the germ. Treatment is based on azithromycin (1 g per os in a single dose) or ceftriaxone (250 mg administered intramuscularly in a single dose). We report the case of a 30-year old man with well-defined deep scrotum ulcer with necrotic center which occurred 1 week after unprotected sexual intercourse. Haemophilus ducrey has been detected by culture and the patient underwent Azithromycin therapy with good outcome." }, { "id": "wiki20220301en001_138382", "title": "Syphilis", "score": 0.013478668541959681, "content": "Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person. Approximately 2–6 weeks after contact (with a range of 10–90 days) a skin lesion, called a chancre, appears at the site and this contains infectious spirochetes. This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders approximately 0.3–3.0 cm in size. The lesion may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer. Occasionally, multiple lesions may be present (~40%), with multiple lesions being more common when coinfected with HIV. Lesions may be painful or tender (30%), and they may occur in places other than the genitals (2–7%). The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally in men who have sex with men (34%). Lymph node enlargement frequently (80%) occurs around the" }, { "id": "pubmed23n1009_23257", "title": "[Lentigines].", "score": 0.01346448087431694, "content": "Chancroid (also known as soft chancre and ulcus molle) is a sexually transmitted disease (STD) due to the Ducrey's bacillus (or Haemophilus ducreyi) characterized by chancre at the site of ulcerated inoculation associated with lymphadenopathy. The disease manifests as a small pinkish papule at the site of penetration of the bacterium. After an incubation period ranging from 24 hours to 15 days (on average 5 days). The lesion rapidly evolves into a more or less extended pinkish, painful, deep ulcer with very inflamed and sharp edges and a ragged appearance. The lymphadenopathies usually occur 2-3 weeks after the contact. They are often unilateral and can evolve into ulcers with pus discharge at the level of the skin. Some complications can occur: penile gangrene, extended gangrene of the skin, local superinfection, association with other sexually transmitted diseases. Bacterium can be identified by microscopic examination of a smear of the chancre-like ulcer, more rarely by fine-needle puncture biopsy of a lymphadenopathy. Giemsa or Pappenheim coloration allows identification of the germ. Treatment is based on azithromycin (1g per os in a single dose) or ceftriaxone (250mg administered intramuscularly in a single dose). We report the case of a 30-year old man with well-defined deep scrotum ulcer with necrotic center which occurred 1 week after unprotected sexual intercourse. Haemophilus ducrey has been detected by culture and the patient underwent Azithromycin therapy with good outcome." }, { "id": "InternalMed_Harrison_16021", "title": "InternalMed_Harrison", "score": 0.012618422100151263, "content": "Other Candida skin infections include paronychia, a painful swelling at the nail-skin interface; onychomycosis, a fungal nail infection rarely caused by this genus; intertrigo, an erythematous irritation with redness and pustules in the skin folds; balanitis, an erythematouspustular infection of the glans penis; erosio interdigitalis blastomycetica, an infection between the digits of the hands or toes; folliculitis, with pustules developing most frequently in the area of the beard; perianal candidiasis, a pruritic, erythematous, pustular infection surrounding the anus; and diaper rash, a common erythematous-pustular perineal infection in infants. Generalized disseminated cutaneous candidiasis, another form of infection that occurs primarily in infants, is characterized by widespread eruptions over the trunk, thorax, and extremities. The diagnostic macronodular lesions of hematogenously disseminated candidiasis (Fig. 240-1) indicate a high probability of dissemination to multiple" }, { "id": "article-18119_2", "title": "Balanitis -- Introduction", "score": 0.012445435125847497, "content": "Balanitis is an inflammation of the glans penis (head of the penis); it is fairly common and affects approximately 3-11% of males during their lifetime. Posthitis is an inflammation of the foreskin (prepuce). Balanoposthitis involves both the glans and the foreskin and occurs in approximately 6% of uncircumcised males. Balanoposthitis occurs only in uncircumcised males. [1] [2] However, balanitis and balanoposthitis often occur together, and the terms are commonly used interchangeably.  Infectious etiologies of balanitis include certain fungi like yeast and certain bacteria or viruses (including those that cause STDs such as gonorrhea). Balanitis is not a sexually transmitted infection. The actual disease is not transferable from one person to another; however, the transfer of organisms that cause balanitis is possible.  Recurrent episodes of balanoposthitis should raise the concern for occult diabetes. Patients with recurrent episodes should undergo blood glucose screening for diabetes and evaluation by a urologist." }, { "id": "pubmed23n0992_1246", "title": "Psoriasiform lesions of glans and palms: A rare presentation in secondary syphilis.", "score": 0.012433862433862432, "content": "Erythematous scaly papules on the palms and soles are a common manifestation of secondary syphilis. We report a case of 19-year-old male who presented with erythematous, scaly, psoriasiform lesions over the palms and glans penis. The papules over the palms showed tenderness on blunt vertical pressure. There was a history of sexual contact and ulcer over the glans around 2 months back, which resolved on its own. Venereal Disease Research Laboratory test was positive in 1:32 dilution. <iTreponema pallidum</i hemagglutination test was also positive. This case highlights the atypical presentation of secondary syphilis." }, { "id": "wiki20220301en017_7709", "title": "Chancroid", "score": 0.01184640522875817, "content": "Complications Extensive lymph node inflammation may develop. Large inguinal abscesses may develop and rupture to form draining sinus or giant ulcer. Superinfection by Fusarium and Bacteroides. These later require debridement and may result in disfiguring scars. Phimosis can develop in long-standing lesion by scarring and thickening of foreskin, which may subsequently require circumcision. Sites For Chancroid Lesions Males Internal and external surface of prepuce. Coronal sulcus Frenulum Shaft of penis Prepucial orifice Urethral meatus Glans penis Perineum area Females Labia majora is most common site. \"Kissing ulcers\" may develop. These are ulcers that occur on opposing surfaces of the labia. Labia minora Fourchette Vestibule Clitoris Perineal area Inner thighs" }, { "id": "wiki20220301en017_7717", "title": "Chancroid", "score": 0.011783254501701104, "content": "Pregnant and lactating women, or those below 18 years of age regardless of gender, should not use ciprofloxacin as treatment for chancroid. Treatment failure is possible with HIV co-infection and extended therapy is sometimes required. Prognosis Prognosis is excellent with proper treatment. Treating sexual contacts of affected individual helps break cycle of infection. Follow-up Within 3–7 days after commencing treatment, patients should be re-examined to determine whether the treatment was successful. Within 3 days, symptoms of ulcers should improve. Healing time of the ulcer depends mainly on size and can take more than two weeks for larger ulcers. In uncircumcised men, healing is slower if the ulcer is under the foreskin. Sometimes, needle aspiration or incision and drainage are necessary." }, { "id": "pubmed23n0806_2254", "title": "Pustular secondary syphilis: report of three cases and review of the literature.", "score": 0.011679354544863036, "content": "Pustular syphilis is an extremely rare manifestation of secondary syphilis. Failure to recognize the disease can have devastating consequences. We present three patients with pustular syphilis as the primary manifestation of secondary syphilis. Patient 1 was initially diagnosed by Venereal Disease Research Laboratory (VDRL) test (titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Patient 2 was screened for syphilis by VDRL (titers 1 : 64), yielding a positive result, and tested negative for HIV. Secondary syphilis was confirmed by EIA. In Patient 3, a diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA. Treponema pallidum was detected by dark field microscopy in three patients. Testing for HIV infection was negative in all patients. Diagnosis in secondary syphilis remains challenging because of the diversity of clinical presentations. The most commonly observed cutaneous presentation is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement. The diagnostic methods used to identify secondary syphilis are the same as those used to diagnose other stages of syphilitic infection. The persistence of syphilis in both developed and underdeveloped regions highlights the importance of considering syphilitic infection in the setting of a cutaneous pustular eruption, especially one that fails to respond to standard therapy. Testing for other sexually transmitted diseases, including HIV, should be performed in all patients diagnosed with syphilis." }, { "id": "article-28956_39", "title": "Sexually Transmitted Infections -- History and Physical -- Chancroid", "score": 0.011490269261530258, "content": "Females and males: Signs and symptoms: Often occurs in the 20 to 30-year-old age group, frequently among sex workers and their clients. The areas most often affected include the distal portion of the penis in men, while in women, the vagina, labia, and perianal regions are involved. The most significant symptom is the extremely high pain level noted when the lesion reaches the ulcerative stage. [6] Physical Exam: The lesion starts as a reddish papule which rapidly progresses to a pustule followed by an extremely painful ulcer. The ulcer sometimes called a \"soft chancre,\" will have soft and irregular margins with a friable base and a grayish-yellowish exudate. It tends to bleed easily. The ulcers are typically 1 cm to 2 cm in diameter and usually resolve spontaneously within three months, even if left untreated. Close to half of the affected individuals will develop regional lymphadenopathy, which may be tender. A minority (about 25%) of these patients will progress to infected bulla or abscesses, which can rupture and become superinfected leading to significant tissue destruction and damage to the genitalia. It is estimated that 10% of affected individuals will also have syphilis or genital herpes as well." }, { "id": "wiki20220301en138_47927", "title": "Circumcision", "score": 0.011447463116228858, "content": "Although genital warts are caused by a type of HPV, there is no statistically significant relationship between being circumcised and the presence of genital warts. Other infections Studies evaluating the effect of circumcision on the rates of other sexually transmitted infections have generally, found it to be protective. A 2006 meta-analysis found that circumcision was associated with lower rates of syphilis, chancroid and possibly genital herpes. A 2010 review found that circumcision reduced the incidence of HSV-2 (herpes simplex virus, type 2) infections by 28%. The researchers found mixed results for protection against trichomonas vaginalis and chlamydia trachomatis, and no evidence of protection against gonorrhea or syphilis. It may also possibly protect against syphilis in men who have sex with men." }, { "id": "wiki20220301en126_43028", "title": "Venereology", "score": 0.011267872360571916, "content": "Venereology is a branch of medicine that is concerned with the study and treatment of sexually transmitted diseases (STDs). The name derives from Roman goddess Venus, associated with love, beauty and fertility. A physician specializing in venereology is called a venereologist. In many areas of the world, the specialty is usually combined with dermatology. The venereal diseases include bacterial, viral, fungal, and parasitic infections. Some of the important diseases are HIV infection, syphilis, gonorrhea, candidiasis, herpes simplex, human papillomavirus infection, and genital scabies. Other sexually transmitted infections studied in the field include chancroid, lymphogranuloma venereum, granuloma inguinale, hepatitis B, and cytomegalovirus infection." }, { "id": "wiki20220301en154_45003", "title": "Genital ulcer", "score": 0.011251839242953175, "content": "Overview A genital ulcer may be located on the vulva, penis, perianal region, or anus. Globally, the incidence of genital ulcers is estimated to be approximately 20 million cases annually. The most likely cause of a genital ulcer varies depending on the characteristics of a population and location. The most common cause of genital ulcers in the United States is herpes simplex infections, with syphilis the second most common cause, and chancroid the third. These common causes of genital ulcer disease (HSV-1, HSV-2 and treponema pallidum) can all be efficiently transmitted through oral sex. Important signs associated with genital ulcers that may assist in the diagnosis of the cause of the genital ulcer may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of vesicular lesions, which are small, painful, elevated blisters." }, { "id": "pubmed23n0877_12247", "title": "Penile Granuloma Annulare.", "score": 0.011236309692895245, "content": "A 50-year-old man presented to the genitourinary medicine clinic with a 3-year history of skin-colored circular papules over the shaft and glans of the penis. There were multiple lesions that were initially small, around 0.3 cm in diameter, and gradually enlarged. Physical examination revealed five nodules over the glans and shaft of the penis, with the largest lesion measuring 3×1 cm over the lateral aspect of the shaft (Figure 1). There were no similar lesions elsewhere. There was no lymphadenopathy and the rest of the examination was unremarkable. The patient complained of discomfort during sexual intercourse but the lesions were otherwise asymptomatic and nontender. There was no history of trauma to the area and no dermatological history. He had had the same sexual partner for the past 22 years, no significant medical history, and was not taking any medication. He was a smoker with a 32-pack-year history. His family history did not include any dermatological diseases. His father was diagnosed with type II diabetes at 65 years of age and his mother had hypertension since age 60 years. He had consulted his general practitioner regarding the penile eruption a year earlier and was treated for a presumed fungal infection with clotrimazole cream for 1 month with no effect. Results from genitourinary investigations for sexually transmitted diseases including syphilis were all negative. " }, { "id": "pubmed23n0745_24618", "title": "Pattern of sexually transmitted infections in males in interior Sindh: a 10-year-study.", "score": 0.011050995740762057, "content": "Sexually transmitted infections (STIs) are widespread in Pakistan and have not been fully documented particularly in Sindh Province. The aim of this study is to determine the number and clinical pattern of various types of STIs in general population of Larkana division and its surrounding cities. A hospital based prospective study was carried out at Male-STD-Clinic in the Department of Dermatology, Shaheed Muhtarma Benazir Bhutto Medical University Hospital Larkana from January 2000 to December 2009. Among 4,288 patients, 3,947 (92.04%) had the history of extra marital sexual contact and simultaneously had developed the clinical signs of STIs; 341 (7.95%) had history of extra marital sexual contact but did not have the manifestation of STIs. Majority of the patients (3,860, 90.01%) had the history of heterosexual contact with different partners, but only few 171 (3.98%) of them had the history of homosexual contact. According the syndromic diagnosis 1930 (45.00%) patients had genital ulcer (including herpes genitals) with or without skin manifestations, 690 (16.09%) had urethral discharge, 431 (10.05%) had genital warts, 349 (8.14%) had lesions other than STIs related, 304 (7.08%) had more than one syndrome, 193 (4.50%) had scrotal swelling, 46 (1.07%) had inguinal bubo, 3 (0.06%) were human immunodeficiency virus (HIV) positive, and 1 (0.02%) had ophthalmia neonatorum. Based on the clinical and etiological grounds: 2560 (59.70%) had syphilis, 640 (14. 92%) had gonorrhoea, 399 (9.30%) had mixed infections, 40 (0.93%) had chancroid, 431 (10.05%) had genital warts, 40 (0.93%) had lymphogranuloma venerum (LGV) and granuloma inguinale (GI), 3 (0.06%) were HIV positive, 208 (4.85%) had genital herpes, 120 (2.79%) had orchitis, 56 (1.30%) had non gonococcal urethritis (chlamydia were 19), and 1 (0.02%) had ophthalmia neonatorum. Mode of transmission of STIs in this region is mainly by heterosexual contact and syphilis is the commonest followed by gonorrhoea." }, { "id": "pubmed23n0820_23599", "title": "[Generalized exanthematous pustular dermatophytid, a rare clinical presentation of dermatophytid reaction].", "score": 0.010007986423080761, "content": "Dermatophytids are immunologically mediated dermatologic presentations secondary to sensitization to a dermatophyte infection. They are most frequently associated with toe-web intertrigo and usually present as localized, palmar, pruriginous vesicular eruptions. We report three original cases of generalized exanthematous pustular dermatophytid associated with kerions. Two boys aged 11 and 6 years, and one girl aged 6 years initially presented with kerion secondary to Trichophyton tonsurans (case 1), Trichophyton soudanense (case 2) and Trichophyton mentagrophytes (case 3), respectively. Two to three days after initiation of griseofulvin treatment, all patients presented with a pustular eruption extending from the head to the trunk, associated in one case with fever of 39°C and inflammatory chondritis. Samples obtained from the pustular lesions were sterile, serum inflammatory markers were within the normal range and skin lesions resolved on oral corticosteroid treatment (prednisone 0.75 mg/kg, case 1) or high-potency topical steroids (cases 2 and 3) given as an adjunct to griseofulvin treatment (19 to 23 mg/kg/d). Dermatophytids occur during the acute phase of infection or within a few days of treatment initiation. Lesions are remote from the infection site, contain no dermatophyte, and resolve after treatment of the infection. We report three original cases of generalized exanthematous pustular dermatophytid, associated in one case with fever and inflammatory chondritis. The main differential diagnosis is acute generalized exanthematous pustulosis secondary to antifungal drugs. Differences in clinical presentation between the two enable the appropriate diagnosis to be made as well as continued use of the antifungal medication needed to cure the patient. General or topical steroids may also be used in combination." }, { "id": "pubmed23n0707_15333", "title": "Plasma cell balanitis presenting in a patient with a history of syphilis.", "score": 0.009900990099009901, "content": "Plasma cell balanitis (PCB), also knows as Zoon balanitis, is a benign asymptomatic but chronic and erosive inflammatory condition of the glans penis and prepuce that generally affects uncircumcised men in later years. Clinical presentation involves a single, shiny, well defined reddish patch. We describe the first case of PCB ever reported in a patient with a previous history of syphilis, and include a review of the current literature. A 57-year-old Hispanic man with a remote history of syphilis presented with a 6-month nonhealing, granulating ulcer of the foreskin and glans penis that had been repeatedly mistaken for syphilis and treated unsuccessfully with circumcision 3 weeks previously. Biopsy of the glans penis demonstrated sections with denuded chronic granulation tissue showing a fibrotic stroma with numerous blood vessels and a mixed inflammatory infiltrate including scattered plasma cells. It is important to differentiate PCB from a syphilitic chancre in a patient presenting with a nonhealing penile lesion. This case report demonstrates that these entities may be seen in the same patient at different times." }, { "id": "pubmed23n0846_19348", "title": "Penoscrotal porokeratosis: A distinct entity.", "score": 0.00980392156862745, "content": "A 26-year-old man presented with five months history of redness associated with itching and burning over the scrotum and shaft of the penis with a persistent rash on those sites. There had been no response to topical steroid and antifungal creams. Clinical examination revealed a large well-circumscribed erythematous plaque with a thready raised border with a tiny groove at its summit that involved almost two-thirds of the ventral part of the shaft of the penis. Ill-defined erythema with a granular surface was seen over the anterior scrotal skin. A 4 mm punch biopsy of the plaque on the penile shaft revealed multiple cornoid lamellae located adjacent to one another. The patient was treated with topical emollients. Follow up after four months revealed almost complete resolution of the plaque on the penile shaft. Penoscrotal porokeratosis appears to be a distinct entity in the family of porokeratotic diseases, described only in young males in their twenties with involvement of the penile shaft and anterior scrotum with severe burning and itching and histologically associated with multiple cornoid lamellae. It may represent an unusual epidermal porokeratotic reaction pattern and may be a self-resolving condition. " }, { "id": "pubmed23n0793_4457", "title": "[Zoon's balanitis in circumcised and HIV infected man, at Cotonou (Benin)].", "score": 0.009708737864077669, "content": "Balanitis of Zoon (BZ) characterized by an important plasma cell infiltration occurs exclusively in uncircumcised men aged between 40-80 years. We report here a case of BZ in an HIV infected patient who was circumcised since birth. A 43-year old man consulted in 2009 for itchy and not painful glans erosion evolving for one year. He is HIV1 infected and has been under didanosine, lamiduvine and nelfinavir for three years. Under this treatment, his CD4 count increased from 26 cells/mm(3) in 2007 to 206 cells/mm(3) at the time of the consultation. We noted after examination clean burgeoning erosion, red in places, pink in other places, with fuzzy boundary, sitting on the glans and extending into the preputial sulcus. Histopathology showed infiltration by sheets of plasma cells with perivascular topography in the dermis. The bacterial cultures and syphilis serology were negative. We noted a good outcome after four weeks of application of 3% oxytetracycline ointment. This observation suggests that the BZ can occur on a HIV infected patient whether he was circumcised or not. Thus, it appears fair to think of BZ faced with a chronic erosion of the glans in HIV infected patient." }, { "id": "pubmed23n0353_6395", "title": "Mycotic infections of the penis.", "score": 0.009708737864077669, "content": "Balanitis/balanoposthitis caused by Candida albicans is the most frequent mycotic infection of the penis. Its incidence is increasing and it seems to be primarily transmitted by sexual intercourse. Although the groin is a common site for tinea, dermatophytic infections of the penis are rare. Penile involvement in systemic mycosis is usually a sign of severe disease. In immunocompromised individuals, nearly every fungal agent may cause the disease. It normally presents as ulceration, and biopsy and culture can help to confirm the diagnosis. In most cases, superficial infections of the penis respond satisfactorily to local antifungal treatment, especially if provovatice factors and the possibility of sexual transmission are considered. Systemic treatment is recommended in cases of widespread dermatophytic infection, candidosis or systemic mycosis." }, { "id": "InternalMed_Harrison_16162", "title": "InternalMed_Harrison", "score": 0.009655937846836847, "content": "Tinea capitis occurs most commonly in children 3–7 years old. Children with tinea capitis usually present with well-demarcated scaly patches in which hair shafts are broken off right above the skin; alopecia can result. Tinea corporis is manifested by well-demarcated, annular, pruritic, scaly lesions that undergo central clearing. Usually one or several small lesions are present. In some cases, tinea corporis can involve much of the trunk or manifest as folliculitis with pustule formation. The rash should be differentiated from contact dermatitis, eczema, and psoriasis. Tinea cruris is seen almost exclusively in men. The perineal rash is erythematous and pustular, has a discrete scaly border, is without satellite lesions, and is usually pruritic. The rash must be differentiated from intertriginous candidiasis, erythrasma, and psoriasis." }, { "id": "pubmed23n0991_470", "title": "Dermatologically challenging syphilis presentation.", "score": 0.009615384615384616, "content": "An atypical early primary syphilis case presentation with multiple umbilicated papular lesions on the penis and a nonreactive syphilis serology was misdiagnosed as molluscum contagiosum. Over a period of eight weeks, prior to dermatologic consultation, the papules enlarged, ulcerated, and healed. New plaque and patch formation on the penis and scrotum led to a differential diagnosis of inverse psoriasis vs. syphilis. Histological examination of a shave biopsy specimen revealed numerous Treponema pallidum organisms and repeat syphilis serological test results confirmed a syphilis diagnosis. Lesions responded to treatment with benzathine penicillin. One must keep a high index of suspicion for syphilis in light of its diverse presentation and increasing incidence." }, { "id": "pubmed23n0903_3522", "title": "Dorsal longitudinal foreskin cut is associated with reduced risk of HIV, syphilis and genital herpes in men: a cross-sectional study in Papua New Guinea.", "score": 0.009523809523809525, "content": "Various forms of penile foreskin cutting are practised in Papua New Guinea. In the context of an ecological association observed between HIV infection and the dorsal longitudinal foreskin cut, we undertook an investigation of this relationship at the individual level. We conducted a cross-sectional study among men attending voluntary confidential HIV counselling and testing clinics. Following informed consent, participants had a face-to-face interview and an examination to categorize foreskin status. HIV testing was conducted on site and relevant specimens collected for laboratory-based Herpes simplex type-2 (HSV-2), syphilis, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) testing. Overall, 1073 men were enrolled: 646 (60.2%) were uncut; 339 (31.6%) had a full dorsal longitudinal cut; 72 (6.7%) a partial dorsal longitudinal cut; and 14 (1.3%) were circumcised. Overall, the prevalence of HIV was 12.3%; HSV-2, 33.6%; active syphilis, 12.1%; CT, 13.4%; NG, 14.1%; and TV 7.6%. Compared with uncut men, men with a full dorsal longitudinal cut were significantly less likely to have HIV (adjusted odds ratio [adjOR] 0.25, 95%CI: 0.12, 0.51); HSV-2 (adjOR 0.60, 95%CI: 0.41, 0.87); or active syphilis (adjOR 0.55, 95%CI: 0.31, 0.96). This apparent protective effect was restricted to men cut prior to sexual debut. There was no difference between cut and uncut men for CT, NG or TV. In this large cross-sectional study, men with a dorsal longitudinal foreskin cut were significantly less likely to have HIV, HSV-2 and syphilis compared with uncut men, despite still having a complete (albeit morphologically altered) foreskin. The protective effect of the dorsal cut suggests that the mechanism by which male circumcision works is not simply due to the removal of the inner foreskin and its more easily accessible HIV target cells. Exposure of the penile glans and inner foreskin appear to be key mechanisms by which male circumcision confers protection.Further research in this unique setting will help improve our understanding of the fundamental immunohistologic mechanisms by which male circumcision provides protection, and may lead to new biomedical prevention strategies at the mucosal level." }, { "id": "pubmed23n0517_199", "title": "Nine male cases of tinea genitalis.", "score": 0.009523809523809525, "content": "Nine cases of tinea genitalis observed in Siena and Terni (Italy) between 1988 and 2003 are reported because of their infrequency. The patients were males ranging in age from 23 to 45 years. The lesions, situated on the penis, glans and scrotum, were preceded by dermatophytosis in other sites (groin five cases; feet two cases; toenails two cases; hands in one; beard in another). Mycological examination consisting of direct microscopy and culture led to isolation of Trichophyton rubrum in five cases, Epidermophyton floccosum in two and T. mentagrophytes var. interdigitalis in the others. Clinical diagnosis is not always easy. In three cases the lesions had been misdiagnosed as eczema." }, { "id": "InternalMed_Harrison_4015", "title": "InternalMed_Harrison", "score": 0.009433962264150943, "content": "associated with candidal infection. In addition, candidal infections have an affinity for sites that are chronically wet and macerated, including the skin around nails (onycholysis and paronychia), and in intertriginous areas. Intertriginous lesions are characteristically edematous, erythematous, and scaly, with scattered “satellite pustules.” In males, there is often involvement of the penis and scrotum as well as the inner aspect of the thighs. In contrast to dermatophyte infections, candidal infections are frequently painful and accompanied by a marked inflammatory response. Diagnosis of candidal infection is based upon the clinical pattern and demonstration of yeast on KOH preparation or culture." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 128, 202 ] ], "word_ranges": [ [ 22, 33 ] ], "text": "The rest of the diagnoses are consistent with these analytical parameters." }, "2": { "exist": true, "char_ranges": [ [ 0, 127 ] ], "word_ranges": [ [ 0, 22 ] ], "text": "This is because in early ovarian failure FSH and LH are elevated. This is confirmed by the SEGO protocol called Early Menoguia." }, "3": { "exist": true, "char_ranges": [ [ 128, 202 ] ], "word_ranges": [ [ 22, 33 ] ], "text": "The rest of the diagnoses are consistent with these analytical parameters." }, "4": { "exist": true, "char_ranges": [ [ 128, 202 ] ], "word_ranges": [ [ 22, 33 ] ], "text": "The rest of the diagnoses are consistent with these analytical parameters." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Administration of combined oral contraceptives.", "2": "Premature ovarian failure.", "3": "Eating behavior disorder.", "4": "Craniopharyngioma.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0001_9671", "title": "Pituitary and ovarian response to acute stimulation with LH-RH in normal and anovulatory women.", "score": 0.016270416850602258, "content": "The LH FSH estradiol and progesterone responses to acute stimulation with LH-RH were studied in 12 normal women with ovulatory cycles (4 in the initial follicular phase, 4 in the mid-follicular phase and 4 in the late follicular phase) and in two castrated women, two under hormonal contraception, two with ovarian amenorrhea, twelve with central amenorrhea of no detectable origin (6 with normal and 6 with low basal gonadotrophins), eleven anovulatory patients with pseudomenstruation, two with anorexia nervosa, and two with pituitary amenorrhea. Each woman received a rapid i.v. injection of 100 microgram synthetic LH-RH at 9:00 a.m. Serum levels of LH, FSH, estradiol and progesterone were determined by radioimmunoassay in samples collected before and 60, 120, 240 and 480 minutes after injection. The findings were : 1) A significant rise in estradiol and progesterone levels, in addition to LH and FSH elevation, in normal women; 2) A lack of ovarian steroid response in the castrated women and in ovarian amenorrheas, which suggests that the source of steroid response to stimulation is not extragonadal; 3) Significant differences in the responses of the four hormones to LH-RH in the women with central amenorrhea in comparison with the normal group with great variability of results; the steroid response in the presence of a positive LH response might correlate with the severity and/or prognosis of the disorder, a point deserving further study; 4) In anovulatory women with pseudomenstruation, LH responses for the most part normal, and particularly, progesterone responses." }, { "id": "pubmed23n0275_16128", "title": "[Secondary amenorrhea and LH hypersecretion. An unusual report of a granulosa cell ovarian tumor].", "score": 0.01508295625942685, "content": "Granulosa cell ovarian tumors are infrequent. Since they originate from the gonadal stroma, they retain a high secretory potential and some of their clinical manifestations may be secondary to the production of sexual steroids. A 36 year old woman with an ovarian tumor presenting as a secondary amenorrhea is reported. This patient had a positive progesterone test and her hormonal profile showed a maintained LH hypersecretion (&gt; 75 mUl/ml) which, joined to the presence of a hypophyseal microadenoma lead to suspect the presence of a gonadotrophin secreting tumor. The absence of LH response to TRH and its adequate suppression using oral contraceptives discarded this diagnosis. The histopathology of the excised ovarian tumor demonstrated that it is was a granulosa cell tumor. The physiopathological explanation of the case is based on the maintained levels of estrogens produced by the tumor that, through a positive feed-back mechanism similar to that of the polycystic ovary syndrome, produced a tonic LH elevation and GnRH hyper response. After the tumor excision, ovulatory cycles resumed and the patient became pregnant, facts that confirm the postulated hypothesis." }, { "id": "wiki20220301en203_18623", "title": "Functional hypothalamic amenorrhea", "score": 0.012333878079615182, "content": "In all cases of amenorrhea, pregnancy should be excluded. This can be done by obtaining serum B-hCG levels. In cases of suspected FHA, screening laboratory tests include a complete blood count (CBC), electrolytes, glucose, bicarbonate, blood urea nitrogen (BUN), creatinine, liver panel, and when appropriate, sedimentation rate and/or C-reactive protein levels. Liver function tests may be abnormal in females with extreme energy restriction. The initial endocrine evaluation includes testing for levels of TSH and free T4, prolactin, LH, FSH, estradiol (E2), and anti-Müllerian hormone (AMH). FHA patients may display a combination of the following: FSH concentrations that are normal but lower than LH levels, low or low normal LH, E2 <50 pg/mL, and progesterone <1 ng/mL. LH and FSH are often normal in FHA patients. No single E2 value can confirm FHA as each reflects only a certain time point, but in individuals whose E2 is <20 pg/mL persistently, an acute gonadotropin response to GnRH" }, { "id": "wiki20220301en381_28806", "title": "Gonadotropin-releasing hormone insensitivity", "score": 0.011681582666038625, "content": "Diagnosis When suspected on the basis of the clinical presentation or physical findings, the diagnosis of GnRH insensitivity should be confirmed biochemically. The diagnosis requires the following findings: The demonstration of prepubertal serum concentrations of sex steroid hormones (serum testosterone less than 100 ng/dL [3.5 nmol/L] in males or serum estradiol less than 20 pg/mL [73 pmol/L] in females). Inappropriately low or normal serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) concentrations (usually less than 4 to 5 international units/L) rather than the high concentrations expected with primary gonadal failure. Otherwise normal anterior pituitary function." }, { "id": "pubmed23n0052_18690", "title": "Effect of \"missed\" pills on oral contraceptive effectiveness.", "score": 0.010924095348353964, "content": "The purpose of this study was to determine whether missing pills in an oral contraceptive (OC) cycle resulted in folliculogenesis and eventual ovulation. Fifteen women selected from a population requesting tubal reanastomosis were randomized into three groups and issued pill packs missing four consecutive pills in specific sequences, as follows: group I, days 1-4; group II, days 3-6; and group III, days 6-9. Serum was drawn for assay of LH, FSH, estradiol (E2), and progesterone, and serial ovarian ultrasound examinations were done to study follicular development throughout the cycle at 4-day intervals. No subject ovulated, as suggested by serum progesterone concentrations (not exceeding 0.63 ng/mL for any woman) and ultrasound assessment of follicular development (no follicular diameter exceeding 13 mm). The highest (mean +/- standard deviation) serum concentrations of LH and FSH in any group (13.25 +/- 18.71 and 14.40 +/- 7.71 mIU/mL, respectively) and of E2 (44.35 +/- 26.79 pg/mL) were observed during or immediately after the pill-free interval. Ovarian ultrasound examinations suggested suppressed folliculogenesis in all groups. No functional ovarian cysts were detected. Oral contraceptives exerted a similar degree of pituitary and ovarian suppression even when the subjects missed four pills at varying times in a cycle. The anovulatory effect persisted when the OC pills were reinstituted and taken reliably after an interval of noncompliance." }, { "id": "wiki20220301en164_39637", "title": "Poor ovarian reserve", "score": 0.01077282101378487, "content": "Pretreatment with 50 mcg ethinylestradiol three times a day for two weeks, followed by recombinant FSH 200 IU/day subcutaneously. Ethinylestradiol treatment was maintained during FSH stimulation. When at least one follicle reached 18mm in diameter and serum estradiol was greater or equal to 150 pg/ML ovulation was induced with an intramuscular injection of 10,000 IU of hCG (human chorionic gonadotropin hormone). For luteal phase support 5,000 IU of hCG was administered every 72 hours. Out of 25 patients 8 ovulated and 4 became pregnant. In the control group there were no ovulations. The patients ranged in age between 24 and 39 years with an average age of 32.7. All women had amenorrhea for at least 6 months (average 16.75 months) and FSH levels greater or equal than 40 mIU/mL (average FSH 68 mIU/ML). The researchers believe this protocol would work for women in early post menopause as well." }, { "id": "wiki20220301en558_21966", "title": "Pharmacodynamics of estradiol", "score": 0.009900990099009901, "content": "Generally, estrogens are antigonadotropic and inhibit gonadotropin secretion. However, in women, a sharp increase in estradiol levels to about 200 to 500 pg/mL occurs at the end of the follicular phase (mid-cycle) during the normal menstrual cycle and paradoxically triggers a surge in LH and FSH secretion. This occurs when estradiol concentrations reach levels of about 250 to 300 pg/mL. During the mid-cycle surge, LH levels increase by 3- to 12-fold and FSH levels increase by 2- to 4-fold. The surge lasts about 24 to 36 hours and triggers ovulation, the rupture of the dominant ovarian follicle and the release of the egg from the ovary into the oviduct. This estrogen-mediated gonadotropin surge effect has also been found to occur with exogenous estrogen, including in transgender women on hormone therapy and pre-hormone therapy transgender men acutely challenged with a high dose of an estrogen, but does not occur in men, pre-hormone therapy transgender women, or transgender men on" }, { "id": "pubmed23n0703_17609", "title": "Testicular failure and male infertility in the monogenic Mulibrey nanism disorder.", "score": 0.00980392156862745, "content": "Few monogenic mutations causing human male infertility have been identified to date. We studied pubertal development and fecundity in males with Mulibrey nanism (MUL) caused by mutations in the TRIM37 gene. Twenty-eight male MUL patients of the Finnish national cohort aged 8.7 to 50.0 yr (median age, 28.8) at the end of observation were followed for 10 yr beginning from 2000-2001. Clinical characteristics, reproductive hormone levels, semen quality, and testicular histology were assessed. The external genital phenotype was normal. In childhood and prepuberty, serum levels of FSH, LH, testosterone (T), and inhibin B were normal. Puberty started spontaneously at a median age of 12.6 yr (range, 11.1-15.0), and FSH, LH, T, and inhibin B levels increased adequately until midpuberty. Thereafter, testicular growth and virilization proceeded slowly. Concomitantly, FSH, and to a lesser extent LH, showed a progressive increase to hypergonadotropic levels in all patients, whereas inhibin B decreased and T leveled off. Testicular size was small (median volume, 8.7 ml; range, 3.5-18.3 ml in adults). All semen samples showed severe oligoasthenozoospermia or azoospermia. None of the patients had a history of spontaneous fertility, but four men had undergone infertility treatment, which in one case was successful. All histological MUL samples showed varying degrees of degeneration. All adult MUL males have a unique disorder of testicular function with small testes, elevated FSH and LH, and low inhibin B. In MUL, mutations in TRIM37 lead to disturbance of sexual maturation, and fertility is severely compromised. Thus, TRIM37 is a novel gene causing male infertility." }, { "id": "pubmed23n0214_14421", "title": "[Gonadal function in anorexia nervosa patients in the postcritical phase].", "score": 0.00980392156862745, "content": "Resuming of menstruation is generally held as a hall mark of recovery in Anorexia Nervosa. Nevertheless, fifteen young women (17 to 28 years old) consulted us about secondary amenorrhea while the acute phase of illness was over. Basal gonadotropins and Estradiol (E2) were measured and a GnRH- TRH stimulation test was performed. Two groups of patients were considered: A - 7 patients with a normal Body Weight Index; B - 8 patients with a Body Weight Index still low. (- 20% - 30%). In group A, 6 out of 7 patients had a early onset of anorexia nervosa (within two years after menarche). In group B, 6 out of 8 patients had a late onset of their disease (more than five years after puberty). As for Body Weight, it seems that the prognosis is better when Anorexia Nervosa occurs within few years after menarche. By comparison with normal women of same age explored in early follicular phase, our population of Anorexia Nervosa showed no significant difference in basal levels of F.S.H., L.H., E2. Cumulative Response F.S. H./L.H. was slightly increased (= 1) compared with normal control (= 0,34). Basal and stimulated Prl were normal. When Body Weight Index was still low, LH and E2 were decreased whereas cumulative response F.S. H./L.H. was dramatically increased. A correlation between E2 and Body Weight Index was shown, low E2 usually fitting well with Low Body Weight Index. Prognosis is poorer for recovery of normal gonadal function in late onset Anorexia Nervosa. Nevertheless, in each group, some patients escaped this rule. Induction of ovulation with Clomifene let us disappointed.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0348_16997", "title": "[Sublingual thyroid gland associated with polycystic ovaries].", "score": 0.009708737864077669, "content": "To describe a young woman with polycystic ovary syndrome and a lingual thyroid gland. A 19-year old woman with secondary amenorrhea whose previous history had been uneventful. She had a normal spontaneous puberty with menarche at 13 years, followed by cyclical menstruations until six months before, when a period of four months of amenorrhea occurred. Physical exploration disclosed a normal young adult woman, without goiter, galactorrhea, acne, nor hirsutism. A pelvic ultrasound showed bilateral enlargement of the ovaries. Hormonal studies showed FSH 4 mUl/mL (nl = 2-12), LH 6 mUl/mL (nl = 2-14) and PRL 12 ng/mL (nl = &lt; 25); TSH 8 microU/mL (nl &lt; 5) and a free thyroxine level of 8.4 ng/dl (nl = 0.75-1.8). A thyroid gammagram with radioiodine disclosed a 6% caption (nl = 8.15%) and a small nodular gland at the base of the tongue. Levothyroxine 100 micrograms/day was initiated and a month later the TSH level was normal but cyclical menstruations were not established after six months of follow up. The polycystic ovary syndrome is the main endocrine cause of secondary amenorrhea in young women." }, { "id": "pubmed23n0086_15080", "title": "[Usefulness of determining serum levels of prolactin in women with menstruation disorders].", "score": 0.009708737864077669, "content": "In 173 women with oligomenorrhea or amenorrhea, serum level of prolactin (PRL) was determined by radioimmunoassay method. In 22 cases (12.7%) the concentration of PRL was above 15 ng/ml. From the above women in 9 cases (5.2%) of all examined patients pituitary microadenoma was diagnosed. In 1 patient with pituitary microadenoma, coexisting partially empty sella was diagnosed. The mean basal PRL concentration in women with menstruation disturbances without hyperprolactinemia (group I) was found to be 7.1 +/- 3.1 ng/ml while the women with hyperprolactinemia without pituitary microadenoma (group II) was 32.9 +/- 5.8 ng/ml. In women with diagnosed pituitary microadenoma (group III) PRL concentration was 131.8 +/- 47.7 ng/ml. The group II and III demonstrated statistically significant increase of serum prolactin level in comparison to group I. Moreover in comparison with group I, statistically significant reduction of serum level of FSH, LH and estradiol 17 beta was confirmed in group with pituitary microadenoma. In group II significant decrease of serum concentration of LH and estradiol 17 beta was stated as well as lack of significant difference in serum level of FSH, in comparison to group I." }, { "id": "pubmed23n0041_5797", "title": "[Diagnosis of pregnancy before the menstrual period is delayed. Interest of the determination of plasma chorionic gonadotropin (HCG) in fertility disorders].", "score": 0.009615384615384616, "content": "Estimating plasma HCG levels in the last days of the menstrual cycle have very early diagnosis of pregnancy. In 86 cycles occurring in 65 women being treated for sterility the levels were estimated between the 10th and the 15th day following the low point in the temperature curve for the purpose of trying to estimate the practical use of this method. In 30 cycles studied one case of fertilisation took place and was confirmed by the evolution of a pregnancy. From the 11th day onwards with the exception of one solitary case the concentrations of HCG ranged between 15 and 405 mUl-2 degrees-IS-hCC/ml. These levels, therefore are higher than the apparent concentrations found in a group of women used as controls who were not pregnant (0 to 4.5 mUl/ml.). In 56 other cycles apparently normal periods followed on the expected date. All the same, the apparent concentration of HCG (2 to 32 mUl/ml) is far higher often than in the control group. The interference of LH in the level makes it impossible to decide between two hypotheses: whether raised levels of LH are associated with irregular menstrual function or with fertilisation, followed by premature expulsion of the oocyte." }, { "id": "Gynecology_Novak_5822", "title": "Gynecology_Novak", "score": 0.009615384615384616, "content": "Brain imaging (MRI is the gold standard) to exclude  Pituitary microadenoma  Pituitary macroadenoma  Other abnormal brain mass Hypothyroidism  Exclude secondary causes  Treat condition  Supplement with thyroid hormone if indicated  Spontaneous ovulation will occur when thyroid function normalizes  Treat underlying condition  When prolactin normalizes, spontaneous ovulation should occur Anovulation Normal or high day 3 FSH and LH Ovarian disorders (see Figure 30.3) Low LH, FSH, TSH, GH, ACTH High serum prolactin levels Abnormal TSH or T4Low FSH, LH, E2 Hypothalmic disorders Thyroid disease Hyperprolactinemia Panhypopituitarism Assess and treat condition Repeat test to exclude false positive Elevated prolactin If a pituatary microadenoma is diagnosed  Bromocriptine or cabergoline to normalize prolactin level  Spontaneous ovulation should occur when prolactin is normal Anorexia  Medical and psychiatric assessment  Treat condition  Aim to increase BMI to allow spontaneous" }, { "id": "pubmed23n0950_4857", "title": "Premature ovarian insufficiency and early depletion of the ovarian reserve in the monogenic Mulibrey nanism disorder.", "score": 0.009523809523809525, "content": "What is the timing of onset and clinical course of premature ovarian insufficiency (POI) in patients with Mulibrey nanism (MUL), a monogenic disorder caused by mutations of the peroxisomal TRIM37 gene? The number of ovarian follicles is highly reduced already in infant and young MUL girls and the majority of them will have early depletion of follicles resulting in clinical and biochemical signs of POI. Both female and male patients with MUL show failure of sexual maturation, signs of hypogonadism and infertility. We studied the gonadal function, pubertal development and ovarian reserve in 33 MUL patients aged 5.1-47.3 years (median age 22.3) at the end of observation. The patients were followed between 2004 and 2014 and 19 pubertal or postpubertal patients were enrolled in a cross-sectional study. The period of postnatal activation of the hypothalamic-pituitary-gonadal axis (minipuberty), pubertal development and menstrual history were assessed longitudinally. The cross-sectional study included gynecological examination, analysis of reproductive hormones and ultrasonography with evaluation of ovarian volume and antral follicle count. Infant girls experienced a transient minipuberty with a high FSH surge. In childhood, gonadotropins were normal or slightly elevated but began to rise to hypergonadotropic levels in prepuberty. Anti-Müllerian hormone (AMH) levels remained undetectable or low throughout childhood. The onset of puberty occurred spontaneously and the median age at menarche was 12.5 years. Of the patients, 54% never attained regular menses and 10 years from menarche, only 8% of the women menstruated regularly. In the cross-sectional study, none of the patients had normal ovarian morphology under ultrasonography. Ovaries were hypoplastic and 82% had no or fewer than two visible antral follicles. AMH levels were undetectable in the vast majority (89%). The Finnish MUL patients genotypically form a homogenous group and therefore it is possible, that different TRIM37 mutations lead to different hypogonadal phenotypes. However, to date there is no known genotype-phenotype correlation in MUL. In MUL, AMH is a useful marker of ovarian function. MUL should be added to the list of syndromes associated with POI and correspondingly, TRIM37 should be added to the list of genes associated with POI. To our knowledge, TRIM37 is the first known gene coding for a peroxisomal membrane protein associated with female gonadal failure and infertility. Elucidating the role of syndromic genes in reproduction may aid in a greater understanding of ovarian biology. This study was supported by the Finnish Foundation for Pediatric Research, Finska Läkaresällskapet, the Sigrid Jusélius Foundation and Helsinki University Hospital Research Funds. The authors declare no conflicts of interest. Not applicable." }, { "id": "pubmed23n0558_19930", "title": "Menstrual abnormalities in a woman with ACTH-dependent pituitary macroadenoma mimicking polycystic ovary syndrome.", "score": 0.009523809523809525, "content": "Here, we present a case of ACTH-dependent pituitary macroadenoma (Cushing's disease) resulting in secondary amenorrhea mimicking polycystic ovary syndrome (PCOS). A 20-year-old nulligravid woman had been suffering from oligomenorrhea, amenorrhea, and moderate hirsutism since the age of 18 years. She visited a gynecologic clinic where PCOS was impressed according to the clinical manifestation and ultrasound finding. The patient responded to medication in the 1st year, but gradually failed to induce menses. She was advised to visit the endocrinology department for secondary amenorrhea and endocrine survey. Physical examination revealed central obesity, supraclavicle fatpad, abdominal striae, and myopathy of four limbs. Endocrine studies revealed: serum prolactin 21 ng/mL (3.0-20 ng/mL), FSH 5.69 mIU/mL (3.4-10.0 mIU/mL), LH 1.01 mIU/mL (1.1-11.6 mIU/mL), E2 &lt; 20 pg/mL (follicular phase 53-258 pg/mL), ACTH 110 pg/mL (0-46.0 pg/mL), cortisol 26.7 microg/dL at 8 a.m. (5.0-25 microg/dL), cortisol 21.3 microg/dL at 11 p.m. (half of normal morning value). Right pituitary macroadenoma was diagnosed through a series of dexamethasone tests and MRI. The patient received staging surgery including transsphenoidal adenomectomy and right frontotemporal craniotomy. As a result, the patient's physical condition gradually improved, and her menstrual cycle became regular with medication after the operation in the outpatient follow-up. PCOS is a common disease resulting in secondary amenorrhea. However, Cushing's syndrome resulting from pituitary macroadenoma should also be considered. Therefore, a careful history, observation, physical examination, and endocrine studies can differentiate between patients with PCOS and Cushing's disease." }, { "id": "pubmed23n0009_4611", "title": "Evidence for ovarian \"inhibin\": suppression of the secondary rise in serum follicle stimulating hormone levels in proestrous rats by injection of porcine follicular fluid.", "score": 0.009433962264150943, "content": "The present studies were carried out to see if porcine follicular fluid could inhibit increases in serum follicle stimulating hormone (FSH) levels when injected into the rat. For these studies the pentobarbital-treated proestrous rat was chosen as the major test animal model. If an artificial surge of luteinizing hormone (LH) is administered to these rats, it can induce a synchronized secondary rise in FSH secretion rate. Normal saline-treated rats were also used as test animals. They exhibit preovulatory endogenous \"surges\" of LH and FSH, and also a secondary FSH rise. Porcine follicular fluid was harvested from medium-sized and large (3- to 10-mm diameter) follicles and treated with charcoal to remove endogenous steroids. Charcoal-treated porcine serum served as a control solution. The fluid was injected intraperitoneally in two 0.5-ml doses into pentobarbital-treated proestrous rats immediately and 3 hr after LH injection. Follicular fluid, but not the serum, suppressed the secondary, LH-induced FSH rise (P &lt; 0.01) in a dose-dependent manner, without altering the effects of LH upon serum ovarian steroid levels or follicular rupture. It was effective down to a total dose of 200 mul. Porcine follicular fluid also blocked the secondary FSH surge in normal proestrous rats exhibiting endogenous LH/FSH primary surges. Thus, it would appear that porcine follicular fluid contains a non-steroidal substance(s) that can block the secretion of FSH that is secondary to a natural or artificial LH surge." }, { "id": "pubmed23n0350_17771", "title": "Ovarian hyperstimulation caused by gonadotroph adenoma secreting follicle-stimulating hormone in 28-year-old woman.", "score": 0.009433962264150943, "content": "Ovarian hyperstimulation caused by a gonadotroph adenoma in premenopausal women has been described only twice before this report. A 28-yr-old woman presented with menstrual disturbances and pelvic pains that began after stopping the use of contraceptive pills. Transvaginal ultrasound revealed enlarged ovaries with multiple cysts. The patient had elevated serum estradiol (up to 2900 pmol/L; normal, 80-300 pmol/L in the follicular phase) and inhibin (6.4 kU/L; normal, 0.5-2.5 kU/L) levels. Serum LH was appropriately suppressed (0.6 IU/L), but serum FSH varied from 4.9-8.1 IU/L. Both gonadotropins as well as the free alpha-subunit showed a paradoxical response to the stimulus by TRH. A nuclear magnetic resonance study unraveled a pituitary tumor, 12-14 mm in diameter, extending up to the suprasellar cistern. After pituitary surgery, all hormone values normalized, and the patient resumed regular ovulatory cycles. In immunostaining, 20-30% of the cells of the tumor stained positively for FSHbeta. We conclude that a gonadotropin-producing adenoma must be considered in the differential diagnosis of a patient presenting with large multicystic ovaries and high estradiol levels in the absence of exogenous gonadotropins." }, { "id": "wiki20220301en483_20567", "title": "Elagolix", "score": 0.009345794392523364, "content": "In clinical trials, elagolix produced dose-dependent decreases in gonadotropin, estradiol, and progesterone levels in women. Median levels of estradiol were partially suppressed to 42 pg/mL (follicular phase levels) with 150 mg once daily and were fully or near-fully suppressed to 12 pg/mL (postmenopausal levels) with 200 mg twice daily. In a 21-day study in premenopausal women, the effects of elagolix on FSH levels were found to be maximal at a dosage of 300 mg twice per day or above, whereas its effects on LH and estradiol levels were maximal at a dosage of 200 mg twice per day or above. Levels of progesterone were maintained at anovulatory levels (<2 ng/mL) across the 21-day study period at dosages of elagolix of 100 mg twice per day and above. A dosage of elagolix of 400 mg twice per day appears to produce no greater suppression in gonadotropin or estradiol levels than a dosage of 300 mg twice per day in premenopausal women. Suppression of gonadotropin and sex hormone levels with" }, { "id": "pubmed23n0275_8736", "title": "[A study with diagnostic standard of occult hyperprolactinemia (OHP) and the effect of bromocriptine administration].", "score": 0.009345794392523364, "content": "It is well known that the transient excessive increase of serum prolactin level is harmful for the mechanism of ovulation or the steroidogenesis of the ovaries. The pathogenesis of latent or occult hyperprolactinemia (OHP) has been investigated recently. The present study was conducted to determine the diagnostic standard of OHP, and to elucidate the efficacy of bromocriptine administration for the treatment of OHP and other ovulatory disturbances. 110 cases of hypothalamic anovulations were selected from 385 cases of infertile patients by the LH-RH and TRH loading tests. Bromocriptine (5mg/day) was administered to all of the subjects for more than three months, and the efficacy of the bromocriptine administration was investigated. Follicular development was observed by transvaginal ultrasonography (mature follicular diameters &gt; or = 20mm), and also luteal function was estimated by the duration of the luteal phase in the BBT charts (high phase &gt; or = 12 days), the mid-luteal serum estradiol (&gt; or = 200pg/ml) and progesterone (&gt; or = 10ng/ml) levels. The subjects were divided into two groups: group A, bromocriptine effective patients (63 cases) and group B, bromocriptine non effective patients (47 cases). The results of the LH-RH and TRH loading tests were compared between these two groups. Serum prolactin levels at 30 min. after TRH loading (PRL30) in group B (61.5 +/- 28.3 vs. 38.0 +/- 19.3ng/ml, p &lt; 0.01). At the cut-off points of 50, 60 and 70ng/ml over in the values of the PRL, the efficacies of the bromocriptine administration were 77.4, 78.9 and 88.5%, respectively. From these facts, it was thought suitable that the diagnostic standard of OHP was PRL30 &gt; or = 70ng/ml, and values of PRL30 from 50 to 70ng/ml were borderline cases of OHP. The efficacy of the bromocriptine administration in the cases without OHP (n = 57) was also investigated. Serum LH levels at 30 min. after LH-RH loading (LH30) were compared between the cases of the bromocriptine effective (n = 22) and non effective (n = 35). As a result, the LH30 of the former was significantly higher than that of the latter (96.5 +/- 64.2 vs. 45.1 +/- 31.5mIU/ml, p &lt; 0.005). In conclusion, the diagnostic standard of OHP was determined as PRL30 &gt; or = 70ng/ml (borderline: 50 &gt; 70ng/ml), and bromocriptine administration was effective not only in cases of OHP, but also in cases of hyperreactivities of LH (so-called endocrinological PCOD)." }, { "id": "wiki20220301en560_9917", "title": "Pharmacokinetics of progesterone", "score": 0.009259259259259259, "content": "Progesterone can be taken by mouth, in through the vagina, and by injection into muscle or fat, among other routes. A progesterone vaginal ring and progesterone intrauterine device are also available as pharmaceutical products. Normal levels Progesterone is used as part of hormone replacement therapy in people who have low progesterone levels, and for other reasons. For purposes of comparison with normal physiological circumstances, luteal phase levels of progesterone are 4 to 30 ng/mL, while follicular phase levels of progesterone are 0.02 to 0.9 ng/mL, menopausal levels are 0.03 to 0.3 ng/mL, and levels of progesterone in men are 0.12 to 0.3 ng/mL. During pregnancy, levels of progesterone in the first 4 to 8 weeks are 25 to 75 ng/mL, and levels are typically around 140 to 200 ng/mL at term. Production of progesterone in the body in late pregnancy is approximately 250 mg per day, 90% of which reaches the maternal circulation. Routes of administration" }, { "id": "InternalMed_Harrison_27518", "title": "InternalMed_Harrison", "score": 0.009259259259259259, "content": "Onset of Breast/ Age of Peak woman is ±2 days. Luteal phase length is relatively constant between 12 and 14 days in normal cycles; thus, the major variability in cycle length is due to variations in the fol-White 10.2 11.9 12.6 14.3 17.1 licular phase. The duration of menstrual bleeding in ovula-Black 9.6 11.5 12 13.6 16.5 tory cycles varies between 4 and 6 days. There is a gradual Source: From FM Biro et al: J Pediatr 148:234, 2006. Abbreviations: CNS, central nervous system; GnRH, gonadotropin-releasing hormone; hCG, human chorionic gonadotropin. The differential diagnosis of precocious and delayed puberty is similar in boys (Chap. 411) and girls. However, there are differences in the timing of normal puberty and differences in the relative frequency of specific disorders in girls compared with boys." }, { "id": "pubmed23n0027_9648", "title": "Pituitary stalk portal blood collection in rhesus monkeys: evidence for pulsatile release of gonadotropin-releasing hormone (GnRH).", "score": 0.009174311926605505, "content": "Hypothalamic-pituitary stalk portal blood was collected from 12 female rhesus monkeys. The pituitary stalk was approached transorbitally and cut at the level of the diaphragma sellae under direct visualization. After complete heparinization of the animal, stalk portal blood was obtained continuously, for periods of 30 minutes to 9 hours, using a constant exfusion pump at a rate of 30 to 40 mul/min. The mean GnRH in portal blood, as measured by radioimmunoassay, was 66 +/- 6.6 pg/ml (+/- SE) in 7 ovariectomized animals and 51 +/- 5.3 pg/ml (+/- SE) in 2 monkeys during the early follicular phase. Fluctuations in portal blood GnRH were most prominent in ovariectomized animals, with peak levels of 200-800 pg/ml and intervals of 1 to 3 hours between pulses. Peaks of GnRH during the early follicular phase did not exceed 200 pg/ml. The administration of estradiol (1000 ng, iv) to 3 monkeys did not decrease GnRH levels within the next 2 hours. These data provide direct evidence for a hypothalamic mediation of pituitary LH pulsatile release." }, { "id": "pubmed23n0537_18998", "title": "Premature ovarian failure in the early age 20s: 3 case reports.", "score": 0.009174311926605505, "content": "Premature ovarian failure in the early age 20s is a very rare phenomenon. In a woman presenting with amenorrhea and symptoms of hypoestrogenism, the confirmatory diagnosis of premature ovarian failure relies upon the finding of postmenopausal level of the follicle-stimulating hormone (FSH &gt; 40 mIU/ml). Three women at the age of 25, 30 and 32 years presented with 5, 6 and 10 years secondary amenorrhea, respectively. They used to have regular menses, and two of them gave birth to a healthy baby(ies). Although the etiology remains enigmatic, their gonadotropin and estradiol serum values were found to be in the postmenopausal range. Serum FSH values in the three cases were 135.4, 41.9 and 86.5 mlU/ml. Both combined oral contraceptive pills and progesterone challenge test were administered but couldn't bring about recommencement of menstrual flow. These three women who were diagnosed as a case of premature ovarian failure, evidenced by long standing secondary amenorrhea, secondary infertility, signs and symptoms of postmenopause and biochemical evidences of hypergonadotropic hypoestrogenism, were put on continuous combined oral contraceptive pills and felt better. Literature on the potential serious complications of premature menopause and treatment options in low setting areas is revised." }, { "id": "pubmed23n0552_19130", "title": "[Ovarian cysts and tumors as the cause of isosexual pseudoprecocious puberty].", "score": 0.00909090909090909, "content": "Precocious puberty in girls is generally defined as appearance of secondary sexual characteristics before eight years of age. Menarche before the ninth birthday may serve as an additional criterion. Precocious puberty is divided in central precocious puberty and pseudoprecocious puberty. Central precocious puberty (GnRH dependent) occurs because of premature activation of hypothalamic-pituitary-gonadal axis and activity of gonadotrophins. Pseudoprecocious puberty (GnRH independent) is caused by activity of sexual steroids that are not the result of gonadotrophin activity. Objective of our study was to examine the etiology, clinical and laboratory manifestations of isosexual pseudoprecocious puberty in girls. In the period between 1995 and 2004, clinical and laboratory sings of 34 girls with precocious puberty were studied at the Endocrine Department of the Institute of Mother and Child Health Care of Serbia. Initial evaluations included height measurement, staging of puberty, bone age assessment and pelvic ultrasound. Important diagnostic sonographic parameters of precocious puberty were the volumes of ovaries and uterus as well as ovarian structure. The initial hormonal evaluation included measuring of plasma oestradiol, luteinizing hormone (LH) and follicle stimulating hormone (FSH). The luteinizing hormone releasing hormone (LHRH) stimulation test was used to evaluate LH and FSH responsiveness (60 microg/m2 LHRH-Relefact LHRH, Ferring). Blood samples were collected at 0, 20 and 60 minutes. Basal and GnRH stimulated LH and FSH were determined by immunoradiometric assay. Estradiol concentration was measured using the fluoroimmunometric assay. Thirty-four girls aged 6 months to 9 years (mean age 4.5 years) with precocious puberty were studied during the period of 9 years. Eleven girls presented with breast development, six with vaginal bleeding and seventeen with signs of puberty. On the basis of clinical signs, bone age, estradiol levels and LHRH test, premature thelarche was diagnosed in eleven patients (32.4%), premature menarche in six (17.6%) and central precocious puberty in ten girls (29.4%). Seven girls (20.6%) presented with pseudoprecocious puberty. Pelvic ultrasound examination revealed unilateral ovarian cysts in six patients and granulosa cell tumor in one. Elevated estrogen serum levels and failure of gonadotropin responses after gonadotropin releasing hormone were the classical findings in patients with isosexual pseudoprecocious puberty during the acute period of disease. In four patients, the cyst decreased spontaneously after several months, while in two patients, the cyst was removed by laparotomy. Surgical treatment was performed in a patient with granulosa cell tumor. Our work demonstrates that autonomous functional ovarian follicle cyst is the most often cause of isosexual pseudoprecocious puberty. Short period of observation is suggested because the cyst can resolve spontaneously. On the other hand, juvenile granulosa cell tumor, as highly malignant tumor, should be removed as soon as diagnosis is established." }, { "id": "pubmed23n0071_20358", "title": "[Ovarian stimulation for in vitro fertilization using LHRH agonists: comparison of plasma and intra-follicular hormone profiles using \"short\" and \"long\" protocols].", "score": 0.009009009009009009, "content": "Plasmatic estradiol (E2), progesterone (P) and LH were measured during the follicular phase of 343 cycles induced for in vitro fertilization (IVF) using a LHRH agonist in a \"long protocol\" (Group I) and 76 cycles in a \"short protocol\" (Group II). Moreover measurements in the plasma and follicular fluid (FF) of E2, P, LH, Delta-4-androstenedione (A), Testosterone (T) and prolactin (PRL) were performed on the day of oocyte retrieval (DO) in 46 women of the group I (111 FF) and 27 of the group II (67 FF). In the group I, plasma LH always remains below 3 mUl/ml, whatever the type of agonist (Buserelin or DTRP6-LHRH) and the type of stimulation (HMG or FSH) are used. On the other hand in the group II, mean plasma LH and P levels from D-5 to D-2 and those of FF LH, T and A on DO are significantly higher than in the group I. These changes are associated with a significant decrease of retrieved oocytes (5.8 versus 7.8 p less than 0.0001), pregnancy rate (15% versus 30%, p less than 0.01) and ongoing pregnancy rate (10% versus 22%, per oocyte retrieval, p less than 0.01). They suggest that the pituitary desensitization could be unsatisfactory with the short protocol use of agonist." }, { "id": "pubmed23n0601_4240", "title": "LH as a diagnostic criterion for polycystic ovary syndrome in patients with WHO II oligo/amenorrhoea.", "score": 0.009009009009009009, "content": "Elevated LH is common in polycystic ovary syndrome (PCOS), but is not part of the diagnostic criteria. LH concentrations are usually assessed in the early 'follicular' phase when it is suppressed, and therefore the prevalence is underestimated. In this study, LH is measured during the 'specific oligomenorrhoeic phase', when LH is least suppressed, and its importance as a diagnostic tool for PCOS is evaluated. Patients presenting with oligo- or amenorrhoea between 2002 and 2006 were selected, with the exclusion of women with WHO III oligoamenorrhoea, hyperprolactinaemia or with wrongly timed endocrine measurements. A total of 252 patients were included (198 oligo/amenorrhoeic PCOS patients and 54 oligo/amenorrhoeic controls). Mean LH concentrations were higher in PCOS patients than in controls (11.0 versus 4.1 IU/l, P &lt; 0.001). The receiver operating characteristics (ROC) curve showed an optimal cut-off for LH of &gt; or =6.5 IU/l, resulting in a sensitivity of 84%, specificity of 78% and a likelihood ratio of 3.8, and elevated LH concentrations predicted PCOS accurately in 93%. In conclusion, elevated LH concentrations are found in a large majority of PCOS patients when measured at the appropriate time, and could be used as an additional diagnostic test to differentiate between oligo/amenorrhoeic PCOS patients and other causes of oligo- or anovulation." }, { "id": "wiki20220301en203_6253", "title": "Estrone sulfate", "score": 0.008928571428571428, "content": "Levels E1S levels have been characterized in humans. E1S using radioimmunoassay (RIA) have been reported to be 0.96 ± 0.11 ng/mL in men, 0.96 ± 0.17 ng/mL during the follicular phase in women, 1.74 ± 0.32 ng/mL during the luteal phase in women, 0.74 ± 0.11 ng/mL in women taking oral contraceptives, 0.13 ± 0.03 ng/mL in postmenopausal women, and 2.56 ± 0.47 ng/mL in postmenopausal women on menopausal hormone therapy. In addition, E1S levels in pregnant women were 19 ± 5 ng/mL in the first trimester, 66 ± 31 ng/mL in the second trimester, and 105 ± 22 ng/mL in the third trimester. E1S levels are about 10 to 15 times higher than those of estrone in women. References Further reading Estranes Estrogens Estrone esters Human metabolites Prodrugs Phenol esters Sulfate esters" }, { "id": "pubmed23n0122_15711", "title": "[Hypergonadotropic ovarian failure in three patients with pituitary hyperplasia].", "score": 0.008928571428571428, "content": "Three patients with ovulatory disturbances associated with increased production of gonadotropins and normal excretion of estrogen were endocrinologically examined. Patient A was 25 years old and had irregular menstruation of 13 years' duration. Patients B and C were 32 and 36 years old, the former with secondary amenorrhea of 19 years' duration and the latter with one of 2 months. Endocrinological analyses revealed a markedly increased plasma concentration of both LH (greater than 117 mIU/ml) and FSH (greater than 113 mIU/ml) in all three patients. The plasma concentration of estradiol was over 56 pg/ml in A and C before medication, and in the other patient (case B) the plasma estradiol level rose to 53 pg/ml after the administration of clomiphene. There was excessive LH and FSH response in the LH-RH stimulation test. Episodic gonadotropin secretions were observed and two weeks' administration of estrogen plasma concentrations of LH and FSH were suppressed. Computerized tomography revealed a high density area about 9-11 mm in diameter in the sella turcica of all three patients. Patient A underwent surgery via the transsphenoidal approach. Histology shows pituitary hyperplasia. After operation, the elevated LH and FSH concentration decreased to below 30 mIU/ml and the plasma concentration of estradiol and progesterone was increased to 260 pg/ml and 2 ng/ml, respectively." }, { "id": "pubmed23n0278_18097", "title": "[Analysis of cause and test treatment of amenorrhea in teenagers].", "score": 0.008849557522123894, "content": "The population of 49 young, secondary amenorrheic women aged 17 to 20 was divided according to reaction on i.m. injection of progesterone in oil. The positive category was subdivided into I--polycystic ovarian disease with elevated serum LH and II--hypothalamic-pituitary dysfunction (HPD) with normal (or decreased) level of LH. The negative category consists of subgroup, III--hypothalamic-pituitary failure (HPF) with normal or low serum FSH and IV--ovarian failure with elevated level of FSH (two patients were noted). The bleeding response was obtain in two third of the patients, and also two third of them ovulated after clomiphene citrate treatment, including all six women with POC. The ovulatory response in patients with hypothalamic pituitary failure was noted in more than 40%. The low concentration of serum FSH (below 5 mU/ml) was more frequent in HPF (57%) in comparison with HPD (48%). The resistance to clomiphene citrate treatment was correspondingly 62.5% and 70%. When the ovulation occurred no difference in the regular function of corpus luteum in POC, HPD and HPF patients was noted." }, { "id": "pubmed23n0026_3442", "title": "[Effect of the steroid sex hormones on the LH and FSH responses to LHRH in the normal subject].", "score": 0.008771929824561403, "content": "In man both basal gonadotrophin levels and the pituitary responses to LHRH remained relatively constant throughout life. In women the pituitary sensitivity varied in the menstrual cycle due to the typical cyclic variation of oestradiol and progesterone. The max delta LH increase to 100 mug LHRH was observed in the periovulatory period (183 +/- 41 mU/ml); it was also significantly higher in the luteal (49 +/- 7 mu/ml) than in the early follicular phase (18 +/- 3 mU/ml). The effect of exogenous sex steroid hormones taken as contraceptive drugs was then studied in 15 women. Significantly lower LH and FSH basal values as well as responses to LHRH were observed in 8 normal women under oral combined contraceptives. Conversely, in 7 women under oral sequential contraceptives, basal LH and FSH remained in the normal range. The LH-FSH responses were increased and delayed when these tests were performed during the period of estrogen treatment. Thus, with combined oral contraceptives, constant and high levels of estrogens and progesterone not only inhibit the LH peak, but also decrease the basal LH-FSH levels and responses to releasing hormone. Conversely, with sequential oral contraceptives, the low level of estradiol does not inhibit these responses and even enhances them. In menopausal women both basal and gonadotrophin responses to LHRH were increased indicating an important pituitary reserve. In menstruating women a significant estradiol increase is observed 2 and 4 hours after a 100 mug LHRH injection, both during the follicular and the luteal phases whereas progesterone increases only in the luteal phase. In men, testosterone was found to increase 4 hours after a 100 mug LHRH injection. These studies show that in normal subjects, sex steroid hormones are important regulators of the sensitivity of the pituitary responsiveness to releasing hormone." }, { "id": "pubmed23n0367_8089", "title": "Evolution of clinical symptoms in a young woman with a recurrent gonadotroph adenoma causing ovarian hyperstimulation.", "score": 0.008771929824561403, "content": "To demonstrate the clinical course in a young female with gonadotroph adenoma causing ovarian stimulation. Our patient was a 23-year-old woman with a history of oligomenorrhea who had previously undergone bilateral ovarian wedge resection owing to the clinical appearance of polycystic ovaries. Two years later, she sought treatment for headache, galactorrhea, history of spotting and lower abdominal distension. FSH, LH, beta-LH, inhibin A and B, estradiol, prolactin (PRL), and beta-chorionic gonadotrophin (beta-CG) were measured, and the responses of FSH, LH and beta-LH to thyrotrophin-releasing hormone (TRH) were documented. Immunohistochemical analysis of the tumor tissue was performed after surgery. Five years after the trans-sphenoidal surgery, the patient again became oligomenorrheic. A large recurrent adenoma was diagnosed on CT one year later. Transvaginal ultrasound showed ovaries of normal size with multiple small cystic formations simulating a polycystic pattern, While the patient was awaiting surgery, a pituitary apoplexy occurred. Emergency decompressive surgery was performed and the patient fully recovered. Enlarged ovaries were found on ultrasound examination simulating a hyperstimulation-like pattern. At that time, elevated levels of FSH (13.4IU/l) and marginally elevated levels of beta-LH (1.43ng/ml) were found, whereas the level of LH (0.5IU/l) was subnormal. Plasma estradiol was markedly supranormal (6150pmol/l). Levels of inhibin A and B were elevated (326pg/ml and 588pg/ml respectively). The prolactin level (70ng/ml) was increased, whereas beta-chorionic gonadotrophin (beta-CG) was normal. Significantly increased FSH, LH, and beta-LH responses to TRH stimulation were documented. Pituitary macroadenoma was found on MRI scan and removed by trans-sphenoidal surgery. Immunohistochemical examination showed high positivity for beta-CG and LH, and slight positivity for FSH. Five years after the surgery, estradiol was elevated (1160pmol/l), whereas basal levels of LH (4.65IU/l) and FSH (3.98IU/l) were not suppressed. After the second operation, immunostaining of the adenoma tissue confirmed the previous findings. Measurement of gonadotrophins in our case did not prove to be a method for identifying a large recurrent gonadotroph pituitary adenoma. The sonographic ovarian imaging varied from a polycystic- to an ovarian hyperstimulation-like pattern during the evolution of the tumour." }, { "id": "wiki20220301en558_21992", "title": "Pharmacokinetics of estradiol", "score": 0.008695652173913044, "content": "Different estradiol routes and dosages can achieve widely varying circulating estradiol levels (see the table below). For purposes of comparison with normal physiological circumstances, menstrual cycle circulating levels of estradiol in premenopausal women are 40 pg/mL in the early follicular phase, 250 pg/mL at the middle of the cycle, and 100 pg/mL during the mid-luteal phase. Mean integrated levels of circulating estradiol in premenopausal women across the whole menstrual cycle are in the range of 80 to 150 pg/mL, according to some sources. In postmenopausal women, circulating levels of estradiol are below 15 pg/mL. During normal human pregnancy, estrogen production increases progressively and extremely high estrogen levels are attained. Estradiol levels range from 1,000 to 40,000 pg/mL across pregnancy, are on average 25,000 pg/mL at term, and reach levels as high as 75,000 pg/mL in some women. Oral administration" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 251, 403 ] ], "word_ranges": [ [ 40, 63 ] ], "text": "Although GMN and renal amyloidosis are relatively frequent in RA, the anodyne urine sediment and the absence of proteinuria make these options unlikely." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 88 ] ], "word_ranges": [ [ 0, 15 ] ], "text": "Prerenal acute renal failure due to NSAIDs seems the most plausible option in this case." }, "4": { "exist": true, "char_ranges": [ [ 89, 250 ] ], "word_ranges": [ [ 15, 40 ] ], "text": "Tubulointerstitial nephritis due to methotrexate is less likely due to the absence of rash, fever or eosinophilia, which although rare in the MIR usually appear." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Renal amyloidosis.", "2": "Glomerulonephritis secondary to rheumatoid arthritis.", "3": "Renal failure due to non-steroidal anti-inflammatory drugs.", "4": "Interstitial nephritis due to methotrexate.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0038_1381", "title": "[Chronic interstitial nephritis caused by analgesics].", "score": 0.018978233495232956, "content": "Interstitial nephritis secondary to analgesic ingestion is apparently an uncommon subject in pediatric literature. Two cases are reported in this article: case 1 is a girl followed for the last fifteen years when she had lipoid nephrosis which was treated initially with corticosteroids; she responded satisfactorily, but presented frequent relapses. After 8 years, she was given cyclophosphamide plus prednisone and lately, she responded and has remained well. Further on, her urinalysis showed specific gravity of 1,033 and no proteinuria. Five years ago, because of protracted headache due to psychological disturbance, she started to ingest a variety of analgesics in progressively increasing doses. For the last 2 years, abdominal pains, paleness, polydipsia and polyuria have been observed; at present, her blood pressure, serum chemistry, and urine sediment are normal, but there is a marked failure in the renal concentration capacity, as well as marked sodium urinary losses. A percutaneous renal biopsy showed tubulo-interstitial fibrosis and edema with normal glomeruli. Case 2 is a girl with rheumatoid arthritis which appeared 3 years ago; for over one year, the patient was given 15 mg/day prednisone plus 1.5 g. acetylsalycilic acid. She was admitted to the hospital because her osteoarticular problem did not improve. Her blood pressure, blood chemistries and urinary sediment were also normal. LE tests were negative. Renal concentrating capacity was reduced and the renal biopsy showed tubular atrophy; there was intestinal edema and mononuclear infiltration. Chronic interstitial nephritis, secondary to analgesics is supported in both cases; polyuria and a marked defect of renal concentrating capacity are the earliest and most characteristic features. Normal urinary sediment is a common finding leading to erroneous assessment of a lack of renal involvement. Pathological lesions are located in the interstice of the renal medulla and sometimes in the papilla. Early arrest of analgesic ingestion may stop and even reverse the renal lesion and the renal insufficiency." }, { "id": "pubmed23n0480_11602", "title": "[Renal tubular dysfunction in patients with rheumatoid arthritis starting with low dose of methotrexate].", "score": 0.017973200673995025, "content": "The elevation of N-acetyl-beta-D-glucosaminidase (NAG) in urine has been shown to be associated with reversible renal tubular damage. The aim of the study was to examine the effect of first oral low dose methotrexate (MTX) on urinary excretion of NAG comparing with MTX concentration in serum and urine in a cohort of patients with rheumatoid arthritis (RA). Urinary NAG to urinary creatinine ratio (NAG index) determined in 43 patients (5 males, 38 females) with RA who started taking the first oral dose of 10 mg of MTX. Urinary NAG index was observed at 24 h and 48 h after the first MTX dose. MTX concentration was measured in blood at 90 minutes and in blood and urine at 24 h after the drug administration. NAG-enzymuria was increased in 72.1% of the patients before administration of MTX therapy (10.8 UI/g creatinine). There was no change in NAG index at 24 and 48 h after first dose of MTX (9.1 and 10.7 UI/g of creatinine). No differences of NAG-enzymuria in non-steroidal anti-inflammatory drug (NSAID)-treated patients and NSAID-free patients before and after MTX administration were revealed. The patients with decreased creatinine clearance had before treatment higher NAG index than those with normal creatinine clearance but there was not any significant increase of NAG activity after first dose of MTX in the patients with decreased creatinine clearance. Continued treatment with MTX resulted in a decrease in NAG activity accompanied by serum C-reactive protein concentration. The use of low dose MTX with or without NSAIDs does not influence the renal tubular function in patients with RA." }, { "id": "pubmed23n0421_17428", "title": "[Kidney involvement in rheumatoid arthritis].", "score": 0.017058652729384435, "content": "Rheumatoid Arthritis (RA) is a widespread disease and its renal involvement, relatively common, is clinically significant because worsens course and mortality of the primary disease. There is still no agreement on the prevalence of renal disorders in RA: data analysis originates from different sources, as death certificates, autopsies, clinical and laboratory findings and kidney biopsies, each with its limitations. Histoimmunological studies on bioptical specimens of patients with RA and kidney damage, led to clarify prevalent pathologies. In order of frequency: glomerulonephritis and amyloidosis (60-65% and 20-30% respectively), followed by acute or chronic interstitial nephritis. Kidney injury during RA includes secondary renal amyloidosis, nephrotoxic effects of antirheumatic drugs and nephropathies as extra-articular manifestations (rheumatoid nephropathy). Amyloidosis affects survival, increases morbidity and is the main cause of end stage renal disease in patients with RA and nephropathy. Strong association between RA activity and amyloidosis needs the use of immunosuppressive and combined therapies, to prevent this complication and reduce risk of dialysis. Long-lasting and combined RA pharmacotherapy involves various renal side effects. In this review we describe NSAIDs and DMARDs (Disease-Modifying Antirheumatic Drugs) nephrotoxicity, particularly by gold compounds, D-penicillamine, cyclosporine A and methotrexate. Rare cases of IgA glomerulonephritis during immunomodulating therapy with leflunomide and TNF blocking receptor (etanercept) are reported; real clinical significance of this drug-related nephropathy will be established by development of RA treatment. In RA nephropathies, mesangial glomerulonephritis is the most frequent histological lesion (35-60 % out of biopsies from patients with urinary abnormalities and/or kidney impairment), followed by minimal change glomerulopathy (3-14%) and p-ANCA positive necrotizing crescentic glomerulonephritis." }, { "id": "pubmed23n1002_12200", "title": "Spectrum of glomerulonephritis in Egyptian patients with rheumatoid arthritis: A University Hospital experience.", "score": 0.017042606516290727, "content": "Rheumatoid arthritis (RA) is accompanied by a variety of nephropathies. It is often difficult to distinguish between disease-associated and drug-associated renal diseases. Three hundred and seventy-six RA patients with renal involvement were included in our study; they were subjected to full history and clinical examination, kidney function, 24-h urinary protein, and kidney biopsy. All our patients were on methotrexate, low dose steroids, and nonsteroidal anti-inflammatory drugs, in addition to the previous medications. About 79.3%, 20.7%, 6.9%, and 5.9% of our patients were on leflunomide, hydroxychloroquine, etanercept, and infliximab, respectively. Renal presentation was in the form of nephrotic syndrome (33.5%), persistent subnephrotic proteinuria (12.2%), persistent proteinuria and recurrent hematuria (13.3%), acute nephritis (23.9), recurrent hematuria (7.4%), and creatinine &gt;1.5 mg/dL (10.6%). Renal biopsies were glomerular amyloidosis (28.1%), mesangioproliferative (19.1%), membranous (6.1%), crescent (16.8%), focal segmental glomerulosclerosis (18.6%), and minimal changes (11.7%). There was a statistically significant difference in the incidence of membranous nephritis between patients who took leflunomide, and hydroxychloroquine and those did not. Etanercept in our study seems not to be related to any form of renal involvement, while infliximab is related to focal segmental sclerosis and amyloidosis of tubulointerstitial type. Kidney involvement in RA is not a rare complication. Any type of histopathological changes can be present, with amyloidosis on top of the list. Hydroxychloroquine and leflunomide are accused in membranous nephropathy. Infliximab is associated with focal segmental sclerosis and amyloidosis of tubulointerstial type, and etanercept appear to be safe as regards kidney affection." }, { "id": "pubmed23n0620_23607", "title": "Proliferative glomerulonephritis with acute renal failure-a rare manifestation in seronegative rheumatoid arthritis.", "score": 0.016928571428571428, "content": "A 55 years old lady with advanced rheumatoid arthritis (RA) presented with severe acute renal failure with significant proteinuria preceded by fever for 14 days. She had no history of taking drugs usually responsible for glomerulonephritis, neither had she any clinico-biochemical evidence of peri-infectious glomerulonephritis. Acute interstitial nephritis (AIN) was excluded by absence of eosinophilia and eosinophils in urine. Renal biopsy reveled absence of amyloidosis and showed Focal segmental proliferative glomerulonephritis (FSGN). Patient was successfully managed with methyl-prednisolone followed by steroid and immunosuppressive and patient came over renal failure. So FSGN should be considered as one of the causes of acute renal failure in a patient with seronegative RA which may respond to immune-therapy like rapidly progressive glomerulonephritis." }, { "id": "pubmed23n0675_8680", "title": "[Renal involvement in patients with rheumatoid arthritis].", "score": 0.016771929824561403, "content": "In rheumatoid arthritis (RA) kidney is commonly affected organ with clinical presentation characterised by proteinuria (often nephrotic range) and microhematuria followed by chronic renal failure. This condition is well recognized as a rheumatoid nephropathy (rheumatoid glomerulonephritis), which is mediated by an immunological inflammation and by nephrotoxic effects of numerous drugs usually used in rheumatoid arthiritis treatment, such as NSAID, DMARD. In the patohistological examination various kinds of associated renal lesions could be seen. The most often are amyloidosis, glomerulonephritis, interstitial nephritis. In this study, we presented 15 patients, 10 women and 5 men, mean age of 60.2 with average rheumatoid arthritis duration of 19.4 years and signs of rheumatoid nephropathy. In all patients renal biopsy was performed with frequency of histopathological findings as follows: amyloidosis in 5 patients, IgA nephropathy in 3 patients, FSGS in 3 patients, mesangial proliferative glomerulonephritis in 3 patients, minimal change disease, pauci-immune glomerulonephritis and thin membrane disease in 1 patient. In all patients (except patient with thin membrane nephropathy) we started immunossuppresive therapy with glucocorticoids in combination with cyclophosphamide or cyclosporin or azatioprine. In conclusion, in all patients with rheumatoid arthritis, parameters of renal function should be monitored and in the case of patologic results, renal biopsy should be be performed. In the treatment of RA patients with related renal disorder, suspected causal drug should be removed from the treatment and specific immunosuppressive therapy initiated." }, { "id": "pubmed23n0056_2618", "title": "[Clinicopathological study of nephropathy in patients with rheumatoid arthritis].", "score": 0.0167013167013167, "content": "We carried out a retrospective study to investigate the clinical and pathological findings in 31 patients with rheumatoid arthritis (RA). In clinical findings, 17 patients showed nephrotic syndrome, five had isolated proteinuria, two had proteinuria and hematuria and seven had renal failure. In pathological findings, there were 16 patients with membranous nephropathy (MN), two with proliferative glomerulonephritis (DPGN), two with minor glomerular abnormality (MGA), six with amyloidosis, 2 with tubulointerstitial nephritis, and three patients had accompanying lupus nephritis. Eleven of 16 with MGN had been treated with gold, bucillamine or D-penicillamine, so they were diagnosed as drug induced MGN. In the other five patients, we could not decide which drugs induced the nephropathy. The 2 cases of MGA were associated with nephrotic syndrome and acute renal failure, which were caused by non-steroidal antiinflammatory drugs. There were two cases of non-Ig A DPGN, which was regarded as the native nephropathy in RA. The three cases with lupus nephritis were diagnosed as systemic lupus erythematosus by the criteria of the American Rheumatism Association (ARA). In conclusion, the nephropathy in patients with RA was varied and renal biopsy was a useful examination." }, { "id": "pubmed23n0377_7290", "title": "Severe reversible renal failure due to naproxen-associated acute interstitial nephritis.", "score": 0.01654003899683991, "content": "Acute interstitial nephritis is uncommon in children and has very rarely been described with naproxen treatment. We report the occurrence of severe acute renal failure in a 10-year-old girl with juvenile rheumatoid arthritis after 1 month of naproxen therapy. Renal biopsy showed severe acute interstitial nephritis. The patient recovered completely after discontinuation of naproxen and administration of methylprednisolone. A review of the literature regarding non-steroidal anti-inflammatory drug-associated acute interstitial nephritis is provided. In an era of increasing popularity of non-steroidal anti-inflammatory drugs for use in children, paediatricians should be aware of the potential renal complications of this class of drugs." }, { "id": "pubmed23n0780_11864", "title": "Renal involvement in rheumatoid arthritis: analysis of renal biopsy specimens from 100 patients.", "score": 0.01578785075547333, "content": "Abstract  We analyzed renal biopsy specimens from 100 patients to evaluate the characteristics of renal involvement in patients with rheumatoid arthritis (RA). Membranous nephropathy (MN) was the most common renal histological pattern (31%). Mesangial proliferative glomerulonephritis (GN) was found in 21% of cases (IgA nephropathy 12%, non-IgA GN 9%), minor changes in 17%, renal amyloidosis in 11%, interstitial nephritis in 9%, sclerotic GN in 4%, and crescentic GN in 2%. MN was relatively more frequent in men than in women, and most developed nephrotic syndrome, while a few developed renal failure. Disease-modifying antirheumatic drugs (DMARDs) correlated with MN in 26 of 31 cases. Mesangial proliferative GN showed high-grade hematuria. Amyloidosis correlated with long duration of RA; approximately half of the cases with amyloidosis also had nephrotic syndrome, and 82% developed renal failure. Of the 100 patients, 82% showed some tubulo-interstitial changes, which might be related to non-steroidal anti-inflammatory drugs. Because renal lesions in RA are very diverse, and early stage cases of MN and amyloidosis can be detected only by histological examinations, renal biopsy should be performed in cases with continuous urinary abnormalities or progressive renal failure. " }, { "id": "pubmed23n0334_8720", "title": "Remission of the nephrotic syndrome in a patient with renal amyloidosis due to rheumatoid arthritis treated with prednisolone and methotrexate.", "score": 0.015753259295026557, "content": "A 46-year-old woman developed nephrotic syndrome secondary to rheumatoid arthritis (RA). A renal biopsy showed deposition of amyloid fibrils in the subendothelial space of the glomerular capillary walls. After treatment with prednisolone (PSL, 40 mg/day), the levels of C-reactive protein (CRP) and serum amyloid A decreased to within normal limits for 2 weeks. However, the nephrotic syndrome persisted for 6 months after the therapy. To maintain the suppression of disease activity and to reduce PSL, methotrexate (5 mg/week) was added. The nephrotic syndrome resolved gradually, and the level of serum albumin returned to normal. Although renal prognosis of patients with nephrotic syndrome due to amyloidosis caused by RA has been considered poor, adequate and long-term treatment of RA with antiinflammatory drugs, including PSL and methotrexate, is useful for patients with secondary amyloidosis complicated by RA." }, { "id": "pubmed23n0500_710", "title": "Renal function in rheumatoid arthritis patients treated with methotrexate and infliximab.", "score": 0.014552152889707575, "content": "This study was aimed at monitoring the early and late effects of infliximab on renal proximal function in RA patients treated with methotrexate. N-acetyl-3-D-glucosaminidase (NAG) activity in urine served as an indicator of proximal tubular damage NAG activity was estimated in 21 patients during the course of treatment with infliximab and methotrexate. In every patient NAG-enzymuria was estimated directly before and 60 min after infliximab infusions and 62 weeks after starting the therapy. The total of mean NAG activities observed before each infusion of infliximab was significantly lower (p &lt; 0.02) than NAG-enzymuria before the start of infliximab treatment (7.4 UI/g vs 11.8 UI/g). The proportion of patients in whom NAG activity rose by more than 50% during treatment ranged from 5.3% to 25%. Administration of infliximab did not significantly change the mean serum creatinine levels or creatinine clearance. No significant differences were observed in the mean values of NAG values before and 60 min after infliximab infusion. Patients who demonstrated elevated NAG activities during the course of the whole treatment demonstrated significantly more pronounced NAG enzymuria before treatment and one hour after the first infusion (p &lt; 0.0005), as well as higher RA activity (p &lt; 0.05). There was no observed influence of NSAIDs or prednisone on the frequency of elevated NAG activities. Raised creatinine concentrations (&gt; 1.3 mg/dL) were noted before and during the course of infliximab treatment in 3 patients. In 16 patients abdominal fat aspiration biopsy was performed and in 3 the presence of amyloid deposits was demonstrated. In these patients NAG activity exceeded twice the upper normal limit. The introduction of infliximab during methotrexate therapy demonstrated no early or delayed nephrotoxicity of the drug in patients with rheumatoid arthritis." }, { "id": "pubmed23n0888_17503", "title": "A Case Report Describing a Rare Presentation of Simultaneous Occurrence of MPO-ANCA-Associated Vasculitis and Rheumatoid Arthritis.", "score": 0.014288529759558534, "content": "<iBackground</i. Renal-limited myeloperoxidase vasculitis with simultaneous rheumatoid arthritis is reported as a rare occurrence. Review of literature suggests that most patients had a diagnosis of rheumatoid arthritis for several years prior to presenting with renal failure from myeloperoxidase vasculitis. <iCase Presentation</i. A 58-year-old Caucasian male presented to the hospital experiencing malaise, fevers, decreased oral intake, nausea, and vomiting for one week duration. His past medical history consisted of newly diagnosed but untreated rheumatoid arthritis, hypertension, and non-insulin-dependent diabetes mellitus. He was found to have acute renal failure, proteinuria, and hypoglycemia. Standard therapy, including intravenous fluids, did not improve his acute renal failure. A vasculitis workup resulted in a positive myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA). Renal biopsy revealed crescentic glomerulonephritis (GN) pauci-immune type, suggestive of MPO-ANCA-associated vasculitis (MPO-AAV). Treatment consisted of prednisone, cyclophosphamide, and seven cycles of plasmapheresis, in addition to hemodialysis for uremia. Upon discharge, he received hemodialysis for another week and continued treatment with cyclophosphamide and prednisone. <iConclusion</i. Patients with longstanding rheumatoid arthritis may develop renal failure due to nonsteroidal anti-inflammatory medication use and AA type amyloidosis; however, necrotizing glomerulonephritis with crescent formation has been rarely reported. This stresses the importance of early recognition and swift initiation of treatment." }, { "id": "pubmed23n0305_22233", "title": "[Focal segmental glomerulosclerosis presenting nephrotic syndrome and acute renal failure in a patient with rheumatoid arthritis].", "score": 0.014245444478002618, "content": "A 45-year-old woman with rheumatoid arthritis(RA) who developed nephrotic syndrome and acute renal failure was reported. She first noticed polyarthritis in June 1990, and was diagnosed as RA. Since her RA was not controlled with nonsteroidal anti-inflammatory drugs (NSAID), she started taking prednisolone 10 mg daily and received 100 mg of D-penicillamine from October 1990 with improvement of the RA. In March 1991, she noticed edema of the face and legs, at which time massive proteinuria and hematuria were first noted. Because of her nephrosis, she was referred to our hospital for further evaluation. Laboratory investigations revealed 24-hour urine proteinuria of 37 g, serum creatinine, 2.7 mg/dl, blood urea nitrogen, 43.5 mg/dl, total protein, 4.1 g/dl, albumin, 1.5 mg/dl, and total cholesterol, 600 mg/dl. The rheumatoid factor and anti-nuclear antibody were positive. Renal biopsy showed focal segmental glomerulosclerosis (FSGS). Her nephrotic syndrome and renal dysfunction recovered after the administration of prednisolone at 60 mg/day. The possible pathogenesis of FSGS in patients with RA was discussed." }, { "id": "pubmed23n0372_19243", "title": "A prospective study of renal disease in patients with early rheumatoid arthritis.", "score": 0.013989953523308764, "content": "This prospective study was designed to clarify the frequency, causes, and clinical course of renal disease in patients with early rheumatoid arthritis (RA). 235 patients (185 women, mean age 49.4 years) with early RA of less than one year's duration were enrolled and assessed monthly. Proteinuria was defined as a positive dipstick result and microscopic haematuria was defined as the presence of &gt; or =5 red blood cells per high power field. Urinary abnormalities lasting three months or longer were defined as persistent abnormalities. At entry, 40 patients exhibited haematuria, two had a raised serum creatinine concentration, and none had proteinuria. During the observation period (average 42 months), persistent haematuria was found in 43, persistent proteinuria in 17, and a raised serum creatinine concentration in 14 patients. Persistent proteinuria was caused by drugs in 14 of 17 patients and disappeared in most cases. Risk factors for drug induced proteinuria included a raised C reactive protein and erythrocyte sedimentation rate and age over 50 at entry. Drugs resulted in a raised serum creatinine concentration in eight of 14 patients. The incidence of haematuria at entry did not differ among patients who had been treated with non-steroidal anti-inflammatory drugs, disease modifying antirheumatic drugs, or no drugs. In some patients with isolated haematuria, the haematuria appeared when the activity of RA was high and resolved when it was low. This study suggests that a raised serum creatinine concentration or persistent proteinuria in patients with early RA is predominantly drug related whereas, in contrast, isolated haematuria is more directly associated with the activity of the disease process." }, { "id": "pubmed23n0381_14266", "title": "[Clinico-immunological aspects of renal lesions in rheumatoid arthritis].", "score": 0.013678065054211843, "content": "The aim of this study was to examine the incidence of different renal lesions in rheumatoid arthritis (RA) and to determine their relationships with the type of previous drug therapy and with the specific features of immune disorders. Ninety four patients, 84 (89.9%) females and 10 (10.6%) males) with RA whose mean age was 45.2 +/- 11.9 years and duration of the disease 7.5 +/- 6.5 years were examined. Most of them had degrees 2 and 3 PA (62.7 and 24.4%, respectively). Systemic manifestations were encountered in 60 (63.8%) patients. Eighty one patients took nonsteroidal antiinflammatory drugs (NSAID) continuously: 18 patients for a year, 32 for 5 years, 14 for 6 to 10 years, and 17 for over 10 years. All the patients underwent clinical, laboratory, and instrumental study of partial functions of the kidney. Immunological study involved solid-phase immunoassay of IgA and IgM rheumatoid factor, von Willebrand factor antigens (WF:Ag), C-reactive protein. The serum concentrations were measured by the Mancini method. Changes in urinalysis and/or signs of decreased glomerular and tubular functions were found in 69 (73.%) patients, 25 (26.6%) had arterial hypertension. Tubular dysfunctions were more common [31 (32.9%) patients]. Signs of early renal failure were detected in 20 (21.2%) patients. There were no cases of acute renal failure. Amyloidosis, glomerulonephritis, pyelonephritis were diagnosed in 5 (5.3%), 16 (17%), and 13 (13.8%) patients, respectively. The above renal lesions were concurrent in some patients. Renal lesion correlated with the progression and severity of RA, the presence of systemic manifestations, and age. There was no relationship of both 5- and 10-year use of NSAID to the symptoms of renal disease. The use of these drugs for over 10 years was concurrent with the signs of chronic renal failure and arterial hypertension. Analyzing immunological disorders showed an association of increased erythrocytic sedimentation rates and WF:Ag with amyloidosis, that of higher IgA concentrations with proteinuria and tubular dysfunctions. It is concluded that renal lesion is common in RA, there is a predominance of tubular interstitial changes. In rare cases nephropathy is characterized by a benign course and fails to result in uremia. The symptoms of renal diseases are largely associated with RA progression and severity and the patients' age. Prolonged continuous use of NSAID may contribute to the development of renal failure. Different immune mechanisms are involved in the pathogenesis of glomerular and tubular nephropathy in RA." }, { "id": "pubmed23n0254_18091", "title": "[Methotrexate treatment of amyloidosis secondary to rheumatoid arthritis].", "score": 0.01340542472854015, "content": "Amyloidosis secondary to rheumatoid arthritis is a complication with a poor prognosis and as yet an undefined medical therapy. In the last decades the use of different cytostatics has been advocated to avoid renal function deterioration. The clinical characteristics and course in eight patients with amyloidosis secondary to rheumatoid arthritis are here reported after therapy with low dosage methotrexate. In twelve patients who followed a 12-month therapy a clinical improvement was observed, with a marked decrease in proteinuria; in one of them proteinuria disappeared. These results suggest that methotrexate at low doses might be an alternative in the early treatment of amyloidosis secondary to rheumatoid arthritis in patients with preserved renal function." }, { "id": "pubmed23n0770_6883", "title": "Idiopathic membranous nephropathy preceding the onset of rheumatoid arthritis: a case report.", "score": 0.013369963369963371, "content": "Membranous nephropathy (MN) in the context of rheumatoid arthritis (RA), is often an iatrogenic complication due to the nephrotoxic effects of antirheumatic drugs. Rare cases of non-iatrogenic association between these two diseases were reported in the literature. A 30-year-old female patient presented in September 2005 with nephrotic syndrome. Renal biopsy showed features consistent with MN. Search for etiology was negative, particularly lupus serology which remained negative throughout the course of her illness. Accordingly, she was diagnosed as a case of idiopathic MN. Initially, she was treated with angiotensin converting enzyme inhibitors and angiotensin receptor blockers which maintained her protein excretion below nephrotic range for two years. Her nephrotic syndrome then relapsed and was treated with steroids and chlorambucil, according to the Ponticelli protocol. A few months later, she presented with early morning joint stiffness, polyarthritis involving the small joints of the hands, and strongly positive rheumatoid factor, fulfilling the diagnostic criteria of rheumatoid arthritis (RA). Her serum creatinine remained normal and a second renal biopsy revealed the same features of MN. Her RA was treated with pulsed methylprednisolone followed by oral steroids and methotrexate resulting in remission of the joints disease and the nephrotic syndrome. Remission was maintained for the last two years up to the time of this report. We hereby report a case of secondary membranous nephropathy that preceded the onset of rheumatoid arthritis by three years." }, { "id": "pubmed23n0906_12677", "title": "Acute interstitial nephritis with membranous nephropathy in bucillamine-treated rheumatoid arthritis.", "score": 0.013208369659982563, "content": "In bucillamine-treated patients, persistent proteinuria caused by membranous nephropathy (MN) is a major adverse effect affecting the kidneys. We experienced a case of acute interstitial nephritis (AIN) with MN caused by bucillamine. An 81-year-old Japanese woman with a past medical history of rheumatoid arthritis and hypertension presented with a fever, epigastric pain, and nausea of 1 week's duration. She had commenced bucillamine 4 months earlier. At the time of admission, her baseline creatinine (0.8 mg/dl) had risen to 6.8 mg/dl. A renal biopsy revealed AIN with concomitant MN. Renal function gradually improved after bucillamine administration was stopped. In addition to MN, bucillamine can cause AIN, which requires a renal biopsy for definitive diagnosis. Given the host of pathological findings that tend to develop in patients using bucillamine, patients receiving the drug who present with symptoms of acute kidney injury should undergo a renal biopsy to determine the presence of AIN." }, { "id": "pubmed23n0545_2382", "title": "Effect of indomethacin and selective cyclooxygenase-2 inhibitors on proteinuria and renal function in patients with AA type renal amyloidosis.", "score": 0.012922589520196755, "content": "Because the cardiovascular system (CVS) side-effects of cyclooxygenase-2 (COX-2) selective inhibitors have recently been questioned, we aimed to compare the renal and haemodynamic effects of cyclooxygenase selective (celecoxib and rofecoxib) and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) (indomethacin) in patients with renal amyloidosis secondary to rheumatological diseases who required anti-inflammatory agents and are taking maximum tolerable dose of angiotensin-converting enzyme inhibitors. The present study was performed on 11 patients with stable proteinuria who were diagnosed as AA amyloidosis secondary to rheumatological diseases confirmed by renal biopsies. The study had three consecutive stages (celecoxib 200 mg/day; indomethacin 100 mg/day; rofecoxib 25 mg/day.) Each was given for 4 weeks and a wash-out phase of 3 weeks was allowed between consecutive stages. Although the decrease of proteinuria in the celecoxib period was higher than in the rofecoxib and indomethacin periods, the difference was not statistically significant. No statistically significant differences were found between serum urea, creatinine, creatinine clearance and urinary sodium excretion. In this study, no differences were found between indomethacin and the two selective COX-2 inhibitors in respect to proteinuria and renal functions in 11 patients with renal amyloidosis secondary to rheumatological diseases with varying degrees of proteinuria. Routine doses of NSAIDs brought no additional benefit to the ACE inhibitor use in terms of proteinuria and renal functions. The use of selective COX-2 inhibitors should be limited to their anti-inflammatory and analgesic effects in this population." }, { "id": "pubmed23n0346_5589", "title": "[Rheumatoid arthritis and the kidney. Pinpointing an aspect of confusing contours].", "score": 0.012905374464010657, "content": "In literature there are only a few papers about renal involvement in rheumatoid arthritis. The scarcity of reports is due to the difficulties of pinpointing this subject; in fact a bloody investigation like kidney biopsy is necessary to obtain an exact diagnosis. Moreover it is often clinically hard to distinguish renal injury provoked by rheumatoid arthritis from nephropathy caused by drugs, either non steroidal antiinflammatory drugs or disease modifying antirheumatic drugs. This topic is perhaps neglected because primary renal involvement in rheumatoid arthritis is not considered to influence the survival, with the exception of renal amyloidosis. Pathologic examination of kidney biopsy shows in order of frequency: mesangial nephritis, renal amyloidosis, membranous nephritis, focal proliferative nephritis, minimal nephritis, interstitial nephritis. Both immune complexes and antineutrophil cytoplasmic antibodies may play a pathogenetic role. The mesangial nephritis with IgA or IgM deposits is linked to high levels of rheumatoid factor of IgA or IgM class; it has been hypothesized that the ability of mesangium to remove circulating immune complexes provokes the mesangial damage. Moreover it has been observed that rheumatoid arthritis with renal involvement shows positivity for perinuclear antineutrophil cytoplasmic antibodies more frequently than rheumatoid arthritis without nephropathy. Also in the former cases the title of these autoantibodies is higher. The aim of this paper is to bring the terms of the problem into focus by the revision of the literature. Further and wider studies are necessary to obtain more available data." }, { "id": "pubmed23n0328_12106", "title": "[A case of malignant rheumatoid arthritis complicated by secondary amyloidosis and membranous nephropathy].", "score": 0.012594367015098723, "content": "A 30-year-old man had been treated for malignant rheumatoid arthritis from 1989 with a non-steroidal anti-inflammatory drug, then bucillamine for six months and prednisolone. Mild proteinuria appeared in May 1994, 4 years after bucillamine therapy was conducted. The patient was admitted to our hospital for a renal biopsy in July 1994. The specimen revealed secondary amyloidosis and membranous nephropathy (MGN). These findings suggest that MGN unrelated to bucillamine therapy might have occurred with secondary amyloidosis in rheumatoid arthritis." }, { "id": "pubmed23n1112_22579", "title": "Use of biologic agents and methotrexate improves renal manifestation and outcome in patients with rheumatoid arthritis: a retrospective analysis.", "score": 0.012514529252227818, "content": "We examined whether advances in treatment strategies from older disease-modifying antirheumatic drugs (DMARDs) to new biologic agents and methotrexate improved renal complications and outcome in patients with rheumatoid arthritis (RA). We reviewed records of 156 patients with RA who underwent kidney biopsy at our institute between January 1990 and December 2019. All patients were assigned to one of three periods: period 1, 1990-1999 (n = 48); period 2, 2000-2009(n = 57); period 3, 2010-2019 (n = 51). Membranous nephropathy, nephrosclerosis, AA-amyloidosis, and IgA nephropathy were the four major renal manifestations of RA. AA-amyloidosis was diagnosed by kidney biopsy in 21 patients: period 1, 7 patients (15%); period 2, 10 patients (18%); and period 3, 4 patients (8%). The 4 patients in period 3 were in the years 2010-2014, and no new case of AA-amyloidosis was recorded from 2015 to 2019. In all 21 of the patients with AA-amyloidosis, neither a biologic agent nor methotrexate was administered. Fifteen of the 21 patients required dialysis, and 13 died in periods 1-3 because of amyloid-related cardiac dysfunction less than 2 years after the initiation of dialysis. Two of them are doing well using biologic agent despite dialysis. The remaining three patients who received a biologic agent or methotrexate does not progress to end-stage renal failure. In addition, the other renal complications showing progression to dialysis also decreased over time. Advances in treatment strategies have improved renal outcome and reduced mortality in patients with RA." }, { "id": "pubmed23n0977_10678", "title": "[Biologics-Induced Kidney Injury -with Special Attention to Anti-Rheumatic Drugs -].", "score": 0.012406675450153712, "content": "A variety of anti-rheumatic drugs including biologics are currently used to treat rheumatoid arthritis (RA). These drugs, as well as RA itself, can cause kidney injury. RA may trigger mesangial proliferative glomeru- lonephritis (MesPGN), membranous nephropathy (N), thin basement membrane disease, and renal amyloi- dosis. As for anti-rheumatic drugs, non-steroidal anti-inflammatory drugs (NSAID) increase serum Cr lev- els due to a reduction of glomerular circulation, particularly in the presence of dehydration. Among disease- modifying anti-rheumatic drugs (DMARD), methotrexate as an anchor drug for RA rarely causes tubular ob- struction as a result of its crystallization, and bucillamine occasionally elicits IN. Calcineurin inhibitors induce vasoconstriction of the afferent arteries. Recently developed anti-rheumatic drugs, biologics, include biological inhibitors of TNF-a, IL6, and CD80/26. These can generally induce the remission of RA, while they have been reported to albeit uncom- monly trigger autoimmune renal disorders (AIRD). A recent meta-analysis identified a total of 29 cases with biologics-induced AIRD, 62% of who manifested AIRD within 12 months after treatment with biologics. AIRD cases were classified into 3 different groups: isolated autoimmune renal disorders (IARD, n =13), glo- merulonephritis with systemic vasculitis (GNSV, n= 12), and glomerulonephritis with lupus-like syndrome (GNLS, n=4). The IARD cases had 4 MesPGN, 4 MN, and 2 crescentic GN, while the GNSV cases had 8 crescentic GN and 3 purpura GN, and the GNLS cases had all MesPGN. To detect these renal disorders early in RA patients, urinalysis and serum Cr measurement should be peri- odically performed. New urinary biomarkers (L-FABP and Ngal) may be more sensitive for kidney injury. Notably, in RA patients receiving biologics, ANA, anti-dsDNA, and ANCA should also be tested at the base- line and regular intervals. [Review]." }, { "id": "wiki20220301en000_105195", "title": "Chemotherapy", "score": 0.012070187495973024, "content": "Some chemotherapy drugs are used in diseases other than cancer, such as in autoimmune disorders, and noncancerous plasma cell dyscrasia. In some cases they are often used at lower doses, which means that the side effects are minimized, while in other cases doses similar to ones used to treat cancer are used. Methotrexate is used in the treatment of rheumatoid arthritis (RA), psoriasis, ankylosing spondylitis and multiple sclerosis. The anti-inflammatory response seen in RA is thought to be due to increases in adenosine, which causes immunosuppression; effects on immuno-regulatory cyclooxygenase-2 enzyme pathways; reduction in pro-inflammatory cytokines; and anti-proliferative properties. Although methotrexate is used to treat both multiple sclerosis and ankylosing spondylitis, its efficacy in these diseases is still uncertain. Cyclophosphamide is sometimes used to treat lupus nephritis, a common symptom of systemic lupus erythematosus. Dexamethasone along with either bortezomib or" }, { "id": "pubmed23n0968_3383", "title": "Should a patient with rheumatoid arthritis be a kidney donor?", "score": 0.01130717288826602, "content": "We cared for a woman with sero-positive rheumatoid arthritis (RA), in clinical remission on oral methotrexate (MTX) and hydroxychloroquine, who wished to donate a kidney to a brother with end-stage renal disease (ESRD). We could find scant literature about this unusual clinical circumstance, and therefore review pertinent aspects of renal disease in RA, perioperative medical management, maintenance of disease remission, outcomes for RA patients who have donated kidneys, and relevant ethical issues. Renal complications in RA are not uncommon, with as many as 50% of patients at risk of reduced eGFR. This reflects anti-rheumatic and analgetic medication use (non-steroidal anti-inflammatory drugs, acetaminophen, DMARDs [cyclosporine and, historically, D-penicillamine and gold compounds], and others), glomerulitis, interstitial nephritis, complicating Sjogren's syndrome, vasculitis, or amyloidosis, and/or emergence of an \"overlap\" syndrome or other rheumatic disorder. The literature suggests that MTX need not be interrupted for surgery. The risk of perioperative infection to our patient would be low and remission should be sustained. We are aware of one study of six patients with RA who donated kidneys; they experienced no complications, ESRD, or deaths after a median follow-up of 8.2 years. Our ethical responsibilities are to balance patient autonomy of decision-making while assuring clinical beneficence and minimizing potential maleficence. Our perspective was that it would not be unreasonable to support this patient donating a kidney if, when fully informed, that remained her wish." }, { "id": "pubmed23n0253_865", "title": "Juvenile rheumatoid arthritis and renal amyloidosis (case report).", "score": 0.01089845826687932, "content": "Clinical renal abnormalities, including haematuria, proteinuria, abnormal urinary sediment, decreased renal functions and hypertension are relatively common in children with juvenile rheumatoid arthritis (JRA). These findings may be due to renal amyloidosis or administration of drugs that are potentially nephrotoxic. The case of an 11 years old boy diagnosed as JRA at 4.5 months of age and treated with steroids for 10 years is presented. In his history he had hypertension for 5 years and cataract for one year. Renal biopsy was done to evaluate the aetiology for proteinuria, which was overlooked before his admission to our Department. Secondary renal amyloidosis due to JRA was found at biopsy. The importance of investigation for amyloidosis during the long-term follow-up of JRA is reemphasized." }, { "id": "pubmed23n0126_17047", "title": "Necrotizing glomerulonephritis in rheumatoid arthritis.", "score": 0.010649087221095335, "content": "Rheumatoid arthritis may be associated with several glomerular lesions including amyloidosis, mesangial proliferation and membranous glomerulonephritis. Systemic vasculitis is a well-recognized extra-articular complication of rheumatoid arthritis, but necrotizing glomerulonephritis, the glomerular expression of vasculitis, has been described infrequently. This report comprises four patients with rheumatoid arthritis who underwent renal biopsy for declining renal function, proteinuria and active urine sediments. Pathology revealed that three patients had segmental necrotizing glomerulonephritis without significant glomerular immunoglobulin deposition. The fourth had segmental necrosis associated with diffuse membranous glomerulonephritis. We conclude that necrotizing glomerulonephritis is part of the spectrum of glomerular lesions seen in patients with rheumatoid arthritis. Because of therapeutic considerations involving the use of cyclophosphamide, necrotizing glomerulonephritis should be a diagnostic consideration in the rheumatoid arthritis patient with signs of glomerulonephritis and rapidly deteriorating renal function." }, { "id": "pubmed23n0305_22232", "title": "[A case of necrotizing crescentic glomerulonephritis with arteritis due to secondary amyloidosis following rheumatoid arthritis].", "score": 0.010455910455910458, "content": "A 47-year-old woman was admitted on August 4th, 1995, because of edema of the lower extremities. She had been suffering from RA for about 20 years and underwent total knee-replacements 5 years previously. On admission, nephrotic syndrome and rapidly progressive glomerulonephritis had developed in association with ileus, melena, diarrhea, dyspnea and hemoptysis. She showed a high titer of serum rheumatoid factor (357.0 IU/ml) and amyloid A protein (83.9 micrograms/ml) with positive antinuclear antibodies (homogeneous and speckled patterns). However, anti-neutrophil cytoplasmic autoantibody (ELISA), immune complexes and anti-glomerular basement membrane antibody (ELISA) were negative. Renal biopsy showed microscopic PN overlapping A-type positive amyloidosis. Although the maintenance of hemodialysis was necessary, aggressive immunosuppressive therapy with steroid pulse therapy and frequent plasma exchange provided a rapid improvement of systemic symptoms possibly due to vasculitis. We suggested that in this case, massive necrotizing crescentic glomerulonephritis with systemic arteritis developed on the basis of secondary amyloidosis due to rheumatoid arthritis. In such a case, even if various serum autoantibodies and immune complexes were negative, plasma exchange was suggested to be effective to remove not only pathogenic autoantibodies but also various serum inflammatory cytokines which may be related with severe vasculitis and glomerulitis, in addition to aggressive steroid therapy which may suppress the invasion of inflammatory cells producing these cytokines." }, { "id": "wiki20220301en105_45247", "title": "Mixed connective tissue disease", "score": 0.00980392156862745, "content": "For arthritis, non-steroidal anti-inflammatories or low dose prednisone are usually used, which can be used in association with methotrexate or hydroxychloroquine. Temporomandibular joint arthritis has been shown to be successfully treated with condylar reconstruction using chondral grafts. Higher doses of corticosteroids (0.25 to 1 mg/kg/day) are used in complications such as myositis, meningitis, pleuritis, pericarditis, myocarditis, interstitial lung disease, or hematologic abnormalities. On the contrary, Raynaud’s phenomenon, acrosclerosis or peripheral neuropathies are usually resistant to corticosteroids. Cyclophosphamide are useful in interstitial lung disease and in the eventual serious renal involvement. In cases of myositis or thrombocytopenias resistant to corticosteroids, intravenous immunoglobulins may be useful. For Raynaud, general measures (such as tobacco cessation, protection against the cold), calcium antagonists, endovenous prostaglandins or endothelin-2" }, { "id": "pubmed23n0913_15886", "title": "Crescentic glomerular nephritis associated with rheumatoid arthritis: a case report.", "score": 0.009708737864077669, "content": "Rheumatoid arthritis is a systemic disorder where clinically significant renal involvement is relatively common. However, crescentic glomerular nephritis is a rarely described entity among the rheumatoid nephropathies. We report a case of a patient with rheumatoid arthritis presenting with antineutrophil cytoplasmic antibody-negative crescentic glomerular nephritis. A 54-year-old Sri Lankan woman who had recently been diagnosed with rheumatoid arthritis was being treated with methotrexate 10 mg weekly and infrequent nonsteroidal anti-inflammatory drugs. She presented to our hospital with worsening generalized body swelling and oliguria of 1 month's duration. Her physical examination revealed that she had bilateral pitting leg edema and periorbital edema. She was not pale or icteric. She had evidence of mild synovitis of the small joints of the hand bilaterally with no deformities. No evidence of systemic vasculitis was seen. Her blood pressure was 170/100 mmHg, and her jugular venous pressure was elevated to 7 cm with an undisplaced cardiac apex. Her urine full report revealed 2+ proteinuria with active sediment (dysmorphic red blood cells [17%] and granular casts). Her 24-hour urinary protein excretion was 2 g. Her serum creatinine level was 388 μmol/L. Abdominal ultrasound revealed normal-sized kidneys with acute parenchymal changes and mild ascites. Her renal biopsy showed renal parenchyma containing 20 glomeruli showing diffuse proliferative glomerular nephritis, with 14 of 20 glomeruli showing cellular crescents, and the result of Congo red staining was negative. Her rheumatoid factor was positive with a high titer (120 IU/ml), but results for antinuclear antibody, double-stranded deoxyribonucleic acid, and antineutrophil cytoplasmic antibody (perinuclear and cytoplasmic) were negative. Antistreptolysin O titer &lt;200 U/ml and cryoglobulins were not detected. The results of her hepatitis serology, retroviral screening, and malignancy screening were negative. Her erythrocyte sedimentation rate was 110 mm in the first hour, and her C-reactive protein level was 45 mg/dl. Her liver profile showed hypoalbuminemia of 28 g/dl. She was treated with immunomodulators and had a good recovery of her renal function. This case illustrates a rare presentation of antineutrophil cytoplasmic antibody-negative crescentic glomerular nephritis in a patient with rheumatoid arthritis, awareness of which would facilitate early appropriate investigations and treatment." }, { "id": "pubmed23n0663_16006", "title": "Rheumatoid arthritis and renal light-chain deposition disease: long-term effectiveness of TNF-α blockade with etanercept.", "score": 0.009701818516219509, "content": "A 68-year-old woman diagnosed with erosive rheumatoid arthritis (RA) was treated with intramuscular methotrexate 15 mg weekly and oral prednisone 5 mg daily. A favorable outcome of 6 years was followed by RA flare and nephrotic syndrome (NS). Renal biopsy revealed non-amyloid light-chain deposition disease. Laboratory analysis and bone marrow biopsy excluded monoclonal protein and plasma cell dyscrasia. Addition of subcutaneous etanercept, 25 mg twice weekly allowed rapid control of both arthritis and NS. To date, after over 7-year follow-up, RA is in clinical remission, 24-h albuminuria is consistently below 0.5 g, and serum creatinine is 0.9 mg/dl." }, { "id": "wiki20220301en238_25717", "title": "Pulmonary-renal syndrome", "score": 0.009615384615384616, "content": "Other causes include systemic lupus erythematosus, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, dermatomyositis, polymyositis, mixed connective tissue disease, poststreptococcal glomerulonephritis, rheumatoid arthritis, and systemic sclerosis. Less common causes also include IgA vasculitis and cryoglobulinemic vasculitis. Other etiologies include toxic injury such as paraquat poisoning, infection with hantavirus, leptospirosis, or legionella, or vascular, as seen in nephrotic syndrome when a renal vein thrombosis embolizes to the lungs. Diagnosis Differential diagnosis Cardiogenic shock can mimic a pulmonary renal syndrome and lead to coughing up blood due to pulmonary edema and kidney failure from inadequate blood flow. Treatment Treatment is primarily by corticosteroids and immunosuppressive medications like cyclophosphamide, methotrexate, and azathioprine. Plasmapheresis can be used in some circumstances. References Lung disorders Syndromes" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 257, 405 ] ], "word_ranges": [ [ 40, 64 ] ], "text": "In this case, given the vital compromise, the need for transfusion is very urgent, so the indication is emergency blood transfusion (O Rh negative)." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Type-specific blood transfusion required.", "2": "Requires emergency blood transfusion (O Rh negative).", "3": "A possible blood transfusion with crossmatching tests should be prepared.", "4": "Try again infusion of another 20 ml/kg of crystalloids.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0730_7296", "title": "[Emergency incompatible red cell transfusion to a patient whose blood type was suspended from identification].", "score": 0.014731907973406035, "content": "We report a case of a 59-year-old woman who presented with hypovolemic shock and compensated acidosis (preoperative arterial blood gases: pH 7.3, P(CO2) 31.9 mmHg, Pa(O2) 112.3 mmHg, base excess -9.8, Hb 6.4 g x dl(-1)) due to perforated descending colon, necessitating emergency surgery. Tracheal intubation had been performed preoperatively. Prior to induction of anesthesia, blood pressure was 106/74 mmHg, heart rate 119 beats x min(-1), and Sp(O2) 100% breathing room air. Anesthesia was induced with remifentanil influsion at a rate of 0.05 mg x kg(-1) x min(-1), sevoflurane 1% and rocuronium bromide 30mg, and was maintained with oxygen, air, remifentanil and sevoflurane. For a critical hypovolemia, in accordance to the guidelines for intraoperative critical hemorrhage and the Japanese practical guidelines for blood components therapy, we started to transfuse incompatible red cell (O+) since the identification of blood typing was suspended. The duration of surgery was 104 min, with an intraoperative total bleeding of 125 ml. Four units of total blood transfusion and 3,050 ml of infusion of Ringer's acetate solution were administered. The patient was transferred to ICU with tracheal intubation. No adverse reactions associated with blood type incompatibility were recognized." }, { "id": "pubmed23n0626_13813", "title": "[A patient rescued from unexpected intraoperative massive hemorrhage with ABO incompatible blood transfusion].", "score": 0.012694145758661887, "content": "A 67-year-old man was scheduled for resection of thoracic intramedullary tumor. His blood type was AB. Unexpectedly rapid and massive hemorrhage occurred during the operation. We infused a large amount of crystalloid, colloid, and 5% albumin. But he went into circulatory collapse before we could get type AB red blood cell (RBC) and hemoglobin was reduced to 3.8 g x dl(-1). We decided to transfuse 4 units of ABO incompatible type O RBC. Later, type AB RBC and other blood components became available and the patient recovered. We conclude that transfusion of ABO incompatible blood in patient with critical hemorrhage should be encouraged to save life." }, { "id": "article-18403_20", "title": "Blood Transfusion -- Preparation -- Obtain Baseline Vital Signs", "score": 0.012100615329162482, "content": "These include heart rate, temperature, blood pressure, pulse oximeter, and respiratory rate Respiratory sounds and urine output should also be documented Notify the provider if the temperature is more than 100 F" }, { "id": "wiki20220301en004_26465", "title": "Blood transfusion", "score": 0.011916583912611717, "content": "In urgent cases where crossmatching cannot be completed, and the risk of dropping hemoglobin outweighs the risk of transfusing uncrossmatched blood, O-negative blood is used, followed by crossmatch as soon as possible. O-negative is also used for children and women of childbearing age. It is preferable for the laboratory to obtain a pre-transfusion sample in these cases so a type and screen can be performed to determine the actual blood group of the patient and to check for alloantibodies. Compatibility of ABO and Rh system for Red Cell (Erythrocyte) Transfusion This chart shows possible matches in blood transfusion between donor and receiver using ABO and Rh system." }, { "id": "wiki20220301en008_58141", "title": "Bleeding", "score": 0.011241019115034863, "content": "Blood loss Hemorrhaging is broken down into four classes by the American College of Surgeons' advanced trauma life support (ATLS). Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary. Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a reduction in the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not usually required." }, { "id": "wiki20220301en004_26469", "title": "Blood transfusion", "score": 0.011193836926735949, "content": "Acute hemolytic reactions are defined according to Serious Hazards of Transfusion (SHOT) as \"fever and other symptoms/signs of haemolysis within 24 hours of transfusion; confirmed by one or more of the following: a fall of Hb, rise in lactate dehydrogenase (LDH), positive direct antiglobulin test (DAT), positive crossmatch\" This is due to destruction of donor red blood cells by preformed recipient antibodies. Most often this occurs because of clerical errors or improper ABO blood typing and crossmatching resulting in a mismatch in ABO blood type between the donor and the recipient. Symptoms include fever, chills, chest pain, back pain, hemorrhage, increased heart rate, shortness of breath, and rapid drop in blood pressure. When suspected, transfusion should be stopped immediately, and blood sent for tests to evaluate for presence of hemolysis. Treatment is supportive. Kidney injury may occur because of the effects of the hemolytic reaction (pigment nephropathy). The severity of the" }, { "id": "wiki20220301en020_27928", "title": "Hypovolemia", "score": 0.01107451158564289, "content": "Medical personnel should immediately supply emergency oxygen to increase efficiency of the patient's remaining blood supply. This intervention can be life-saving. The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen the way blood does—however, researchers are developing blood substitutes that can. Infusing colloid or crystalloid IV fluids also dilutes clotting factors in the blood, increasing the risk of bleeding. Current best practice allow permissive hypotension in patients suffering from hypovolemic shock, both avoid overly diluting clotting factors and avoid artificially raising blood pressure to a point where it \"blows off\" clots that have formed. Hospital treatment Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4. See also the discussion of shock and the importance of treating reversible shock while it can still be countered." }, { "id": "InternalMed_Harrison_20875", "title": "InternalMed_Harrison", "score": 0.011061507936507935, "content": "Same, plus: 1750 to deficient clotting factors in crystalloids and banked packed red blood cells (PRBCs). Early administration of component therapy during massive transfusion (fresh-frozen plasma [FFP] and platelets) approaching a 1:1 ratio of PRBC/FFP appears to improve survival. In extreme emergencies, type-specific or O-negative packed red cells may be transfused. Following severe and/or prolonged hypovolemia, inotropic support with norepinephrine, vasopressin, or dopamine may be required to maintain adequate ventricular performance but only after blood volume has been restored. Increases in peripheral vasoconstriction with inadequate resuscitation lead to tissue loss and organ failure. Once hemorrhage is controlled and the patient has stabilized, blood transfusions should not be continued unless the hemoglobin is <~7 g/dL. Studies have demonstrated an increased survival in patients treated with this restrictive blood transfusion protocol. Successful resuscitation also requires" }, { "id": "wiki20220301en196_33083", "title": "Masimo", "score": 0.0103125, "content": "rainbow Pulse CO-Oximetry uses more than seven wavelengths of light to continuously and noninvasively measure hemoglobin (SpHb), carboxyhemoglobin (SpCO), and methemoglobin (SpMet), in addition to oxygen saturation (SpO2), pulse rate, perfusion index (Pi), and pleth variability index (PVi). A study at Massachusetts General Hospital showed that SpHb monitoring helped clinicians decrease the frequency of patients receiving blood transfusions during surgery from 4.5% to 0.6%. Another study from Cairo University showed that SpHb monitoring helped clinicians reduce blood transfusions in high blood loss surgery by an average of 0.9 units per patient. A study at CHU Limoges in France found that monitoring with SpHb and PVi, integrated into a hospital-wide fluid and blood administration protocol, was associated with earlier transfusion and reduced mortality at 30 and 90 days by 33% and 29%, respectively. Emergency department studies have shown that SpCO helps clinicians increase the detection" }, { "id": "wiki20220301en387_14769", "title": "Damage control surgery", "score": 0.010215690371711824, "content": "For over a century the casualties of war have provided valuable lessons that can be applied within the civilian sector. Specifically the past decade has seen a paradigm shift in early resuscitation of critically injured patients. Instead of replacing blood volume with high volumes of crystalloid and packed red blood cells with the sporadic use of fresh frozen plasma and platelets, we have now learned that maintaining a transfusion ratio of 1:1:1 of plasma to red blood cells to platelets in patients requiring massive transfusion results in improved outcomes [Borgman 2007] While this was initially demonstrated in the military setting, Holcomb and colleagues extrapolated this to the civilian trauma center showing improved results as well Broad implementation across both the military and civilian sector has demonstrated a decreased mortality in critically injured patients. Debate has gone back and forth as to the correct ratio that should be used; however, recently Holcomb and colleagues" }, { "id": "wiki20220301en008_58142", "title": "Bleeding", "score": 0.010169121658483361, "content": "Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral hypoperfusion (shock) with diminished capillary refill occurs, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary. Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death." }, { "id": "wiki20220301en009_14193", "title": "Sepsis", "score": 0.009900990099009901, "content": "The Surviving Sepsis Campaign has recommended 30 ml/kg of fluid to be given in adults in the first three hours followed by fluid titration according to blood pressure, urine output, respiratory rate, and oxygen saturation with a target mean arterial pressure (MAP) of 65 mmHg. In children an initial amount of 20 ml/kg is reasonable in shock. In cases of severe sepsis and septic shock where a central venous catheter is used to measure blood pressures dynamically, fluids should be administered until the central venous pressure reaches 8–12 mmHg. Once these goals are met, the central venous oxygen saturation (ScvO2), i.e., the oxygen saturation of venous blood as it returns to the heart as measured at the vena cava, is optimized. If the ScvO2 is less than 70%, blood may be given to reach a hemoglobin of 10 g/dL and then inotropes are added until the ScvO2 is optimized. In those with acute respiratory distress syndrome (ARDS) and sufficient tissue blood fluid, more fluids should be given" }, { "id": "wiki20220301en002_144477", "title": "Pneumonia", "score": 0.00980392156862745, "content": "Pneumonia can cause severe illness in a number of ways, and pneumonia with evidence of organ dysfunction may require intensive care unit admission for observation and specific treatment. The main impact is on the respiratory and the circulatory system. Respiratory failure not responding to normal oxygen therapy may require heated humidified high-flow therapy delivered through nasal cannulae, non-invasive ventilation, or in severe cases invasive ventilation through an endotracheal tube. Regarding circulatory problems as part of sepsis, evidence of poor blood flow or low blood pressure is initially treated with 30 ml/kg of crystalloid infused intravenously. In situations where fluids alone are ineffective, vasopressor medication may be required." }, { "id": "pubmed23n0366_3201", "title": "[Oxygen transport values in patients with surgery performed under extracorporeal blood circulation].", "score": 0.00980392156862745, "content": "The aim of the work was to study the O2-transport changes to tissues in cardio-surgical patients suffering from CAD and operated during extra-corporeal blood circulation (ECC). The changes of selected haematologic variables, 2,3-diphosphoglycerate (2,3-DPG) and ATP concentration, acid-base balance parameters with p50 calculation were measured in the venous blood samples taken before the operation, during the operation and on the 1st, 2nd, 3d, 5th, 7th and 10th day after the operation. From the obtained results follows, that extreme haemodilution causes significant decrease of the haematocrit value (Htc) by 35%, the value of haemoglobin (Hb) by 37% and the count of erythrocytes (Er) by 37% from the initial values. The count of reticulocytes (Ret) was increased by 52%. In the days after operation the increase in Htc values, the values of Hb and count of erythrocytes was observed, whereby the initial values were not reach even on the 10th day after the operation. The increase of the reticulocytes count by 33% prevailed to the 10th day after the operation in comparison with the initial values. 2,3-DPG concentration was increased between 3d and 10th day after the operation by 30% and ATP concentration between 5th and 10th day was increased by 23% from the initial values. Hb-O2 saturation (SpO2) and pO2 were increased already during the operation, the increase prevailed until the 7th day by 27%, pO2 until the 3d day by 39% from the initial values. Calculated values p50 did not change in the course of this study--they fluctuated in range +/- 0.04 kPa from the initial value 3.55 kPa. Supposing multifactorial character of Hb oxygenation and deoxygenation process it is possible to conclude, that the determined changes of observed parameters did not significantly influence O2-transport to tissues during ECC. (Fig. 3, Ref. 12.)" }, { "id": "wiki20220301en008_58118", "title": "Shock (circulatory)", "score": 0.009708737864077669, "content": "Fluids Aggressive intravenous fluids are recommended in most types of shock (e.g. 1–2 liter normal saline bolus over 10 minutes or 20 ml/kg in a child) which is usually instituted as the person is being further evaluated. Colloids and crystalloids appear to be similar with respect to outcomes., Balanced crystalloids and normal saline also appear to be similar in critically ill patients. If the person remains in shock after initial resuscitation, packed red blood cells should be administered to keep the hemoglobin greater than 100 g/l. For those with hemorrhagic shock, the current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries allowing mild hypotension to persist (known as permissive hypotension). Targets include a mean arterial pressure of 60 mmHg, a systolic blood pressure of 70–90 mmHg, or until their adequate mentation and peripheral pulses. Hypertonic fluid may also be an option in this group. Medications" }, { "id": "pubmed23n0052_18360", "title": "[Preoperative hemodilution to reduce homologous blood transfusion--effects on hemodynamics and oxygen flux].", "score": 0.009708737864077669, "content": "Many problems arise from homologous blood transfusion in operative patients. Preoperative collection of blood with hemodilution is a simple method to allow autologous blood transfusion. Sixty patients who received gynecological operations were divided into three groups. Patients in the first and second groups underwent preoperative blood collection and hemodilution, and collected blood was transfused during operation when bleeding volume had exceeded prefixed value. The volume and speed of blood collection were 20 ml.kg-1 and 30 minutes in the first group, and 20 ml.kg-1 and 15 minutes in the second group. After the collection of blood, HES solution was infused to maintain blood volume. The patients in the third group were transfused with homologous blood as controls. The blood pressure, heart rate, cardiac index and oxygen flux were maintained well in the first group after collection of blood and hemodilution. The hemoglobin concentration was kept at 10 g.dl-1 when the operation was terminated with a mean bleeding volume of 1,014 ml. The results suggest that the method of preoperative blood collection and hemodilution followed by autologous blood transfusion is a promising technic to reduce the amount of homologous blood transfusion in operative patients." }, { "id": "pubmed23n1040_11848", "title": "Prehospital administration of blood products: experiences from a Finnish physician-staffed helicopter emergency medical service.", "score": 0.009615384615384616, "content": "Massive infusions of crystalloids into bleeding hypotensive patients can worsen the outcome. Military experience suggests avoiding crystalloids using early damage control resuscitation with blood components in out of hospital setting. Civilian emergency medical services have since followed this idea. We describe our red blood cell protocol in helicopter emergency medical services (HEMS) and initial experience with prehospital blood products from the first 3 years after implementation. We performed an observational study of patients attended by the HEMS unit between 2015 and 2018 to whom packed red blood cells, freeze-dried plasma, or both were transfused. The Student's two-sided T-test was used to compare vitals in prehospital phase with those at the hospital's emergency department. A p-value &lt; 0.05 was considered significant. Altogether, 62 patients received prehospital transfusions. Of those, 48 (77%) were trauma patients and most (n = 39, 81%) suffered blunt trauma. The transfusion began at a median of 33 (IQR 21-47) minutes before hospital arrival. Median systolic blood pressure showed an increase from 90 mmHg (IQR 75-111 mmHg) to 107 mmHg (IQR 80-124 mmHg; P &lt; 0.026) during the prehospital phase. Four units of red blood cells were handled incorrectly when unused red blood cells were returned and required disposal during a three-year period. There were no reported adverse effects from prehospital transfusions. We treated two patients per month with prehospital blood products. A prehospital physician-staffed HEMS unit carrying blood products is a feasible and safe method to start transfusion roughly 30 min before arrival to the hospital. The study was retrospectively registered by the Tampere University Hospital's Medical Director (R19603) 5.11.2019." }, { "id": "pubmed23n0727_18988", "title": "Consciously transfusion of blood products. Systematic review of indicative factors for blood components infusion's trigger.", "score": 0.009615384615384616, "content": "With the surgical and anesthetic technology advance the indications for intervention are expanding, as well as the need for blood transfusions. Because of its great scientific value, the content to be exposed is subject for endless discussions that provide different guidelines in various clinical and laboratory aspects. The objective of this review is to determine the clinical, laboratorial, and monitoring signs that should guide blood transfusion initiation, avoiding any risk and unnecessary use of resources, as well as the delay on starting therapy, determining tissue hypoxia and its corollaries. Scientific articles of clinical trials and reviews were used to range various subjects approached in the present content. These subjects were divided according to clinical and laboratorial aspects. Once the described search finished, 2,608 papers were identified, but only 17 original references were selected by inclusion criteria. Literature is unclear about clinical criteria on the ideal moment to begin the transfusion therapy in order to optimize the relations risk/ and cost/benefit. Studies show that there is no significant difference of oxygen supply (O(2)) in a comparison of hemoglobin (Hb) levels between 6 and 10g.dL(-1), mainly by reduced blood viscosity, facilitating the vascular flow to tissues. However, there is a tendency to recommend the transfusion trigger (TT) when it reaches low values as 6-7g.dL(-1). This same tendency indicates that red blood cells should never be administered with Hb levels &gt; 10g.dL(-1), except in special situations." }, { "id": "wiki20220301en554_28198", "title": "Neonatal red cell transfusion", "score": 0.009523809523809525, "content": "When to transfuse Below are suggested transfusion thresholds for very preterm neonates (less than 32 weeks gestation) by the British Society of Haematology. These are based on systematic reviews of transfusion in very preterm babies. There is no evidence for red cell transfusion thresholds in preterm neonates between 32 and 37 weeks gestation, and the British Society of Haematology suggests using the same thresholds as very preterm neonates that require no respiratory support. What to transfuse A small volume transfusion is usually 10 to 20 ml/kg administered at a rate of 5 ml/kg/hour. A large volume transfusion is the estimated entire blood volume of the baby (80 ml/kg) and is usually given during cardiac surgery." }, { "id": "pubmed23n0250_2745", "title": "[Control of the ratio of the flow rate of the substitution fluid to the blood removal rate during preoperative normovolemic hemodilution].", "score": 0.009523809523809525, "content": "Twenty-one patients (mean age 46 +/- 13 years) due to undergo abdominal or ENT surgery, presumed to give rise to an important blood loss were included in this study. None had any contra-indication to the use of normovolaemic haemodilution (NH). Mean initial haematocrit was 40.3 +/- 1.8%. Their estimated total blood volume was 4,867 +/- 857 ml. The patients were anaesthetized with thiopentone, fentanyl, vecuronium or atracurium. Maintenance was carried out with isoflurane (0.5% during NH). Usual haemodynamic monitoring was used throughout. The required haematocrit was decided on before starting NH. The amount of blood to be removed was calculated with usual mathematical formulae. A radial artery cannula (n = 7), or a subclavian or femoral venous cannula (n = 14) was used to remove blood, which was collected within a bag containing CPC-adenine. Six % hydroxyethyl starch (Elohes) was given through a short venous cannula some distance from the first one. An antiparallel double line set in a roller pump was used to carry out the NH. A mean 1,341 +/- 405 ml of blood were withdrawn so as to reach a mean haematocrit of 30.6 +/- 2.4%. NH was completed within 17 +/- 6 min. No major haemodynamic changes occurred during the procedure. No significant differences were observed between expected and observed final haematocrits. There was no effect of the volume of blood withdrawn on the error of haematocrit prediction (0.5 +/- 0.3%). However, a higher rate of blood removal could increase this error. This easy-to-use device seems to provide fast and identical rates of blood removal and replacement. The expected haematocrit may thus be reached reliably, even if this must be checked for the sake of safety." }, { "id": "pubmed23n0808_16878", "title": "Exchange transfusion can be life-saving in severe propanil poisoning: a case report.", "score": 0.009433962264150943, "content": "Propanil is an important cause of herbicide poisoning in Sri Lanka, accounting for about 2% of all cases of self-poisoning. The outcome is extremely poor when the poisoning is severe and current medical care is of limited efficacy. Death usually occurs due to the severe and prolonged methaemoglobinaemia. We describe a case of severe Propanil poisoning, successfully treated by exchange transfusion at a tertiary care hospital in Sri Lanka. A 17-year old Sri Lankan male (body weight--42 kg), presented to a local hospital 1 hour after self-ingestion of nearly 500 ml (4.3 g/kg) of liquid Propanil (concentration--360 g/l). On admission he had dizziness and peripheral cyanosis. He was given intravenous methylene blue (1 mg/kg) within one hour of admission, which was repeated subsequently due to minimal response. The next day morning, (18 hours after poisoning) the patient was transferred to the National Hospital of Sri Lanka (NHSL) for further management. On admission to NHSL, he was drowsy and confused, had a shallow respiratory effort and marked central and peripheral cyanosis. Respiratory rate was 20/min, with a pulse-oximetry of 77% on room air. The arterial blood gas analysis was as follows; pH--7.24, HCO3(-)--12 mmol/l, pCO2--28 mmHg, pO2--239 mmHg and O2 saturation--100%. Exchange transfusion was commenced within two hours of admission to NHSL. A dramatic improvement in oxygen saturation was observed immediately afterwards, with the saturation in pulse-oximetry rising to &gt;95%. The level of consciousness and respiratory effort also improved. He was discharged subsequently 8 days after the initial poisoning. Propanil has potential to produce severe life threatening clinical manifestations, despite categorization as a herbicide with low toxicity. In cases of severe poisoning, exchange transfusion may be life saving. Since methylene blue, intensive care and exchange transfusion facilities are also not readily available in local hospitals, which frequently encounter cases of severe Propanil poisoning, early transfer of patients to tertiary care hospitals should be considered. Exchange transfusion may be helpful even in late stages in patients with severe poisoning." }, { "id": "pubmed23n0043_996", "title": "[Critical hematocrit from the viewpoint of the clinician].", "score": 0.009433962264150943, "content": "The hazards of homologous blood transfusions have been controlled but not eliminated by modern blood banking methods. In addition to the possibility of transmission of infectious diseases, blood transfusion has been reported to induce immunosuppression and thereby impair the host resistance of surgical patients. Experimental and clinical research, particularly in cardiac surgery, have encouraged physicians to accept postoperative anemia. The influence of hemodilution on oxygen supply to the tissues was found to be an increase of local oxygen tension. When hematocrit is progressively lowered under normovolemic conditions, blood cell flux per time and tissue unit is maintained at a hematocrit level as low as 20 vol% as a result of an increase of red blood cell velocity. An increasing number of cardiac operations have been performed upon patients belonging to Jehova's witnesses, inducing an average hematocrit of 11 vol% during extracorporeal circulation. The outcome of these patients was similar to that of patients having received blood transfusion in order to elevate oxygen supply. Some recent studies in critically ill patients demonstrate the importance of oxygen consumption as an important criterion in estimating the effect of oxygen transport. It seems to be proven that, in presence of cardiovascular stability, elevation of the hemoglobin level above 9 g/dl does not result in an increase of oxygen utilization. In accordance with the topical literature we suggest that during the perioperative period a hemoglobin level of 8.5 g/dl will become an accepted transfusion trigger. Particular patients will tolerate even much lower levels." }, { "id": "wiki20220301en013_139379", "title": "Fluid replacement", "score": 0.009345794392523364, "content": "Resuscitation phase - The goal of this phase is to correct the hypotension. Intravenous crystalloid is the first choice of therapy. Surviving Sepsis Campaign recommends 30 ml/kg fluid resuscitation in this phase. Earlier fluid resuscitation is associated with improved survival. Mean arterial pressure should be targeted at more than 65 mmHg. Meanwhile, for early goal directed therapy (EGDT), fluids should be administered within the first six hours of septic shock until central venous pressure (CVP) reaches between 8 and 12 mmHg, with improvement of blood lactate levels, central venous oxygen saturation > 70%, and urine output ≥ 0.5 ml/kg/hour. Higher mean arterial pressures can be used in patients with chronic hypertension in order to reduce the usage of renal replacement therapy. However, if fluid replacement is inadequate in raising blood pressure, then vasopressor have to used. However, there is no definite timing of starting vasopressors. Initiation of vasopressors within the" }, { "id": "pubmed23n0820_13882", "title": "Serotonin syndrome following metaxalone overdose and therapeutic use of a selective serotonin reuptake inhibitor.", "score": 0.009259259259259259, "content": "Metaxalone has only recently been associated with serotonin syndrome. The mechanism of action of this centrally acting muscle relaxant is unknown; however, the observation of serotonin syndrome in patients with metaxalone overdose suggests a role in the serotonergic pathway. (Case 1) A 29-year-old woman with overdose of metaxalone presented to the emergency department with altered mental status, seizure-like activity, hyperthermia, rigidity in the lower extremities, myoclonus, and hyperreflexia. Vital signs on arrival include blood pressure of 168/80 mmHg, heart rate of 208 beats per minute (bpm), respirations of 20/min, a temperature of 41.6° C rectally, and room air oxygen saturation of 97%. She was intubated and sedated with benzodiazepines, and actively cooled. Serum paroxetine concentration was 23 (therapeutic range: 20-200) ng/mL, and serum metaxalone concentration was 31 mcg/mL (peak plasma concentrations average 0.9 mcg/mL at 3.3 h following a single oral dose of 400 mg). (Case 2) A 27-year-old man presented to the emergency department with altered mental status, rigidity in his lower extremities, myoclonus, and hyperreflexia. Vital signs on arrival include blood pressure of 158/131 mmHg, heart rate of 126 bpm, respiratory rate of 20 breaths per minute, and temperature of 37.2°C, with oxygen saturation of 98% on room air. His medication list included metaxalone and escitalopram. He was managed aggressively with IV boluses of diazepam, in total 80 mg, in the emergency department. Serum escitalopram concentration was 24 ng/mL with a therapeutic range of 21-64 ng/mL, and serum metaxalone concentration was 58 mcg/mL. These two cases suggest that at supratherapeutic concentrations metaxalone has serotonergic effects. Severe serotonin toxicity may result from metaxalone abuse in individuals using a selective serotonin reuptake inhibitor therapeutically." }, { "id": "pubmed23n0752_5643", "title": "Effect of rapid plasma volume expansion during anesthesia induction on haemodynamics and oxygen balance in patients undergoing gastrointestinal surgery.", "score": 0.009259259259259259, "content": "To investigate the reasonable dose of Voluven for rapid plasma volume expansion during the anaesthesia induction patients receiving gastrointestinal surgery. Sixty patients were randomly divided into three groups (n=20): Group A (5 ml/kg), Group B (7 ml/kg) and Group C (9 ml/kg). HES 130/0.4 was intravenously transfused at a rate of 0.3 ml/kg/min) at 30 min before anaesthesia induction. Besides standard haemodynamic monitoring, cardiac index (CI), systemic vascular resistance index (SVRI) and stroke volume variation (SVV) was continuously detected with the FloTrac/Vigileo system. Haemodynamic variables were recorded immediately before fluid transfusion (T0), immediately before induction (T1), immediately before intubation (T2), immediately after intubation (T3) and 5 min, 10 min, 20 min and 60 min after intubation (T4-T7). Arterial and venous blood was collected for blood gas analysis, Hb and Hct before volume expansion (t0), immediately after volume expansion (t1) and at 1 h after volume expansion (t2). Oxygen delivery (DO2), oxygen extraction ratio (ERO2) and volume expansion rate were calculated. 1) MAP and CI decreased in Group A in T2~T7 and remained changed in Group B and C. 2) CVP increased in three groups after fluid infusion without significant difference. 3) The decrease in SVRI was more obvious in Group B and C than that in Group A after induction and more obvious in Group C than in Group B in T2-T4 and T6~T7. 4) SVV was lower in Group B and C than that in Group A after intubation, and lower in Group C than that in Group B in T3-T6. 5) Hb and Hct decreased after fluid infusion, and the decrease in Hb and Hct was in the order of C&gt;B&gt;A. 6) Volume expansion rate was in the order of C&gt;B&gt;A. 7) ScvO2, PaO2 and DO2 increased in three groups after fluid infusion and the increase in DO2 was in the order of C&gt;B&gt;A. Rapid plasma volume expansion with Voluven at 7-9 ml/kg can prevent haemodynamic fluctuation during anaesthesia induction, maintain the balance between oxygen supply and oxygen consumption during gastrointestinal surgery, and Voluven at 9 ml/kg can improve the oxygen delivery." }, { "id": "pubmed23n0939_21088", "title": "Multicenter study of crystalloid boluses and transfusion in pediatric trauma-When to go to blood?", "score": 0.009174311926605505, "content": "The 9th edition of Advanced Trauma Life Support recommends up to three crystalloid boluses in pediatric trauma patients with consideration of transfusion after the second bolus; however, this approach is debated. We aimed to determine if requirement of more than one fluid bolus predicts the need for transfusion. The 2010 to 2016 highest tier activation patients younger than 15 years from two ACS Level I pediatric trauma centers were identified from prospectively maintained trauma databases. Those with a shock index (heart rate/systolic blood pressure) greater than 0.9 were included. Crystalloid boluses (20 ± 10 mL/kg) and transfusions administered prehospital and within 12 hours of hospital arrival were determined. Univariate and multivariable analyses were conducted to determine association between crystalloid volume and transfusion. Among 208 patients, the mean age was 5 ± 4 years (60% male), 91% sustained blunt injuries, and median (interquartile range) Injury Severity Score was 11 (6,25). Twenty-nine percent received one bolus, 17% received two, and 10% received at least three. Transfusion of any blood product occurred in 50 (24%) patients; mean (range) red blood cells was 23 (0-89) mL/kg, plasma 8 (0-69), and platelets 1 (0-18). The likelihood of transfusion increased logarithmically from 11% to 43% for those requiring 2 or more boluses (Fig. 1). This relationship persisted on multivariable analysis that adjusted for institution, age, and shock index with good discrimination (Area under the Receiver Operating Characteristic, 0.84). Shock index was also strongly associated with transfusion. Almost half of pediatric trauma patients with elevated shock index require transfusion following two crystalloid boluses and the odds of requiring a transfusion plateau at this point in resuscitation. This supports consideration of blood with the second bolus in conjunction with shock index though prospective studies are needed to confirm this and its impact on outcomes. Therapeutic study, level IV." }, { "id": "pubmed23n0545_4234", "title": "[Preoperative hypervolemic hemodilution with 6% hydroxyethyl starch 130/0,4 (HES 130/ 0.4) solution as a way of reducing needs for donor blood transfusion].", "score": 0.009174311926605505, "content": "The efficacy of hypervolemic hemodilution (HHD) in reducing the rate of donor blood transfusion is controversely discussed. The present prospective, randomized, clinical study analyzes the impact of HHD with 6% hydroxyethyl starch (HES) 130/0.4 solution on the rate transfusion, laboratory parameters, and the incidence of complications as compared with those in the control group receiving no preoperative HHD. 80 patients who had undergone total prostatectomy or cystectomy were randomized into 2 groups. Before anesthesia, the HHD group (n=40) received 15 ml/kg of 6% HES 130/0.4 solution. In the HHD and control (n=40) groups, 6% HES 130/0.4 was intraintraoperatively infused in its maximum dose of 33 ml/kg according to the patients' needs. Indicationsf or blood transfusion trigger were Hb &lt;5 g/dl or packed cell volume &lt; 0.24. Laboratory parameters (Hb, PCV, platelets, prothrombin index, prothrombin time, thrombin time, fibrinogen, antithrombin III were measured before surgery, after HHD and 2, 24, and 48 hours after surgery. The mean blood pressure (MBP), heart rate (HR), and central venous pressure (CVP) were determined before surgery, after HHD, and 2 hours postsurgery. Statistical measurements were made in all patients from the HHD and control groups, as well as in a subgroup, in which intraoperative blood loss was greater than 30% of the total blood volume (70 ml/kg body weight). Demographic data and surgical techniques were similar in both groups. After HHD, CVP rose significantly. The changes in MBP and HR were statistically insignificant. There were no complications after HHD. Of the 40 HHD-group patents, 5 needed donor blood transfusion while in the control group blood was transfused to 10 of the 40 patients in the control group. Comparing both groups showed a lower need for blood transfusion in the HHD-group patients than in the controls (10 versus 24 packed red cells). The postoperative Hb values showed no difference between both groups. Preoperative HHD in patients undergoing surgery with expected &gt;30% blood loss leads to decreased needs for blood transfusion. The method is safe and easy-to-use." }, { "id": "wiki20220301en128_1425", "title": "Hospital emergency codes", "score": 0.00915374947633012, "content": "- Major haemorrhage protocol – activated via the Code red system. A peri-arrest call is put out, but the transfusion lab is also alerted. A specified number of units of O-negative packed red blood cells and (sometimes FFP and platelets) are immediately sent to the location of the call. The transfusion lab will crossmatch any saved blood samples for the patient, or await an urgent cross-match sample to be sent. Once this is done, units matching the patient's blood type will be continually sent until the major haemorrhage protocol is stood down." }, { "id": "wiki20220301en594_9125", "title": "Blood compatibility testing", "score": 0.00909090909090909, "content": "Medical uses Blood compatibility testing is routinely performed before a blood transfusion. The full compatibility testing process involves ABO and RhD (Rh factor) typing; screening for antibodies against other blood group systems; and crossmatching, which involves testing the recipient's blood plasma against the donor's red blood cells as a final check for incompatibility. If an unexpected blood group antibody is detected, further testing is warranted to identify the antibody and ensure that the donor blood is negative for the relevant antigen. Serologic crossmatching may be omitted if the recipient's antibody screen is negative, there is no history of clinically significant antibodies, and their ABO/Rh type has been confirmed against historical records or against a second blood sample; and in emergencies, blood may be transfused before any compatibility testing results are available." }, { "id": "pubmed23n0482_2311", "title": "[Update on transfusion practice among anesthesiologists and its impact on the surgical patient].", "score": 0.00909090909090909, "content": "To determine the effectiveness of a new educational program on transfusion practice, directed to the staff of an anesthesia and postoperative recovery service, by evaluating its impact on intraoperative transfusion (IOT). We reviewed the incidence of IOT during the first semesters of 1996 and 2001 for general, urologic, otolaryngologic, maxillofacial, thoracic, and vascular surgery. Other factors such as sex, age, type of intervention, emergency status, duration of operation, and use of blood products were also taken into consideration. A statistically significant overall reduction in IOT occurred between 1996 (4.9%) and 2001 (3.6%). The decrease in transfusions (a reduction of 18.8% in transfused patients) was even greater in general surgery and urology, particularly in scheduled surgery (4.1% in 1996 vs 2.6% in 2001). However, the total use of packed red blood cells did not change inasmuch as the number of units per patient was higher in 2001 (2.8 units/patient) than in 1996 (2.4 units/patient). In emergency surgery, the IOT rate increased from 7.6% in 1996 to 8.1% in 2001. We also noticed a higher rate of multiple transfusions (defined as the use of 5 or more units of packed red blood cells during surgery) in 2001. The introduction of an educational program directed to anesthesiologists has been useful for reducing IOT, although the overall use of blood products has not decreased." }, { "id": "wiki20220301en031_37316", "title": "Hypovolemic shock", "score": 0.009009009009009009, "content": "Class 1: Volume loss up to 15% of total blood volume, approximately 750 mL. Heart rate is minimally elevated or normal. Typically, there is no change in blood pressure, pulse pressure, or respiratory rate. Class 2: Volume loss from 15% to 30% of total blood volume, from 750 mL to 1500 mL. Heart rate and respiratory rate become elevated (100 BPM to 120 BPM, 20 RR to 24 RR). Pulse pressure begins to narrow, but systolic blood pressure may be unchanged to slightly decreased. Class 3: Volume loss from 30% to 40% of total blood volume, from 1500 mL to 2000 mL. A significant drop in blood pressure and changes in mental status occur. Heart rate and respiratory rate are significantly elevated (more than 120 BPM). Urine output declines. Capillary refill is delayed." }, { "id": "pubmed23n0243_6258", "title": "[The infusion of packed red cells. Usual difficulties (author's transl)].", "score": 0.009009009009009009, "content": "This infusion used instead of whole blood has become increasingly common. However in our, as in other french institutions, the volume and the hematocrit of blood contained in each unit varies often notably. In addition, because of their high viscosity packed erythrocytes cannot be transfused rapidly enough. For transfusion in emergency situations and transfusion in operating room, following suggestions could be made to blood banks: --each unit should provide information on its content (volume and hematocrit or hemoglobin content); --units with low blood content should be transfused outside the operating room, whereas units containing high volumes should be reserved for peroperative transfusion in order to reduce charge of manipulation; --packed erythrocytes units should be prepared in order to allow same transfusion rates as whole blood (i.e. an average of 100 ml per minute for one transfusion line); --packed erythrocytes units should contain about 80 ml of plasma for an average total concentrate volume of 260 ml in order to provide enough antibacterial defense components; --units of fresh whole blood should be provided when approximately 150 p. cent of recipient's blood volume has been replaced in order to maintain the critical platelet level." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 275 ] ], "word_ranges": [ [ 0, 46 ] ], "text": "Angioedema is a type of profound urticaria that can be of drug etiology (not IgE-mediated) and in this case, ACEIs (such as enalapril) are considered the most frequent pharmacological cause, so in this case it would be the correct answer (if we speak in probabilistic terms)." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Enalapril.", "2": "Simvastatin.", "3": "Metformin or levodopa equally.", "4": "Levodopa.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0650_13044", "title": "[Therapeutic behavior to follow in the following clinical case: treatment of type 2 diabetes].", "score": 0.017857142857142856, "content": "A 62-year old woman with obesity, high blood pressure and type 2 diabetes mellitus (DM2) was referred to a Vascular Risk Unit of the Internal Medicine Department due to elevated HbA1C (8.1%) in spite of having taken metformin (850 mg/12h) and glipizide (10 mg/12 h) regularly. She tries to exercise daily (walking 30 min) and has lost weight (from 5 to 12 kg) several times, but always regains what she has lost. Furthermore, she monitors her glucose levels in fasting every two weeks and generally has between 120 and 160 mg/dL. Her high blood pressure is being treated with enalapril/HCTZ and she also takes aspirin 100mg/day and simvastatin 20 mg/day. It is seen in her family background that one brother died suddenly at 50 years of age. Her physical examination shows a BMI of 32.4 Kg/m(2), and she has no edemas in the lower limbs. Her BP is 154/82 mmHg and creatinine 0.9 mg/dL. She has no microalbuminuria and her liver function is normal. What treatment do you think would be the more appropriate? 1 - Add glitazones. 2 - Add incretin mimetics (GLP 1/ DPP-4). 3 - Slow acting insulin." }, { "id": "pubmed23n1025_12186", "title": "Extrapyramidal side effect of donepezil hydrochloride in an elderly patient: A case report.", "score": 0.014904862579281183, "content": "Alzheimer disease (AD) is a neurodegenerative disease characterized by progressive cognitive dysfunction, which is mainly manifested as memory impairment and a reduced ability to self-care, often accompanied by neuropsychiatric and behavioral disorders. Donepezil is the second drug to be approved by the US FDA for the treatment of AD. Of the five FDA-approved drugs for AD treatment, donepezil is currently the most widely used. Here, we report an extrapyramidal adverse reaction to donepezil in an elderly patient with AD. An 87-year-old woman presented with a 1-year history of forgetfulness that was aggravated since the past 2 months. She had a long-term history of multiple major conditions, including hypertension, diabetes, osteoporosis, and arterial plaques. Brain imaging showed age-related changes, and her Mini Mental State Examination score was 20. Other tests revealed no abnormalities apart from multiple thyroid nodules on ultrasonography. She was diagnosed with AD, hypertension, type 2 diabetes mellitus, diabetic neuropathy, osteoporosis, carotid and lower-extremity arterial plaques, thyroid nodules. She was treated with donepezil (5 mg/day), amlodipine besylate (5 mg/day), glimepiride (4 mg/day), methylcobalamin (1.5 mg/day), calcium carbonate D3 (600 mg/day), simvastatin (20 mg/day) and enteric-coated aspirin (100 mg/day). Four days later, she experienced fatigue, panic, sweating, and one episode of vomiting. On the 5th day, she developed increased muscle tension, speech difficulty, and involuntary tremors. Imaging and blood tests revealed no obvious abnormality, and the patient was not receiving psychotropic drugs. An extrapyramidal adverse reaction to donepezil was considered, and the drug was discontinued, after which the symptoms gradually disappeared. Serious adverse reactions to donepezil can occur in elderly patients, who typically require multiple medications for a variety of comorbidities. In particular, extrapyramidal reactions have occurred when donepezil is administered in combination with psychotropic drugs. However, in our patient, an extrapyramidal adverse reaction occurred in the absence of psychotropic drugs. Thus, clinicians must be aware of inter-individual differences in drug actions and possible serious adverse reactions, and carefully monitor these patients to ensure the timely detection of adverse events and their safe treatment." }, { "id": "pubmed23n0042_579", "title": "Cardiovascular effects of levodopa in aged versus younger patients with Parkinson's disease.", "score": 0.013694366635543105, "content": "The cardiovascular effects of prolonged administration of levodopa were studied in 54 men and women with Parkinson's disease; 23 of them were younger than 70 and 31 were 70 or older. The patients were evaluated clinically before treatment was started and at regular intervals thereafter. The average optimal dosage of levodopa for both age groups was 3.0 and 2.5 gm per day, respectively, during an average treatment period of 20.7 months. Eleven patients showed hypotension (systolic BP of 105 mm Hg or less) that was not related to dosage; in only 6 did the drug have to be permanently discontinued because of syncope; 3 of this group had an associated psychiatric disorder. Four patients had pretreatment hypertension; in 3 the BP fell to normal during therapy; in the remaining patient the hypertension persisted and was successfully treated by an antihypertensive drug. In 5 patients an occasional atrial or ventricular ectopic beat was noted both before and during levodopa therapy but no therapeutic intervention was required. Thirty of the 46 patients with adequate ECG follow-up did not show any significant changes; 5 others showed an increase, and 11 a decrease in myocardial ischemia. Thus the administration of levodopa in elderly patients with or without heart disease is a relatively safe procedure. The only exception would be patients over 70 years of age with a history of previous myocardial infarction. In this group there seems to be a higher incidence of clinically significant hypotension. In such patients, levodopa therapy should be carried out with great caution." }, { "id": "InternalMed_Harrison_8144", "title": "InternalMed_Harrison", "score": 0.010591998322059672, "content": "Therapy with colchicine, para-aminosalicylate, neomycin, slow-release potassium chloride, anticonvulsant drugs, metformin, phenformin, cytotoxic drugs Alcohol in close relatives and in persons with other organ-specific autoimmune diseases, e.g., thyroid diseases, vitiligo, hypoparathyroidism, and Addison’s disease. It is also associated with hypogammaglobulinemia, with premature graying or blue eyes, and persons of blood group A. An association with human leukocyte antigen (HLA) 3 has been reported in some but not all series and, in those with endocrine disease, with HLA-B8, -B12, and -BW15. Life expectancy is normal in women once regular treatment has begun. Men have a slightly subnormal life expectancy as a result of a higher incidence of carcinoma of the stomach than in control subjects. Gastric output of hydrochloric acid, pepsin, and IF is severely reduced. The serum gastrin level is raised, and serum pepsinogen I levels are low." }, { "id": "InternalMed_Harrison_30359", "title": "InternalMed_Harrison", "score": 0.010123024278963662, "content": "Centrally acting anticholinergic drugs such as trihexyphenidyl and benztropine were used historically for the treatment of PD, but they lost favor with the introduction of dopaminergic agents. Their major clinical effect is on tremor, although it is not certain that this benefit is superior to what can be obtained with agents such as levodopa and dopamine agonists. Still, they can be helpful in individual patients with severe tremor. Their use is limited particularly in the elderly, due to their propensity to induce a variety of side effects including urinary dysfunction, glaucoma, and particularly cognitive impairment. Carbidopa/levodopa 10/100, 25/100, 25/ 200–1000 mg 250 mg levodopa/d 2–4 times/d Benserazide/levodopa 25/100, 50/200 mg Carbidopa/levodopa CR 25/100, 50/200 mg Benserazide/levodopa 25/200, 25/250 mg MDS Parcopa 10/100, 25/100, 25/250 Carbidopa/levodopa/ 12.5/50/200, entacapone 18.75/75/200, 25/100/200, 31.25/125/200, 37.5/150/200, 50/200/200 mg" }, { "id": "pubmed23n0718_15563", "title": "Liraglutide-associated acute pancreatitis.", "score": 0.00999975610350967, "content": "A case of acute pancreatitis associated with liraglutide is reported. A 53-year-old African-American man (height, 185.4 cm; weight, 108.6 kg) with type 2 diabetes mellitus arrived at the emergency department (ED) with new-onset intolerable abdominal pain in the right upper quadrant and left upper quadrant that had appeared suddenly and lasted two to three hours. He had nausea but no vomiting, with tenderness in the epigastric region. In the ED, his serum amylase concentration was found to be extremely elevated (3,963 units/L), as was his serum lipase concentration (&gt;15,000 units/L). In addition to type 2 diabetes, his medical history included hyperlipidemia, hypertension, peripheral neuropathy, erectile dysfunction, and obesity. His home medications included aspirin 81 mg orally daily, metformin 1000 mg orally every morning and 1500 mg every evening, simvastatin 80 mg orally daily at bedtime, tadalafil 20 mg orally as needed, glimepiride 4 mg orally twice daily, and liraglutide 1.2 mg subcutaneously daily. Two months before his arrival to the ED, the patient's dosage of liraglutide was increased from 0.6 to 1.2 mg subcutaneously daily. Radiographic data were obtained, and acute pancreatitis was diagnosed. Liraglutide was discontinued indefinitely after ruling out elevated triglycerides as the cause of pancreatitis. The patient was initiated on standard therapy for acute pancreatitis and discharged eight days later with complete resolution of symptoms and normal laboratory test values. A 53-year-old man with type 2 diabetes mellitus developed a probable case of liraglutide-induced acute pancreatitis after receiving the drug for approximately two months." }, { "id": "wiki20220301en291_41931", "title": "Levodopa-induced dyskinesia", "score": 0.009900990099009901, "content": "Nicotine (administered by dermal adhesive patches) has also been shown to improve Levodopa-induced dyskinesia and other PD symptoms. Patients with prominent dyskinesia resulting from high doses of antiparkinsonian medications may benefit from deep brain stimulation (DBS), which may benefit the patient in two ways: 1) DBS theoretically allows a reduction in l-DOPA dosage of 50–60% (tackling the underlying cause); 2) DBS treatment itself (in the subthalamic nucleus or globus pallidus) has been shown to reduce dyskinesia. Mavoglurant is also currently studied by Novartis for the treatment of this disease. On August 24, 2017 the FDA approved a drug to treat levodopa-induced dyskinesia for Parkinson's patients. The drug, Gocovri, is amantadine manufactured by Adamas Pharmaceuticals. It is the first FDA approved treatment for this condition. References External links Parkinson's disease" }, { "id": "pubmed23n0763_11218", "title": "[Severe parkinsonism due to metoclopramide: the importance of early recognition].", "score": 0.009900990099009901, "content": "In this article, we present 3 women aged 73, 85 and 88 years who developed metoclopramide-induced parkinsonism. Shortly after starting metoclopramide, bradykinesia and rigidity developed in all 3 patients; tremor and postural instability in 2 of them. We discontinued the metoclopramide after 3-6 months; 2 of the patients had fully recovered 4-6 months later. The 3rd patient died from pneumonia, however, 2 months after discontinuation. Metoclopramide, a dopamine D2-antagonist, is a frequently prescribed anti-emetic drug; however, evidence of its efficacy is limited. In many patients, domperidone, another dopamine D2-antagonist, seems to be a better alternative. Movement disorders due to domperidone are uncommon, presumably because it does not cross the blood-brain barrier. It is likely that metoclopramide-induced parkinsonism is not uncommon; however, it is under-recognized. Risk factors are female sex, advanced age, diabetes mellitus and polypharmacy. Follow-up on patients using metoclopramide is advised. " }, { "id": "pubmed23n0605_21599", "title": "Hypersensitivity to intravenous ondansetron: a case report.", "score": 0.00980392156862745, "content": "Ondansetron, a 5-hydroxytryptamine3 receptor antagonist widely used in the prevention and treatment of chemotherapy-induced nausea and vomiting, is associated with various unusual adverse drug reactions. In this paper, we describe a hypersensitivity reaction to a single intravenous dose of ondansetron. A 19-year-old woman presented to the emergency department of our institute with 3-4 episodes of nausea, vomiting and epigastric distress. She had a diagnosis of polycystic ovarian disease and had been on treatment with cyproterone acetate 2 mg, ethinyl estradiol 0.035 mg, finasteride 5 mg and metformin 500 mg for a month. She had been taking oral roxithromycin 500 mg per day for the past 3 days for treatment of a mild upper respiratory tract infection. She also occasionally took rabeprazole 10 mg for gastritis which had worsened after treatment with roxithromycin. She was treated with a single 4 mg dose of ondansetron intravenously. She immediately developed urticaria, which was treated with intravenous dexamethasone 4 mg and chlorpheniramine maleate 20 mg. The reaction abated within a few minutes and she was discharged within an hour. She was asymptomatic at 72 hours of follow-up.She had no history of ondansetron exposure, or drug or food allergies. On the Naranjo's causality assessment scale, the adverse event was 6 indicating a \"probable\" reaction to ondansetron. 5-hydroxytryptamine3 receptor antagonists have been associated with life-threatening adverse reactions such as hypotension, seizures and anaphylaxis. The wide availability of these drugs in India has promoted their off label use in the treatment of gastritis, migraine and so on. Our case represents an off label use in a patient who could have been treated with a safer drug.Some authors have suggested that anaphylaxis may be a class effect while others think it may be drug specific. In our case, the reaction could be either anaphylaxis or anaphylactoid, but the latter seems more likely given the history of absence of prior sensitization. Other components of the drug, such as solvent, also need to be considered as a cause of this reaction. Considering all of the existing evidence, we need to be more cautious while using ondansetron and also to be aware of the various unusual side effects, especially when used in an out-of-hospital set-up.Our case report underscores the importance of physicians judiciously using the drug, particularly in the outpatient setting so as to reduce the incidence of avoidable adverse drug reactions." }, { "id": "pubmed23n0388_1051", "title": "[Parkinsonism probably induced by manganese].", "score": 0.00980392156862745, "content": "In all cases of young persons with clinical Parkinson s disease it should be suspected that it is secondary to some primary disorder. Therefore a battery of diagnostic tests should be done before classification as idiopathic Parkinson s disease. A 31 year old woman whose only previous illness had been Graves disease. She complained of difficulty with movements of her right arm and leg for some months (she had problems with walking and with rapid, repeated movements of her right hand). She also complained of tremor of her right limbs at rest. She denied taking drugs, having dysphagia, dysarthria, visual changes or sphincter disorders. Neurological examination showed her to have monotonous speech, slight facial hypomimia, slight reduction in spontaneous blinking, walking with less swing of her right arm; postural tremor of both arms, worse on the right; bradykinesia (2/4) of both right limbs and rigidity (1/4), axial and of the right limbs. The results of all the investigations done to rule out secondary Parkinsonism were normal, except for the plasma manganese level which was raised, although it returned to normal when the probable source of exposure to this metal was removed. However, the alterations of movement only disappeared after treatment with levodopa was started. In cases of Parkinsonism in young adults secondary causes should always be rules out, such as exposure to certain metals." }, { "id": "pubmed23n0583_2153", "title": "Metformin-induced lactic acidosis: a case series.", "score": 0.009708737864077669, "content": "Unlike other agents used in the treatment of type 2 diabetes mellitus, metformin has been shown to reduce mortality in obese patients. It is therefore being increasingly used in higher doses. The major concern of many physicians is a possible risk of lactic acidosis. The reported frequency of metformin related lactic acidosis is 0.05 per 1000 patient-years; some authors advocate that this rate is equal in those patients not taking metformin. We present two case reports of metformin-associated lactic acidosis. The first case is a 77 year old female with a past medical history of hypertension and type 2 diabetes mellitus who had recently been prescribed metformin (3 g/day), perindopril and acetylsalicylic acid. She was admitted to the emergency department two weeks later with abdominal pain and psychomotor agitation. Physical examination revealed only signs of poor perfusion. Laboratory evaluation revealed hyperkalemia, elevated creatinine and blood urea nitrogen and mild leukocytosis. Arterial blood gases showed severe lactic acidemia. She was admitted to the intensive care unit. Vasopressor and ventilatory support was initiated and continuous venovenous hemodiafiltration was instituted. Twenty-four hours later, full clinical recovery was observed, with return to a normal serum lactate level. The patient was discharged from the intensive care unit on the sixth day. The second patient is a 69 year old male with a past medical history of hypertension, type 2 diabetes mellitus and ischemic heart disease who was on metformin (4 g/day), glycazide, acetylsalicylic acid and isosorbide dinitrate. He was admitted to the emergency department in shock with extreme bradycardia. Initial evaluation revealed severe lactic acidosis and elevated creatinine and urea. The patient was admitted to the Intensive Care Unit and commenced on continuous venovenous hemodiafiltration in addition to other supportive measures. A progressive recovery was observed and he was discharged from the intensive care unit on the seventh day. We present two case reports of severe lactic acidosis most probably associated with high doses of metformin in patients with no known contraindications for metformin prescription. In both patients no other condition was identified to cause such severe lactic acidosis. Although controversial, lactic acidosis should be considered in patients taking metformin." }, { "id": "pubmed23n0783_2102", "title": "How to prevent and treat pharmacological hypoglycemias.", "score": 0.009708737864077669, "content": "A 58 year-old woman with type 2 diabetes diagnosed 3 years before came to our clinic. Her treatment was metformin 850 mg every 12 hours and glimepiride 4 mg every 24 hours. After the initiation of glimepiride 9 months before her weight has increased 5 kg, and she suffers frequent hypoglycemias which have affected her while driving. Her BMI is 35.5 kg/m². She has a normal eye fund exam. She has hypertension treated with telmisartán and hidroclorotiazide with adequate control, and also hypercholesterolemia treated with atorvastatine 40 mg every 24 hours. Her blood test shows an HbA1c of 7.0%, normal values of microalbuminuria, total cholesterol 149 mg/dl, HDL cholesterol 52 mg/dl, LDL cholesterol 98 mg/dl and triglycerides 123 mg/dl. Her blood pressure is 129/81 mmHg, there was no orthostatic hypotension, and her peripheral neurological examination shows normal results. In summary, our case is a young woman with type 2 diabetes and obesity, without chronic complications and which has frequent hypoglycaemia. How must this woman be evaluated and treated?" }, { "id": "wiki20220301en359_15068", "title": "Sitagliptin/simvastatin", "score": 0.009615384615384616, "content": "History In 1991, Merck & Co's simvastatin was approved as an HMG-COA inhibitor to lower the levels of LDL cholesterol. In 2006, Merck & Co's sitagliptin was approved by the FDA for treatment of diabetes mellitus type 2. The patent for simvastatin expired in 2006 and many companies began to create a generic product of simvastatin. By creating a combined-dosage form of simvastatin and sitagliptin, Merck was able to increase their sales of simvastatin while meeting the need of patients who take both simvastatin and sitagliptin. Regulation Juvisync was the first product to combine a cholesterol lowering drug with a type 2 diabetes drug in the same tablet. Due to the potential for patients to need different doses of the two drugs, different dosage strengths were approved. These doses are for sitagliptin/simvastatin of 100 mg/10 mg, 100 mg/20 mg, 100 mg/40 mg, 50 mg/10 mg, 50 mg/20 mg, or 50 mg/40 mg. Nonclinical toxicology" }, { "id": "pubmed23n0303_22147", "title": "Drugs inducing or aggravating parkinsonism: a review.", "score": 0.009615384615384616, "content": "Drug-induced parkinsonism (DIP) is frequent. The list of drugs able to induce parkinsonism is long and probably incomplete, because new drugs, with previously unknown antidopaminergic activity, are constantly being added. Not all the drugs have the same potency for inducing parkinsonism. We classify these drugs in three groups: (1) drugs with obvious antidopaminergic activity which regularly induce parkinsonism; (2) drugs able to induce parkinsonism in particular individuals and (3) drugs which may aggravate Parkinson's disease treated with levodopa. The reports of isolated cases of parkinsonism induced by widely-used drugs (drugs in group 2) may be the result of either an idiosyncratic side effect or a misdiagnosis of parkinsonism. The antidopaminergic activity of the drugs of this group is weak and not sufficiently demonstrated. Maybe, in these cases, the blockage of other neurotransmitters different from dopamine plays a role in the induction of parkinsonism. Probably, the number of patients with DIP is higher than reported or detected, because many patients suffer from weak symptoms that quickly disappear after drug withdrawal. One of the main points of interest is knowing the list, because all these drugs, specially those of group 1, should be avoided or used with caution in the treatment of some common symptomatic problems in patients with Parkinson's disease, such as depression, arterial hypertension, diabetes mellitus and cardiac disorders. The precautions should extent to other populations especially susceptible to suffer from DIP, such as the elderly or patients with other neurodegenerative disorders, such as Alzheimer's disease." }, { "id": "Pharmacology_Katzung_7287", "title": "Pharmacology_Katzung", "score": 0.009553330154188524, "content": "E, Expected; HP, Highly predictable. Interaction occurs in almost all patients receiving the interacting combination; P, Predictable. Interaction occurs in most patients receiving the combination; NP, Not predictable. Interaction occurs only in some patients receiving the combination; NE, Not established. Insufficient data available on which to base estimate of predictability. TABLE 66–1 Important drug interactions. HMG-CoA reductase inhibitors (statins) (cont.) Iron Binds with drugs in gastrointestinal tract, reducing absorption. Levodopa Levodopa degraded in gut prior to reaching sites of absorption. Agents that alter gastrointestinal motility may alter degree of intraluminal degradation. Antiparkinsonism effect of levodopa susceptible to inhibition by other drugs. Lithium Renal lithium excretion sensitive to changes in sodium balance. (Sodium depletion tends to cause lithium retention.) Susceptible to drugs enhancing central nervous system lithium toxicity." }, { "id": "wiki20220301en002_78800", "title": "Substantia nigra", "score": 0.009523809523809525, "content": "Levodopa The substantia nigra is the target of chemical therapeutics for the treatment of Parkinson's disease. Levodopa (commonly referred to as L-DOPA), the dopamine precursor, is the most commonly prescribed medication for Parkinson's disease, despite controversy concerning the neurotoxicity of dopamine and L-DOPA. The drug is especially effective in treating patients in the early stages of Parkinson's, although it does lose its efficacy over time. Levodopa can cross the blood–brain barrier and increases dopamine levels in the substantia nigra, thus alleviating the symptoms of Parkinson's disease. The drawback of levodopa treatment is that it treats the symptoms of Parkinson's (low dopamine levels), rather than the cause (the death of dopaminergic neurons in the substantia nigra). MPTP" }, { "id": "pubmed23n0407_636", "title": "[Hypothyroidism concealed by Parkinson's disease].", "score": 0.009523809523809525, "content": "Although it is commonly recognised that diseases of the thyroids can simulate extrapyramidal disorders, a review of the causes of Parkinsonism in the neurology literature shows that they are not usually mentioned or, if so, only very briefly. The development of hypothyroidism in a patient with Parkinson s disease can go undetected, since the course of both diseases can involve similar clinical features. Generally speaking there is always an insistence on the need to conduct a thyroidal hormone study in any patient with symptoms of Parkinson, but no emphasis is put on the need to continue to rule out dysthyroidism throughout the natural course of the disease, in spite of the fact that the concurrence of both pathological conditions can be high and that, in the same way hypothyroidism can simulate Parkinson s disease, the latter can also conceal hypothyroidism. We report the case of a female patient who had been suffering from Parkinson s disease for 17 years and started to present on off fluctuations that did not respond to therapy. Hypothyroidism was observed and the hormone replacement therapy used to resolve the problem allowed the Parkinsonian fluctuations to be controlled. We believe that it is very wise to suspect hypothyroidism in patients known to be suffering from Parkinson s disease, and especially so in cases where the clinical condition worsens and symptoms no longer respond properly to antiparkinsonian treatment. These observations stress the possible role played by thyroid hormones in dopaminergic metabolism and vice versa." }, { "id": "pubmed23n0936_5704", "title": "Metformin-Associated Lactic Acidosis: A Case Report.", "score": 0.009433962264150943, "content": "A 54-year-old woman with type 2 diabetes mellitus, hypertension, and peripheral vascular disease developed life-threatening lactic acidosis during treatment with metformin for type 2 diabetes. The woman received metformin at 1000 mg orally twice a day for type 2 diabetes. She presented to our emergency department with a 3-day history of severe watery diarrhea, nausea, and vomiting. Her grandson whom she cared for had gastroenteritis several days prior to the onset of her symptoms. She was confused and hypotensive with a blood pressure of 70/39 mmHg. Her initial laboratory findings were remarkable with an arterial blood gas pH 6.57, HCO[Formula: see text] 2 mEq/L, anion gap 30 mmol/L, and lactate 16.3 mmol/L. She was diagnosed with severe lactic acidosis. Metformin was discontinued. Upon arrival in the emergency department, she became unresponsive and experienced a pulseless electrical activity cardiac arrest. After resuscitation, her severe acidemia persisted despite aggressive intervention with volume resuscitation and vasopressors, leading to the initiation of renal replacement therapy. After multiple dialysis treatments, her severe acidemia resolved. Serum metformin concentration from presentation ultimately returned to 42 mcg/mL (therapeutic concentration: 1-2 mcg/mL). She was discharged from the hospital on day 15 without any neurologic complications. A Naranjo assessment score of 8 was obtained, indicating a probable relationship between the patient's lactic acidosis and her use of the suspect drug." }, { "id": "pubmed23n1087_875", "title": "Gout and Levodopa: An unknown adverse effect?", "score": 0.009433962264150943, "content": "We report the case of a 77-year-old man with Parkinson's disease (PD) who experimented for the first time gout crisis after the initiation of levodopa. Levodopa was withdrawn, and colchicine and allopurinol were initiated to treat the gout crisis. Because of PD progression, levodopa was reintroduced, and the patient presented relapse of gout flare. To further explore the association between gout and levodopa, we extracted and synthetized all Individual Case Safety Reports of gout associated with levodopa in the World Health Organization pharmacovigilance database, VigiBase<sup®</sup , up to April 2021. 43 cases of gout were reported in VigiBase<sup®</sup with drugs from N04BA ATC class. Levodopa was suspected in fifteen cases among which improvement was noticed in six cases (two after levodopa withdrawal, two despite treatment continuation, and two cases lacking details about action taken with levodopa); three cases did not recover; in the remaining six cases, evolution was not known. \"Hyperuricemia\" was not mentioned in the Summary of Product Characteristics of medicine containing levodopa; however, \"abnormality biologics test with uric acid\" was mentioned. Despite few cases of recovery after reduced doses of levodopa, the above-described case of positive reintroduction was an argument in favor of the role of levodopa in gout flare. This study highlights a potential association between levodopa and gout through an analysis of the cases reported in the WHO pharmacovigilance database." }, { "id": "wiki20220301en228_18849", "title": "Carbidopa/levodopa/entacapone", "score": 0.009345794392523364, "content": "Carbidopa/levodopa/entacapone may be combined with the drugs rasagiline or selegiline. These drugs are a different type of MAO inhibitor known as selective MAO inhibitors that are often prescribed for Parkinson's disease. Many drug interactions involving selegiline are theoretical, primarily based on interactions with non-selective MAO inhibitors; at oral doses the risk of these interactions may be very low. However, transdermal selegiline, known by its trade name Emsam, is still contraindicated. Transdermal selegiline results in higher plasma levels at which it behaves like a non-selective MAO inhibitor. Concominant use of entacapone, a component of carbidopa/levodopa/entacapone, with MAO inhibitors may increase toxicity of MAO inhibitors. Levodopa, also a component of carbidopa/levodopa/entacapone, in combination with MAO inhibitors may result in hypertensive reactions. Mechanism of action" }, { "id": "pubmed23n0778_15548", "title": "Lump in the throat - a case study.", "score": 0.009345794392523364, "content": "Jack, aged 66 years, presented to his general practitioner with a foreign body sensation in his throat and altered voice, which developed over 30 minutes. He was otherwise well, having no other new symptoms or recent alterations to medication. He had not eaten anything unusual. He had hypertension, type 2 diabetes, stable ischaemic heart disease, urolithiasis and benign prostatic hypertrophy. His regular medication was metformin, rosuvastatin, carvedilol, candesartan (last 5 years) and saxagliptin (last 6 months). He had no allergies but was intolerant of ramipril due to cough. There was no family history of note. On examination he had no itch or rash, or swelling of the tongue, lips, cheek or neck. However, there was oedema of the soft palate and uvula. He was maintaining his airway, saturating at 98%, and his chest was clear. He was afebrile and systemically well." }, { "id": "wiki20220301en124_4202", "title": "Dihydroergocryptine", "score": 0.009259259259259259, "content": "The relatively long half-life and lack of dietary influence of dihydroergocriptine is considered to contribute to the compound's effectiveness in Parkinson's disease, particularly since it allows for more continuous stimulation of brain dopaminergic receptors than short-acting drugs such as levodopa. DHEC is also proven to be a safe and effective in improving symptoms in Parkinson's patients. Motor improvements in Parkinson's patients are usually observed in patients who take at least a mean daily dose of approximately 40 mg. Patients on DHEC demonstrate a better score than if they were on levodopa on the Webster scale, a standardized rating scale of Parkinson's Disease symptoms such as gait parameters and dyskinesia. Another clinical study has shown that DHEC had superior efficacy in reducing the clinical and motorcomplications associated with long-term levodopa use, as well as in reducing the incidence and severity of adverse effects." }, { "id": "wiki20220301en339_16623", "title": "History of Parkinson's disease", "score": 0.009259259259259259, "content": "History of treatments" }, { "id": "wiki20220301en274_19660", "title": "Befiradol", "score": 0.009174311926605505, "content": "Befiradol was discovered and developed by Pierre Fabre Médicament, a French pharmaceuticals company. In September 2013, befiradol was out-licensed to Neurolixis, a California-based biotechnology company. Neurolixis announced that it intends to re-purpose befiradol for the treatment of levodopa-induced dyskinesia in Parkinson's disease. In support of this indication, Neurolixis received several research grants from the Michael J. Fox Foundation and preclinical data was published describing the activity of befiradol in animal models of Parkinson's disease. In January 2018, the British charity Parkinson's UK announced that it had awarded Neurolixis a grant to advance development of befiradol up to clinical phase in Parkinson's disease patients. In March 2019, Neurolixis announced that the US Food and Drug Administration (FDA) gave a positive response to Neurolixis' Investigational New Drug (IND) application for NLX-112 to be tested in a Phase 2 clinical study in Parkinson's disease" }, { "id": "wiki20220301en048_56794", "title": "The Rush Limbaugh Show", "score": 0.009174311926605505, "content": "Michael J. Fox controversy On the October 23, 2006, broadcast of his radio show, Limbaugh imitated on the \"DittoCam\" (the webcam for Web site subscribers to see him on the air) the physical symptoms actor Michael J. Fox showed in a television commercial raising awareness of Parkinson's disease. He said \"[Fox] is exaggerating the effects of the disease. He's moving all around and shaking and it's purely an act ... This is really shameless of Michael J. Fox. Either he didn't take his medication or he's acting.\" Three days later, on October 26, Limbaugh denied that he was ridiculing Fox, stating that, after seeing Fox without his medication, \"I [was] stunned because I [had] never seen Michael J. Fox that way.\" Limbaugh said that he was \"mov[ing] around like [Fox] does, but never once was I making fun of him. I was trying to illustrate for my audience watching on the Dittocam what I had seen.\"" }, { "id": "wiki20220301en103_27595", "title": "Vildagliptin", "score": 0.00909090909090909, "content": "Vildagliptin, sold under the brand name Galvus among others, is an oral anti-hyperglycemic agent (anti-diabetic drug) of the dipeptidyl peptidase-4 (DPP-4) inhibitor class of drugs. Vildagliptin inhibits the inactivation of GLP-1 and GIP by DPP-4, allowing GLP-1 and GIP to potentiate the secretion of insulin in the beta cells and suppress glucagon release by the alpha cells of the islets of Langerhans in the pancreas. Vildagliptin has been shown to reduce hyperglycemia in type 2 diabetes mellitus. Combination with metformin The European Medicines Agency has also approved a combination of vildagliptin and metformin, vildagliptin/metformin (Eucreas by Novartis) as an oral treatment for type-2 diabetes. Adverse effects Adverse effects observed in clinical trials include nausea, hypoglycemia, tremor, headache and dizziness. Rare cases of hepatoxicity have been reported." }, { "id": "wiki20220301en291_41926", "title": "Levodopa-induced dyskinesia", "score": 0.009009009009009009, "content": "In the context of Parkinson's disease (PD), dyskinesia is often the result of long-term dopamine therapy. These motor fluctuations occur in up to 80% of PD patients after 5–10 years of l-DOPA treatment, with the percentage of affected patients increasing over time. Based on the relationship with levodopa dosing, dyskinesia most commonly occurs at the time of peak l-DOPA plasma concentrations and is thus referred to as peak-dose dyskinesia (PDD). As patients advance, they may present with symptoms of diphasic dyskinesia (DD), which occurs when the drug concentration rises or falls. If dyskinesia becomes too severe or impairs the patient's quality of life, a reduction in l-Dopa might be necessary, however this may be accompanied by a worsening of motor performance. Therefore, once established, LID is difficult to treat. Amongst pharmacological treatments, N-methyl-D-aspartate (NMDA) antagonist, (a glutamate receptor), amantadine, has been proven to be clinically effective in a small" }, { "id": "Neurology_Adams_8669", "title": "Neurology_Adams", "score": 0.009009009009009009, "content": "The once-held notion that the administration of l-dopa early in the disease might reduce the period over which it remains effective has been largely dispelled, but some neurologists continue to adhere to this idea. Cedarbaum and colleagues, who reviewed the course of the illness in 307 patients over a 7-year period, found no evidence that the early initiation of l-dopa treatment predisposed to the development of fluctuations in motor response or to dyskinesia and dementia. In fact, the findings of the “Elldopa” trial by The Parkinson Study Group (2004) were that functional and other measures were better in patients who had taken l-dopa for 40 weeks and then stopped the medications than in those who received no medication. This was tentatively taken to endorse the opposite notion, that l-dopa was somehow protective for the progress of disease but the alternative explanation was that the drug had a symptomatic carry over effect after it was stopped. This was addressed further in a trial" }, { "id": "pubmed23n0972_2158", "title": "Which drugs cause treatment-related problems? Analysis of 10,672 problems within the outpatient setting.", "score": 0.008849557522123894, "content": "Treatment-related problems (TRPs) may pose risks for patients if unaddressed. With the increased complexity of health care, it is important to target pharmacists' efforts to patients that are at high risk for TRPs. The present study aimed to identify medications most commonly associated with TRPs. Outpatient departments of five public and teaching hospitals in Jordan. TRPs and drugs most commonly implicated with TRPs were assessed for patients recruited from outpatient clinics in five major hospitals in Jordan using a standardized and validated pharmaceutical care manual. Drugs associated with different types of TRPs. Ultimately, 2,747 patients, with a total of 10,672 TRPs, were included in the study. The medication groups most commonly associated with TRPs were cardiovascular (53.0%), endocrine (18.1%), and gastrointestinal (7.7%) drugs. The most common specific drugs associated with TRPs from any category were atorvastatin (12.5%), metformin (8.5%), simvastatin (6.2%), and enalapril (5.9%). Cardiovascular medications were the most common drugs implicated with multiple subtypes of TRPs - most commonly, allergic reaction or undesirable effect (88.5%), drug product not available (87.3%), safety interaction issues (81.8%), a need for additional or more frequent monitoring (78.0%), and more effective drugs available (77.2%). Hypertension, diabetes mellitus, and dyslipidemia were the most common diseases associated with different subtypes of TRPs. The present study identified high-risk drugs for TRPs, which can be used as identification of targeting approach TRPs. Such an approach would improve care provided to patients and can inform health care policies." }, { "id": "pubmed23n1122_17094", "title": "Parkinson's disease, treatment choice and survival over time.", "score": 0.008849557522123894, "content": "We compared Monoamine oxidase B (MAO-B) - and dopamine agonist (DA) monotherapy patients with respect to survival, considering gender, age, first prescriber's specialty and relevant co-morbidity, and compared their specialist health care contacts and hospitalizations. With data from health registries, we considered 21,047 patients without redemptions for MAO-B, DA or levodopa 6 months prior to their first MAO-B or DA redemption in 2006 and followed them throughout 2016. We considered Cox proportional hazard regression models for comparing the risk of death among MAO-B and DA monotherapy patients. MAO-B-users had a higher mortality than DA-users, [HR: 1.587, 95% CI: 1.056; 2.384] for patients under 74 years. There was an increased mortality risk with increasing age, women had lower risk than men and previous diabetes-, antihypertensive-, and cardiac drug users had higher risk compared to patients without such history. Previous use of hypothyroid drugs and having a specialist as first prescriber were not significant risk factors.Among patients without hospitalizations 13.7% died, while among patients who spent at least one night in hospital 36.73% died. The median duration of a hospitalization among those who died and not were 17.5 and 7 days. Among the small proportion with specialist health care contacts circulatory- and respiratory-system diseases were the most frequent cause of contact. DAs were most frequently given when initiating Parkinson's treatment. DA-users had a lower mortality risk compared to MAO-B-users and less specialist health care contact." }, { "id": "wiki20220301en420_29449", "title": "Neurolixis", "score": 0.008771929824561403, "content": "and Drug Administration (FDA) gave a positive response to Neurolixis' Investigational New Drug (IND) application for befiradol to be tested in a Phase 2 clinical study in Parkinson's disease patients with troublesome Levodopa-induced dyskinesia. Studies published in 2020 using non-human primate models of Parkinson's disease, (MPTP-treated marmosets and MPTP-treated macaques), found that befiradol potently reduced Levodopa-induced dyskinesia at oral doses as low as 0.1 to 0.4 mg/kg." }, { "id": "pubmed23n0387_21894", "title": "Effect of levodopa on orthostatic and postprandial hypotension in elderly Parkinsonian patients.", "score": 0.008771929824561403, "content": "This study describes orthostatic and postprandial hypotension in elderly Parkinsonian patients and evaluates the effect of levodopa therapy on orthostatic and postprandial hypotension in these patients. Seventeen elderly patients with a clinical diagnosis of Parkinson's disease or Parkinsonism based on the U.K. Parkinson's Disease Society Brain Bank criteria (age range, 66-84 years) participated in the study. Blood pressure was continuously monitored during standardized standing and meal tests, after starting 125-mg b.i.d. doses of levodopa/benserazide (Madopar) or placebo, in a double-blind, randomized, cross-over design. Seventeen age- and sex-matched healthy subjects served as controls. Orthostatic hypotension was infrequently found in Parkinsonian patients (13%) and healthy subjects (6%; p =.58, between groups), whereas postprandial hypotension was more frequent in Parkinsonian patients (82%) than in healthy subjects (41%; p &lt;.05, between groups). Doses of levodopa/benserazide, administered 2 times per day, did not result in significantly larger blood pressure decreases after standing or eating, or in higher frequencies of orthostatic or postprandial hypotension in the Parkinsonian group. Postprandial hypotension was related to disease severity (r = -.56, p &lt;.05). Postprandial hypotension, but not orthostatic hypotension, was more common in elderly Parkinsonian patients than in healthy subjects. Therapy with 125-mg b.i.d. doses of levodopa/benserazide did not significantly aggravate orthostatic or postprandial hypotension." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 149, 448 ] ], "word_ranges": [ [ 22, 69 ] ], "text": "The first one would not be correct because although within the age range of multiple sclerosis debut, the presentation is usually gradual over days and the nuclear involvement of the VII cranial nerve (which could simulate a peripheral facial) would not cause dysgeusia, hyperacusis or mastoid pain." }, "2": { "exist": true, "char_ranges": [ [ 0, 148 ] ], "word_ranges": [ [ 0, 22 ] ], "text": "We describe a picture of typical peripheral facial paralysis, with dysgeusia, hyperacusis and mastoid pain. In this case the treatment is corticoid." }, "3": { "exist": true, "char_ranges": [ [ 449, 585 ] ], "word_ranges": [ [ 69, 94 ] ], "text": "In the third answer they propose us that it is a vascular picture and therefore that the facial paralysis is central, so it is discarded" }, "4": { "exist": true, "char_ranges": [ [ 590, 714 ] ], "word_ranges": [ [ 95, 114 ] ], "text": "the last one is not correct because most of the idiopathic peripheral facial paralysis (Bell's palsy) heal without sequelae." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The most probable diagnosis is a demyelinating plaque in the contralateral hemiprotuberance, the most necessary complementary exploration would be a cranial MRI.", "2": "Oral corticosteroids are the treatment of choice for the patient.", "3": "Intravenous fibrinolysis should be considered if the evolution time is less than 3h.", "4": "Most likely the picture is irreversible.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0973_23808", "title": "Paraneoplastic Encephalopathy in a Patient With Metastatic Lung Cancer: A Case Study.", "score": 0.009900990099009901, "content": "<bCASE STUDY</b RS, a 36-year-old female, presented to the emergency department (ED) of a large academic medical center upon the advice of her primary care provider because of 3 weeks of progressive mental status changes, weakness, and decreased oral intake. According to her husband, RS was diagnosed with stage IIIA large cell lung cancer 8 months earlier and was treated with concurrent chemotherapy (carboplatin, pemetrexed, and bevacizumab) and radiation therapy that was completed 4 months prior to admission. No other specific information about her treatment or outside health records was available. According to her husband, RS had been in her usual state of health until approximately 3 weeks prior, when she began having significant mental status changes. She first exhibited some difficulty finding words and later was noted to be putting food in a coffee maker. This spontaneously resolved after approximately 1 week; however, she rapidly developed slurred speech and began to make nonsensical statements. These manifestations also slowly improved but were followed by worsening speech deficit, difficulty walking, and impaired balance. During one of these episodes, she had an occurrence of incontinence. Her husband also noted an incident where her \"eyes were beating back and forth and the left side of her face was twitching.\" RS also had periods (according to her husband) where she \"did not seem to be interacting with her environment.\" These progressively worsened during the last week, and she completely stopped walking and talking 2 days prior to coming to the ED. According to her husband, RS had rheumatoid arthritis and no surgical history. Her family history was unknown except that RS's mother had \"seizures.\" RS had reportedly not used tobacco, alcohol, or drugs, and she was sexually active with her husband. Home medications included transdermal fentanyl 12 μg/hr patch changed every 72 hours; oxycodone-acetaminophen tablets 5-325 mg, two every 4 hours as needed for pain; prednisone 10 mg, one tablet daily; and megestrol 40 mg/mL suspension, 20 mL once daily for appetite stimulation. RS was admitted to an inpatient medical oncology service and evaluated by the oncology advanced practitioner (AP) on her second inpatient day. Upon exam, RS was nonverbal except for moaning in response to painful stimuli and to her sister's voice. Her vital signs were normal. She appeared ill but well-nourished, and she was mildly diaphoretic. Neurologic examination revealed that her pupils were slightly sluggish but equal, round, and reactive to light. Extraocular muscle movements were intact, but she did not move her eyes in response to commands. She tracked the AP and family members around the room with her eyes. Cranial nerve examination was intact with the exception of cranial nerves IX, X, and XI, which were difficult to examine given her inability to cooperate and open her mouth. Motor examination revealed increased tone throughout and intermittent, inconsistent resistance to passive movement. She was seen to move all four extremities spontaneously although not in response to commands. Deep tendon reflexes were intact and equal in all extremities. Examination of other body systems was as follows: there was dry, peeling skin on her lips, but her mucous membranes were moist and free of erythema or lesions. Her lungs were clear to auscultation bilaterally. Her heart rate and rhythm were regular, there were no murmurs, rubs, or gallops, and distal pulses were intact. Her abdomen was nondistended with normally active bowel sounds in all four quadrants. Her abdomen was soft, nontender to palpation, and without palpable masses. There was no peripheral discoloration, temperature changes, or edema, and examination of her skin was benign. <bWorkup</b On admission to the emergency department, serum laboratory studies were unrevealing for any potential causes of encephalopathy. Kidney and liver function were normal, making diagnoses of uremic and hepatic encephalopathies less likely. Cultures of the urine and blood were negative. Samples of cerebrospinal fluid (CSF) were obtained via lumbar puncture and were unrevealing for any abnormalities. Computed tomography (CT) of the head without contrast was negative for any acute intracranial process. Ultrasound of the right upper quadrant revealed a single, nonspecific, hypoechoic hepatic lesion. Computed tomography scans of the chest, abdomen, and pelvis demonstrated the primary malignancy in the upper lobe of the left lung, as well as possible metastatic disease within the left lung, right lung, and liver, and widespread osseous metastatic disease. Magnetic resonance imaging (MRI) of the brain performed 1 day after admission demonstrated numerous scattered punctate foci of enhancement throughout the supratentorial and infratentorial brain parenchyma, measuring at most 3 to 4 millimeters in diameter. There was no significant mass effect or midline shift. A paraneoplastic panel was sent to an outside laboratory and returned positive for antivoltage-gated potassium channel (VGKC) autoantibodies. <bDifferential Diagnosis</b Clinically, RS was exhibiting signs of encephalopathy, a broad term that indicates general brain dysfunction, the hallmark of which is altered mental status. Diagnosing encephalopathy is challenging, as many differential diagnoses must be considered. The clinician must consider metabolic derangements, toxic and infectious etiologies, psychiatric disorders, and less commonly, prion disorders and progressive dementia. Cultures of RS's blood and urine as well as other specialized endocrine tests were negative, decreasing the likelihood of a metabolic or infectious cause for her presentation. The abnormalities on her brain MRI were reviewed by a neuro-oncology team, who felt that the faint, nondescript nature of the visualized lesions was not suspicious for metastatic disease. Sequelae of seizures was also considered by neuro-oncology but dismissed given a grossly normal prolonged electroencephalogram. Some encephalopathies are caused by autoimmune or inflammatory mechanisms, which are confirmed by the presence of autoantibody markers and/or clear response to immunomodulatory treatment (Vernino, Geschwind, &amp; Boeve, 2007). These types of encephalopathies have been seen in patients with cancer and have thus been termed paraneoplastic. The presence of anti-VGKC antibodies on RS's paraneoplastic panel directed the inpatient medical oncology team toward a paraneoplastic neurologic disorder (PND) as the most likely diagnosis." }, { "id": "pubmed23n1111_11183", "title": "A Case of Steroid-Associated Expressive Aphasia.", "score": 0.009900990099009901, "content": "Expressive aphasia (non-fluent aphasia) is characterized by the inability to produce words or sentences. The most common cause of expressive aphasia is stroke, usually due to thrombus or emboli in the middle cerebellar artery or internal carotid artery affecting Broca's area. We present an important, reversible, and previously undescribed cause of a purely expressive aphasia secondary to steroid use. A case of a steroid-induced expressive aphasia has not yet been described in the medical literature. Recognition of this presentation is critical to appropriate therapy and excess morbidity, particularly as steroid (dexamethasone) utilization has increased since the COVID-19 pandemic." }, { "id": "pubmed23n0911_9004", "title": "A case of neuropsychiatric lupus Erythematosus characterized by the Owl's eye sign: a case report.", "score": 0.00980392156862745, "content": "Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disorder characterized by multiple affected systems. More than half of SLE patients will suffer from neuropsychiatric lupus erythematosus (NPSLE) during the course of their disease. Although nearly half of the NPSLE patients have normal MRI manifestations, the abnormalities found in the remainder can be located anywhere in the brain, and especially in the subcortical white matter of the frontal and temporal lobe. However, NPSLE involving the medulla oblongata and spinal cord which presents as the \"owl's eye\" sign has to our best knowledge not been reported to date. A 19-year-old girl presented at our hospital with a 7-day history of fever and headache since a one day's exertion, accompanied by 2 days of weakness. The patient had slurred speech. Neurological examination revealed the presence of horizontal nystagmus and a limitation of bilateral eye movement when looking up and down. At the same time, she showed difficulty in raising the jaw, accompanied by a weak pharyngeal reflex. Muscle strength was remarkably decreased in all four extremities: the MRCS grade of the upper limbs was 4/5, while in the lower limbs it was 0/5. Hypotonia was apparent in the lower extremities. Regarding subjective sensation, the patient appeared to be experiencing an increased sense of pain in the whole body, and especially in the cervical region, abdomen, and feet. An examination of shallow reflex documented the reinforcement of the abdominal reflex. Deep tendon reflexes were symmetric: absent in lower, normal in upper extremities. The patient also had a stiff neck with a positive Kernig's sign. The laboratory examination showed elevated C - reactive protein and rheumatoid factor, as well as complement components 3 and 4. Symptomatic treatments were applied, but she did not respond well, after which we did immunological laboratory examinations. The results showed the presence of anti-nRNP/Sm, anti-dsDNA and anti-AMA M2 antibodies. An MRI scan and enhancement of the cervical and thoracic regions displayed abnormal signs in the medulla and bilateral anterior horn of the lower thoracic spine. Following the exclusion of other possible diseases, neuropsychiatric lupus was diagnosed. High-dose intravenous gamma-globulin combined with methylprednisolone gradually improved her condition. We report the first case of NPSLE presenting with medulla oblongata and spinal cord involvement, manifesting as the \"owl's eye\" sign in MRI." }, { "id": "pubmed23n0510_4987", "title": "[The importance of neurological examinations in the age of the technological revolution].", "score": 0.00980392156862745, "content": "Neurologic practice and care have been modified in many important ways during the past ten years, to adapt to the explosion of new information and new technology. Students, residents and practicing physicians have been continuing programs to a model that focuses almost exclusively on the applications to neurologic disorders of the new knowledge obtained from biomedical research. On the other hand high demand for outpatient neurologic care prevents adequate patient's evaluation. Case 1: 65 years old female. Occipital headache diagnosed of tensional origin (normal computerized tomography). Two months later is re-evaluated due to intractable pain and hypoglossal lesion. An amplified computerized tomography revealed a occipital condyle metastasis. Case 2: 21 years old female. Clinical suspicion of demyelinating disease due to repeated facial paresis and sensitive disorder. General exploration and computerized tomography revealed temporo-mandibular joint. Case 3: 60 years old female. Valuation of anticoagulant therapy due to repeated transient ischemic attacks. She suffered from peripheral facial palsy related to auditory cholesteatoma. Neurologic education is nowadays orientated to new technologies. On the other hand, excessive demand prevents adequate valuation and a minute exploration is substituted by complementary evaluations. These situations generate diagnostic mistakes or iatrogenic. It would be important a consideration of the neurologic education profiles and fulfillment of consultations time recommendations for outpatients care." }, { "id": "wiki20220301en025_36555", "title": "Lateral medullary syndrome", "score": 0.009708737864077669, "content": "Lateral medullary syndrome is a neurological disorder causing a range of symptoms due to ischemia in the lateral part of the medulla oblongata in the brainstem. The ischemia is a result of a blockage most commonly in the vertebral artery or the posterior inferior cerebellar artery. Lateral medullary syndrome is also called Wallenberg's syndrome, posterior inferior cerebellar artery (PICA) syndrome and vertebral artery syndrome. Signs and symptoms This syndrome is characterized by sensory deficits that affect the trunk and extremities contralaterally (opposite to the lesion), and sensory deficits of the face and cranial nerves ipsilaterally (same side as the lesion). Specifically a loss of pain and temperature sensation if the lateral spinothalamic tract is involved. The cross body finding is the chief symptom from which a diagnosis can be made." }, { "id": "pubmed23n0585_12893", "title": "[Really drunk?].", "score": 0.009708737864077669, "content": "We report about a 42-year-old patient who was admitted to the emergency department because of suspected alcohol abuse. He declared himself to be drunk. He stated in his case history that he had suffered from right sided neck and facial pain for several days. The clinical examination revealed a left sided hemiparesis. Together with the demonstrated right hemispherical brain ischemia by computed tomography, a presumptive diagnosis of a dissection of the right internal carotid artery was made. This diagnosis was finally confirmed by ultrasound and magnetic resonance imaging. A therapy with full dose heparin was begun and oral anticoagulation was subsequently initiated. After two weeks of follow-up, the neurological deficiencies were partially regredient." }, { "id": "pubmed23n1048_8012", "title": "Morbihan Disease - An Old and Rare Entity Still Difficult to Treat.", "score": 0.009615384615384616, "content": "Morbihan disease (MD), also known as Morbihan syndrome, \"solid persistent facial edema and erythema\", \"rosacea lymphedema\", and \"solid facial edema in acne\", is a rare and often unrecognizable entity, that presents with a slow occurrence of persistent lymphoedema of the upper two-thirds of the face (1,2). A 30-year-old woman presented to our Department with persistent, asymptomatic face edema and erythema lasting for 18 months. She was previously treated for rosacea with doxycycline (100 mg/day for four months) without improvement. Dermatological examination revealed erythematous, nonpitting, solid edema located on the mid-forehead, nose, and cheeks with sparse erythematous papules and pustules on the entire face including the chin and comedones, papules, and pustules on the back (Figure 1 and Figure 2). She was otherwise healthy and was not taking any medication. Laboratory tests with immunological tests and Quantiferon test together with MRI of the orbits, chest X-ray, chest high-resolution computed tomography, cranial X-ray, and abdominal ultrasound were all within normal limits. Histopathology revealed dermal edema, perivascular and peri-adnexal lymphohistiocytic infiltrate, and sebaceous gland hyperplasia. Based on the typical clinical picture, histopathological findings, and the exclusion of several differentials the diagnosis of MD was established. The patient was treated with oral isotretinoin (20 mg/day for eight months) without regression of solid edema and erythema on the face but with complete regression of acne on the trunk. She was started on oral corticosteroids (prednisolone, 20 mg/day for two months followed by reduction of the dose over three months), again with only slight short transient improvement and rapid relapse of facial erythema and edema. The patient refused any other suggested treatment. We treated our patient for a total 2 years and followed up for 5 years. The pathogenesis of MD is still unknown. It is considered a clinical variety or a complication of rosacea or acne which does not tend to regress spontaneously. It is believed that chronic inflammation in patients with MD is due to acne or rosacea causing structural damage to blood and lymph vessels (1,3,4). However, cases of MD without previous history of rosacea and acne have been reported supporting the distinct disease theory (3,4). Edema and erythema are localized on the upper half of the face affecting the forehead, glabella, eyelids, nose, and cheeks. Although the symptoms may come and go, MD usually does not improve without treatment (5). Several therapeutic options have been reported, although there is no established standard treatment for MD. Reported therapy includes short-term oral isotretinoin (0.5 mg/kg/day), long-term oral isotretinoin (40-80 mg/day, 10-24 months), long-term doxycycline, combination of systemic corticosteroids and antibiotic (prednisolone 20 mg/day for 2 weeks and doxycycline 200 mg/day for 12 weeks), slow-releasing doxycycline monohydrate (40 mg/day for 6 months), long-term minocycline (50 mg/day for 4 months), and a combination of both oral retinoid and ketotifen (isotretinoin 0.7 mg/kg/day for 4 months, ketotifen 2 mg/day for 4 months) (1,2,6,8). The disease is frequently recalcitrant to therapy, and only several cases of successfully treated patients with MD have been reported (1,2,4, 6-8). We presented a patient with characteristic features of MD, which is a persistent, cosmetically disturbing condition, unfortunately mostly refractory to therapeutic measures." }, { "id": "Neurology_Adams_1347", "title": "Neurology_Adams", "score": 0.009615384615384616, "content": "The transient neurologic deficits were mainly sensorimotor, often involving the hand and lips, and aphasia; only 6 patients had visual symptoms. The patients were asymptomatic between attacks and in none did the entire illness persist beyond 7 weeks. We have observed several cases, all in otherwise healthy middle-aged men and we found corticosteroids to be helpful." }, { "id": "wiki20220301en157_31899", "title": "Brown-Séquard syndrome", "score": 0.009523809523809525, "content": "In addition, if the lesion occurs above T1 of the spinal cord it will produce ipsilateral Horner's syndrome with involvement of the oculosympathetic pathway. Diagnosis Magnetic resonance imaging (MRI) is the imaging of choice in spinal cord lesions. Brown-Séquard syndrome is an incomplete spinal cord lesion characterized by findings on clinical examination which reflect hemisection of the spinal cord (cutting the spinal cord in half on one or the other side). It is diagnosed by finding motor (muscle) paralysis on the same (ipsilateral) side as the lesion and deficits in pain and temperature sensation on the opposite (contralateral) side. This is called ipsilateral hemiplegia and contralateral pain and temperature sensation deficits. The loss of sensation on the opposite side of the lesion is because the nerve fibers of the spinothalamic tract (which carry information about pain and temperature) crossover once they meet the spinal cord from the peripheries." }, { "id": "pubmed23n0747_17145", "title": "[Bilateral ageusia caused by right thalamic infarction].", "score": 0.009523809523809525, "content": "A 58-year-old man noticed left hemiparesis at 01:00 pm on a particular day in March 2006. Because his symptoms developed gradually, he was referred to the emergency room of our hospital at 05:00 pm and was admitted with the diagnosis of cerebral infarction. While he presented slight left hemiparesis involving the face, impairment of sensation was not apparent. Diffusion-weighted magnetic resonance imaging of the head showed a high-intensity area in the ventromedial area in the right thalamus. The patient was treated with anticoagulant and edaravone, and his symptoms resolved on hospital day 3. When he began eating, he noticed that he was unable to distinguish tastes. On day 5, we performed taste examination using a commercial kit. The taste sensation on both sides of his tongue was severely affected, while the touch sensations in the mouth and olfaction were preserved. His symptoms improved spontaneously and resolved on hospital day 15. This is the second case report of bilateral ageusia caused by right thalamic infarction. Our study indicates the importance of the right thalamus in taste sensation involving both sides of the tongue." }, { "id": "Neurology_Adams_11036", "title": "Neurology_Adams", "score": 0.009460654288240495, "content": "The onset of Bell’s palsy is acute; about one-half of cases attain maximum paralysis in 48 h and practically all within 3 or 4 days. Pain behind the ear may precede the paralysis by a day or two and in a few patients is intense and persistent. Although a report by the patient of fullness or numbness in the face is common, in a small number there is hypesthesia in 1 or more branches of the trigeminal nerve. The explanation of this finding is not clear. Impairment of taste is present in most patients but it rarely persists beyond the second week of paralysis. This indicates that the lesion has extended proximal to the point at which the chorda tympani joins the facial nerve. Hyperacusis or distortion of sound is then experienced in the ipsilateral ear and, as mentioned, indicates paralysis of the stapedius muscle." }, { "id": "wiki20220301en001_38826", "title": "Optic neuritis", "score": 0.009433962264150943, "content": "When an inflammatory recurrent optic neuritis is not demyelinating, it is called \"Chronic relapsing inflammatory optic neuropathy\" (CRION) When it is anti-MOG related, it is demyelinating and it is considered inside the anti-MOG associated inflammatory demyelinating diseases. Some reports point to the possibility to establish a difference via OCT Treatment In most MS-associated optic neuritis, visual function spontaneously improves over 2–3 months, and there is evidence that corticosteroid treatment does not affect the long term outcome. However, for optic neuritis that is not MS-associated (or atypical optic neuritis) the evidence is less clear and therefore the threshold for treatment with intravenous corticosteroids is lower. Intravenous corticosteroids also reduce the risk of developing MS in the following two years in patients with MRI lesions; but this effect disappears by the third year of follow up." }, { "id": "pubmed23n0400_18462", "title": "[Opercular syndrome of vascular aetiology].", "score": 0.009433962264150943, "content": "Facio linguo masticatory paralysis resulting from bilateral lesion of the anterior opercular region, known today as Foix Chavany Marie syndrome, appears very frequently in adult patients as a consequence of generally ischemic vascular lesions, which directly affect the Rolandic opercula or the subcortical area surrounding them. However, forms that are secondary to infections, neoplasias and even unilateral lesions have been reported. Female patient, aged 70, with unknown auricular fibrillation, which started suddenly with right faciobrachial paresis secondary to a left striated ischemic infarction. Approximately 24 hours after beginning intravenous heparinization, the patient presents anarthria, facial hypomimia without asymmetries, dysphagia above all for liquids and bilateral lingual paresis. Extraoccular movements, blinking and corneal reflex were normal. Understanding of spoken and written language was maintained and there were no apraxias or agnosias. Neurological exploration was compatible with an opercular syndrome (OS). Urgent brain CT revealed the existence of a right cortiico subcortical temporal haemorrhage, in addition to the prior contralateral ischemia. The association of both lesions, ischemic and haemorrhagic, mirrored, justified all the symptomatology. Anterior OS is characterised by a bilateral voluntary central paresis of the muscles innervated by the 5th, 7th, 9th, 10th and 12th cranial pairs with preservation of emotional or automatic mobility. Underlying mechanisms are also discussed." }, { "id": "pubmed23n1099_18582", "title": "Spontaneous spinal epidural abscess in pregnancy: a case series.", "score": 0.009345794392523364, "content": "Spontaneous spinal epidural abscess (SEA) is a rare diagnosis; only eight cases have been reported during pregnancy. Diagnosis of SEA can be difficult, especially when the classic triad of fever, back pain, and neurologic deficits are not present. Early diagnosis and treatment are necessary to reduce potential morbidity and mortality. We report two separate cases of SEA in pregnancy and summarize the existing literature. Case 1: A 20-year-old G1P0 presented at 35-week gestation with low back pain and lower extremity (LE) weakness. Magnetic resonance imaging (MRI) revealed thoracic SEA. The patient underwent cesarian delivery followed by posterior thoracic laminectomy and fusion (T9-11), abscess decompression, and antibiotic therapy. Unfortunately, there was a recurrence of her infection requiring a second irrigation and debridement 1 month after index procedure. At final follow-up, the patient had complete neurologic recovery. Case 2: A 38-year-old G10P0 presented at 36-week gestation in labor with LE weakness and difficulty ambulating. After delivery, she had significant LE neurologic deficits. MRI demonstrated thoracic osteodiscitis with associated epidural abscess. She underwent thoracic laminectomy and fusion (T7-12), abscess decompression, and antibiotic therapy. Unfortunately, despite aggressive treatment, she has persistent LE neurologic deficits. Pregnancy complicates the diagnosis and treatment strategies of SEA: back pain is very commonly underestimated, especially in the absence of fever and gross neurologic deficits. Prompt diagnosis and treatment are paramount to prevent neurologic decline and facilitate recovery. It is important to perform a focused physical exam noting motor strength, sensation, and reflexes. Coordinated management between the Emergency Department, OB-GYN, and spinal surgery team is required for best possible patient outcomes. Typically, management consists of aggressive surgical decompression and antibiotic therapy." }, { "id": "pubmed23n0364_22126", "title": "[A case of ipsilateral ageusia, sensorineural hearing loss and facial sensorimotor disturbance due to pontine lesion].", "score": 0.009345794392523364, "content": "We report a 58-year-old woman with pontine lesion presented with subacute onset of unilateral gustatory disturbance accompanied by facial numbness, and hearing loss. Neurologic examination revealed superficial hypesthesia and paresthesia on the right side of the face, right peripheral type facial paresis, ageusia on the right half of the tongue and right sensorineural deafness. No other neurologic signs were observed, and laboratory data were all normal. Brain MRI revealed a small lesion in the right dorsolateral tegmentum of the middle pons. Electrogustometry showed marked reduction in the sense of taste on the right half of the tongue. ABR showed diminished amplitude in the IV-V wave of the right side, while SEP and VEP were normal. The clinical diagnosis was demyelinating lesion and intravenous methylprednisolone (1 g/day) was administered for 3 consecutive days, resulting in prompt improvement in the symptoms. The lesion was suspected of affecting ipsilateral side of the spinal trigeminal nerve tract and the nucleus, the intraaxial infranuclear facial nerve fiber, the lateral lemniscus adjacent to the superior olivary nucleus and the central gustatory tract. Our case suggests that the central gustatory pathway projecting from the nucleus of the solitary tract to the parabrachial nucleus, presumed to be pontine taste area, ascends ipsilaterally and is located laterally from the medial lemniscus." }, { "id": "pubmed23n0750_8582", "title": "Brown-Séquard syndrome in a 11-year-old girl due to penetrating glass injury to the thoracic spine.", "score": 0.009259259259259259, "content": "Injuries in children are one of the most frequent causes of high morbidity and mortality, and they present a challenge to the treating physician. Fortunately, spinal trauma in pediatric patient is relatively rare. Brown-Séquard syndrome is a rare form of incomplete spinal cord injury consisting of ipsilateral upper motor neuron paralysis (hemiplegia) and loss of proprioception with contralateral pain and temperature sensation deficits resulting from hemisection or lateral injury to the spinal cord. A 11-year-old girl was admitted to our Pediatric Trauma Emergency Department after she had suffered a penetrating back injury. Neurological examination demonstrated left lower extremity paresis and moderate spastic paralysis of the right lower extremity. The examination showed loss of temperature sensation contralateral to and below the lesion. The examination of the pain sensation was difficult because the patient was in pain shock, but it was diminished on the side opposite to the damage. Multislice spiral computed tomography (MSCT) demonstrated a triangular foreign body in spinal canal at the level of the Th11-Th12. After a Th11-L2 laminectomy and retrieval of foreign bodies, dura repair was performed. Patient was discharged from the hospital with partial recovery. Operative decompression of the neural elements in case of spinal canal compromise is the treatment of choice. Indication for surgical intervention in existing cerebrospinal fluid fistula includes closure of the dura and reducing neural elements compression and lowering the risk of infectious complications by removing bone or foreign body fragments. Patients with Brown-Séquard syndrome have good prognosis for functional recovery. " }, { "id": "wiki20220301en049_27560", "title": "The Brain of Morbius", "score": 0.009259259259259259, "content": "of Radio Times awarded it five stars out of five. He noted that Solon's insistence that he only use the Doctor's head was \"a fundamental lapse in logic\", but otherwise said that the serial was \"a salivating treat\". The A.V. Club reviewer Christopher Bahn found some minor problems in the script, but gave a positive review of the story, pointing out how it did not rip off classic stories but repurposed them. DVD Talk's David Cornelius gave the serial four out of five stars, saying that it \"allows for a wide range of storytelling tones without feeling cluttered or uneven\", though at points the \"silliness\" of the Morbius costume threatened to \"overtake\" the story." }, { "id": "pubmed23n0876_17161", "title": "Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl.", "score": 0.009174311926605505, "content": "Trichotillomania (TTM) is defined by the Diagnostics and Statistic Manual of Mental Disorders, 4th edition (DMS-IV) as hair loss from a patient`s repetitive self-pulling of hair. The disorder is included under anxiety disorders because it shares some obsessive-compulsive features. Patients have the tendency towards feelings of unattractiveness, body dissatisfaction, and low self-esteem (1,2). It is a major psychiatric problem, but many patients with this disorder first present to a dermatologist. An 11-year-old girl came to our department with a 2-month history of diffuse hair loss on the frontoparietal and parietotemporal area (Figure 1). She had originally been examined by a pediatrician with the diagnosis of alopecia areata. The patient`s personal history included hay fever and shortsightedness, and she suffered from varicella and mononucleosis. Nobody in the family history suffered from alopecia areata, but her father has male androgenetic alopecia (Norwood/Hamilton MAGA C3F3). The mother noticed that the child had had changeable mood for about 2 months and did not want to communicate with other persons in the family. The family did not have any pet at home. At school, her favorite subjects were Math and Computer Studies. She did not like Physical Education and did not participate in any sport activities during her free time. This was very strange because she was obese (body-mass index (BMI) 24.69). She was sometimes angry with her 13-year-old sister who had better results at school. The girl had suddenly started to wear a blue scarf. The parents did not notice that she pulled out her hair at home. Dermatological examination of the capillitium found a zone of incomplete alopecia in the frontoparietal and parietotemporal area, without inflammation, desquamation, and scaring. Hairs were of variable length (Figure 1). There was a patch of incomplete alopecia above the forehead between two stripes of hair of variable length (Figure 2). The hair pull test was negative along the edges of the alopecia. Mycological examination from the skin capillitium was negative. The trichoscopy and skin biopsy of the parietotemporal region of the capillitium (Figure 3) confirmed trichotillomania. Laboratory tests (blood count, iron, ferritin, transferrin, selenium, zinc, vitamin B12, folic acid, serology and hormones of thyroid gland) were negative. We referred the girl for ophthalmologic and psychological examination. Ophthalmologic examination proved that there was no need to add any more diopters. The psychological examination provided us with a picture in which she drew her family (Figure 4). The strongest authority in the family was the mother because she looked after the girls for most of the day. She was in the first place in the picture. The father had longer working hours and spent more time outside the home. He worked as a long vehicle driver. He was in the second place in the picture. There was sibling rivalry between the girls, but the parents did not notice this problem and preferred the older daughter. She was successful at school and was prettier (slim, higher, curly brown hair, without spectacles). Our 11-years-old patient noticed all these differences between them, but at her level of mental development was not able to cope with this problem. She wanted to be her sister's equal. The sister is drawn in the picture in the third place next to father, while the patient's own figure was drawn larger and slim even though she was obese. Notably, all three female figures had very nice long brown hair. It seemed that the mother and our patient had better quality of hair and more intense color than the sister in the drawing. The only hairless person in the picture was the father. The girl did not want to talk about her problems and feelings at home. Then it was confirmed that our patient was very sensitive, anxious, willful, and withdrawn. She was interested in her body and very perceptive of her physical appearance. From the psychological point of view, the parents started to pay more interest to their younger daughter and tried to understand and help her. After consultation with the psychiatrist, we did not start psychopharmacologic therapy for trichotillomania; instead, we started treatment with cognitive behavioral therapy, mild shampoo, mild topical steroids (e.g. hydrocortisone butyrate 0.1%) in solution and methionine in capsules. With parents' cooperation, the treatment was successful. The name trichotillomania was first employed by the French dermatologist Francois Henri Hallopeau in 1889, who described a young man pulling his hair out in tufts (3-5). The word is derived from the Greek thrix (hair), tillein (to pull), and mania (madness) (5). The prevalence of TTM in the general adult population ranges from 0.6% to 4%, and 2-4% of the general psychiatric outpatient population meet the criteria for TTM (2-5). The prevalence among children and adolescents has been estimated at less than 1% (5). The disease can occur at any age and in any sex. The age of onset of hair pulling is significantly later for men than for women (3). There are three subsets of age: preschool children, preadolescents to young adults, and adults. The mean age of onset is pre-pubertal. It ranges from 8 to 13 years (on average 11.3 years) (2-5). The occurrence of hair-pulling in the first year of life is a rare event, probably comprising &lt;1% of cases (5). The etiology of TTM is complex and may be triggered by a psychosocial stressor within the family, such as separation from an attachment figure, hospitalization of the child or parent, birth of a younger sibling, sibling rivalry, moving to a new house, or problems with school performance. It has been hypothesized that the habit may begin with \"playing\" with the hair, with later chronic pulling resulting in obvious hair loss (2). Environment is a factor because children usually pull their hair when alone and in relaxed surroundings. The bedroom, bathroom, or family room are \"high-risk\" situations for hair-pulling (5). Men and women also differed in terms of the hair pulling site (men pull hair from the stomach/back and the moustache/beard areas, while women pull from the scalp) (3). Pulling hair from siblings, pets, dolls, and stuffed animals has also been documented, often occurring in the same pattern as in the patient (5). Genetic factors contributing to the development of TTM are mutations of the SLITRK1 gene, which plays a role in cortex development and neuronal growth. The protein SAPAP3 has been present in 4.2% of TTM cases and patients with obsessive-compulsive disorder (OCD). It may be involved in the development of the spectrum of OCD. A significantly different concordance rate for TTM was found in monozygotic (38.1%) compared with dizygotic (0%) twins in 34 pairs (3). The core diagnostic feature is the repetitive pulling of hairs from one`s own body, resulting in hair loss. The targeted hair is mostly on the scalp (75%), but may also be from the eyebrows (42%), eyelashes (53%), beard (10%), and pubic area (17%) (3,5). There are three subtypes of hair pulling - early onset, automatic, and focused. Diagnostic criteria for TTM according to DSM-IV criteria are (2,3,5): 1) recurrent pulling of one`s hair resulting in noticeable hair loss; 2) an increasing sense of tension immediately prior to pulling out the hair or when attempting to resist the behavior; 3) pleasure, gratification, or relief when pulling out the hair; 4) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition); 5) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The differential diagnosis includes alopecia areata (Table 1) (6), tinea capitis, telogen effluvium, secondary syphilis, traction alopecia, loose anagen syndrome, lichen planopilaris, alopecia mucinosa, and scleroderma (2-5). Biopsy of an involved area (ideally from a recent site of hair loss) can help to confirm the diagnosis (5). On histologic examination, there are typically increased numbers of catagen and telogen hairs without evidence of inflammation. Chronic hair pulling induces a catagen phase, and more hairs will be telogen hairs. Pigment casts and empty anagen follicles are often seen. Perifollicular hemorrhage near the hair bulb is an indicator of TTM (2). Complications of TTM are rare, but they comprise secondary bacterial infections with regional lymphadenopathy as a result of picking and scratching at the scalp. Many patients play with and ingest the pulled hairs (e.g. touching the hair to lips, biting, and chewing). Trichophagia (ingestion of the hair) can lead to a rare complication named trichobezoar (a \"hair ball\" in stomach). This habit is present in approximately 5% to 30% of adult patients, but it is less frequent in children. Patient with trichophagia present with pallor, nausea, vomiting, anorexia, and weight loss. Radiologic examination and gastroscopy should not be delayed (2,4,5). The management of the disease is difficult and requires strong cooperation between the physician, patient, and parents. The dermatologist cannot take part in the therapy, strictly speaking, but without the psychological, psychopharmacologic, and topic dermatologic treatment a vicious circle will be perpetuated. " }, { "id": "wiki20220301en191_10300", "title": "Bertha Pappenheim", "score": 0.009174311926605505, "content": "Throughout the two years of her illness, she developed a wide spectrum of symptoms: Language disorders (aphasia): on some occasions she could not speak at all, sometimes she spoke only English, or only French, or Italian. She could however always understand German. The periods of aphasia could last for days, and sometimes varied with the time of day. Neuralgia: she suffered from facial pain which was treated with morphine and chloral and led to addiction. The pain was so severe that surgical severance of the trigeminus nerve was considered. Paralysis (paresis): signs of paralysis and numbness occurred in her limbs, primarily on only one side. Although she was right-handed, she had to learn to write with her left hand because of this condition. Visual impairments: she had temporary motor disturbances in her eyes. She perceived objects as being greatly enlarged and she squinted." }, { "id": "pubmed23n1117_25863", "title": "Acupuncture Therapies for Addressing Post Odontectomy Neuropathy.", "score": 0.00909090909090909, "content": "<bBackground:</b Third-molar extraction is a common oral surgical procedure that can cause complications. Although rare, nerve injuries that result in permanent neuropathy can occur and include a variety of complaints such as sensory disorders, taste-sensation disorders, speech articulation disorders, etc. Acupuncture is one of several nonpharmacologic therapies that has played a role in managing neuropathic lesions and has been proven to produce good results. <bCase:</b A 44-year-old woman with postodontectomy neuropathy developed paresthesia, dysarthria, xerostomia, dysgeusia, pain in the gums and lower right jaw, a chewing disorder, and cephalgia. Her numerical rating scale (NRS) results were: lower right gum pain, 3/10; numbness of the tongue, 4/10; and headache, 1/10. A physical examination revealed dysarthria, a decreased sense of sharpness and dullness in the right mandibular nerve branches, decreased right masseter muscle contractions, and tenderness on the right GB 20 point. Electromyography revealed partial functional lesions in the postganglion at the right fifth cranial nerve. She had body acupuncture therapy at GV 20, GB 20, ST 5, ST 6, ST 7, CV 23, LI 4, HT 5, ST 36, LU 7, and KI 6; ear acupuncture at the Parotid and <iShenmen</i points; and treatment with the Tan Balance Method. <bResults:</b After 3 consecutive sessions of acupuncture therapy, this patient's symptoms were reduced. <bConclusions:</b Acupuncture was helpful for reducing paresthesia, dysarthria, xerostomia, dysgeusia, gum and lower right jaw pain, a chewing disorder, and cephalgia in this patient with postodontectomy neuropathy. Clinical trials are needed to support the findings in this case." }, { "id": "Neurology_Adams_3359", "title": "Neurology_Adams", "score": 0.00909090909090909, "content": "The first step in diagnosis is to recognize that the patient is confused. This is obvious in most cases but, as pointed out earlier, the mildest forms, particularly when some other alteration of personality is prominent, may be overlooked. Sometimes, the patient’s attention can be best engaged by speaking softly or whispering rather than shouting or using a conversational amplitude of voice. A subtle disorder of orientation may be betrayed by an incorrect response regarding dates (off by more than one day of the month or day of the week), or in misnaming the hospital. The ability to retain a span of digits forward (normally 7) and backward (normally 5), spelling a word such as “world” or “earth” forward and then backward, reciting the months of the year in their reverse order, and serial subtraction of 3s from 30 or 7s from 100 are useful bedside tests of the patient’s capacity for attentiveness and sustained mental activity, though some of these presuppose that the patient is" }, { "id": "pubmed23n0970_2857", "title": "Spontaneous spinal epidural hematoma mimicking Guillain-Barre Syndrome.", "score": 0.009009009009009009, "content": "The initial symptoms of Guillain-Barre Syndrome (GBS) can be similar to a case of spontaneous spinal epidural hematoma (SSEH) located at the cervicothoracic junction. Therefore, SSEH may be misdiagnosed as GBS. A previously healthy 6-year-old girl presented with a 2-day history of progressive pain in the lower extremities and an inability to walk. On initial evaluation, she was completely paraparetic in the lower extremities. Deep tendon reflexes were absent in the lower extremities, and Babinski reflexes were positive on both sides. She exhibited reduced response to light touch and pinprick with a sensory level below T10, and experienced difficulty during urination. However, the strength, sensation and flexion of upper extremities were normal. Because her presentation and examinations were consistent with GBS, we initiated intravenous immunoglobulin therapy. The next day, she also developed pain and muscle weakness of the right upper extremity. Three days after admission, respiratory depression progressed rapidly. Spinal MRI showed a mass extending from the level of C7-T3, with spinal cord compression. The patient underwent an emergency laminectomy with evacuation of hematoma, and was diagnosed with SSEH. Sixty days after admission, she was transferred to the rehabilitation hospital with severe neurologic sequelae of paralysis in both legs. SSEH might have severe consequences, including neurologic deficits and risk of death. This case report serves to raise the awareness of SSEH that mimics the initial presentation of GBS." }, { "id": "pubmed23n0052_6415", "title": "[The early hemiparesis of stroke in evolution of basilar artery--case report].", "score": 0.009009009009009009, "content": "In basilar artery thrombosis, hemiparesis without obvious brainstem signs may precede the tetraplegia with coma or a locked-in state. This premonitory hemiparesis was called as \"herald hemiparesis\" by Fisher (1988). Its early detection is important because immediate anticoagulant therapy may prevent its evolution. We reported two patients with such hemiparesis. The first case was a 71-year-old diabetic and hypertensive man who was admitted because of right hemiparesis, dysarthria and decreased spontaneous speech. Initially, his symptoms looked like those of a left cerebral lesion. CT scans revealed no fresh cerebrovascular lesion. A few hours later, a myoclonic movement appeared in his left lower limb, and right MLF syndrome developed. We thought he had basilar artery thrombosis and we started intravenous administration of heparin. But he developed tetraplegia with locked-in state. The second case was a 76-year-old diabetic and hypertensive man with a confusional state, right hemiparesis, dysarthria and conjugate gaze deviation to left. After admission, he rapidly became comatose and developed respiratory arrest. CT scans revealed low density areas in the brainstem, cerebellum and the occipital lobe. He died ten days later. Early detection of herald hemiparesis is by no means easy. However, severe dysarthria and myoclonic jerks in a patient with hemiparesis should be considered as warning signs to indicate the herald hemiparesis with subsequent severe brainstem infarction." }, { "id": "pubmed23n0380_19119", "title": "[Ciguatera: clinical relevance of a marine neurotoxin].", "score": 0.008928571428571428, "content": "A 45-year-old woman complained of gastrointestinal symptoms followed by paraesthesiae of the mouth, face, hands, feet, and trunk after she had eaten fish while she was on a journey to the red sea. Additionally, she suffered from headaches and muscle aches, weakness of the arms and legs, instability of gait as well as troubles of vision, taste, speech, and swallowing. Neurological examination revealed a cerebellar syndromE with mild dysarthria, multifocal dysaesthesiae, paresis of the arms and legs, generalized hyporeflexia, bilaterally reduced vision, and ataxic gait. Laboratory work-up provided no diagnostic clues. Cranial and spinal magnetic resonance imaging were normal. The cerebrospinal fluid showed a normal cell count and a moderately impaired barrier function. Electrophysiological evaluation suggested a sensory and motor axonal neuropathy. Based on the history and the characteristic clinical findings we made a diagnosis of ciguatera, a marine food poisoning caused by the ingestion of fish contaminated with ciguatoxin. Symptomatic treatment with mannitol, amitriptyline, carbamazepine, and corticosteroids started 3 weeks after the onset of symptoms proved inefficient, however, during the 21 months of follow-up there was a marked spontaneous clinical and electrophysiological reversal of symptoms. In the age of growing foreign tourism marine food intoxications have to be considered in the differential diagnosis of the frequently occurring travellers-diarrhea. The diagnosis of ciguatera is based on the typical history of a fishmeal followed by characteristic clinical findings with predominant neurological symptoms, often including dysaesthesiae, besides gastrointestinal disturbances. In the early phase of the disease intravenous therapy with mannitol has emerged as an efficient treatment." }, { "id": "wiki20220301en042_12293", "title": "Verbum dicendi", "score": 0.008928571428571428, "content": "Diagnostics of direct speech in Japanese" }, { "id": "wiki20220301en170_30299", "title": "Middle cerebral artery syndrome", "score": 0.008849557522123894, "content": "Signs and Symptoms Hemiparesis or hemiplegia of the lower half of the contralateral face Hemiparesis or hemiplegia of the contralateral upper and lower extremities* Sensory loss of the contralateral face, arm and leg* Ataxia of contralateral extremities* Speech impairments/aphasia: Broca's area, Wernicke's or Global aphasia as a result of a dominant hemisphere lesion (usually the left brain) Perceptual deficits: hemispatial neglect, anosognosia, apraxia, and spatial disorganization as a result of a non-dominant hemisphere lesion (usually the right brain) Visual disorders: déviation conjuguée, a gaze preference towards the side of the lesion; contralateral homonymous hemianopsia Note: *faciobrachial deficits greater than that of the lower limb Diagnosis Diagnosis can be confirmed by CT Scan or MRI for advanced investigations. References External links Stroke Syndromes affecting the nervous system" }, { "id": "Neurology_Adams_3934", "title": "Neurology_Adams", "score": 0.008849557522123894, "content": "This pattern of speech is caused by weakness or paralysis of the articulatory muscles, the result usually of disease of the motor nuclei of the medulla and lower pons or their intramedullary or peripheral extensions (lower motor neuron paralysis). In advanced forms of this disorder, the shriveled tongue lies inert and fasciculating on the floor of the mouth, and the lips are lax and tremulous. Saliva constantly collects in the mouth because of dysphagia, and drooling is troublesome. Dysphonia, an alteration of the voice to a rasping monotone because of vocal cord paralysis, is often an additional feature. As this condition evolves, speech becomes slurred and progressively less distinct. There is special difficulty in the enunciation of vibratives, such as r, and as the paralysis becomes more complete, lingual and labial consonants are finally not pronounced at all. In the past, bilateral paralysis of the palate, causing nasality of speech, often occurred with diphtheria and" }, { "id": "pubmed23n1004_25988", "title": "Oral and Vulvar Lichen Sclerosus.", "score": 0.008771929824561403, "content": "Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin (1). Simultaneous involvement of the oral mucosa is extremely rare, but it may be the only affected area (2). A 55-year-old woman was referred to the Department of Oral Medicine, School of Dental Medicine University of Zagreb due to whitish lesions on the right ventrolateral part of the tongue and buccal mucosa with desquamative gingivitis (Figure 1, a-c). The lesions were asymptomatic but indurated on palpation. Histology was conclusive for oral lichen sclerosus (OLS). The lesions on gingiva were successfully treated with betamethasone ointment, three times a day for two weeks. One year earlier, she had been referred to the Department of Dermatology and Venereology with progressive pruritus and dyspareunia, white patches, obliteration of the labia minora, and stenosis of the introitus (Figure 2). Histology was conclusive for vulvar LS (Figure 3, a and b). She was successfully treated for 5 months with clobetasol propionate 0.05% ointment. The patient was taking levothyroxine to treat hypothyroidism associated with Hashimoto's thyroiditis and was otherwise healthy. Oral LS is clinically characterized by the appearance of white macules, papules, or plaques mostly appearing on labial mucosa but also on buccal, palate mucosa and on the lower lip (2,3). On the genitals, it typically manifests as atrophic white plaques, which may be accompanied by purpura or fissuring (1). While vulvar LS is often associated with pruritus, dyspareunia, and dysuria, OLS is often asymptomatic, although pain, soreness, pruritus, and tightness when opening the mouth can be present (1,2). Oral manifestations of LS, as well as association of anogenital and oral LS, are rarely reported in the literature (4-6). Tomo et al. searched the Medline database for papers reporting oral LS cases with histological diagnosis confirmation from 1957 to 2016 and found only 34 cases of oral LS with histopathologic confirmation of the diagnosis (4). Kakko et al. reported 39 histologically proven cases of OLS (2). Attilli et al. (5) reviewed the clinical and histologic features of 72 cases of LS with oral/genital involvement. They reported that LS was diagnosed with exclusive genital lesions in 45, exclusive lip involvement in 20, and orogenital involvement in only 7 cases (5). Some believe that many cases of clinically diagnosed lichen planus may actually be LS and that isolated oral mucosal LS may not be as rare as is generally thought (2). While vulvar LS can occur at any age with increasing incidence with age, the median age of patients with OLS was 34 years and most of the patients were female (1,2,5). Due to the small number of patients in the literature, treatment recommendations for OLS are not available. In case of symptomatic oral lesions, topical or intralesional corticosteroids are considered to be the first-line treatment (2). First-line treatment for anogenital LS is a potent to very potent topical corticosteroid ointment, and second-line therapies include topical calcineurin inhibitors 1% pimecrolimus and 0.1% and 0.03% tacrolimus (1). For treatment-resistant genital LS, oral retinoids, methotrexate, and possibly local steroid injections for single lesions are mainly applicable for women (1). There is limited evidence for systemic treatments for both conditions. If it is not treated, genital LS is associated with a greater degree of scarring and an elevated risk of progression to squamous cell cancer; however, malignant transformation of OLS has not been reported (1-6). Due to the very rare presentation in the oral cavity, it is important to notice these lesions during a dental exam." }, { "id": "Neurology_Adams_3911", "title": "Neurology_Adams", "score": 0.008771929824561403, "content": "Writing is, of course, an integral part of language function, but a less essential and universal component, for a segment of the world’s population speaks but does not read or write. It might be supposed that all the rules of language derived from the study of aphasia would be applicable to agraphia. In large part, this is true. One must be able to formulate ideas in words and phrases in order to have something to write as well as to say; hence, disorders of writing, like disorders of speaking, reflect all the basic defects of language. But there is an obvious difference between these two expressive modes. In speech, only one final motor pathway coordinating the movements of lips, tongue, larynx, and respiratory muscles is available, whereas if the right hand is paralyzed, one can still write with the left one, or with a foot, and even with the mouth by holding a pencil between the teeth (a contrivance used by individuals whose arms are paralyzed by cervical root avulsion from" }, { "id": "pubmed23n1016_11663", "title": "Moyamoya Syndrome after Radiation Therapy: a Clinical Report.", "score": 0.008695652173913044, "content": "Moyamoya syndrome (MMS) is a rare, chronic and progressive vasculopathy with a characteristic angiographic pattern and well-recognized predisposing conditions, such as cranial therapeutic radiation. We report the case of a 36-year-old Caucasian female with a history of craniopharyngioma treated with whole-brain radiotherapy 20 years previously. She was admitted to the emergency department with disorientation and imperceptible speech lasting for 1 hour. Upon examination, she had slight motor aphasia, without sensory or motor deficits. However, the neurological deficits worsened on standing position. The computed tomography (CT) angiogram and transcranial Doppler ultrasonography revealed occlusion of the distal portion of the left internal carotid artery (ICA). Mechanical thrombectomy was attempted without success. Head CT was repeated, revealing left periventricular acute ischaemic stroke. The cerebral angiography showed total occlusion of the left ICA with an exuberant network of transdural collateral vessels, confirming MMS. The patient completed a functional rehabilitation program with progressive improvement of deficits and maintained a multidisciplinary follow-up. MMS is a serious late complication from cranial radiation therapy and a well-described risk factor for ischaemic stroke in younger patients. Therefore, early detection and prompt treatment are mandatory, as the consequences can be disastrous, such as cognitive and neurologic decline due to repeated strokes. Moyamoya syndrome should be considered in younger patients presenting with acute neurologic deficits, particularly those treated with cranial radiotherapy.The treatment of acute stroke in patients with moyamoya syndrome should include intravenous hydration and avoidance of hypotension.The benefit of antiplatelet agents is limited and equivocal for patients with moyamoya syndrome and oral anticoagulants are not recommended for long-term treatment." }, { "id": "Neurology_Adams_3854", "title": "Neurology_Adams", "score": 0.008695652173913044, "content": "In the most advanced form of the syndrome, patients lose all power of speaking. Not a word can be uttered in conversation, in attempting to read aloud, or in trying to repeat words that are heard. One might suspect that in this mutism the lingual and phonatory apparatus is paralyzed, until patients are observed to have no difficulty chewing, swallowing, clearing the throat, crying or shouting, and even vocalizing without words. Occasionally, the words yes and no can be uttered, usually in the correct context. Or patients may repeat a few stereotyped utterances over and over again, as if compelled to do so, a disorder referred to as monophasia (Critchley), recurring utterance (Hughlings Jackson), verbal stereotypy, or verbal automatism. If speech is possible at all, certain habitual expressions, such as “hi,” “fine, thank you,” or “good morning,” seem to be the easiest to elicit, and the words of well-known songs may be sung hesitantly, or counting by consecutive numbers may remain" }, { "id": "pubmed23n1146_5621", "title": "Seropositive Neuromyelitis Optica in a Case of Undiagnosed Ankylosing Spondylitis: A Neuro-Rheumatological Conundrum.", "score": 0.008620689655172414, "content": "Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels. Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases. However, AQP-4-antibody-positive NMOSD coexisting with ankylosing spondylitis (AS) is rare. AS is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27. In this study, a 35-year-old Indian man with an undiagnosed progressive axial spondyloarthropathy (i.e., AS) is reported presenting with acute-onset longitudinally extensive transverse myelitis, a clinical subset of NMOSD. Neuromyelitis optica spectrum disorder (NMOSD), a primary demyelinating disorder of the central nervous system (CNS), is an autoimmune astrocytopathy against foot processes of aquaporin-4 (AQP4) water channels, which manifests with optic neuritis, longitudinally extensive transverse myelitis (LETM), area-postrema syndrome, brainstem syndrome diencephalic syndrome, and cerebral syndrome.<sup1-4</sup Ankylosing spondylitis (AS) is an immune-mediated disorder, a subset of axial spondyloarthropathies, which commonly manifests as chronic inflammatory back pain in young people, and it has a strong association with HLA-B27.<sup5,6</sup AS characteristically targets the axial skeleton, peripheral joints, entheses (connective tissues between tendons/ligaments and bones), and gut.<sup5,6</sup Patients with NMOSD tend to have other coexisting autoimmune/connective tissue diseases.<sup7</sup For example, cases with NMOSD and multiple sclerosis, which are other autoimmune primary demyelinating disorders of the CNS, have been reported.<sup8,9</sup However, concurrent existence of AS and NMOSD in the same patient even over years of disease course is rare.<sup10,11</sup In addition, studies describing neurological manifestations of AS are limited,<sup12</sup and they focus on joint inflammation and long-standing bony pathology (ankylosis) related to compressive myelopathy, myelo-radiculopathy, and cauda equina syndromes.<sup12,13</sup The authors present a case of a young Indian man with an undiagnosed progressive AS (misdiagnosed and mismanaged by an indigenous medical practitioner) presenting with acute-onset LETM variant of AQP4-positive NMOSD. A 35-year-old healthy, non-comorbid man from rural India came to the outpatient department with complaints of persistent tingling, numbness, and weakness of both lower limbs (right more than left) for 10 days. The clinical picture showed acute-onset urinary retention, which was relieved by urinary catheterization. An indigenous medical practitioner had prescribed drugs to treat a urinary tract infection. His weakness gradually progressed over the following week, causing him to become bedridden. During the removal of the catheter, he felt urgency, increased frequency of micturition, and overt urinary incontinence. He gave no history suggestive of any girdle-like sensations, root/radicular/tract pain, vertebral pain, trauma, recent vaccination, and diarrheal or febrile illness. For the last 8 months, he had a complaint of an insidious-onset, persistent, bilateral, dull aching pain in the gluteal region accompanied by low-back pain and morning stiffness up to 1 h, which markedly improved with activity and reoccurred following long periods of inactivity. He sometimes had to rise in the middle of the night because of excruciating pain, which could be relieved after moving around the room and corridors for half an hour. He was taking over-the-counter diclofenac tablets for pain relief prescribed by some indigenous medical practitioners who told him that it was due to overwork in agricultural fields, that is, mechanical back pain. He also had a normal X-ray of the lumbosacral spine. He had no addiction liabilities, and none of the family members had ever suffered from a similar kind of illness. He had never consulted any trained medical practitioner, as his previous back-pain-related symptoms responded well to the tablets prescribed by the indigenous medical practitioner(s). During examination, he was found to have recent-onset, asymmetric spastic paraparesis (right more than left) with upper motor neuron-type urinary bladder symptoms. Cognitive assessment (assessed by the Montreal cognitive assessment test) was normal, and posterior column sensations were preserved. Sensory system examination revealed no definite sensory level. Except for the paretic lower limbs, cerebellar functions were normal in other regions. Neuro-ophthalmological examinations were also normal, and no signs of meningeal irritation were observed. The history and course of the disease and clinical examinations were analyzed. Selective tractopathy (early and predominant motor and autonomic tract affection) was suggested for an intramedullary demyelinating pathology affecting the anterior central cord. This case was initially classified as acute-onset non-compressive myelopathy at the lower cervical/upper dorsal region level in a patient with a pre-existing axial spondyloarthropathy. Complete blood cell count; liver, kidney, and thyroid function tests; and plasma glucose and electrolytes were normal, except for an increased erythrocyte sedimentation rate (66 mm in the first hour). Magnetic resonance imaging (MRI) of the spinal cord revealed a demyelinating LETM from C5 to D4 level (Figure 1). Meanwhile, an MRI of the sacroiliac joints revealed bilateral sacroiliitis. Brain and orbital MRIs were devoid of any lesions. Anti-aquaporin 4 (AQP-4) antibodies were tested by cell-based assay in serum and cerebrospinal fluid (CSF), and both were positive. CSF further revealed lymphocytic pleocytosis and increased intrathecal protein production. Visually evoked potential recordings were also normal. In addition, anti-myelin oligodendrocyte glycoprotein antibodies were negative. Anti-nuclear antibody (ANA), ANA-profile, autoimmune vasculitis profile (c-ANCA, p-ANCA), neurovirus panel (i.e., polymerase chain reaction for adenovirus, Epstein-Barr virus, herpes simplex viruses 1 and 2, human herpesviruses 6 and 7, cytomegalovirus, enteroviruses, varicella-zoster virus, Japanese encephalitis, and dengue virus), CSF-polymerase chain reaction for <iMycobacterium tuberculosis</i, angiotensin-converting enzyme, anti-phospholipid, and anti-thyroid antibodies were negative. Anti-CCP-antibody and rheumatoid factor were also negative, including creatine phosphokinase level and serum vitamin B12. Moreover, serologies for hepatitis B, C, human immunodeficiency virus, and scrub typhus were negative. However, HLA-B27 assay was positive. The final diagnosis was AQP4-positive NMOSD associated with AS. He was placed on pulse intravenous methylprednisolone (1 g/day for 5 days). Consequently, his lower limb power improved remarkably. Cyclical rituximab therapy was initiated to prevent relapses. At 3-month follow-up, he had no residual neurological deficit except for persistence of paresthesias. Neuroimaging and visually evoked potential studies revealed no active or new lesions. After 6 months of therapy, a subjective and objective improvement was observed in disease severity based on the Ankylosing Spondylitis Disease Activity Score. Our patient satisfied the new Assessment of SpondyloArthritis International Society diagnostic/classification criteria for AS and the Wingerchuk criteria for NMOSD,<sup4,14</sup an association that has been rarely reported.<sup10,11</sup Amid the extra-articular complications of long-standing AS, neurological manifestations are considered infrequent.<sup15</sup However, subclinical neurological complications may be frequent in AS.<sup12</sup Common neurological manifestations result from bony (vertebral) ankylosis, subluxation of joints, ossification of anterior and posterior longitudinal ligaments, secondary spinal canal stenosis, bony (vertebral) fractures, and subsequent compressions over nerve radicles/roots/cauda equina, and inflammation-related (entrapment) peripheral neuropathies.<sup12,16,17</sup Acute transverse myelitis can occur as a subset of several primary demyelinating disorders of the CNS (i.e., multiple sclerosis, NMOSD, myelin oligodendrocyte glycoprotein antibody disease, and acute disseminated encephalomyelitis) and various systemic autoimmune connective tissue disorders (i.e., systemic lupus erythematosus, mixed connective tissue disease, Sjögren syndrome, inflammatory bowel disease, and neurosarcoidosis).<sup18</sup Acute transverse myelitis (short or long segment) is an infrequent extra-articular complication of AS.<sup18</sup It has been reported to evolve either as a distinct neurological complication of AS, or it may develop secondary to TNF-alpha-inhibitor therapy for the treatment of AS.<sup18,19</sup AS is a heritable inflammatory spondyloarthropathy that primarily affects the axial skeleton, which is mediated by T-cells; B-cells only play a minor role.<sup5</sup On the contrary, the key for the pathogenesis of NMOSD is the production of autoantibodies against AQP-4 channels expressed on astrocytes, leading to complement-mediated damage, with ensuing demyelination. Myelitis usually shows high signal intensity on the tbl2-weighted image and contrast enhancement in the spinal cord.<sup1-4</sup Despite the difference in molecular mechanisms, the diagnosis of these diseases in the same individual may not be coincidental. Recent evidence has shown T-cell-mediated inflammatory responses in cases of NMOSD.<sup20</sup In particular, Th17 and Th2-related cytokines are elevated in the CSF of NMO patients.<sup20</sup Environmental factors such as <iEscherichia coli</i have also been proven to aggravate autoimmunity in AS and NMOSD (however, body fluid cultures for <iEscherichia coli</i, performed in our patient, showed similar association, and they were found negative two times).<sup21,22</sup Although large-scale epidemiological studies investigating the underlying pathogenesis related to these diseases are lacking, studies have demonstrated an increased incidence of optic neuritis among patients with AS.<sup23</sup Systemic sclerosis and mixed and undifferentiated connective tissue diseases were excluded after expert opinions (from two board-certified rheumatologists and two dermatologists) because of the lack of suggestive clinical findings (e.g., absence of skin thickening, salt-and-pepper appearance, nail changes, Mauskopf facies, sclerodactyly, calcinosis cutis, Raynaud's phenomenon, other cutaneous manifestations, pulmonary arterial hypertension/interstitial lung disease, dysphagia, muscular pain/weakness renal impairments, absence of ANA, anti-centromere antibodies, anti-Scl-70, PM-Scl antibodies, anti-ds DNA, PCNA, CENP-B, anti-nucleosomes, anti-Smith, anti-U1-RNP, anti-Jo1, anti-Mi2, anti-Ro52, anti-La antibodies, and normal C3 and C4 complement levels) (The European League Against Rheumatism and the American College of Rheumatology classification criteria 2019).<sup24</sup Finally, our patient was treated with intravenous steroids followed by rituximab infusions, a monoclonal anti-CD20 antibody directed against B-cells. In particular, this patient clinically and radiologically responded to immunomodulatory drugs, which might support a possible common pathogenic basis of the two processes. TNF-alpha inhibitors are commonly used as novel therapeutics in AS; however, they can potentially result in serious complications, that is, secondary demyelinating disorders.<sup25</sup However, such inhibitors in this patient were not used. When used in cases of AS, they show satisfactory results.<sup25,26</sup Therefore, it was decided to treat him with rituximab only without adding any second immunomodulatory. Other possible therapeutic options include cyclophosphamide and mycophenolate mofetil, but they were not used because of their low efficacy-safety balance. Moreover, plasmapheresis was not available in our specific setting, despite solid evidence that early treatment with therapeutic strategy (5-7 courses) provides good long-term outcomes in patients with NMOSD.<sup27</sup Therefore, when dealing with a case of acute non-compressive myelopathy, history and clinical examination are important to determine the potential underlying etiology and identify an undermined systemic disorder with apparently unrelated non-specific features. Connective tissue disorders should always be considered as a differential diagnosis and be ruled out in all cases of either seropositive or seronegative NMOSD. A diagnosis of AS should be considered in relevant circumstances when dealing with a case of isolated seronegative LETM. Moreover, early diagnosis and treatment of AS are quintessential to prevent lifelong distressing disabilities. However, whether patients with AS have any extra predilection to develop NMOSD throughout their life requires further studies." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 361 ] ], "word_ranges": [ [ 0, 56 ] ], "text": "In this case, he is describing the cardinal symptoms of polymyalgia rheumatica. Older patient, over 50 years of age, presenting with pain and stiffness in both girdles, associated with an elevation of acute phase reactants. He presents all the indispensable criteria: age equal to or greater than 50 years, bilateral omalgia and increased acute phase reactants." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Rheumatoid arthritis, would initiate treatment with methotrexate.", "2": "Fibromyalgia, would initiate treatment with duloxetine.", "3": "Polymyalgia rheumatica, would initiate treatment with corticosteroids.", "4": "Ankylosing spondylitis, I would initiate treatment with non-steroidal anti-inflammatory drugs.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0797_6382", "title": "[Polymyalgia rheumatica in daily routine practice].", "score": 0.019075302025615408, "content": "Polymyalgia rheumatica (PMR) is a very painful inflammatory disease which regularly affects the shoulder region but in 70% of cases the pelvic girdle region is also affected. The disease occurs in people over the age of 50 years and reaches a peak at 72 years old. Women are affected twice as often as men. The prevalence is estimated to be 0.3-0.7% in the Caucasian population over 50 years old. Misdiagnosis of PMR is common. The differential diagnosis primarily includes impingement syndrome, osteoarthritis of the shoulders, calcifying tendinitis of the rotator cuff, bursitis, omarthritis or inflammatory rheumatic diseases, such as rheumatoid arthritis. Taking a structured medical history and performing a thorough clinical examination are crucial. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are usually highly elevated and should be investigated particularly in patients who present with new onset bilateral shoulder pain and pronounced general impairment of movement. Imaging shows characteristic inflammatory changes around the shoulders and hip joints. The new European League Against Rheumatism and American College of Rheumatology (EULAR/ACR) classification criteria of PMR including ultrasound imaging are superior to previous classification and diagnostic criteria in terms of positive and negative predictive values. Glucocorticoids are still the mainstay of treatment. Recommended daily prednisolone starting doses are between 15 mg and 25 mg with a weekly dose reduction until 10 mg/day and then further dose reductions of 1 mg per month. Methotrexate can aid reducing prednisolone doses in patients who fail to reach doses below the Cushing threshold quickly enough, which can have major side effects." }, { "id": "pubmed23n0962_15295", "title": "Polymyalgia Rheumatica (PMR) with Normal Values of Both Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) Concentration at the Time of Diagnosis in a Centenarian Man: A Case Report.", "score": 0.018433571185864764, "content": "The possibility that polymyalgia rheumatica (PMR) can be diagnosed when both ESR and CRP are normal at the time of diagnosis and before therapy with glucocorticoids, has been often discussed in the literature. We present a case report of a 100-year-old Caucasian man referred to our outpatient clinic, complaining of chronic pain in the shoulder and hip girdle associated with normal values of both ESR (21 mm/1st hour) and CRP (4 mg/dL). In the previous four months, several anti-inflammatory drugs and painkillers associated with physiotherapy treatments gave no significant improvement in pain and self-care. After an ultrasound (US) and an 18-fluorodeoxyglucose positron emission tomography associated with total body computed tomography (18-FDG PET/CT) examination, PMR was diagnosed and he started therapy with 17.5 mg prednisone, obtaining a fast improvement in pain and self-care. After 10 months of tapering, he stopped prednisone without relapse. During a 3-year follow-up, no alternative diagnosis was done. When a patient complains of chronic bilateral shoulder and hip girdle pain associated with normal inflammatory indices, it is reasonable to think in the first instance that this person is not suffering from PMR. Moreover, the possibility that PMR may onset in a centenarian person, is exceptional. In our patient, when we piece the puzzle together, the diagnosis of PMR was the most possible one." }, { "id": "pubmed23n0877_878", "title": "[Diagnostics and treatment of polymyalgia rheumatica].", "score": 0.018162393162393164, "content": "Polymyalgia rheumatica (PMR) is the most common autoimmune inflammatory disease in older persons with an average age of onset of 73 years. Typical symptoms include acute or subacute bilateral shoulder pain with severe stiffness and often neck and bilateral hip pain. Giant cell arteritis (GCA) occurs in approximately 20 % of cases and up to two thirds of patients with GCA have symptoms of PMR. There are many disease which mimic PMR, elderly onset rheumatoid arthritis is frequently misdiagnosed as PMR. Although there are no specific laboratory tests, C‑reactive protein and erythrocyte sedimentation rates are elevated in over 90 % of patients. The diagnosis may be aided by imaging, especially ultrasonography and magnetic resonance imaging (MRI). Treatment currently consists of glucocorticoids at an initial dose of 12.5-25 mg prednisone equivalent daily. Treatment duration is typically 2‑3 years but may be longer. Under certain conditions low-dose methotrexate can be used as adjuvant therapy. " }, { "id": "pubmed23n0073_3828", "title": "Polymyalgia rheumatica.", "score": 0.017412370353546824, "content": "Polymyalgia rheumatica is a syndrome that occurs in the elderly and is characterized by pain and stiffness involving the neck, the shoulder girdle, and the hip girdle. The aching should be present for greater than one month. Polymyalgia rheumatica may be more common than reported. The etiology remains unknown. There is generally little found pathologically in this disease. The physical examination is often not impressive. Synovitis may be a main contributing factor to many of the symptoms seen in patients with polymyalgia rheumatica. Symptoms often do not correlate with physical findings. Polymyalgia rheumatica must be differentiated from many conditions since the diagnosis remains entirely clinical. Osteoarthritis, flu syndromes, inflammatory myopathies, fibromyalgia, and depression all have features that may mimic polymyalgia rheumatica. Malignancies and infections may also be difficult to separate from polymyalgia rheumatica. Polymyalgia rheumatica may also be extremely difficult to differentiate from seronegative rheumatoid arthritis in patients older than 50 years. Although some patients with polymyalgia rheumatica have underlying giant cell arteritis, the majority apparently do not. The distinction between polymyalgia rheumatica and giant cell arteritis cannot be made on the basis of laboratory studies and relies solely on clinical symptoms and physical findings. Although nonsteroidal antiinflammatory medications may control symptoms in patients with mild disease, most patients with polymyalgia rheumatica require low-dose corticosteroids. The tapering schedule for the corticosteroids is contingent upon the response of symptoms and laboratory parameters. Polymyalgia rheumatica usually follows a benign course with almost complete response to an adequate treatment program. Recently, there have been several studies suggesting that the course of polymyalgia rheumatica may not be as short and simple as once proposed. Nevertheless, many patients may be completely weaned from corticosteroids. Other agents have been used in this disease, but for the most part their use remains somewhat controversial. Patients must be monitored carefully. Most patients do well, and treatment is effective." }, { "id": "pubmed23n0783_19462", "title": "Advances and challenges in the diagnosis and treatment of polymyalgia rheumatica.", "score": 0.017011197243755383, "content": "Polymyalgia rheumatica (PMR) is a common inflammatory condition that often affects people over the age of 50 years. Characteristic symptoms are shoulder and hip girdle pain and prolonged morning stiffness. Markers of inflammation are often elevated. Clinicians are often faced with the challenge of distinguishing PMR from other conditions, particularly rheumatoid arthritis and spondyloarthropathy that can mimic symptoms of PMR in older people. Additionally, there is an association between PMR and giant cell arteritis, a common large-vessel vasculitis which also affects people over the age of 50 years. Imaging of the large vessels in asymptomatic patients with PMR often reveals findings of subclinical vasculitis. Presently, there are no tests that are specific for the diagnosis of PMR and clinicians rely on a combination of history, physical examination, laboratory tests and imaging studies to make a diagnosis. A recent undertaking by the European League Against Rheumatism/American College of Rheumatology has led to the publication of provisional classification criteria of PMR. Ultrasonography, which is being increasingly used by rheumatologists, can greatly aid in the diagnosis of PMR and often shows changes of synovitis and tenosynovitis. Treatment consists of low doses of glucocorticoids which are associated with morbidity. Evaluation of newer biologic therapies targeting inflammatory cytokines is underway. Despite treatment, relapses are common. " }, { "id": "pubmed23n0356_3197", "title": "[Rheumatic polymyalgia].", "score": 0.01667129758266185, "content": "Polymyalgia rheumatica (PMR) is a common clinical syndrome that is characterized by pain and stiffness in neck, shoulder girdle and pelvic girdle. The aetiology is unknown. However, recent studies have documented an association with HLA antigens and infectious agents. It occurs mostly after the age of 50 years and is often accompanied by systemic features such as fever, asthenia, hyporexia and weight loss. An erythrocyte sedimentation rate (ESR) of at least 40 mm/hour has been considered diagnostic criterion. Nevertheless, a normal ESR accounted for up to 20% of cases of PMR. A dramatic and prompt response to corticosteroid treatment is characteristic. Giant cell arteritis/temporal arteritis (GCA) has been found in 0-80% of cases of PMR. Temporal biopsy could initially be deferred in patients with PMR younger than 70 years with no cranial symptoms, in which the risk of GCA is very low." }, { "id": "pubmed23n0782_22403", "title": "Polymyalgia rheumatica--diagnosis and classification.", "score": 0.01662087912087912, "content": "Polymyalgia rheumatica is the most common inflammatory rheumatic disease of the elderly, and shares many pathogenetic and epidemiological features with giant cell arteritis. The typical symptoms are bilateral aching of the shoulder girdle, associated with morning stiffness. The neck and hip girdle may also be involved. The diagnosis of polymyalgia rheumatica is made primarily on clinical grounds. There is no single diagnostic test, but sets of diagnostic or classification criteria have been suggested by several groups of investigators, based on the typical clinical presentation and laboratory evidence of acute-phase reaction. Other conditions that may mimic polymyalgia rheumatic, such as elderly-onset rheumatoid arthritis, must be excluded by appropriate testing and close monitoring of the disease course. Glucocorticoids at low doses (15-20 mg prednisone per day initially) are the mainstay of treatment." }, { "id": "pubmed23n0312_4607", "title": "[A case of polymyalgia rheumatica with excessive increase of rheumatoid factor].", "score": 0.016601495506620018, "content": "A 76 year-old woman suffered from muscle pain and stiffness of acute onset in her shoulder girdle and pelvic girdle, which were followed by mild left temporal headache and transient arthralgia. Neither joint swelling nor sicca symptom was observed. Laboratory data showed high ESR (128 mm/hr), positive CRP (12.9 mg/dl), increased fibrinogen (485 mg/dl) and high titer of rheumatoid factor (RF) (RAHA x 640). Other autoantibodies examined were negative. Muscle enzymes and electromyogram were within normal limits. Joint X ray didn't reveal the finding suggestive of RA. After the treatment with prednisolone (PSL) 15 mg/day, clinical symptoms and laboratory data improved dramatically. Though she had excessive increase of RF (RAHA x 10240) during therapy, no recurrence of articular symptoms were recognized. She continues to be well with PSL 5 mg/day after 1 year 5 months from onset. As for polymyalgia rheumatica (PMR) followed by RA, the appearance or exacerbation of arthritis corresponding to the elevation of RF occurred in all previously reported 17 cases. Recurrence of arthralgia corresponding to the elevation of RF was not recognized in this case. In addition, Hunder et al reported that PMR with little or no observable joint swelling after several weeks of symptoms is unlikely to develope RA. Therefore, it is speculated that this case in unlikely to develope RA and assessment of arthritis corresponding to the elevation of RF is important to differentiate PMR and elderly-onset RA. This case of PMR is the 5th case with excessive increase of RF in Japan." }, { "id": "pubmed23n1143_5946", "title": "Polymyalgia Rheumatica After ChAdOx1 nCov-19 Vaccine: A Case Report.", "score": 0.016151332327802918, "content": "Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease characterized by severe pain and morning stiffness, mainly affecting the shoulder girdle. A 75-year-old woman, previously healthy, received the first dose of ChAdOx1 vaccine and two weeks later started with pain in the shoulder and pelvic girdles and knees of inflammatory characteristics, accompanied by morning stiffness (about one hour), anorexia, asthenia, and activities of daily living (ADL) dependence. She started analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) with no improvement. The symptoms aggravated three days after the second vaccine dose, and she was referred to our center. At observation, she presented shoulder, hip, and knee active range of motion limitation. Blood analysis revealed an Erythrocyte Sedimentation Rate (ESR) of 120mm/h (reference value &lt; 20mm/h) and C-Reactive Protein (CRP) of 80mg/L (reference value &lt; 5mg/L). Ultrasound showed effusion on both shoulders, hips, and knees. The paraneoplastic syndrome was ruled out. She started oral corticosteroids and a rehabilitation program, and a month later, she presented controlled pain, normal analysis, and ADL independence. This case shows symptomatic and analytic features of PRM after the first vaccine dose and aggravation soon after the second. As such, we consider establishing a potential relationship between the inoculation and the development of PRM. A few cases were published reporting a PRM-like syndrome following a COVID-19 vaccine; however, the underlying mechanism and prognosis are still unknown." }, { "id": "pubmed23n0796_9966", "title": "Polymyalgia rheumatica: clinical update.", "score": 0.015843707189231043, "content": "Polymyalgia rheumatica is a relatively common inflammatory rheumatic disease. There are no validated international guidelines available for the diagnosis and treatment of PMR; however, diagnostic and classification criteria are currently being developed. The aim of this article is to summarise the main management options suggested by American College of Rheumatology and discusses the role of the general practitioner in the diagnosis and early management of PMR. Diagnosis is made on the basis of a combination of clinical and laboratory findings. Patients typically present with shoulder and hip girdle pain with pronounced stiffness. Inflammatory markers are usually elevated and an ultrasound and MRI of the shoulder and hip can be done to localise inflamed tissues. Response to steroids should not be used as a defining feature of PMR but treatment with low dose prednisone should be considered. PMR has an excellent prognosis if diagnosis is prompt and therapy adequate." }, { "id": "pubmed23n0721_76", "title": "Patient-reported outcomes in polymyalgia rheumatica.", "score": 0.0158125, "content": "To prospectively evaluate the disease course and the performance of clinical, patient-reported outcome (PRO) and musculoskeletal ultrasound measures in patients with polymyalgia rheumatica (PMR). The study population included 85 patients with new-onset PMR who were initially treated with prednisone equivalent dose of 15 mg daily tapered gradually, and followed for 26 weeks. Data collection included physical examination findings, laboratory measures of acute-phase reactants, and PRO measures. Ultrasound evaluation was performed at baseline and Week 26 to assess for features previously reported to be associated with PMR. Response to corticosteroid treatment was defined as 70% improvement in PMR on visual analog scale (VAS). At baseline, 77% had hip pain in addition to shoulder pain and 100% had abnormal C-reactive protein or erythrocyte sedimentation rate. On ultrasound, 84% had shoulder findings and 32% had both shoulder and hip findings. Response to corticosteroid treatment occurred in 73% of patients by Week 4 and was highly correlated with percentage improvement in other VAS measures. Presence of ultrasound findings at baseline predicted response to corticosteroids at 4 weeks. Factor analysis revealed 6 domains that sufficiently represented all the outcome measures: PMR-related pain and physical function, an elevated inflammatory marker, hip pain, global pain, mental function, and morning stiffness. PRO measures and inflammatory markers performed well in assessing disease activity in patients with PMR. A minimum set of outcome measures consisting of PRO measures of pain and function and an inflammatory marker should be used in practice and in clinical trials in PMR." }, { "id": "pubmed23n0749_18027", "title": "[Polymyalgia rheumatica].", "score": 0.015705838876570587, "content": "Polymyalgia rheumatica is characterized by bilateral pain in the shoulder and pelvic girdles, malaise, morning stiffness and weight loss. The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level are elevated. Imaging using ultrasound, magnetic resonance imaging (MRI) or positron emission tomography (PET) displays inflammatory changes in the painful anatomical areas. Nearly all patients are older than 50 years and the average age is 70-75 years. Polymyalgia rheumatica occurs 2-3 times more often in women than in men and some patients exhibit temporal arteritis or giant cell arteritis. Symptoms rapidly decrease with glucocorticoid treatment and the dose can normally be reduced during the course of the disease. Methotrexate may be given only if high glucocorticoid doses do not sufficiently control symptoms. On average treatment can be stopped after 2 years." }, { "id": "pubmed23n0504_6258", "title": "Polymyalgia rheumatica.", "score": 0.01562881562881563, "content": "Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology characterized by aching and stiffness in the shoulder and in the pelvic girdles and neck. In the past, PMR was considered a manifestation of giant cell arteritis (GCA) or a variant of elderly-onset rheumatoid arthritis (EORA). The current diagnostic criteria for PMR were empirically formulated by clinical experts who had studied the disease extensively. Arthroscopic, radioisotopic and magnetic resonance imaging studies all have indicated the presence of a synovitis in proximal joints and periarticular structures. The synovitis is probably responsible for the musculoskeletal symptoms in PMR. The prominence assigned to the proximal symptoms has probably overshadowed the less well recognized and more variable distal musculoskeletal manifestations which are present in about half of the cases. A normal erythrocyte sedimentation rate does not exclude a diagnosis of PMR. C-reactive protein and interleukin-6 seem to be more sensitive indicators of disease activity both at diagnosis and during relapse/recurrence. Corticosteroids are the drugs of choice for treating PMR. A course of treatment of 1-2 years is often required. However, some patients have a chronic, relapsing course and require low doses of corticosteroids for several years. Large, multicenter, double-blind, placebo-controlled studies are required to define the role of methotrexate and anti-TNF-alpha agents as corticosteroid-sparing drugs in PMR." }, { "id": "pubmed23n0661_4997", "title": "[Dutch College of General Practitioner's practice guideline on polymyalgia rheumatica and temporal arteritis].", "score": 0.015549662487945998, "content": "The practice guideline for general practitioners (GPs) on polymyalgia rheumatica and temporal arteritis was published in February 2010 by the Dutch College of General Practitioners. This guideline provides GPs with recommendations for the diagnosis and treatment of polymyalgia rheumatica. After other disorders have been excluded, the diagnosis of 'polymyalgia rheumatica' is made in patients over the age of 50 who have bilateral pain in the neck and shoulder girdle and/or hip girdle that has lasted for longer than 4 weeks, morning stiffness that lasts longer than 60 minutes and an ESR &gt; 40 mm in the first hour. After the diagnosis is made treatment with prednisone or prednisolone 15 mg per day is started. This dosage is diminished very gradually according to a uniform treatment schedule during a period of 3 months, thereafter depending on the clinical course. The practice guideline pays attention to the diagnosis and management of temporal arteritis only when it occurs concurrently with polymyalgia rheumatica." }, { "id": "pubmed23n0684_20087", "title": "[Dutch College of General Practitioner's practice guideline on polymyalgia rheumatica and temporal arteritis].", "score": 0.01542935137380571, "content": "The practice guideline for general practitioners (GPs) on polymyalgia rheumatica and temporal arteritis was published in February 2010 by the Dutch College of General Practitioners. This guideline provides GPs with recommendations for the diagnosis and treatment of polymyalgia rheumatica. After other disorders have been excluded, the diagnosis of 'polymyalgia rheumatica' is made in patients over the age of 50 who have bilateral pain in the neck and shoulder girdle and/or hip girdle that has lasted for longer than 4 weeks, morning stiffness that lasts longer than 60 minutes and an ESR &gt; 40 mm in the first hour. After the diagnosis is made treatment with prednisone or prednisolone 15 mg per day is started. This dosage is diminished very gradually according to a uniform treatment schedule during a period of 3 months, thereafter depending on the clinical course. The practice guideline pays attention to the diagnosis and management of temporal arteritis only when it occurs concurrently with polymyalgia rheumatica." }, { "id": "pubmed23n0853_4864", "title": "[Polymyalgia rheumatica update, 2015].", "score": 0.015281423155438904, "content": "Polymyalgia rheumatica is an inflammatory musculoskeletal disorder of people aged 50 years or over, characterised by pain, aching and morning stiffness in the shoulder girdle and often hip girdle and neck. Marked systemic inflammation and rapid response to corticosteroid therapy are characteristic features. Giant cell arteritis is a well-known association of polymyalgia rheumatica. Recent clinical evidence and scientific results in the field have provided new challenges for rheumatologists. Besides the aspecific - although characteristic - proximal syndrome, less well recognizable and more variable distal musculoskeletal manifestations were observed. Magnetic resonance and ultrasound studies showed mild, remitting and non-erosive synovitis, with dominating inflammation of the extraarticular synovial structures. As no pathognostic sign is known, the diagnosis of polymyalgia rheumatica is based on its differential diagnosis, differentiation from the polymyalgia mimics; particularly from elderly onset inflammatory arthritides, such as elderly onset rheumatoid arthritis and late onset seronegative spondylarthritis. In 2012 the international polymyalgia rheumatica work group under the guidance of the American College of Rheumatology and European League Against Rheumatism elaborated new classification criteria, the scoring algorythm of which is based on clinical symptoms, with ultrasonography increasing the specificity. Corticosteroids remain the cornerstone of the therapy of polymyalgia rheumatica. No effective steroid-sparing drug has been found to date. Corticosteroids are generally needed for 1-1.5 years, though some patients have a chronic-relapsing course and require corticosteroids for several years. Well known corticosteroid-related side effects (diabetes, hypertension, hyperlipidaemia and osteoporosis) cause significant morbidity and economic burden on the society. Novel therapeautic approaches are on trial. Early recognition of the disease, early start of corticosteroids and a well-defined course, prevention and management of side effects are everyday tasks for rheumatologists and family doctors. Knowledge of polymyalgia rheumatica is essential for all medical specialties." }, { "id": "pubmed23n0936_25578", "title": "[Coexistence of polymyalgia rheumatica with ankylosing spondylitis: A case report].", "score": 0.015164147993746744, "content": "Ankylosing spondylitis is a chronic inflammatory disease that affects the spine and peripheral joints. Polymyalgia rheumatica is an inflammatory disease characterized by aching and prolonged morning stiffness mainly in the shoulder and pelvic girdles. Many other diseases may mimic polymyalgia rheumatica, and thus differential diagnosis is predominantly required. A wide variety of diseases, including spondyloarthropathies, may present polymyalgia-like symptoms, and two diseases rarely coexist. We present a case of a 54-year-old man who had been followed-up for ankylosing spondylitis and presented with pain in the shoulder and pelvic girdles, restricted movement, and morning stiffness for 2 months. Physical examination revealed that the pain was located mostly in the shoulder and pelvic girdles. In addition, increased erythrocyte sedimentation rate revealed the coexistence of the two diseases. Corticosteroid treatment dramatically improved the patient's symptoms and supported the diagnosis. This case demonstrated that ankylosing spondylitis may present polymyalgia-like symptoms, and the two diseases may rarely coexist in the elderly. The coexistence of these two diseases has been rarely reported in literature. Accurate diagnosis of the two diseases is essential for improving the patient's symptoms and quality of life." }, { "id": "pubmed23n0923_200", "title": "Diagnosis and management of polymyalgia rheumatica.", "score": 0.015008960573476702, "content": "Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology with a prevalence of 1 in 133 in the over 50s, and a female to male ratio of 2:1. Symptoms develop over a matter of weeks; typically bilateral shoulder or pelvic girdle pain and stiffness, that is worse in the mornings. Associated symptoms include low-grade fever, malaise, fatigue, low mood, poor appetite, and weight loss. There is no specific diagnostic test for PMR but the usual pattern is a commensurate rise in CRP and ESR. A small proportion of PMR patients will have normal inflammatory markers. PMR is associated with giant cell arteritis (GCA). Half of patients with GCA will have some PMR symptoms and up to one fifth of patients with PMR will have evidence of GCA. Other conditions that can mimic PMR include: rheumatic disease in the elderly e.g. rheumatoid arthritis; inflammatory muscle diseases; thyroid disease; malignancy; infection; bilateral shoulder capsulitis; osteoarthritis, Parkinsonism and depressive illness. At diagnosis and each follow-up visit it is imperative to consider the potential for associated GCA. The patient should be asked about headaches, jaw claudication and visual disturbance. If there is any suspicion of GCA, urgent discussion with the rheumatologist should take place that day." }, { "id": "pubmed23n0363_21471", "title": "Polymyalgia rheumatica and temporal arthritis.", "score": 0.014982308712958867, "content": "Polymyalgia rheumatica and temporal arteritis are closely related inflammatory conditions that affect different cellular targets in genetically predisposed persons. Compared with temporal arteritis, polymyalgla rheumatica is much more common, affecting one in 200 persons older than 50 years. Temporal arteritis, however, is more dangerous and can lead to sudden blindness. The diagnosis of polymyalgia rheumatica is based on the presence of a clinical syndrome consisting of fever, nonspecific somatic complaints, pain and stiffness in the shoulder and pelvic girdles, and an elevated erythrocyte sedimentation rate. Temporal arteritis typically presents with many of the same findings as polymyalgia rheumatica, but patients also have headaches and tenderness to palpation over the involved artery. Arterial biopsy usually confirms the diagnosis of temporal arteritis. Early diagnosis and treatment of polymyalgia rheumatica or temporal arteritis can dramatically improve patients' lives and return them to previous functional status. Corticosteroid therapy provides rapid and dramatic improvement of the clinical features of both conditions. Therapy is generally continued for six to 24 months. Throughout treatment, clinical condition is assessed periodically. Patients are instructed to see their physician immediately if symptoms recur or they develop new headache, jaw claudication or visual problems." }, { "id": "pubmed23n1039_20194", "title": "[Inflammatory Muscle Pain: Polymyalgia Rheumatica with or without Large Vessel Vasculitis].", "score": 0.014869281045751633, "content": "Polymyalgia rheumatica (PMR) is characterized by rapidly evolving shoulder and pelvic girdle pain with fatigue, weight loss, night sweats and elevated CRP and ESR. Giant cell arteritis (GCA) can occur in PMR and vice versa. Headache and scalp tenderness are typical for GCA. GCA may be complicated by visual loss or by strokes.Imaging, particularly ultrasound, is helpful for distinguishing PMR from similar conditions such as shoulder osteoarthritis, rheumatoid arthritis and chondrocalcinosis. Subdeltoid bursitis, biceps tenosynovitis and hip joint effusions are common in PMR. The diagnosis of GCA needs to be either confirmed by imaging or by histology. Ultrasound is the imaging method of choice provided that expertise and adequate equipment are available. Inflamed arteries exhibit a concentric wall thickening. Patients with extracranial GCA are younger, more often female. Vasculitis commonly involves the aorta, subclavian arteries, axillary arteries and other arteries. The diagnosis of extracranial GCA may be confirmed by ultrasound, CT, MRI or PET.Prednisolone with a starting dose of 15-25 mg/d for PMR and of 40-60 mg/d for GCA results in rapid improvement of symptoms. Fast-track clinics provide clinical and ultrasound examinations by experts within 24 hours. Their introduction led to a decrease of visual loss in GCA. The prednisolone dose can be discontinued within 1 year in about 50 % of GCA patients. Additional treatment with tocilizumab allows to reduce flares and decrease glucocorticoid doses. Tocilizumab is particularly useful in patients with relapses and with increased risk of glucocorticoid side effects." }, { "id": "pubmed23n0556_18602", "title": "[Polymyalgia rheumatica].", "score": 0.014447835208849895, "content": "Polymyalgia rheumatica is a disorder that affects people over 50 years of age. The etiology of the disease has not been hitherto clarified exactly. Its incidence among people over 50 is in the range of 0.1-0.5%. The incidence rate peaks in the age group of 60-70 years. It is also found in younger people, but far less frequently. The diagnosis is based primarily on locomotor complains--namely on pronounced pain, morning stiffness of the shoulder girdle, pelvic girdle and neck. Complaints relating to the arms and legs (such as muscular weakness, oedema, tendonitis etc.) are also observed, however, in one third of the cases. The diagnostic criteria are defined empirically. Polymyalgia rheumatica was formerly considered to be a form of elderly onset rheumatoid arthritis. The progressive erosion process is absent in the case of polymyalgia rheumatica unlike in the case of rheumatoid arthritis. Numerous factors are known, which point to a link between polymyalgia rheumatica and giant cell vasculitis, arthritis, but the precise nature of this relationship remains unknown. Both conditions affect the same age group in the general population and they are even found--not infrequently--in the same patient. Polymyalgia rheumatica can be found in 40% of the patients suffering from arthritis while the histological examination detected mild vasculitis in approximately 10% of the patients suffering for \"isolated\" polymyalgia rheumatica. The response to be given to the acute phase is similar in both disorders. Scandinavian authors consider polymyalgia rheumatica as the appearance of generalised arthritis. Arthroscopic, nuclear magnetic resonance imaging as well as isotopic studies show unequivocally, that in the background of the osteo-muscular symptoms, complaints, inflammation is to be found partly of the joints but primarily that of the periarticular synovial structures. The above mentioned--dominant--proximal symptoms can often mask the distal locomotor disorders (pitting oedema of the hands and feet, tendonitis, tendosynovitis, carpal tunnel syndrome). The disorder may be accompanied by atypical generalised symptoms (loss of appetite, weight loss, fever, fatigue). An excellent indicators of the acute phase reactions are erythrocyte sedimentation rate, C-reactive protein and interleukin-6. These are suitable for monitoring the effectiveness of the therapy, for indicating a relapse/recurrence. It should be noted, that polymyalgia rheumatica may also be present if the erythrocyte sedimentation rate and C-reactive protein values are low. This disorder is also characterised by fast and effective response to corticosteroid, which should be administered for 1-2 years. In some individual cases a different dosage regime may be necessary: steroid administered in low dosage over a longer period of time. Administration of methotrexate and anti-tumor necrotic factor-alpha may also be considered as alternative or adjuvant therapy for lowering the quantity of corticosteroid. Further multicenter, double blind studies should, however, be performed on large number of patients in this regard." }, { "id": "pubmed23n0584_6459", "title": "Diagnosis and management of polymyalgia rheumatica/giant cell arteritis.", "score": 0.01437817845584836, "content": "There are no standardised diagnostic criteria for polymyalgia rheumatica. The combination of persistent pain (at least 1 month) with marked morning stiffness in at least 2 of the neck, shoulder or pelvic girdle is characteristic of polymyalgia rheumatica. The other criteria are age &gt;50 years, erythrocyte sedimentation rate (ESR) &gt;40 mm/hour, rapid response to corticosteroids and an absence of other diseases capable of causing the musculoskeletal symptoms. A normal ESR does not exclude a diagnosis of polymyalgia rheumatica. Diagnostic temporal artery biopsy is recommended in all patients suspected of having giant cell arteritis. The segment of temporal artery with abnormality on physical examination should be biopsied. The drugs of choice in the treatment of polymyalgia rheumatica/giant cell arteritis are corticosteroids. An initial prednisone dosage of 40 to 60 mg/day is adequate in almost all cases of giant cell arteritis. Higher dosages and/or intravenous pulse methylprednisolone can be tried on patients with partial response or with recent visual loss. Polymyalgia rheumatica in the absence of giant cell arteritis requires an initial dose of prednisone 10 to 20 mg/day. In some cases of mild polymyalgia rheumatica, a short course of nonsteroidal anti-inflammatory drugs may be tried. Long term corticosteroid therapy in polymyalgia rheumatica and giant cell arteritis is complicated by serious adverse effects in between 48 and 65% of patients. Vertebral fractures and infections are among the most dangerous and frequent complications. Although there are limited data on the use of cytotoxic or immunosuppressive drugs, such as methotrexate, azathioprine and cyclosporin, in these indications, they might be effective either in sparing corticosteroids or in treating patients who do not respond to treatment with corticosteroids." }, { "id": "wiki20220301en046_42761", "title": "Polymyalgia rheumatica", "score": 0.014329113924050632, "content": "PMR was first established as a distinct disease in 1966 by a case report on 11 patients at Mount Sinai Hospital in New York, NY. It takes its name from the Greek word Πολυμυαλγία polymyalgia, which means \"pain in many muscles\". Signs and symptoms A wide range of symptoms can indicate if a person has polymyalgia rheumatica. The classic symptoms include: Pain and stiffness (moderate to severe) in the neck, shoulders, upper arms, thighs, and hips, which inhibits activity, especially in the morning/after sleeping. Pain can also occur in the groin area and in the buttocks. The pain can be limited to one of these areas as well. It is a disease of the \"girdles\" meaning shoulder girdle or pelvic girdle. Fatigue and lack of appetite (possibly leading to weight loss) Anemia An overall feeling of illness or flu-like symptoms. Low-grade (mild) fever or abnormal temperature is sometimes present. In most people, it is characterized by constant fatigue, weakness and sometimes exhaustion." }, { "id": "pubmed23n0702_678", "title": "Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management.", "score": 0.014164173522812266, "content": "Giant cell arteritis (GCA) is an inflammatory vasculopathy that involves large- and medium-sized arteries and can cause vision loss, stroke and aneurysms. GCA occurs in people aged &gt;50 years and is more common in women. A higher incidence of the disease is observed in populations from Northern European countries. Polymyalgia rheumatica (PMR) is a periarticular inflammatory process manifesting as pain and stiffness in the neck, shoulders and pelvic girdle. PMR shares the same pattern of age and sex distribution as GCA. The pathophysiology of PMR and GCA is not completely understood, but the two conditions may be related and often occur concurrently. A delay in the diagnosis should be avoided because of the risk of vascular ischaemic complications due to GCA. The diagnosis should be considered in patients aged &gt;50 years presenting with symptoms such as new headache, visual disturbances, jaw claudication or symptoms of PMR. GCA can also present as a systemic inflammatory syndrome with fever of unknown origin. Marked elevation of acute-phase reactants, recognizable in higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, is often seen in both PMR and GCA. However, some patients can present with a normal ESR. Confirmation of the diagnosis of GCA by temporal artery biopsy is important because clinical findings and laboratory tests are not specific, and because a diagnosis of GCA commits patients to long-term treatment with corticosteroids. The role of imaging techniques for the diagnosis of GCA remains unclear, but these modalities can be helpful in assessing the extent of vascular involvement, especially when extra-cranial disease is present. In PMR, subdeltoid and subacromial bursitis can be identified by imaging techniques, especially ultrasound or MRI. The clinical manifestations of GCA and PMR respond dramatically within 12-48 hours of starting corticosteroid treatment. The initial corticosteroid dosage commonly used in GCA is oral prednisone 40-60 mg/day, and for patients with PMR a dosage of 15-20 mg/day is often sufficient. A prolonged course of treatment is necessary, and corticosteroids are gradually tapered, guided by regular clinical evaluation and ESR (and/or CRP) measurement. Methotrexate is the best studied corticosteroid-sparing agent in GCA, and may be useful for patients with frequent disease relapses and/or corticosteroid-related toxicity. Retrospective studies favour aspirin (acetylsalicylic acid) as an effective adjuvant treatment for reducing the ischaemic complications of GCA. The long-term course of corticosteroid therapy frequently exposes elderly patients with PMR/GCA to various adverse effects, which can be attenuated with appropriate prophylactic measures. Co-morbid diseases and polypharmacy can pose particular challenges in the geriatric population. In general, the life expectancy of patients with GCA does not appear to be shortened, whereas the morbidity associated with the disease and its treatment is well recognized." }, { "id": "pubmed23n0363_5892", "title": "Polymyalgia rheumatica with normal erythrocyte sedimentation rate: clinical aspects.", "score": 0.013931254268153882, "content": "Polymyalgia rheumatica is a relatively common syndrome of the elderly characterized by severe pain and stiffness in the neck shoulder and pelvic girdles, along with increased acute phase reactants. The current diagnostic criteria include as a requirement an erythrocyte sedimentation rate (ESR) higher than 30 or 40 mm/1 hr. Nevertheless, in several reports, a sizable proportion of patients with PMR, from 7% up to 22%, had an ESR that was either normal or slightly increased at the time of diagnosis, supporting the notion that an increased ESR should not be an absolute requirement for its diagnosis. This subset is characterized by a younger age, a less marked predominance of females, a longer diagnostic delay and a lower frequency of constitutional symptoms such as fever or weight loss. When determined, a majority of these patients had increased levels of C reactive protein. The recognition of this subset of patients with PMR and a low ESR can be very useful to the clinician, avoiding unnecessary suffering of the patients and the risks of ineffective therapy with nonsteroidal antiinflammatory drugs. To avoid the over-diagnosis of PMR in patients with a low ESR, we propose a set of criteria that can be easily applied in daily practice to patients with a clinical picture consistent with PMR but with a normal or slightly increased ESR." }, { "id": "pubmed23n0585_12751", "title": "Developing classification criteria for polymyalgia rheumatica: comparison of views from an expert panel and wider survey.", "score": 0.01369798971482001, "content": "This report summarizes the findings from a consensus process to identify potential classification criteria for polymyalgia rheumatica (PMR). A 3-stage hybrid consensus approach was used to develop potential PMR classification criteria. The first stage consisted of a facilitated meeting of 27 international experts who anonymously rated the importance of 68 potential criteria. The second stage involved a meeting of the experts, who were provided with the results of the first round of ratings and were then asked to re-rate the criteria. In the third stage, the wider acceptance of the 43 criteria that received &gt; 50% support at round 2 was evaluated using an extended mailed survey of 111 rheumatologists and 53 nonrheumatologists in the United States, Canada, and Northern and Western Europe. A total of 68 and 50 criteria were identified and rated in round 1 and round 2, respectively. In round 2, 43 of the 50 items achieved at least 50% support, including 10 core criteria achieving 100% support. In round 3, over 70% of survey respondents agreed on the importance of 7 core criteria. These were age &gt;or=50 years, duration &gt;or=2 weeks, bilateral shoulder and/or pelvic girdle aching, duration of morning stiffness &gt; 45 min, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and rapid steroid response (&gt; 75% global response within 1 wk to prednisolone/prednisone 15 20 mg daily). Among physical signs, more than 70% of survey respondents agreed on the importance of assessing pain and limitation of shoulder (84%) and/or hip (76%) on motion, but agreement was low for peripheral signs like carpal tunnel, tenosynovitis, and peripheral arthritis. There are differences in opinion as to what PMR is and how it should be treated. These findings make it important to develop classification criteria for PMR. The next step is to perform an international prospective study to evaluate the utility of candidate classification criteria for PMR in patients presenting with the polymyalgic syndrome." }, { "id": "pubmed23n0603_8382", "title": "Polymyalgia rheumatica: clinical picture and principles of treatment.", "score": 0.013542893378023372, "content": "Polymyalgia rheumatica (PMR) is a common disease of the elderly. It is characterized by pain and stiffness in the neck, shoulders and the pelvic girdle. In most cases erythrocyte sedimentation rate and C-reactive protein levels are highly elevated. Polymyalgia rheumatica is frequently associated with giant cell arteritis. Steroids are the standard treatment for PMR but their dosage requires adjustment depending on clinical picture, co-morbid conditions and adverse effects. The most prominent features of the disease as well as the main principles of treatment are presented." }, { "id": "pubmed23n0743_5916", "title": "Clinical characteristics and prognostic factors for relapse in patients with polymyalgia rheumatica (PMR).", "score": 0.01352508132169149, "content": "Polymyalgia rheumatica (PMR) is a common inflammatory disease of the elderly in western countries, but the prevalence is apparently different between races and countries. Until now, an epidemiologic study of PMR is limited in Korea. We retrospectively evaluated the clinical data of 78 patients with PMR who were treated in 5 tertiary hospitals, and analyzed initial laboratory data, symptoms, therapeutic responses, and prognostic factors for relapse 1 year after treatments. Sixty percent of patients had pain in both shoulder and hip girdles with 10.6 weeks of duration, 75.9 ± 32.7 mm/h of erythrocyte sedimentation rate (ESR), and 6.2 ± 6.4 mg/dl of C-reactive protein. The rate of relapse and remission at 1 year was 38.4 and 2.5 %, respectively. The rate of overall relapse was 46.1 %, and the relapse occurred mostly in a year, especially between 6 and 12 months after diagnosis. There were more female in relapse group (88.9 %, p = 0.037), and cumulative steroid dose of 1 year was significantly higher in relapse group (5.5 ± 2.7 vs. 4.4 ± 2.5 g, p = 0.018). Independent risk factors for relapse were initial CRP ≥ 2.5 mg/dl (OR 6.296, p = 0.047) and the use of hydroxychloroquine (OR 6.798, p = 0.035). Initial dosage or tapering speed of steroid did not influence on prognosis. In Korean patients with PMR, baseline clinical characteristics and relapse rate were similar to previous studies, but our patients accompanied no giant cell arteritis and showed lower remission rate as well as delayed therapeutic response and later occurrence of relapse. More aggressive management would be needed according to the clinical status of patients." }, { "id": "pubmed23n0652_5549", "title": "Diagnosing joint pain in the older people.", "score": 0.01318975955717004, "content": "There are many potential causes of joint pain in older patients. The most likely aetiology is OA. However, the differential diagnosis includes conditions which should not be missed such as septic arthritis and inflammatory disease. The pattern of joint involvement points to the diagnosis. Bilateral symmetrical small joint pain, swelling and stiffness should arouse the suspicion of RA. The wrist and knee are commonly affected by pseudogout and the first metatarsophalangeal joint or knee joint involvement may represent gout. Stiffness in the shoulder and hip girdles, worse in the morning, suggests polymyalgia rheumatica. In straightforward cases of OA no specific investigations are required. If doubt exists, however, tests may be necessary including FBC, ESR and CRP, uric acid for suspected gout and X-rays of the affected joints especially following trauma, or pseudogout. Patients with OA should be offered education and advice as well as strengthening exercises and aerobic fitness training (if physically possible). If the patient is overweight, weight loss is critical, especially in OA of the knee. Paracetamol and topical NSAIDs are the first-line drug treatments. Elderly onset RA differs from younger onset RA in the following ways: a more balanced gender distribution; a higher frequency of acute onset; an association with systemic features; more frequent involvement of the shoulder girdle and higher disease activity. DMARD therapy should be used according to disease severity, as in younger onset RA. The current approach is for early, intensive intervention with combination therapy. Corticosteroids may be very effective in the elderly, however, prolonged use and/or high dosage may lead to marked toxicity especially osteoporosis and diabetes." }, { "id": "pubmed23n0941_9870", "title": "Update on treatment of polymyalgia rheumatica.", "score": 0.013130881094952952, "content": "Polymyalgia rheumatica (PMR) is the second most common inflammatory rheumatic disease in the elderly after rheumatoid arthritis. It is clinically characterised by pain and stiffness in the neck, proximal shoulder and hip girdle. Glucocorticoids (GCs) are the cornerstone of PMR treatment, but they are associated with potentially severe side effects. Among GC-sparing agents, methotrexate revealed a modest benefit in clinical trials, and recently, there have been promising reports from tocilizumab. In this review, we summarize the available evidence on the treatment of PMR and the possible role in the future of other agents under investigation." }, { "id": "pubmed23n0739_4005", "title": "Polymyalgia rheumatica.", "score": 0.01280897037158291, "content": "Polymyalgia rheumatica is a chronic, inflammatory disorder of unknown cause that affects people over age 50 years. Classic symptoms include pain and long-term morning stiffness of the neck, shoulders, hips, upper arms, and thighs. Although markers of inflammation are often raised, no specific laboratory test exists for the disorder and the diagnosis is based on clinical assessment. Provisional classification criteria were published in April, 2012, by a collaborative initiative of the European League Against Rheumatism and the American College of Rheumatology. Several other disorders can mimic polymyalgia rheumatica. In particular, clinical manifestations can be difficult to differentiate from other forms of inflammatory arthritis such as spondyloarthritis and rheumatoid arthritis. Imaging studies such as ultrasonography and MRI typically show a predominantly periarticular inflammatory process. A subset of patients has an associated inflammatory vasculopathy affecting large arteries (giant cell arteritis). The standard treatment is low-dose glucocorticoids, which provide symptomatic relief for most patients. However, disease relapses are common, and treatment with glucocorticoids is associated with substantial morbidity. Improved understanding of disease pathogenesis might allow for more targeted immunotherapy." }, { "id": "pubmed23n0547_5170", "title": "Diagnosis, differential diagnosis and treatment of polymyalgia rheumatica.", "score": 0.012784090909090908, "content": "Polymyalgia rheumatica (PMR) is a common disorder in the elderly population. The diagnosis is based upon recognition of a clinical syndrome, consisting of pain and stiffness in the shoulder and pelvic girdle, muscle tenderness of the upper and lower limbs and nonspecific somatic complaints. In addition, in most cases the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentration are highly elevated. Although PMR and giant cell arteritis (GCA) are commonly regarded as two clinical variations of the same disease, their clinical picture is quite different. Whilst in PMR the musculoskeletal symptoms predominate, the major features of GCA are arterial inflammation and its consequences, which suggests clinical and pathological discrepancies between the two syndromes and important differences with respect to morbidity and mortality. The prognosis of correctly diagnosed PMR is excellent. It is well known that corticosteroid therapy in PMR usually leads to rapid and dramatic improvement of patients' complaints and returns them to previous functional status. However, prolonged corticosteroid treatment, sometimes for several years, may be necessary to maintain clinical improvement. Despite all the knowledge about the beneficial effects of corticosteroid treatment, data concerning the optimal dosage regimen are lacking. Long-term corticosteroid use can be associated with various adverse events, of which induction of osteoporosis, diabetes mellitus and infection among the worst. A Corticosteroid Side Effect Questionnaire has been shown to dose-dependently detect adverse effects perceived by patients. The European League Against Rheumatism (EULAR) response criteria for PMR comprise a core set of markers for monitoring therapeutic responses in PMR, namely ESR or CRP, the visual analogue scale of patient's pain and physician's global assessment, as well as morning stiffness and the ability to elevate the upper limbs. The PMR-disease activity score has been developed on the basis of EULAR response criteria as a means of expressing disease activity as an absolute number. A score &lt;7 indicates low disease activity, scores 7-17 suggest medium activity, and a score &gt;17 is indicative of high disease activity. The PMR-disease activity score has been proven to be highly correlated with patient's global assessment, patient satisfaction and ESR. It provides an easily applicable and valid tool for disease activity monitoring in patients with PMR. Improved knowledge of disease activity processes, exact monitoring of disease activity and treatment responses, and increased risk-estimation of treatment schedules should ultimately improve the care of patients with PMR." } ] } } }

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{ "1": "Dilated cardiomyopathy.", "2": "Pericardial effusion with cardiac tamponade.", "3": "Constrictive pericarditis.", "4": "Ischemic heart disease.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0293_15205", "title": "[Purulent pericardial effusion with tamponade: a rare initial manifestation of o pneumococcal infection].", "score": 0.015006744604316547, "content": "A 70-year-old man, admitted for a haemorrhoid operation, suddenly went into circulatory shock (heart rate 150/min, blood pressure 100/70 mm Hg), necessitating transfer to an intensive care unit. His neck veins were prominent and he had a paradoxical pulse. Heart sounds were distant and there was an arrhythmia (atrial fibrillation in the ECG). No murmurs were heard. Breath sounds were decreased, especially in the lung bases. Differential blood count showed 30% stab cells with 12,200 white cells per microliter. Erythrocyte sedimentation rate was 118 mm in the first hour, C-reactive protein was raised to 11.8 mg/dl. There was a partially compensated respiratory acidosis (pH 7.12; pO 93.4 mm Hg; pCO 16.3 mm Hg; base deficit -22.6 mmol/l). In the chest radiogram the cardiac silhouette was greatly enlarged bilaterally. The echocardiogram demonstrated a large pericardial perfusion with a \"swinging heart\". At pericardial needle puncture 700 ml of amber-coloured fluid, containing pneumococci, were aspirated with immediate circulatory improvement. Penicillin, 10 mill.U twice daily for 13 days, was administered intravenously, followed by amoxycillin, 1 g three times daily by mouth, for a further 15 days. In addition he was given anti-inflammatory treatment with diclofenac and methylprednisolone. Despite this pericardial effusion recurred after 14 days and 600 ml of sterile fluid were removed. Subsequently the inflammatory signs disappeared. Three months later no effusion was present and there were no signs of constrictive pericarditis." }, { "id": "pubmed23n0575_6474", "title": "A young man with intractable ascites and effort dyspnoea without echocardiographic signs of pericardial thickening: the importance of clinical investigation, CT scan and MRI in the diagnosis of constrictive pericarditis.", "score": 0.014161220043572984, "content": "A 35-year-old male patient suffering from dyspnoea on effort for 8 months, with abdominal and jugular venous distension, was previously studied in another hospital and discharged with a diagnosis of restrictive cardiomyopathy. Physical examination revealed a blood pressure of 110/60 mm Hg and absence of pericardial knock and also of paradoxical pulse. Chest X-ray showed no cardio-pulmonary alterations. Transthoracic echocardiography showed mild LV dysfunction (LVEF 46%) and lack of pericardial effusion and thickening. Doppler interrogation of transmitral flow showed a restrictive pattern. Computed tomography showed diffusely thickened pericardium, with the absence of calcification and of pericardial effusion. Cardiac magnetic resonance confirmed pericardial thickening and showed lack of myocardial alterations. Mild LV dysfunction was noted with dyskinesia of interventricular septum. The patient underwent cardiac catheterization, demonstrating an equalisation of RV and LV diastolic pressures with \"square root\" sign. The patient underwent pericardiectomy with consequent resolution of his symptoms and improvement of LV function." }, { "id": "pubmed23n0944_25265", "title": "Diagnostic Challenges in Chronic Constrictive Pericarditis.", "score": 0.013710178365427279, "content": "Chronic constrictive pericarditis (CCP) is a disease that has multiple possible causes and is associated with variable clinical findings, depending on its severity. It develops insidiously, and in many cases, particularly in developed countries, no antecedent diagnosis can be found. These cases are termed idiopathic. Tuberculosis is the leading cause of constrictive pericarditis in developing nations but represents only a small minority in developed countries. Here the authors describe two different case reports where tuberculosis was the probable cause of CCP. A 21-year-old man born in Cape Verde living in Europe for 4 years and a 24-year-old man born in Guiné Bissau were both admitted due to intense precordial pain and syncope after exertion. Interestingly both had fatigability, dyspnea, chest discomfort and palpitations on exertion, as well as progressive involuntary weight loss and decubitus cough. On physical examination they had tachycardia, jaundice, cachexia, elevated jugular venous pressure, hepatomegaly and ascites. Both electrocardiograms showed prominent P waves and chest X-ray showed bilateral pulmonary interstitial infiltrates and enlargement of the right cavities. Analytically, elevated bilirubin, leukopenia and thrombocytopenia was also found in both. Echocardiography revealed findings, in both cases, compatible with CCP including less common signs as annulus reversus and annulus paradoxus. Thoraco-abdomino-pelvic CT from both patients revealed chronic liver disease with congestion, pleural effusion, pericardial calcifications, ascites and massive mediastinal and abdominal adenopathies. Blood cultures and IGRA test were negative. However, given the presumptive diagnosis of tuberculosis (TB), anti-TB therapy was started. Despite the diagnosis of \"end-stage\" CCP with very high operative risk multidisciplinary team decided after informed consent, to perform total anterior pericardiectomy, that occurred without complications. Pericardial and mediastinal biopsies, pericardial/pleural fluid cultures/ immune-phenotyping were inconclusive. Anti- tuberculosis therapy was maintained. After surgery, the patients had a remarkable clinical improvement (NYHA I) that persisted in 6- month follow-up. These two case reports illustrate that despite the markedly elevated operative risk of pericardiectomy in \"end-stage\" forms of disease after patients informed consent must be a considered option. The other point to consider is that, despite rare, tuberculosis still is a possible diagnosis to consider in CCP in Portugal." }, { "id": "pubmed23n0052_18986", "title": "[A case of subacute effusive-constrictive pericarditis].", "score": 0.01369485294117647, "content": "A 30-year-old female with effusive-constrictive pericarditis was admitted to our hospital because of dyspnea, ascites and edema. On examination, her blood pressure was 118/94 mmHg and her pulse rate was 90 bpm. Physical examination revealed pulsus paradoxus, markedly raised venous pressure and pericardial knock sound. Chest X-ray showed marked cardiomegaly and bilateral pleural effusion. After cardiac catheterization there was elevation of mean right atrial pressure, right ventricular end-diastolic pressure, pulmonary-capillary-wedge pressure, and their pressures during diastole were approximately 30 mmHg. After successful pericardiocentesis, their diastolic pressures still remained at 15 mmHg. Additionally, pressure wave of the right ventricle showed distinct diastolic dip and plateau pattern, and that of the right atrium showed deep x and y descents. The pressure pattern suggested that not only pericardial effusion but also decreased compliance of the pericardium was the main factor contributing to the cardiac diastolic dysfunction. Histological examination of the pericardium showed diffuse lymphocyte infiltration and fibrosis. These findings strongly suggested that there might have been viral infection." }, { "id": "wiki20220301en025_33861", "title": "Pericarditis", "score": 0.013555194805194805, "content": "Physical examinations The classic sign of pericarditis is a friction rub heard with a stethoscope on the cardiovascular examination, usually on the lower left sternal border. Other physical signs include a person in distress, positional chest pain, diaphoresis (excessive sweating); possibility of heart failure in form of pericardial tamponade causing pulsus paradoxus, and the Beck's triad of low blood pressure (due to decreased cardiac output), distant (muffled) heart sounds, and distension of the jugular vein (JVD)." }, { "id": "pubmed23n0552_7649", "title": "[Recurrent autoreactive pericardial effusion. Impact of an aetiological classification of pericarditis].", "score": 0.013355521420037549, "content": "A 36 year-old man suffered from fever, fatigue, pleurodynia and precordial discomfort. His family physician suspected febrile tracheobronchitis and treated it with ampicillin for 5 days. Because symptoms persisted an ECG was done which suggested acute myocardial infarction. The patient underwent an emergency coronary angiography which excluded coronary artery disease and aortic dissection. Pericarditis was suspected and the patient put on aspirin, 500 mg/d. Because of persisting cardiac symptoms an echocardiography was performed which revealed systolic separation between epi- and pericardium, characteristic of a small pericardial effusion after acute pericarditis. The symptoms improved after one week of treatment with diclofenac and the ECG had become normal. Two months later the patient was seen at our cardiac outpatient clinic. He had night sweats, sporadic precordial pain and severe dyspnoe. Further investigations revealed tachycardia (120/min), hypotension (95/70 mm Hg), pulsus paradoxus and jugular vein sustension. Echocardiography revealed a large pericardial effusion (\"swinging heart\"), which explained the low voltage and the electrical alternans in the ECG. Pericardiocentesis was carried out the same day to relieve the tamponade. It was followed by pericardioscopy and epi- as well as pericardial biopsy. 485 ml of a serous effusion were drained. Cytology and histology demonstrated a lymphocytic fibrinous pericarditis. Polymerase chain reaction (PCR) on viral and bacterial RNA and DNA of potentially cardiotropic agents remained negative. The pigtail catheter was left in place and 80 mg of gentamycin were given intrapericardially on day 1 and 2, followed by 500 mg of crystalloid triamcinolone acetate after the PCR was found to be negative. Oral treatment with 0.5 mg colchicine three times a day (off-label use) was started and maintained for 6 months. After 9 months no effusion was detected and the patient was free of symptoms. After exclusion of bacterial and viral pericardial infection, a high single dose of intrapericardial triamcinolone combined with long-term oral colchicine has proven to be a highly efficacious treatment of autoreactive pericarditis which will avoid relapses in most cases." }, { "id": "pubmed23n0495_3220", "title": "Cases from the Osler Medical Service at Johns Hopkins University.", "score": 0.01289490651192779, "content": "PRESENTING FEATURES: A 70-year-old African American man was admitted with a history of fever, chills, and malaise of several days' duration. His past medical history was notable for end-stage renal disease requiring hemodialysis, coronary artery disease, and aortic stenosis requiring a bioprosthetic aortic valve replacement. On the day of admission, the patient was noted to have a shaking chill while undergoing dialysis through his catheter and was admitted to the hospital. He complained of pain at the catheter insertion site, shortness of breath, and dyspnea on exertion, but denied chest pain. On physical examination, the patient had a temperature of 100.4 degrees F, with a heart rate of 64 beats per minute, blood pressure of 127/72 mm Hg, and an oxygen saturation of 97% on room air. He was a mildly obese man in no apparent distress. He had shotty cervical lymphadenopathy and a right subclavian dialysis catheter in place, with erythema and pus at the entry site. His jugular venous pressure was 10 cm H(2)O. Lung examination showed bibasilar rales. Heart sounds were normal, with no rub or gallop. He had a 2/6 systolic ejection murmur best heart at the left sternal border as well as a 3/6 holosystolic murmur at the apex that radiated to his left axilla. Examination of the abdomen and extremities was unremarkable. The patient's neurological examination was unremarkable, and he was alert and oriented to person, place, and time. Laboratory studies showed an elevated white blood cell count of 16,700 cells/microL. His blood urea nitrogen level was 43 mg/dL and his serum creatinine level was 4.9 mg/dL. Multiple blood cultures grew methicillin-resistant Staphylococcus aureus. An admission, chest radiograph showed no infiltrate. An admission electrocardiogram showed normal sinus rhythm with first degree atrioventricular block, left anterior fascicular block, and left ventricular hypertrophy. shows rhythm strips from lead II electrocardiograms 5 months before admission (top), on admission (middle) and 5 days after admission (bottom). What is the diagnosis?" }, { "id": "pubmed23n0681_24001", "title": "[Constrictive pericarditis: the story of a constrained heart].", "score": 0.012817422050787529, "content": "Symptoms of constrictive pericarditis may be nonspecific, misleading and may delay or lead to an incorrect diagnosis. We present the case of a 28-year-old male who was admitted to the hospital with progressive dyspnea, thoracic pain and a history of 25 kg of weight gain during the last 2 years. He was evaluated at another facility and his clinical presentation led to an erroneous diagnosis of primary hepatic disease (cirrhosis and portal hypertension). Physical examination showed that he was dyspneic, emaciated, had marked distention of his frontal cranial veins, diminished heart sounds, massive ascites and leg edema. Laboratory tests reported abnormal liver function tests and abdominal paracentesis chylous ascites. Electrocardiogram showed sinus rhythm with generalized low voltage and nonspecific repolarization changes. Heart size was normal on chest radiography. Doppler echocardiography reported bilateral atrial dilatation, a thickened pericardium and a short deceleration time of transmitral flow. A thickened and calcified pericardium was seen on CT scan. Pericardiectomy was performed. Spontaneous polyuria was observed during and after surgery with subsequent improvement of ascites and edema. The pericardium was found to be grossly thickened and inflamed. Clinician must be aware of the slow and progressive course of right ventricular failure, as well as to recognize constrictive pericarditis as a cause of chronic ascites.The hemodynamic aspects of the disease are of paramount importance for early diagnosis and opportune treatment." }, { "id": "InternalMed_Harrison_18858", "title": "InternalMed_Harrison", "score": 0.01274999294801275, "content": "Viral or idiopathic acute pericarditis occurs at all ages but is more common in young adults and is often associated with pleural effusions and pneumonitis. The almost simultaneous development of fever and precordial pain, often 10–12 days after a presumed viral illness, constitutes an important feature in the differentiation of acute pericarditis from AMI, in which chest pain precedes fever. The constitutional symptoms are usually mild to moderate, and a pericardial friction rub is often audible. The disease ordinarily runs its course in a few days to 4 weeks. The ST-segment alterations in the ECG usually disappear after 1 or more weeks, but the abnormal T waves may persist for several years and be a source of confusion in persons without a clear history of pericarditis. Pleuritis and pneumonitis frequently accompany viral or idiopathic acute pericarditis. Accumulation of some pericardial fluid is common, and both tamponade and constrictive pericarditis are possible, but infrequent," }, { "id": "wiki20220301en324_30932", "title": "Myocardial infarction diagnosis", "score": 0.012612049197415053, "content": "Physical examination The general appearance of patients may vary according to the experienced symptoms; the patient may be comfortable, or restless and in severe distress with an increased respiratory rate. A cool and pale skin is common and points to vasoconstriction. Some patients have low-grade fever (38–39 °C). Blood pressure may be elevated or decreased, and the pulse can become irregular. If heart failure ensues, elevated jugular venous pressure and hepatojugular reflux, or swelling of the legs due to peripheral edema may be found on inspection. Rarely, a cardiac bulge with a pace different from the pulse rhythm can be felt on precordial examination. Various abnormalities can be found on auscultation, such as a third and fourth heart sound, systolic murmurs, paradoxical splitting of the second heart sound, a pericardial friction rub and rales over the lung. Electrocardiogram" }, { "id": "pubmed23n0903_10751", "title": "Purulent Pericarditis Due to an Infected Pacemaker Lead.", "score": 0.012418276781474853, "content": "Intravenous drug users have a substantially increased risk of infective endocarditis, especially in the setting of implanted cardiac devices. Purulent pericarditis is a rare occurrence that can occur iatrogenically or through direct or hematogenous spread. A 75 year old man with a past medical history significant for hepatitis C, IV drug abuse, and sick sinus syndrome status post pacemaker was brought in by EMS with a chief complaint of diaphoresis and chest pain. Initial EKG revealed atrial fibrillation with ST elevations in multiple leads. The patient was taken urgently to the cardiac catheterization lab due to concern for STEMI. Left heart catheterization revealed nonobstructive CAD; bedside echo was significant for a pericardial effusion and a pacemaker lead vegetation. CT of the chest revealed extension of the ventricular pacemaker lead through the anterior right ventricular wall and pericardium and into the pleural cavity. Cardiothoracic surgery performed a pacemaker removal as well as pericardial window due to early tamponade; approximately 900 mL of purulent fluid was drained from the pericardial space. The patient was septic with initial blood cultures growing MSSA. He was also found to have multiple other foci of infection including a left-sided pleural effusion and a perihepatic fluid collection, both of which were drained and also grew out MSSA. The patient initially improved on antibiotics after his pacemaker removal and drainage of the infected fluid collections. However, several days after the pacemaker removal he gradually became more bradycardic; due to his multiple comorbidities and active infection, he was not a candidate for a replacement implanted pacemaker. He became profoundly bradycardic and hypotensive overnight and died despite the use of multiple pressors to maintain his blood pressure as well as transcutaneous pacing to maintain his heart rate. Purulent pericarditis has become a relatively uncommon occurrence since the development of effective antibiotics. This case illustrates a rare example of purulent pericarditis and cardiac tamponade secondary to the extension of an infected pacemaker wire through the pericardium and into the thoracic cavity. The presence of multiple other infected fluid collections in this case also illustrates the need to thoroughly assess for secondary foci of infection in cases of bacterial endocarditis." }, { "id": "wiki20220301en028_9481", "title": "Kussmaul's sign", "score": 0.012310802405142028, "content": "Causes The differential diagnoses of Kussmaul's sign includes constrictive pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure. With cardiac tamponade, jugular veins are distended and typically show a prominent x descent and an absent y descent as opposed to patients with constrictive pericarditis (prominent x and y descent), see Beck's triad. Other possible causes of Kussmaul's sign include: Right ventricular infarction - low ventricular compliance Right heart failure Cardiac tumours Tricuspid stenosis Restrictive cardiomyopathy Pulmonary embolism Constrictive pericarditis History Kussmaul's sign is named after the German doctor who first described it, Adolph Kussmaul (1822-1902). He is also credited with describing Kussmaul breathing. See also Pulsus paradoxus References Symptoms and signs: Vascular" }, { "id": "InternalMed_Harrison_2955", "title": "InternalMed_Harrison", "score": 0.012270287158803649, "content": "Additional clues to the etiology and importance of a heart murmur can be gleaned from the history and other physical examination findings. Symptoms suggestive of cardiovascular, neurologic, or pulmonary disease help focus the differential diagnosis, as do findings relevant to the jugular venous pressure and waveforms, the arterial pulses, other heart sounds, the lungs, the abdomen, the skin, and the extremities. In many instances, laboratory studies, an ECG, and/or a chest x-ray may have been obtained earlier and may contain valuable information. A patient with suspected infective endocarditis, for example, may have a murmur in the setting of fever, chills, anorexia, fatigue, dyspnea, splenomegaly, petechiae, and positive blood cultures. A new systolic murmur in a patient with a marked fall in blood pressure after a recent MI suggests myocardial rupture. By contrast, an isolated grade 1 or 2 mid-systolic murmur at the left sternal border in a healthy, active, and asymptomatic young" }, { "id": "wiki20220301en001_252441", "title": "Heart", "score": 0.01219012744224144, "content": "Pericardial disease The sac which surrounds the heart, called the pericardium, can become inflamed in a condition known as pericarditis. This condition typically causes chest pain that may spread to the back, and is often caused by a viral infection (glandular fever, cytomegalovirus, or coxsackievirus). Fluid can build up within the pericardial sac, referred to as a pericardial effusion. Pericardial effusions often occur secondary to pericarditis, kidney failure, or tumours, and frequently do not cause any symptoms. However, large effusions or effusions which accumulate rapidly can compress the heart in a condition known as cardiac tamponade, causing breathlessness and potentially fatal low blood pressure. Fluid can be removed from the pericardial space for diagnosis or to relieve tamponade using a syringe in a procedure called pericardiocentesis. Congenital heart disease" }, { "id": "wiki20220301en028_11540", "title": "Jugular venous pressure", "score": 0.012118736383442266, "content": "Prominent 'x' descent Cardiac tamponade Slow 'y' descent Tricuspid stenosis Cardiac tamponade Prominent & deep 'y' descent Constrictive pericarditis Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with expiration) Pericardial effusion Constrictive pericarditis Pericardial tamponade" }, { "id": "pubmed23n0741_6379", "title": "A case of dilated cardiomyopathy.", "score": 0.011752136752136752, "content": "Dilated cardiomyopathy is a significant health problem in Africa. Diagnosis and treatment can be challenging as it frequently affects young patients and those without risk factors for cardiac disease. A previously well HIV negative 17 year old boy presented to Mseleni hospital in December 2011 with a short history of worsening shortness of breath on exertion. The history had been preceded by a brief upper respiratory tract infection with general malaise and headache, from which he had recovered fully. On examination, he was clammy, peripherally shut down and clearly in respiratory distress. He had a raised jugular venous pressure (JVP) and palpable displaced apex beat. He had a loud P2, third heart sound and pansystolic murmur over the apex. He had scattered inspiratory crepitations bibasally. Routine blood tests on admission, including malaria and viral serology, were unremarkable. A chest x-ray showed a grossly dilated cardiac shadow and enlarged pulmonary trunk. A cardiac ultrasound ruled out pericardial effusion but did show a dilated and hypokinetic left ventricle. He was diagnosed with dilated cardiomyopathy secondary to a viral infection and managed accordingly. Dilated cardiomyopathy, although rare worldwide, is a significant problem throughout Africa. It has been shown to account for up to 48% of admissions with heart failure. Its aetiology is multifactorial and includes exposure to toxins and infectious agents. Presenting symptoms can be vague but improved prognosis and outcomes require prompt diagnosis and appropriate management." }, { "id": "wiki20220301en025_33862", "title": "Pericarditis", "score": 0.011686214516403195, "content": "Complications Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in people who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus (decrease of at least 10 mmHg of the systolic blood pressure upon inspiration), low blood pressure (due to decreased cardiac index), (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid." }, { "id": "pubmed23n0662_16071", "title": "A 63-year-old woman with a pericardial effusion, bilateral pleural effusions, and ascites: is the whole greater than the sum of its parts?", "score": 0.011666666666666667, "content": "A 63-year-old female presented with dyspnea, leg edema, and abdominal distention. Exam revealed blood pressure of 104/58, pulse 108/min, jugular venous pressure of 8 cm, no pulsus paradoxus, a pericardial rub, muffled heart sounds, decreased basilar breath sounds, ascites, and ankle edema. Electrocardiogram showed low voltage. Imaging revealed thickened pericardium and a pericardial effusion. Hemodynamic tracings postpericardiocentesis revealed elevated right-sided pressures. The patient was diagnosed with effusive constrictive pericarditis. The case and review of this condition are described. Patients with a pericardial effusion and symptoms unresponsive to pericardiocentesis or with pericardial thickening should undergo evaluation for effusive-constrictive pericarditis." }, { "id": "wiki20220301en093_40523", "title": "Acute pericarditis", "score": 0.011597122302158274, "content": "Corticosteroids are usually used in those cases that are clearly refractory to NSAIDs and colchicine and a specific cause has not been found. Systemic corticosteroids are usually reserved for those with autoimmune disease. Prognosis One of the most feared complications of acute pericarditis is cardiac tamponade. Cardiac tamponade is accumulation of enough fluid in the pericardial space --- pericardial effusion --- to cause serious obstruction to the inflow of blood to the heart. Signs of cardiac tamponade include distended neck veins, muffled heart sounds when listening with a stethoscope, and low blood pressure (together known as Beck's triad). This condition can be fatal if not immediately treated." }, { "id": "wiki20220301en074_29969", "title": "Pericardial effusion", "score": 0.01151622418879056, "content": "Signs and symptoms Pericardial effusion presentation varies from person to person depending on the size, acuity and underlying cause of the effusion. Some people may be asymptomatic and the effusion may be an incidental finding on an examination. Others with larger effusions may present with chest pressure or pain, dyspnea, shortness of breath, and malaise (a general feeling of discomfort or illness). Yet others with cardiac tamponade, a life-threatening complication, may present with dyspnea, low blood pressure, weakness, restlessness, hyperventilation (rapid breathing), discomfort with laying flat, dizziness, syncope or even loss of consciousness. This causes a type of shock, called obstructive shock, which can lead to organ damage." }, { "id": "wiki20220301en012_131370", "title": "Cardiac tamponade", "score": 0.011473453966991448, "content": "Diagnosis may be suspected based on low blood pressure, jugular venous distension, or quiet heart sounds (together known as Beck's triad). A pericardial rub may be present in cases due to inflammation. The diagnosis may be further supported by specific electrocardiogram (ECG) changes, chest X-ray, or an ultrasound of the heart. If fluid increases slowly the pericardial sac can expand to contain more than 2 liters; however, if the increase is rapid, as little as 200 mL can result in tamponade." }, { "id": "InternalMed_Harrison_17406", "title": "InternalMed_Harrison", "score": 0.011134453781512605, "content": "or absence of a third heart sound (S3). Accurate characterization of cardiac murmurs provides important insight into the natural history of many valvular and congenital heart lesions. Finally, the important role played by the physical examination in enhancing the clinician-patient relationship cannot be overestimated. THE GENERAL PHYSICAL EXAMINATION Any examination begins with an assessment of the general appear-ance of the patient, with notation of age, posture, demeanor, and 267 SEC Tion 2 DiAgnoSiS oF CARDiovASCulAR DiSoRDERS overall health status. Is the patient in pain or resting quietly, dyspneic or diaphoretic? Does the patient choose to avoid certain body positions to reduce or eliminate pain, as might be the case with suspected acute pericarditis? Are there clues indicating that dyspnea may have a pulmonary cause, such as a barrel chest deformity with an increased anterior-posterior diameter, tachypnea, and pursed-lip breathing? Skin pallor, cyanosis, and jaundice can be" }, { "id": "pubmed23n1066_8587", "title": "Case Report: ST-Segment Elevation in a Man With Acute Pericarditis.", "score": 0.011091445427728615, "content": "<bBackground:</b Acute pericarditis is a rapid inflammatory condition of the pericardium with both infectious and non-infectious etiology. Most acute pericarditis is self-limited, with a small portion evolving rapidly. The definitive diagnosis of acute pericarditis often requires detailed physical examination, ECG, echocardiography, blood analysis and chest X-ray. It's usually challenging to distinguish acute pericarditis from ST-elevated myocardial infarction (STEMI) due to the similar ECG characteristics (ST segment change). Here we present a case of purulent pericarditis probably caused by esophageal perforation. <bCase:</b A 52 year-old male presented with chest pain and dyspnea for 16 h. ST-segment elevation and positive cardiac markers lead to the initial diagnosis of ST-elevated myocardial infarction. Coronary angiography demonstrated normal coronary artery, while transthoracic echocardiography (TTE) showed massive pericardial effusion. Then, pericardiocentesis was performed with 250 ml of yellowish-green pus-like fluid extracted. A detailed history examination revealed a week history of possible esophageal perforation caused by a fishbone. And a further computed tomography (CT) demonstrated the presence of pneumomediastinum, and effusions in mediastinum, which lead to the diagnosis of purulent pericarditis. However, the patient's family refused further treatment and the patient died soon after discharge. <bConclusion:</b The differential diagnosis of chest pain should include acute pericarditis, which can be equally critical and fatal. And it's important to note the peculiar characteristics of acute pericarditis, which include concave and diffused ST-segment elevation, PR segment depression, and the ratio of ST-segment elevation to T wave &gt;0.24 in lead V6. Moreover, comprehensive medical history and physical examination are crucial to the differential diagnosis of chest pain patients." }, { "id": "article-18905_7", "title": "Cardiac Tamponade -- History and Physical", "score": 0.010744603444094105, "content": "Patients with cardiac tamponade present similar to patients with other forms of cardiogenic or obstructive shock. They may endorse vague symptoms of chest pain, palpitations, shortness of breath, or in more severe cases, dizziness, syncope, and altered mental status.  They may also present in a pulseless electrical activity cardiac arrest. The classic physical findings in cardiac tamponade included in Beck’s triad are hypotension, jugular venous distension, and muffled heart sounds. Pulsus paradoxus, which is a decrease in systolic blood pressure by more than 10 mm Hg with inspiration is an important physical exam finding that suggests a pericardial effusion is causing cardiac tamponade. Pulsus paradoxus may be absent in patients with ASD, elevated diastolic pressures, pulmonary hypertension and aortic regurgitation. The Kussmaul sign - a paradoxical elevated in JVP and pressure during inspiration is sometimes seen in cardiac tamponade." }, { "id": "article-26960_10", "title": "Constrictive-Effusive Pericarditis -- History and Physical", "score": 0.010624755189972582, "content": "In effusive-constrictive pericarditis, patients commonly present with chronic symptoms that mimic volume overload. These include jugular venous distension, ascites, hepatomegaly, peripheral edema, and pleural effusions. Tachycardia occurs reflexively due to decreased cardiac output. Other signs and symptoms of decreased cardiac output include increased fatigue, hypotension, altered mental status, dyspnea, and tachypnea. Signs of active pericarditis may also ensue, including fever, pleuritic substernal chest pain, and a pericardial friction rub. Jugular venous distention also occurs due to decreased right heart filling and subsequent backup into the venous system." }, { "id": "article-38171_16", "title": "Cardiac Syncope -- History and Physical", "score": 0.01056225894342026, "content": "A careful physical exam will assess heart rate and rhythm. Any abnormalities will increase suspicion of cardiac arrhythmia. In addition, an elevated respiratory rate or hypoxia will increase suspicion of a pulmonary embolism. Jugular venous distention and hypotension are suggestive signs of an obstructive mechanical cardiac etiology. Pathological cardiac murmurs, specifically new ones, will clue one into a valvular etiology, hypertrophic cardiomyopathy, or an obstructive intracardiac lesion. Muffled sounds can be heard with pericardial tamponade. Pedal edema or other evidence of deep venous thrombosis increases a patient's risk of pulmonary embolism. [10]" }, { "id": "pubmed23n0083_1888", "title": "[Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction: a case report].", "score": 0.010256410256410258, "content": "A case of Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction was reported. A 49-year-old man, who had been diagnosed by indirect fluorescent antibody test as the first case of Lassa fever in Japan, was referred to the Hiroo Hospital because of syncope, progressive hepatomegaly, ascites and pericardial effusion in spite of pericardiocentesis and corticosteroid therapy. On admission, his blood pressure was 92/60 mmHg and he had a paradoxical pulse. Two-dimensional echocardiography revealed a localized pericardial effusion adjacent to the right ventricular wall and behind the left ventricular posterior wall. Bilateral atrioventricular annular constriction was also present. On pulsed Doppler echocardiography, the peak inflow velocities of the right and left ventricles increased during atrial systole. Right heart catheterization revealed a mean diastolic pressure gradient of 8 mmHg across the tricuspid valve. After pericardiectomy, a diastolic dip and plateau pattern became evident in the right ventricular pressure tracing, suggesting the presence of residual constriction. However, the atrioventricular annular constriction was no longer evident on two-dimensional echocardiography. This is considered the first reported case of subacute effusive constrictive pericarditis caused by Lassa fever." }, { "id": "article-17105_12", "title": "Acquired Immune Deficiency Syndrome -- History and Physical -- Cardiac System [8]", "score": 0.010158966716343766, "content": "HIV infection and ART likely contribute to increased cardiovascular disease in patients. Common presenting symptoms may include chest pain, shortness of breath, or fatigue. The examination should proceed as one would when assessing for acute coronary syndrome or valvular disease, palpating for chest wall pain, observing for jugular venous distension and peripheral edema, and auscultating for abnormal heart sounds, murmurs, or evidence of pulmonary edema. Cardiovascular AIDS-related illnesses could include purulent pericarditis or cardiac tamponade caused by Mycobacterium tuberculosis . If these conditions are suspected, observing for Beck’s triad of low blood pressure, jugular venous distension, and muffled heart sounds may confirm a compressive pericardial effusion." }, { "id": "wiki20220301en023_18131", "title": "Dilated cardiomyopathy", "score": 0.010087045570916539, "content": "Signs and symptoms Dilated cardiomyopathy develops insidiously, and may not initially cause symptoms significant enough to impact on quality of life. Nevertheless, many people experience significant symptoms. These might include: Shortness of breath Syncope (fainting) Angina, but only in the presence of ischemic heart disease A person suffering from dilated cardiomyopathy may have an enlarged heart, with pulmonary edema and an elevated jugular venous pressure and a low pulse pressure. Signs of mitral and tricuspid regurgitation may be present." }, { "id": "pubmed23n0975_2231", "title": "Acute Influenza Infection Presenting with Cardiac Tamponade: A Case Report and Review of Literature.", "score": 0.010053851094313521, "content": "Cardiac complications associated with influenza infection can occur either via a direct effect of the virus on the heart or through exacerbation of preexisting cardiovascular disease. We present a case of a 57-year-old man with acute influenza infection complicated by pericardial effusion and cardiac tamponade. A 57-year-old white man presented to the Emergency Department with sudden onset of severe, nonexertional, retrosternal, pressure-like chest pain for a few hours and with fever and muscle aches for 2 days. The patient was initially admitted because of suspected acute coronary syndrome. The next morning, he complained of acute-onset shortness of breath and had hypotension and tachycardia. On examination, his peripheral extremities were cold and heart sounds were distant. Pulsus paradoxus was 20 mmHg. The electrocardiogram showed low-voltage QRS complex with electrical alternans. An urgently performed bedside echocardiogram showed moderate pericardial effusion with a small right ventricular cavity with diastolic collapse. Emergent pericardiocentesis was performed, with removal of 250 mL of fluid from the pericardial space. The patient's hemodynamic status immediately improved. Analyses of pericardial fluid demonstrated no bacteria, acid-fast bacilli, or malignant cells. The result of a rapid influenza diagnostic test with polymerase chain reaction was positive for influenza A virus, with other viral panels yielding normal results. The patient was treated with oseltamivir for 5 days. Pericardial involvement is a rare and perhaps underreported complication of influenza infection. Early recognition of cardiac symptoms and appropriate diagnostic workup in a patient presenting with influenza-like symptoms is important to avoid life-threatening complications." }, { "id": "InternalMed_Harrison_18884", "title": "InternalMed_Harrison", "score": 0.010024730612965908, "content": "Subacute Effusive-Constrictive Pericarditis This form of pericardial disease is characterized by the combination of a tense effusion in the pericardial space and constriction of the heart by thickened pericardium. It shares a number of features with both chronic pericardial effusion producing cardiac compression and with pericardial constriction. It may be caused by tuberculosis (see below), multiple attacks of acute idiopathic pericarditis, radiation, traumatic pericarditis, renal failure, scleroderma, and neoplasms. The heart is generally enlarged, and a paradoxical pulse and a prominent x descent (without a prominent y descent) are present in the atrial and jugular venous pressure pulses. After pericardiocentesis, the physiologic findings may change from those of cardiac tamponade to those of pericardial constriction. Furthermore, the intrapericardial pressure and the central venous pressure may decline, but not to normal. The diagnosis can be established by pericardiocentesis" }, { "id": "wiki20220301en028_11539", "title": "Jugular venous pressure", "score": 0.009950343773873185, "content": "An exaggerated \"y\" wave or diastolic collapse of the neck veins from constrictive pericarditis is referred to as Friedreich's sign. Raised JVP, normal waveform Bradycardia Fluid overload Heart failure Raised JVP, absent pulsation Superior vena cava syndrome Large 'a' wave (increased atrial contraction pressure) Tricuspid stenosis Right heart failure Pulmonary hypertension Cannon 'a' wave (atria contracting against closed tricuspid valve) Atrial flutter Premature atrial rhythm (or tachycardia) Third degree heart block Ventricular ectopics Ventricular tachycardia Absent 'a' wave (no unifocal atrial depolarisation) Atrial fibrillation Large 'v' wave (c–v wave) Tricuspid regurgitation Absent 'x' descent Tricuspid regurgitation (sometimes 'x' wave is replaced by a positive wave) Prominent 'x' descent Cardiac tamponade Slow 'y' descent Tricuspid stenosis Cardiac tamponade Prominent & deep 'y' descent Constrictive pericarditis" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 192, 539 ] ], "word_ranges": [ [ 36, 95 ] ], "text": "In my opinion, the most suitable would be alternative 2, since hydroxyloroquine has been reported to decrease the absorption of folic acid, and since she has a complication of SLE, in this case, we could be dealing with an autoimmune hemolytic anemia with folic acid consumption. And for this it would be first to determine with the direct coombs." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Haptoglobin.", "2": "Coombs' test.", "3": "Vitamin B12.", "4": "Antinuclear antibodies.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1098_18165", "title": "Immune-mediated Coombs negative intravascular haemolysis in systemic lupus erythematosus (SLE).", "score": 0.019149715961150816, "content": "A 27-year-old woman presented with a history of excessive hair loss, loss of appetite, loss of weight, amenorrhoea and loss of axillary and pubic hair for 6 months followed by fever and vomiting for 5 months and abdominal pain for 1 month. During the course of her illness, the patient developed intravascular haemolysis as evidenced by a drop in haemoglobin, indirect hyperbilirubinaemia, raised lactate dehydrogenase (LDH) and haemoglobinuria. Examination revealed severe pallor, mild icterus, elevated jugular venous pressure, generalised lymphadenopathy and hyperpigmentation. Investigations revealed severe anaemia, indirect hyperbilirubinaemia, raised LDH and negative Coombs test. Antinuclear antibody and anti-dsDNA, anti-Sm and anti-SS-A/Ro antibodies were positive and complement C3 was low. The patient was diagnosed to have systemic lupus erythematosus and immune-mediated intravascular haemolysis and was treated with prednisolone and hydroxychloroquine. Haemolysis resolved following steroid therapy, and during follow-up, there were no further episodes of haemolysis." }, { "id": "pubmed23n0060_1206", "title": "[An elderly case of systemic lupus erythematosus associated with herpes zoster, anemia, and hemiparesis].", "score": 0.018575851393188854, "content": "An elderly case of systemic lupus erythematosus (SLE) with suspected hemolytic anemia was experienced. A 70 year-old female was admitted to our hospital on December 31 with complaints of herpetic eruption. She complained of arthralgia since 3 month prior to her admission. The positive findings on examination were skin eruption in the left chest, a systolic heart murmur and a palpable elastic hard liver. Laboratory data showed raised erythrocyte sedimentation rate of 149 mm per hour, decreased Hb (10.1 g/dl), decreased hematocrit (30.0%), increased reticulocytes (33%1000), decreased thrombocytes (73,000/mm3), increased gamma-globulin (33%) and positive rheumatoid factor. During admission, she developed anemia. A stool test for occult blood was negative. The haptoglobin was 38.8 mg/dl and bone marrow aspiration showed increased erythropoiesis, suggesting features of immune hemolytic anemia, except she was negative on Coomb'test. Eye fundi were similar to case of typical bleeding observed in SLE. Concerning immunological findings, the antinuclear factor was x 1280 and the anti-dsDNA antibody was x 80, on which a diagnosis of SLE was based. She experienced numbness of the left arm and developed left hemiparesis 2 days later. Therapy with 15 mg/day prednisone obtained a good response and anemia, abnormal immunological findings and hemiparesis disappeared." }, { "id": "pubmed23n1102_1154", "title": "Late-Onset Systemic Lupus Erythematosus Associated with Autoimmune Hemolytic Anemia and Sixth Cranial Nerve Palsy.", "score": 0.018543956043956044, "content": "BACKGROUND Patients with late-onset systemic lupus erythematosus (SLE) do not present with typical SLE symptoms or serology, and this can lead to a major delay in diagnosis. We report a complex case of an older woman who developed autoimmune hemolytic anemia and sixth cranial nerve palsy that posed considerable challenges in diagnosing late-onset SLE. CASE REPORT A 78-year-old Japanese woman presented with polyarthritis associated with generalized fatigue for 2 months, who later developed diplopia. Physical examination revealed conjunctival pallor, polyarthritis, and subsequent development of sixth cranial nerve palsy. Laboratory data revealed a decreased white blood cell count; macrocytic anemia; elevated levels of lactate dehydrogenase, indirect bilirubin, and erythrocyte sedimentation rate; hypocomplementemia; positive Coombs test; antinuclear antibodies (ANAs, 1: 40); and positive anti-double-strand DNA antibodies. Lymphoma, cerebral venous sinus thrombosis, and varicella-zoster virus infection were unlikely based on head computed tomography, brain magnetic resonance imaging, and cerebrospinal fluid analysis. She was diagnosed with late-onset SLE associated with autoimmune hemolytic anemia and sixth cranial nerve palsy. The patient was successfully treated with prednisone and hydroxychloroquine. CONCLUSIONS The difficulty in diagnosing late-onset SLE with atypical presentations and uncommon complications must be recognized. SLE cannot be excluded based on a low titer of ANA in a particular subgroup such as the elderly, and the prozone effect should be considered responsible for low ANA titers. In this case, late-onset SLE was diagnosed by considering multisystem pathologies despite low ANA titers." }, { "id": "pubmed23n0297_3204", "title": "[Autoimmune hemolytic anemia with eosinophilia in elderly patient].", "score": 0.018452380952380953, "content": "A 70-year-old woman was admitted to our hospital in November 1992 for evaluation of anemia. Physical examination revealed anemia, jaundice, swelling of axial and inguinal lymph nodes, and splenomegaly. Abnormal hematological findings were as follows: Hb of 3.9 g/dl, reticulocyte count of 58.2% (61.7 x 10(4)/microliters), hyperplasia of normal erythroblasts in bone marrow, and eosinophilia (21.0%, 2352/microliters) in peripheral blood. Routine laboratory examinations revealed polycolonal hypergammaglobulinemia 3.0 g/dl, a high level of serum LDH (797 IU/I) and a total bilirubin of 2.4 mg/dl (indirect, 1.6 mg/dl). The serum haptoglobin level was very low (&lt; 5 mg/dl). Results of serological examinations were as follows: IgG of 3366 mg/dl, CH50 of 16.0 U/ml, positive Coombs test 2+, and positive tests for antinuclear antibody, rheumatoid factor, and cold agglutinin. CRP was negative. PHA-stimulated lymphocyte blast formation, NK activity, and ADCC activity were found to be suppressed, and the percentage of CD4-positive lymphocytes in peripheral blood was also low. An axillary lymph node biopsy revealed reactive lymphadenitis. No signs or history suggested allergy, collagen disease, or parasitic infection. Autoimmune hemolytic anemia (AIHA) complicated by immunologic abnormalities and eosinophilia was diagnosed. Oral prednisolone markedly reduced the hemolytic anemia, eosinophilia, lymph node swelling, and splenomegaly, but NK activity remained low." }, { "id": "pubmed23n0847_23036", "title": "Elderly female with Autoimmune hemolytic anemia.", "score": 0.017582753612109165, "content": "Autoimmune hemolytic anemia (AIHA) is a rare disease with an estimated prevalence of around 17/100,000. It is often difficult to diagnose and treat AIHA, especially in elderly. A 60-year-old female was admitted with the complaints of low grade fever, on-off for 6 months, progressive fatigue and dyspnea on exertion. She was transfused with three units of blood within these 6 months. Examination revealed pallor, edema, hemic murmur, and palpable liver. Hb was 2.9 gm%, T Bil 5.2 mg/dl, ESR 160 mm, and reticulocyte count 44.05%. Direct Coombs test was positive, anti-nuclear antibody (ANA) and Anti ds DNA were positive. A diagnosis of systemic lupus erythematosus (SLE) with AIHA was considered and patient was transfused with two units of packed red cells and put on steroid (prednisolone) at 1 mg/kg body weight daily. After 3 weeks, her Hb had increased to 10.4 gm% with gross clinical improvement. " }, { "id": "pubmed23n0688_12771", "title": "Frequency of anaemia in patients with systemic lupus erythematosus at tertiary care hospitals.", "score": 0.016750305167503053, "content": "To analyze the frequency and causes of anaemia in systemic lupus erythematosus (SLE) patients attending in department of medicine at tertiary care hospitals. This retrospective, descriptive and analytical study was planned to analyze the frequency and causes of anaemia in SLE patients attending the department of medicine at (MMC) and (LUMHS) hospitals during the period of Jan 2006 to Nov 2008. The criteria used in this study were from the American College of Rheumatology. Investigations recorded were blood complete picture, absolute values, peripheral smear, and reticulocyte count in all patients of anaemia. These investigations were necessary to analyse the cases of anaemia in SLE. All investigations were not done in all cases. Patients with hypochromic microcytic anaemia were advised to have serum iron and ferritin levels, seven patients with macrocytic anaemia were advised to have direct and indirect coomb's test, LFTs, serum LDH, serum B12 and folate levels. Patients with normochromic and normocytic anaemia were considered to have anaemia of chronic disease. Bone marrow aspiration and Hb electrophoresis were done in two patients with anaemia of chronic disease. Thirty adult patients were included in this study. Special proforma were prepared to record the information from case sheets of patients including basic information, symptomatology and laboratory investigations. Severity and various types of anaemias were recorded. Anaemia was graded according to severity, as mild (Hb 10-12 G/dl), Moderate (Hb 8-10 G/dl) and severe (Hb &lt; 8 G/dl). Haemoglobinopathies and other types of anaemias were excluded from study. Thirty adult diagnosed patients of SLE, were included. Their ages ranged from twenty years to fifty years at time of presentation. The mean age +/- SD (range) was 28 +/- 6.22 (20-50) years and median age was 31 years. Out of thirty patients, twenty seven (90%) were females and three (10%) were males. Twenty eight (93.33%) patients presented with anaemia, 14 (46.66%) patients were of mild anaemia, 8 (26.66%) patients were of moderate grade anaemia and 6 (20%) patients had severe anaemia. Iron deficiency anaemia was found in 9 (30%) patients, 12 (40%) patients had anaemia of chronic disease and 7 (23.33%) patients had haemolytic anaemia, out of theses 7 patients, 5 (16.66%) patients had Coomb's positive haemolytic anaemia. All thirty patients had ANA positive titres &gt; 1:80; and nineteen (63.33%) patients had anti ds DNA positive, titres &gt; 1:10. Haematologic abnormalities are common manifestations in patients with SLE. Most patients exhibit anaemia at some point during their disease course." }, { "id": "pubmed23n0479_1305", "title": "[Successful treatment of intravenous cyclophosphamide pulse therapy for systemic lupus erythematosus complicated with steroid-resistant hemolytic anemia].", "score": 0.016112170223233503, "content": "(Case 1) A 13-years-old female had multiple arthralgia and butterfly rush, when she admitted in our hospital in May 2001. Nephropathy, hemolytic anemia (Hb 6.3 g/dl and direct Coombs 3+) and high titers of antinuclear antibodies and anti-ds-DNA antibody were disclosed and she was diagnosed as systemic lupus erythematosus (SLE). Although combination therapy of PSL 60 mg/day with a steroid pulse therapy, cyclosporine or an immunosorbent treatment, severe hemolytic anemia remained. However, monthly cyclophosphamide pulse therapy (IV-CY), which was started for the steroid-resistant hemolytic anemia, has gradually become effective and Hb improved up to 11.4 g/dl after 6 courses of IV-CY. (Case 2) A 53-years-old woman diagnosed as SLE in 1978 and she had PSL 5 mg for over 10 years. Severe anemia (Hb 5.9 g/dl) was disclosed with a slight fever in June 2001, and she admitted in our hospital for further examinations. Progressive hemolytic anemia was revealed with marked decrease of Hb (3.4 g/dl) and high titer of direct Coombs (3+). Neither PSL (50 mg/day) nor steroid pulse therapy were effective against hemolytic anemia. In contrast, 3 courses of monthly IV-CY (500 mg/day) resulted in the resolution of hemolysis. It is well known that the steroid-resistant hemolytic anemia is extremely hard to treat and leads to miserable prognosis, but we here propose IV-CY as an alternative and invaluable choice for the treatment of refractory hemolytic anemia complicated with SLE." }, { "id": "pubmed23n0771_4606", "title": "A puzzle of hemolytic anemia, iron and vitamin B12 deficiencies in a 52-year-old male.", "score": 0.015443560271146479, "content": "A 52-year-old male with no significant past medical history reports increasing generalized fatigue and weakness for the past 2 weeks. Physical examination reveals jaundice and pallor without organomegaly or lymphadenopathy. His hemoglobin was 5.9 g/dL with a mean corpuscular volume of 87.1 fL and elevated red blood cell distribution width of 30.7%. His liver function test was normal except for elevated total bilirubin of 3.7 mg/dL. Serum LDH was 701 IU/L, and serum haptoglobin was undetectable. Further investigation revealed serum vitamin B12 of &lt;30 pg/mL with elevated methylmalonic acid and homocysteine level. In addition, serum ferritin and transferrin saturation were low. The patient was diagnosed with hemolytic anemia secondary to vitamin B12 deficiency with concomitant iron deficiency anemia. " }, { "id": "pubmed23n0501_23829", "title": "Klinefelter's syndrome presenting with leg ulcers.", "score": 0.01521898427371625, "content": "A 54-year-old man of Persian origin presented to our department with a 1-year history of ulcers on the right leg that had been unresponsive to numerous topical treatments, accompanied by lymphedema of the right leg. Medical history included hypergonadotropic hypogonadism, which had not been further investigated. He was treated for 20 years with testosterone IM once monthly, which he stopped a year before the current hospitalization for unclear reasons. The patient reported no congenital lymphedema. Physical examination revealed two deep skin ulcers (Figure 1) on the right leg measuring 10 cm in diameter with raised irregular inflammatory borders and a boggy, necrotic base discharging a purulent hemorrhagic exudate. Bilateral leg pitting edema and right lymphangitis with lymphadenitis were noted. He had low head hair implantment, sparse hair on the body and head, hyperpigmentation on both legs, onychodystrophia of the toenails (mainly the large toe and less prominent on the other toes), which was atrophic lichen-planus-like in appearance and needed no trimming (Figure 2), normal hand nails, oral thrush, and angular cheilitis. Other physical findings were gynecomastia, pectus excavatum, small and firm testicles, long extremities, asymmetrical goiter, systolic murmur 2/6 in left sternal border, and slow and inappropriate behavior. The patient's temperature on admission was 39 degrees C. Blood cultures were negative for bacterial growth. Results of laboratory investigations included hemoglobin (11.2 g/dL), hematocrit (26.8%), normal mean corpuscular volume and mean corpuscular hemoglobin volume, and red blood cell distribution width (16%). Blood smear showed spherocytes, slight hypochromia, anisocytosis, macrocytosis, and microcytosis. Blood chemistry values were taken for iron (4 micro g/dL [normal range 40-150 micro g/dL]), transferrin (193 mg/dL [normal range 220-400 mg/dL]), ferritin (1128 ng/mL [normal range 14-160 ng/mL]), transferrin saturation (1.5% [normal range 20%-55%]), serum folate (within normal limits), and vitamin B12 (within normal limits). Direct Coombs' test equaled positive 2 + IgG. All these values indicated anemia of chronic diseases combined with hemolytic anemia. Further blood work-up tested antinuclear antibody (positive &lt;1:80 homogeneous pattern), rheumatoid factors (143 IU/mL [positive &gt;8.5 IU/mL]), C-reactive protein (286 mg/L [normal range 0-5 mg/L]), anticardiolipin IgM antibody (9.0 monophosphoryl lipid U/mL [normal range 0-7.00 MPL U/mL]) and antithrombin III activity (135% [normal range 74%-114%]). Results of other blood tests were within normal limits or negative, including lupus anticoagulant, beta2 glycoprotein, anticardiolipin IgG Ab, anti-ss DNA Ab, C3, C4, anti-RO, anti-LA, anti-SC-70, anti-SM Ab, P-ANCA, C-ANCA, TSH, FT4, anti-T microsomal, antithyroglobulin, protein C activity, protein S free, cryoglobulins, serum immunoelectrophoresis, VDRL, hepatitis C antibodies, hepatitis B antigen, and human immunodeficiency virus. Endocrinological work-up examined luteinizing hormone (22.9 mIU/mL [normal range for adult men 0.8-6 mIU/mL]), follicle stimulating hormone (49.7 mIU/mL [normal range for adult men 1-11 mIU/mL]), testosterone (0.24 ng/mL [normal range for adult men 2.5-8.0 ng/mL]), bioavailable testosterone (0.02 ng/mL [normal range for adult men &gt;0.6 ng/mL]), and percent bioavailable test (8.1% [normal value &gt;20%]). These results indicate hypergonadotropic hypogonadism. Plasminogen activator inhibitor 1 was 6 U (normal value 5-20 U/mL). Karyotyping performed by G-banding technique revealed a 47 XXY karyotype, which is diagnostic of Klinefelter's syndrome. Doppler ultrasound of the leg ulcers disclosed partial thrombus in the distal right femoral vein. X-rays and bone scan displayed osteomyelitis along the right tibia. Histological examination of a 4-mm punch biopsy from the ulcer border revealed hyperkeratosis, acanthosis, hypergranulosis, and mixed inflammatory infiltrate containing eosinophils compatible with chronic ulcer. Multiple vessels were seen, compatible with a healing process. Direct immunofluorescence of the biopsy revealed granular IgM in the dermo-epidermal junction. Indirect immunofluorescence was negative. Thyroid function tests showed normal thyroid stimulating hormone and free throxine4. Multinodular goiter was seen on thyroid scan and ultrasound. Thyroid fine needle aspiration was compatible with multinodular goiter (normal follicular cells, free colloid, macrophages with pigment). IV treatment with amoxicillin-clavulanic acid 1 g t.i.d. was administered for 2 weeks, with a decrease in temperature and normalization of the leukocyte level. Oral antibiotic treatment with amoxicillin-clavulanic acid was continued for 10 more days, followed by 25 days of ciprofloxacin for the osteomyelitis. Local treatment included saline soakings followed by application of Promogran (Johnson &amp; Johnson, New Brunswick, NJ) and Kaltostat (ConvaTec Ltd., a Bristol-Myers Squibb Company, New York, NY) with slight improvement. At the same time, the patient was treated with warfarin sodium due to deep vein thrombosis under international normalized ratio 2-3. The patient was treated with IM testosterone once monthly for 1 year, which resulted in a reduction in the diameter and depth of the leg ulcers (Figure 3). Blood tests were not performed for follow-up of the immune state." }, { "id": "pubmed23n0870_7365", "title": "Paroxysmal Nocturnal Haemoglobinuria in the Differential Diagnosis of Unresponsive Iron Deficiency Anemia: A Case Report.", "score": 0.013898112133573665, "content": "A 16-year-old male patient who was on oral iron treatment for iron deficiency anemia for the last one year was seen at the Haematology clinic with complaints of weakness, pallor, and jaundice. A complete blood count revealed Hb of 4.2 mmol/L, Hct of 0.14, and MCV of 76 fl. A blood smear showed 50% neutrophils, 40% lymphocytes, and 10% monocytes with anisocytosis, poikilocytosis, polichromasia in erythrocytes and normoblasts. Reticulocyte count was under 1%. There was a slight erythroid hyperplasia in the bone marrow aspiration. Biochemical examinations showed total bilirubin of 3.9 mg/dL, indirect bilirubin of 3.4 mg/dL, and lactate dehydrogenase (LDH) of 6085 U/L (220-450). In re-evaluating the history of the patient, he was seen to be complaining of dark discoloration of morning urine. Perl's reaction was found to be positive for hemosiderin in the urine sediment. Because Ham's test was positive, the levels of CD55, 58, and 59 proteins on erythrocyte membranes were found to be lower. The patient was started 32 mg of methylprednisolone and his anaemia was improved by the 14th day of treatment. When evaluating iron deficiency anemia resistant to iron supplementation, PNH should be kept in mind. " }, { "id": "pubmed23n1019_11883", "title": "When systemic lupus erythematosus affects vision: a rare presentation of this condition.", "score": 0.012683122616897451, "content": "A 23-year-old woman with fever, oral ulcers, arthalgias and weight loss of 2-week duration suddenly developed blurred vision, with reduced visual acuity, cotton wool exudates and retinal vascular tortuosity. Laboratory testing revealed anaemia, lymphopaenia, positive antinuclear antibody and high anti-dsDNA antibody titre with low complement components. There was no evidence of infection, clinching the diagnosis of lupus retinopathy. Steroid therapy alone was highly effective and was also accompanied by a normalisation of haemoglobin and lymphocyte counts, after which azathioprine was added. Hydroxychloroquine was introduced after resolution of retinal changes. Immunosuppressive therapy was progressively tapered over the course of 12 months and then discontinued, and the patient remains in remission 48 months after the initial presentation. Our patient exemplifies a very rare manifestation of systemic lupus erythematosus. We emphasise the importance of its early detection and complexity of treatment in order to reduce visual morbidity." }, { "id": "pubmed23n0273_11418", "title": "[Lupus erythematosus in old age].", "score": 0.01240257793764988, "content": "Over a period of 2 months an 88-year-old man developed progressively more severe breathing-related pain under the right shoulder blade, loss of appetite, general weakness, depressive mood, sub-febrile temperature and nocturnal sweating. Various inflammation parameters were raised (sedimentation rate 43 mm in the first hour; C-reactive protein 26 mg/dl; white cell count 12,500/microliters). There also were pleural effusion and signs of mild nonspecific hepatitis. Antibiotics were administered because bacterial pneumonia was suspected. But the patient's condition deteriorated and he developed nightly periods of disorientation. There was no evidence for any advanced malignancy. Immunological tests pointed towards older-onset systemic lupus erythematosus: titre for antinuclear antibodies markedly raised to 1:20 480; anti-DNA titre moderately raised to 1:125 IU/ml. The patient's general condition and the pleuritic pain improved within 2 days under treatment with prednisone (50 mg daily); the depression, disorientation and fever receded within a week. The anti-DNA titre fell to 47 IU/ml after 8 weeks. He was able to resume his usual social activities and was kept on a maintenance prednisone dose of 5.0 mg daily." }, { "id": "pubmed23n0265_17510", "title": "[A case of systemic lupus erythematosus presenting with myelofibrosis as a cause of pancytopenia].", "score": 0.011916093777542746, "content": "A 54 year-old woman who had a 6 month history of polyarthralgias, oral ulcers, weight loss and fatigue was admitted to the Urawa Municipal Hospital. She developed high fever, dyspnea and thrombocytopenia. Chest radiograph revealed massive right pleural effusion. At this time, laboratory investigations gave the following results: hemoglobin 12.7 g/dl, WBC 7700/microliters and platelet count 9.2 x 10(4)/microliters. Antibody to DNA was negative. Antinuclear antibody was positive at a titer of 320x in a centromere pattern; Anti-RNP and anti-Sm antibodies were negative. CH50 was 18.6 u/ml. C3 was 42.9 mg/dl. C4 was 11.5 mg/dl. Circulating immune complex (Clq) was 30.5 micrograms/ml. Circulating lupus anti-coagulant and anticardiolipine antibodies were positive. Thoracocentesis was performed; the material was a straw-colored exudate with over two thousands white cell per ul and showed marked reduction of complement titiers and elevated immune complex levels. She was then diagnosis as having SLE. Two weeks after admission, progressive leukopenia and anemia succeedingly occurred and resulted in severe pancytopenia. Bone marrow biopsy demonstrated marked marrow fibrosis and increased reticulin content with no evidence of malignancy. Steroid pulse therapy for 3 days started, and subsequently she was treated with 60 mg/day of prednisolone. Three weeks after starting on steroids, the massive pleural effusion was completely disappeared and complement titiers were normalized. Circulating immune complex has not been detected any more. After 8 weeks, the peripheral blood count was normalized. The dose of prednisolone was reduced progressively. On this occasion, the biopsy showed normocullular marrow with a marked reduction in the amount of reticulin.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "InternalMed_Harrison_1673", "title": "InternalMed_Harrison", "score": 0.01172754024580232, "content": "Fever >38.3°C (101°F) on at least two occasions 2. Illness duration of ≥3 weeks 3. 4. Diagnosis that remains uncertain after a thorough history-taking, physical examination, and the following obligatory investigations: determination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis; urinalysis; blood cultures (n = 3); urine culture; chest x-ray; abdominal ultrasonography; and tuberculin skin test (TST). The range of FUO etiologies has evolved over time as a result of changes in the spectrum of diseases causing FUO, the widespread Percentage of Cases Due to Indicated Cause" }, { "id": "pubmed23n0715_15091", "title": "Coexistence of Crohn's disease in a patient with systemic lupus erythematosus.", "score": 0.009708737864077669, "content": "The concurrence of inflammatory bowel disease with systemic lupus erythematosus (SLE) is rare. The concomitant diagnosis of Crohn's disease and SLE is even more rare. The patient, a 40-year-old woman, was admitted to our hospital because of relapsing episodes of abdominal pain, diarrheas upper and lower extremities arthralgias, Raynaud's phenomenon with positive antinuclear antibodies, and fever for the last 2 years. The patient was diagnosed elsewhere with SLE and treated with hydroxychloroquine. Her medical history also included tonsillectomy and total hip replacement after a car accident. Family history was unremarkable. Physical examination was unremarkable except of very mild pain at lower left abdominal quadrant. Laboratory tests showed erythrocyte sedimentation rate at 32 mm/h, C-reactive protein at 36 mg/dl, positive rheumatoid factor, and increased C3, C4, positive antinuclear antibodies with the presence of anti-Sm and anti-RNP antibodies. Ileocolonoscopy revealed colonic inflammation with ulcers and pseudopolyps. Subsequent biopsies were diagnostic of Crohn's disease. Patient was diagnosed with Crohn's colitis concomitant to systemic lupus erythematosus and was started on therapy with azathioprine 2 mg/Kg, methylprednisolone 16 mg/d with slow tapering, mesalazine 1.5 g/day, and hydroxychloroquine. Patient is in excellent health status on the six-month follow-up." }, { "id": "pubmed23n0298_13034", "title": "[Sarcoidosis in a patient with autoimmune hemolytic anemia].", "score": 0.009615384615384616, "content": "A 65-year-old woman was admitted to our hospital because of severe anemia. A skin biopsy was done in January 1994 and sarcoidosis was diagnosed. Diffuse reticular shadows were seen in both lung fields on a chest X-ray film and mediastinal lymph node swelling was seen on a chest CT scan. She was followed as an outpatient and was not treated. She suddenly experienced vertigo and general fatigue in March 1995. Laboratory findings on admission were as follows: Hb 6.2 g/dl, MCV 115.9 fl, Ret 198%, LDH 732 IU/L, I-Bil 1.9 mg/dl, and Coombs' test was positive. Autoimmune hemolytic anemia was diagnosed, and she was treated with prednisolone (1 mg/kg). As of the time of this writing, she has no relapse of hemolytic anemia though prednisolone was discontinued 6 months ago." }, { "id": "pubmed23n0740_15281", "title": "Prevalence of hematinics deficiency amongst female students and its correction.", "score": 0.009523809523809525, "content": "Nutritional anemia (NA) is common in India. While iron deficiency (ID) is a well recognized cause of NA, prevalence of deficiencies of other hematinics is not systematically investigated. Seventy students of a junior class of a polytechnic and 202 inmates of girl students home were taken up for study. Students were given a questionnaire to elicit anemia related symptoms. Blood was collected for complete blood count (CBC), serum ferritin, folic acid and vitamin B12. Students of polytechnic received hematinic at bed time during their menstrual periods whereas inmates of students home received hematinic at bed time, 3 days in a week. After 6 months blood tests were repeated in those who completed the treatment. CBC was done on Coulter counter and ferritin, folic acid and vitamin B12 were assayed by chemiluminescence. Students were divided into three groups-(1) Control group with Hb 12.0 g/dl or more and ferritin 15.0 ng/ml or more; (2) ID Group with Hb 12.0 g/dl or more and ferritin less than 15.0 ng/ml; and (3) Iron Deficiency Anemia (IDA) group with Hb less tha 12.0 g/dl and ferritin less than 15.0 ng/ml. Basal parameters of three groups were compared using students t test. Change in parameters with treatment was compared using paired students t test. Median age-16 years (range 10-25). Anemia ( Hb &lt; 12.0 g/dl)-94 (34.6%); MCV &lt; 80 fl-153 (56.3%); MCH &lt; 27 pg-167 (61.4%); Ferritin &lt; 15.0 ng/ml-161 (59.2%); Folic acid &lt; 3.5 ng/ml-34 (12.5%); Vitamin B12 &lt; 258 pg/ml-133 (48.9%) Pre-therapy: (1) Hb, MCV, MCH and ferritin significantly lower in ID and IDA Groups compared to control group. (2) Hb, MCV, MCH and Ferritin significantly lower in IDA Group as compared to ID Group. POST-THERAPY: (1) IDA group showed significant increase in Hb, MCV, MCH, ferritin, folic acid and vitamin B12. (2) final Hb (11.26+1.07) and ferritin (7.46+4.81) in IDA Group were subnormal. (3) MCV, MCH, ferritin, folic acid and vitamin B12 increased significantly in ID Group and control group. (1) Nutritional anemia is common amongst asymptomatic young female students. (2) Deficiencies of iron, folic acid and vitamin B12 are common and coexist. (3) 105 mg elemental iron for 3 days in a week for 6 months is not adequate to correct IDA. (4) 105 mg iron for 3 days in a week is enough to correct ID. (5) Non-anemic individuals with ID have iron deficient erythropoiesis. (6) Non-anemic individuals without ID, in this cohort, also had iron deficient eryhtropoiesis." }, { "id": "pubmed23n0754_14208", "title": "Subacute cutaneous lupus erythematosus induced and exacerbated by proton pump inhibitors.", "score": 0.009433962264150943, "content": "Subacute cutaneous lupus erythematosus (SCLE) can be induced by numerous drugs. We report 3 cases of SCLE induced by proton pump inhibitors (PPIs). To highlight a rare cutaneous side effect induced by a frequently prescribed drug such as a PPI. Case 1 was a 30-year-old man who developed multiple annular plaques over the trunk and lower limbs 1 month after the initiation of pantoprazole. Antinuclear antibodies (ANA) were positive with anti-Ro/SSA and anti-La/SSB antibodies, and histology confirmed the diagnosis. Clinical improvement was achieved 8 weeks after the discontinuation of pantoprazole and the introduction of a treatment combining topical steroids and hydroxychloroquine. Lesions relapsed when pantoprazole was accidentally rechallenged. The second case was a 31-year-old woman, 28 weeks pregnant, who presented erythematous annular plaques over the trunk 7 weeks after starting esomeprazole. ANA and anti-Ro/SSA antibodies were positive, and the histology was compatible with SCLE. Fetal ultrasound was normal. She was treated with topical and oral steroids and hydroxychloroquine. Clinical improvement was achieved 4 weeks after the discontinuation of esomeprazole. The third case was a 57-year-old woman with systemic erythematosus lupus presenting annular and psoriasiform lesions on the trunk for 15 months. She was treated successively with hydroxychloroquine, azathioprine, mycophenolate mofetil and methotrexate with prednisone. A review of her drug history revealed the introduction of omeprazole a few weeks before the first appearance of skin lesions and omeprazole was contraindicated. SCLE should systematically be suspected in case of eruption after the introduction of PPI. The risk of fetal cardiac complications is important in pregnant women." }, { "id": "pubmed23n0834_13001", "title": "Borderline tuberculoid leprosy in childhood onset systemic lupus erythematosus patient.", "score": 0.009345794392523364, "content": "Leprosy is a contagious and chronic systemic granulomatous disease caused by the bacillus Mycobacterium leprae. To our knowledge, no case of leprosy in a childhood-onset systemic lupus erythematosus (c-SLE) patient has been reported. For a period of 31 years, 312 c-SLE patients were followed at the Pediatric Rheumatology Unit of our University Hospital. One of them (0.3%) had tuberculoid leprosy skin lesions during the disease course and is here reported. A 10-year-old boy from Northwest of Brazil was diagnosed with c-SLE based on malar rash, photosensitivity, oral ulcers, lymphopenia, proteinuria, positive antinuclear antibodies, anti-double-stranded DNA, anti-Sm and anti-Ro/SSA autoantibodies. He was treated with prednisone, hydroxychloroquine and intravenous cyclophosphamide, followed by mycophenolate mofetil. At 12-years-old, he presented asymmetric skin lesions characterized by erythematous plaques with elevated external borders and hypochromic center with sensory loss. Peripheral nerve involvement was not evidenced. No history of familial cases of leprosy was reported, although the region where the patient resides is considered to be endemic for leprosy. Skin biopsy revealed a well-defined tuberculoid form. A marked thickening of nerves was observed, often destroyed by granulomas, without evidence of Mycobacterium leprae bacilli. At that time, the SLEDAI-2K score was 4 and he had been receiving prednisone 15 mg/day, hydroxychloroquine 200 mg/day and mycophenolate mofetil 3 g/day. Paucibacillary treatment for leprosy with dapsone and rifampicine was also introduced. In conclusion, we have reported a rare case of leprosy in the course of c-SLE. Leprosy should always be considered in children and adolescents with lupus who present skin abnormalities, particularly with hypoesthesic or anesthesic cutaneous lesions. " }, { "id": "pubmed23n0223_13278", "title": "[Central nervous system involvement in systemic lupus erythematosus].", "score": 0.009259259259259259, "content": "Three cases are presented, in two of which the CNS lesions revealed the presence of systemic lupus erythematosus (SLE). The diagnosis of SLE was certain according to the criteria of the ARA, and it was further confirmed by results of renal needle puncture biopsy. Case 1: A 16-year-old adolescent developed choreic movements followed, one month later, by psychotic symptoms suggesting a mixed hebephrenic-catatonic schizophrenic affection. Cutaneous lesions and signs of renal insufficiency 3 months later established that these disorders were related to SLE. A favourable outcome was observed rapidly for the systemic signs, recovery from neuropsychic symptoms being obtained after 3 months only but then in a few days. This course suggests the diagnosis of a \"functional psychosis\" of lupus origin. Case 2: A 24-year-old woman developed left hemiparesis followed by febrile coma. The slowly favourable course of the disease led to the appearance of a progressive dementia, with numerous epileptic seizures. Although tests for antinuclear antibodies were negative and the ESR was normal, several minor biological anomalies were suggestive of a systemic disease and the diagnosis of SLE was finally established. Corticotherapy produced only slight transient improvement. This progression towards dementia with progressive cerebral atrophy is most probably related to cerebral lupus lesions, the initial coma in the absence of any other apparent cause possibly being the first sign. Case 3: A 47-year-old woman developed simultaneously or separately episodes of arthralgia and uveitis of unknown origin over a 12-year period, and attacks of regressive multilocular neurological deficiency over a 15-year period.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0575_6282", "title": "[Hematological abnormalities in systemic lupus erythematosus and clinical significance thereof: comparative analysis of 236 cases].", "score": 0.009259259259259259, "content": "To investigate the hematological abnormalities and their relationship to the disease activity of systemic lupus erythematosus (SLE). The clinical data of 236 SLE patients, 29 males and 207 females with the age of confirmed diagnosis of 33.4, were divided into 3 groups: anemia group, with the hemoglobin (Hgb) &lt; 100 g/L, including 2 subgroups, i.e. subgroup of anemia caused by chronic diseases (ACD) and subgroup of hemolytic anemia; low white blood cell group 1 (Group WBC1) with the WBC count &lt; 4.0 x 10(9)/L, white blood cell group 2 (Group WBC2) with the WBC count 3.0 approximately 3.9 x 10(9)/L, immune thrombopenic purpura group (ITP group) with a platelet count &lt; 100 x 10(9)/L, and control group without hematological changes. 72 patients underwent morphologic characterization of their bone marrow. The hematological data and the relationship thereof to the disease activity in different groups were analyzed. Among the 236 SLE patients 168 (71.18%) had hematological abnormalities and 68 of them (28.82%) without hematological abnormalities. 123 of the 168 patients with hematological abnormalities (52.1%) had anemia, 82 of which (66.7%) had characteristics of anemia caused by chronic diseases, 18 (14.6%) had hemolytic anemia, 8 (6.6%) had hematopoietic abnormalities, and the remaining 15 patients (12%) had anemia caused by unknown reasons. 73 of the 236 SLE patients (30.9%) had a WBC count &lt; 4.0 x 10(9)/L and 57 patients (24.2%) had a platelet count &lt; 100 x 10(9)/L. In the groups with hemolytic anemia, WBC count &lt; 3.0 x 10(9)/L and thrombocytopenia, the complement levels were significant lower, and the levels of C-reactive protein (CRP) and positive anti-dsDNA antibody were significantly higher than those of the controls (all P &lt; 0.05) The rate of positive antiphospholipid antibody of the hemolytic anemic patients and patients with thrombocytopenia were 22.2% and 15.8% respectively, both significantly higher than that of the controls (2.9%, both P &lt; 0.05). 49 of the 72 patients undergoing morphologic characterization of bone marrow had normal cell morphology and a normal appearing bone marrow, 10 had varying degrees of pathologic hematopoietic changes, 2 lacked megakaryocytes, 9 expressed decreased proliferation in all three hematopoietic lineages, and 2 had only a decrease in erythropoiesis. The reason of the high proportion of anemia among the SLE patients in China may be the higher proportion of anemia caused by ACD in comparison with that abroad. Although SLE patients have lower rates of hemolytic anemia, HA is an important index of SLE disease activity. Thrombocytopenia and a WBC count &lt; 3.0 x 10(9)/L are related to SLE disease activity. Abnormalities of hemopoiesis by bone marrow is one of the reasons of sever hematological changes in part of the SLE patients." }, { "id": "pubmed23n0956_21239", "title": "Hardness and Painful Lesion of the Breast.", "score": 0.009174311926605505, "content": "Dear Editor, Lupus panniculitis or lupus profundus is a rare inflammatory complication found in patients with systemic lupus erythematosus (SLE), or discoid lupus erythematosus (DLE) (1). When the breast is involved, the term lupus mastitis (LM) is used. This disease involving the breast is rare, and the lesions may precede, coincide with, or occur later than the onset of other lupus lesions. Tissue biopsy is required to confirm the suspected diagnoses of LM. We report a case of a patient with lupus mastitis due to the important differential diagnosis. A 60-year-old woman presented with a painful nodular lesion in her left breast that had appeared 15 days ago (Figure 1, a). She had been previously diagnosed with discoid lupus erythematosus 3 years ago. Physical examination revealed a deep and firm erythematous subcutaneous nodule without overlying skin involvement in the lower-central portion of the left breast. Laboratory findings were positive for antinuclear antibodies (1:80) and double-stranded deoxynucleic acid antibodies (1:10). Mammography and ultrasounds showed an area of increased density and irregular breast tissue along with an important thickening of the overlying skin (Figure 1, b). On suspicion of malignancy, a needle biopsy of the breast lesion was performed and showed vacuolar alteration and lymphocytic infiltrate in the basal layer. Subcutaneous fat showed a lobular panniculitis with a prominent lymphocytic infiltrate and hyalinization of the fat lobules (hyaline fat necrosis). Direct immunofluorescence of the face biopsy revealed IgA, IgG, IgM, and C3 granular deposition. Based on these results, a diagnosis of lupus mastitis associated with DLE was established. Antimalarial therapy resulted in complete resolution of the clinical features. Three years later, the patient presented with a disfiguring atrophy with retraction in the damaged areas of the breast (Figure 2). Lupus mastitis is a very unusual disease that most commonly affects middle-aged women. The first case of LM was described by Tuffanelli in 1971. The lesions usually present following the diagnosis of SLE/DLE; however, on rare occasions they may be observed earlier (2). The histophysiology of this disease remains unclear, but the predominant theory suggests an autoimmune-related etiology. Corroborating evidence for this theory includes the finding of immune complexes, both at the basement membrane of the dermal-epidermal junction and in the blood vessels in the areas of panniculitis (3). Lupus mastitis may be present in the breast as single or multiple subcutaneous nodules that may be tender or painful and can progress to chronic ulcers over time or resolve, leaving atrophic scars. The overlying skin can be normal, erythematous, poikilodermic or ulcerated. When skin changes are prominent, the lesion may clinically and radiologically mimic inflammatory breast carcinoma. Mammographic and ultrasounds findings include an ill-defined breast density with or without associated microcalcifications (4). Histologically, this disease is characterized by lobular lymphocytic panniculitis and predominantly involves the fat lobule and the presence of anucleated adipocytes in a background of a glassy-appearing collagenous stroma (hyaline fat necrosis). Fibrinoid necrosis of the vessel wall has also been reported, but is usually absent (5). Differential diagnosis of lupus mastitis includes inflammatory breast carcinoma, primary medullary carcinoma, and other immune-mediated inflammatory conditions such as diabetic mastopathy. The first line of treatment the use of antimalarial drugs such as hydroxychloroquine. Systemic steroids and cyclophosphamide have also been used. Surgical treatment should be considered only in patients who do not respond to management with medications. In summary, we reported a case of lupus mastitis in a patient with discoid lupus erythematosus. This dermatosis should be considered in the differential diagnosis of breast lesions in lupus patients, and a biopsy of the breast lesion is essential to reject suspected malignancy. If the disease is left untreated, unsightly atrophy will appear; it is thus important to diagnose early on. The course of the disease tends to be chronic with remission and flares, so patients should be followed-up regularly due to the risk of recurrences in the same area or in a different location." }, { "id": "article-22714_13", "title": "Hemiballismus -- Evaluation", "score": 0.009174311926605505, "content": "Thorough routine serum labs, depending on suspected etiology, can include a complete metabolic panel (CMP) and complete blood count (CBC), hemoglobin A1C, serum osmolality, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-nuclear antibody (ANA), extranuclear antibody (ENA), vitamin panel (e.g., B1, B12, etc.), ceruloplasmin, copper level, other heavy metals, drugs of abuse toxicology, HIV antibody screen (if positive opportunistic infection screen), lupus antibodies (C3/C4, double-stranded DNA, anti-histone), antineutrophil cytoplasmic antibodies (ANCA) studies, cryoglobulin, among other immune and infectious markers." }, { "id": "pubmed23n0311_6890", "title": "[A man with systemic lupus erythematosus presenting with spastic paraplegia].", "score": 0.00909090909090909, "content": "We report a 38-year-old man systemic lupus erythematosus who presented with an acute onset of paraplegia and urinary retention. The man had a 12-year history of nodular cutaneous mucinosis and arthralgia. In 1994, he was admitted to our hospital with a sudden onset of weakness and numbness of the right leg followed by an emergence of similar symptoms in the left leg. His elder sister had died at 16 years of age after suffering from systemic lupus erythematosus for 6 years. On examination, the patient had skin rash on his chest, back, head, forehead, and extremities. The neurological examination revealed that his tongue deviated to the right on protrusion. The muscle power was reduced to 2-3/5 in the right leg and to 4/5 in the left leg. The sensory disturbance was noted in the lower extremities with predominant involvement of the right leg. Reflexes were increased in the right biceps, triceps, both patellas, and Achilles tendons. Babinski sign was noted bilaterally. Urinary retention and constipation were also noted. The results of the blood cell count and hepatic and renal function tests were normal. Serum levels of C-reactive protein and complements (C3, C4, CH50) were also normal. Serological examinations showed increased anti-DNA antibody (14 U/ml, [normal, &lt; 6]). Antinuclear antibody was positive at a titer of 1:1380. CSF study showed an increased protein concentration of 83 mg/dl and an IgG level of 14 mg/dl with a normal number of cells. MR images revealed a T1-low, T2-high signal lesion at the upper part of the left ventral medulla. MR images of the brain and spinal cord were normal. The patient was diagnosed as having SLE. High-dose intravenous methylprednisolone (1 g/day) pulse treatment that was started 25 days after the onset of neurological symptoms, produced partial relief. Our case presented with paraplegia with a focal lesion in the left upper ventral part of the medulla on MR images. The incidence of male SLE is low, and paraplegia is a rare complication of SLE. Thus, the medullary lesion in SLE observed in our case appears to be rare. SLE should be considered as a cause of acute onset paraplegia or myelopathy." }, { "id": "pubmed23n0627_7826", "title": "Combined megaloblastic and immunohemolytic anemia associated--a case report.", "score": 0.00909090909090909, "content": "A 55-year-old female with a history of psychosis and rheumatoid arthritis was admitted to the hospital for fatigue and dizziness. At admission, macrocytic anemia, high serum lactic acid dehydrogenase (LDH) and gastrin concentrations, decreased serum vitamin B12 concentration, with macroovalocytes and poikilocytes in peripheral blood smear suggested the diagnosis of pernicious anemia. Indirect antiglobulin test (IAT) was negative. Surprisingly, treatment by vitamin B12 and folic acid administered for two weeks was ineffective and followed by transitory worsening of hemoglobin concentration on day 8. Repeat direct antiglobulin test (DAT) and IAT were positive. This immunotransfusion conversion, suggesting the presence of autoimmune hemolytic anemia, could be explained by change in the macroblastic erythrocyte population, i.e. emerging red cells with completely exposed membrane antigens due to vitamin B12 treatment and/or higher degree of dysregulation of the lymphocyte clone secreting erythrocyte autoantibodies. We proposed the coexistence of pernicious and autoimmune hemolytic anemia; therefore, methylprednisolone was added to vitamin B12 treatment. This therapy successfully improved hemoglobin and erythrocyte concentration. Although megaloblastic-pernicious anemia is a common disease, association of pernicious and autoimmune hemolytic anemia with two mechanisms of hemolysis (ineffective erythropoiesis and immune mechanism) is a rare condition, with only several dozens of cases described so far." }, { "id": "pubmed23n0274_11480", "title": "[Renal and cerebral infarctions in a patient with systemic lupus erythematosus without antiphospholipid antibodies].", "score": 0.009009009009009009, "content": "Renal artery infarction is a very rare complication in patients with systemic lupus erythematosus (SLE), even in patients with antiphospholipid syndrome which often causes thromboembolism: Renal infarctions have only been reported in 4 SLE patients with antiphospholipid antibodies (aPL). Here we report a case of SLE without aPL who accompanied by renal and cerebral infarctions. A 42-year old Japanese woman with 8 year history of SLE manifested by arthralgia, central nervous system symptoms, positive-antinuclear and anti-DNA antibodies was admitted to our hospital for the treatment of progressive lupus nephritis. Physical examinations revealed hypertension (130-160/80-110 mmHg) without pitting pretibial edema. Laboratory evaluations showed proteinuria (3.7 g/day), normal serum creatinine level (0.9 mg/dl), low serum albumin level (2.3 g/dl) and high cholesterol level (317 mg/dl). Old cerebral infarctions were recognized by magnetic resonance imaging. However, hematological and immunological studies revealed that this case has neither a prolonged activated partial thromboplastin time, lupus anticoagulant nor anticardiolipin antibodies. Prednisolone was increased from 30 mg/every other day to 30 mg/day, and oral azathioprine, 50 mg/day, was started for the treatment of lupus nephritis. On the 11th day, she suddenly complained severe abdominal pain, which gradually localized on the right side. Computed tomography of the kidney suggested right renal infarctions, and arteriography of right renal artery confirmed both an obstruction of the ventral branch and a narrowing of the dorsal branch of right renal artery. No intra-cardiac thrombus was demonstrated by echocardiography. Following to the treatment with fibrinolytic agent and anticoagulant, her symptoms have improved.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0089_5266", "title": "[Acquired von Willebrand syndrome associated with Hashitoxicosis and pernicious anemia combined].", "score": 0.009009009009009009, "content": "A new case of acquired von Willebrand syndrome (AvWS) with Hashitoxicosis and pernicious anemia combined in a 73-years-old male is reported. He was admitted because of appetite loss and general malaise. Physical examination showed severe anemia and general edema. The red-cell count was 103 X 10(4)/microliters with a MCV of 122 fl; the white-cell count was 2,900/microliters with 24.5% hypersegmented neutrophils; the platelet count was 17.2 X 10(4)/microliters. the lactate dehydrogenase was 9,513 U/ml and vitamin B12 was 87 pg/dl. An aspirated specimen of bone marrow was diagnostic of megaloblastic anemia. The thyroid hormones were decreased with the thyroid stimulating hormone increased. From the immunological findings, the thyroid-test, microsome-test, and anti-intrinsic factor were positive, but M proteinemia and Bence Jones proteinuria were absent. Histology of the thyroid gland and the gastric mucosa established the diagnosis of chronic thyroiditis and chronic atrophic gastritis. Subcutaneous hemorrhages after veni-puncture were observed on admission. He had a normal bleeding time, but the coagulation studies indicated the presence of von Willebrand disease, but as his family and past history were negative, this suggested the presence of an AvWS. The analysis of von Willebrand factor (vWF) multimeric composition had showed the lack of the larger multimers in the plasma, but it was normalized after the administration of levothyroxine sodium and hydroxocobalamin with vWF: Ag/RCo ratio paralleled. As far as we know, this is the first report of AvWS with Hashitoxicosis and pernicious anemia combined." }, { "id": "pubmed23n0998_19836", "title": "Rowell's Syndrome Triggered by Omeprazole.", "score": 0.008849557522123894, "content": "Dear Editor, Rowell's syndrome is a rare disease, characterized by the appearance of erythema multiforme (EM)-like lesions in patients with lupus erythematosus. It was initially reported by Rowell (1) in 1963 and its existence as a separate clinical entity is currently under debate (2,3). A few cases may have been induced by drugs such as systemic antimycotics, antibiotics, anticonvulsants, and more recently proton pump inhibitors (PPIs). CASE REPORT We present the case of a 67-year-old woman with subacute cutaneous lupus erythematosus (SCLE) and EM-like lesions who fulfilled all the criteria for Rowell's syndrome. The patient had lupus arthritis for two years and was treated with oral methylprednisolone 8 mg/day and hydroxychloroquine 200 mg/day. She started receiving 20 mg of omeprazole daily for gastroprotection. The patient also had arterial hypertension with no current treatment, osteoporosis, and an L1 vertebral fracture. The dermatological examination revealed multiple erythematous infiltrated plaques involving mainly the sun-exposed areas (neck, chest, upper back, and shoulders). Cutaneous lesions had an annular or target pattern and a tendency to form hemorrhagic crusts and scales at the margins (Figure 1, A). The mucous membranes were unaffected. Histological examination (hematoxylin and eosin ×200) found epidermal atrophy, vacuolar degeneration of the basal layer, and sparse perivascular lymphocytic infiltrate in the dermis - features corresponding to lupus erythematosus (Figure 2, A). Single eosinophilic necrotic keratinocytes characteristic for erythema multiforme were observed in the epidermis (Figure 2, B). Direct immunofluorescence (IF) from lesional skin showed granular deposits of C3 on the dermo-epidermal junction. Lupus band test from sun-protected, nonlesional skin was negative. On indirect IF a speckled pattern antinuclear antibodies (ANA) with &gt;1:1280 titers were detected. Anti-Ro (&gt;200 U/mL) and anti-La (&gt;200 U/mL) antibodies were also positive. The blood cell count and differential analysis were within reference ranges. The 24-hour urine protein test showed a non-significant proteinuria - 0.36 g/24h. Photo-testing was impossible considering the extent of the skin lesions. The therapeutic approach consisted of increasing the hydroxychloroquine dose to 400 mg/day, substituting PPI with famotidine 20 mg/day p.o. and ceftriaxone 2 g/day for the superinfection with Ps. aeruginosa, which led to a clinical improvement (Figure 1, B). The methylprednisolone dose remained unchanged due to already existing severe adverse effects. DISCUSSION The diagnosis was based on Zeitouni et al.'s classification (4). The three main criteria are as follows: lupus erythematosus, EM-like lesions, and speckled pattern of ANA. Our patient met all three major and one minor criteria, namely the presence of anti-Ro and anti-La antibodies. As for the other minor criteria, RF was negative and no chilblains were found. Although there was a continuous time lapse (more than 1 year) between the initiation of omeprazole intake and the diagnosis of Rowell's syndrome, we suggest that the connection is probable. For instance, the latency differs depending on the incriminated medication in drug induced SCLE. Longer periods are reported for diuretics and calcium blockers, while the time interval is shorter for chemotherapeutic drugs and antimycotics (5). Our suspicions were further confirmed by the fact that the lesions improved promptly within a month after discontinuation of omeprazole and doubling the dose of hydroxychloroquine. PPIs are reported to be a major cause of drug-induced SCLE (6,7). According to Laurinaviciene et al., the most common drugs involved are PPIs, thiazide diuretics, antifungals, chemotherapeutics, statins, and antiepileptics (6). However, very few cases of Rowell's syndrome are found to be drug-related. The culprit drugs include: oral terbinafine (8,9), norfloxacin (10), sodium valproate (11) and esomeprazole (12) (Table 1). CONCLUSION Despite the common clinical and immunological features shared between SCLE, drug-induced SCLE and EM, Rowell's syndrome seems to be a separate entity rather than a coincidental association. Finally, according to our knowledge this case would be the second of Rowell's syndrome due to PPIs." }, { "id": "pubmed23n0113_14990", "title": "Haematological abnormalities in a 75-year-old population. Consequences for health-related reference intervals.", "score": 0.008771929824561403, "content": "A representative sample (n = 486) of a 75-year-old population was studied, and probands with defined laboratory aberrations were re-investigated. Anaemia was present in 6% of the men and 3% of the women; in 17/22 anaemic subjects a cause was found. The prevalence of plasma cobalamin concentrations less than 130 pmol/l was 6%, of iron deficiency approximately 6%. Divergences in white blood cell and platelet counts were rare. The observed haematological aberrations were almost always caused by disease. Reference intervals for haematological components were calculated in the total study group and two reference sample groups after exclusions based on anamnestic and/or laboratory screening criteria or anamnestic criteria and/or verified disease. The lower reference limits for B-Hb and P-B12 in a group obtained after exclusions based on anamnestic and screening data were considered to be minimum values for healthy subjects. The WHO criteria for anaemia were applicable." }, { "id": "pubmed23n0942_16096", "title": "The devil's in the dosing: severe drug-induced liver injury in a hydroxychloroquine-naive patient with subacute cutaneous lupus erythematosus and porphyria cutanea tarda.", "score": 0.008695652173913044, "content": "A 29-year-old woman with a 1.5 year history of photosensitive skin lesions on her hands presented with a malar rash, bullous lesions on her hands, and was diagnosed with subacute lupus erythematosus after serologies revealed a positive antinuclear antibody test (1:2560), and antibodies to Ro/SSA and dsDNA. Hydroxychloroquine (400 mg/day) was prescribed and the patient developed severe drug-induced liver injury. Biopsy of her bullous skin lesions was consistent with porphyria cutanea tarda, as were her serological and urinary exams. She was successfully treated with therapeutic phlebotomy. This case identifies porphyria cutanea tarda as an important differential diagnosis for the rheumatologist to consider when evaluating patients with bullous skin lesions. Hydroxychloroquine in lower doses is an effective treatment for porphyria cutanea tarda; at doses used to treat systemic lupus erythematosus and subacute cutaneous lupus, there is a potentially life-threatening complication of hepatotoxicity." }, { "id": "pubmed23n0558_18224", "title": "[Relations beetwen severity of anemia and certain antiphospholipid antibodies presence in systemic lupus erythematosus patients].", "score": 0.008695652173913044, "content": "Anaemia is a common hematological abnormality in systemic lupus erythematosus (SLE). Autoimmune hemolytic anaemia (AHA) is one of the types of anaemia in SLE. Other reasons of anaemia in SLE are: chronic inflammatory diseases, insufficient level of elements necessary for erythropoiesis and chronic renal disease. The aim of the study was to examine the relations between severity of anemia and presence of certain antiphospholipid antibodies (aPL) in SLE. The study group consisted of 24 patients (one man and 23 women) with active lupus. Anticardiolipin antibodies (aCL), anti-02 glycoprotein I antibodies (anti-beta2 GPI IgM and IgG) and red cell parameters: haemoglobin level (Hb), erythrocytes (RBC), mean corpuscular volume (MCV), mean corpuscular haemoglobin mass (MCH), mean corpuscular haemoglobin concentration (MCHC) and ferritin level were measured before beginning or intensification of treatment. The activity of SLE was measured by SLEDAI and C3 complements. The patients were divided into two subgroups: subgroup with aCL-IgG above 20 u/ml and below 20 u/ml. In patients with aCL-IgG above 20 u/ml the mean Hb level was lower, and the mean ferritin level was significantly higher than in patients with aCL-IgG level below 20 u/ml. We observed a negative, significant correlations between Hb and aCL-IgG (p = 0.01; R = -0.47) and between Hb and anti-32 GPI IgG (p = 0,0003; R = -0,67) and a negative correlation between Hb and activity of SLE estimated by SLEDAI (p = 0.02; R = -0.45) and positive between Hb and C3 complement (p = 0.02; R = +0.5). antiphospholipid antibodies presence in patients with SLE can influence the severity of anaemia." }, { "id": "pubmed23n1004_25990", "title": "Rowell Syndrome in Nigeria: Systemic Lupus Erythematosus Presenting as Recurrent Erythema Multiforme in a Young Woman.", "score": 0.008620689655172414, "content": "Dear Editor, Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease characterized by diverse patterns of auto-antibody production with multi-organ affectation. Cutaneous involvement, either alone or in association with other systemic illnesses, is one of its most common manifestations (1). Dermatologic disorders like malar and discoid rashes are quite suggestive of SLE. However, the occurrence of non-specific skin lesions like erythema multiforme (EM) in patients with SLE (Rowell syndrome) can rarely occur (1). In such patients, a diagnosis of SLE may be missed or delayed in the absence of other overt clinical features of lupus. Herein we report a case of recurring EM-like eruptions as the cardinal cutaneous manifestation of previously undiagnosed, active SLE in a young Nigerian woman. A 26-year-old Nigerian woman presented with a three-day history of non-pruritic, generalized, and target-like, erythematous annular patches and plaques which mostly affected the trunk. A few lesions had presented with crusting and erosions at the time of examination (Figure 1). Associated symptoms included oral painful ulcers, low grade fever, and malaise. The patient had no other systemic symptoms and her prior drug history was not remarkable. Her erythrocyte sedimentation rate (ESR) was 66 mm/hour using the Westergren method. Screening for HIV and hepatitis B and C was negative. Herpes simplex, cytomegalovirus, and Epstein Barr viruses could not be screened for. Other baseline investigations (complete blood count, electrolytes, urea and creatinine as well as urinalysis) were within normal limits. The patient was managed as a case of EM of an unidentified inciting agent and her symptoms resolved with supportive care and antibiotics. However, she developed a recurrence about 5 weeks later, with more extensive and coalescent skin lesions (Figure 2). Additionally, there was a new onset of alopecia and pain in the small joints of the hands as well as both knees and ankles. At this time, the patient's ESR had gone up to 112 mm/h and she had developed significant proteinuria, with a protein creatinine ratio of 1.3 g/g (reference &lt;0.5 g/g). Her antinuclear antibody (ANA) titer was high (1:320) with a speckled pattern. Anti-Smith antibody was also positive. A renal biopsy was declined. A tentative diagnosis of Rowell syndrome was made. The patient was started on high-dose steroids and hydroxychloroquine 200 mg twice daily. Subsequent care included the use of mycophenolate mofetil 1 g twice daily for 6 months. This was then changed to azathioprine at 50 mg twice daily. Follow-up after 6 months showed sustained clearance of skin lesions, resolution of fever and joint pains, as well as improvement in the renal profile, with a urine protein-creatinine ratio of 0.77 g/g. The presence of systemic lupus erythematosus, EM-like lesions, and a speckled pattern of antinuclear antibody in our patient fulfils the revised diagnostic criteria for RS put forward by Zeitouni et al. at the turn of the twenty-first century (2). Considering the rarity of EM-like lesions in SLE and the possibility of constitutional symptoms in EM, a diagnosis of RS may be readily overlooked in patients like the one described, whose major cutaneous manifestation of severe active SLE was EM-like lesions. In contrast to classic EM, where skin lesions are concentrated in the extremities, a predominant truncal distribution of EM-like lesions as found in our patient may favor a clinical consideration of RS (3). However, some authors have challenged the existence of Rowell syndrome as a distinct clinical laboratory entity. Arguments put forward in this regard include the fact that none of the immunological markers that have been described in RS are specific to any disorder. Additionally, the annular polycyclic dermatosis seen in sub-acute cutaneous lupus erythematosus (SCLE) can be difficult to clinically and histologically differentiate from EM (4,5). Patients with SLE also have a higher likelihood of developing adverse drug reactions (6). The inherent complexity of SLE may make for delayed and oftentimes difficult diagnosis, especially in a country where immunologic tests are expensive and rheumatologists are scarce. When patients do occasionally present with recurrences of skin lesions in the spectrum of EM, Steven-Johnson syndrome, and toxic epidermal necrolysis in the absence of a definite inciting agent, undiagnosed lupus may indeed be present in some of these individuals and should be considered in the differential diagnosis. In conclusion, while it is very rare, SLE may present first with recurrent episodes of EM-like rash. Despite the various possibilities which underlie their association, prompt identification and treatment of SLE in patients presenting with EM is important to prevent death or irreversible organ damage." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 225, 330 ] ], "word_ranges": [ [ 41, 60 ] ], "text": "On the other hand, there are no signs or symptoms that make us think of a sexually transmitted infection." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 25, 224 ] ], "word_ranges": [ [ 5, 41 ] ], "text": "In the inguinal region, the lymph nodes can acquire a size of up to 1.5 cm being normal. In addition, the rest of the data of the inguinal exploration (no pain, mobile, soft, etc.) corroborates this." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "A lupus serology since it is most likely a Treponema pallidum infection.", "2": "A gynecological examination to rule out ovarian cancer.", "3": "From the clinical features it seems to be normal lymph nodes and complementary explorations should not be performed.", "4": "A Paul-Bunell test should be performed to rule out infectious mononucleosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en154_45003", "title": "Genital ulcer", "score": 0.018783068783068783, "content": "Overview A genital ulcer may be located on the vulva, penis, perianal region, or anus. Globally, the incidence of genital ulcers is estimated to be approximately 20 million cases annually. The most likely cause of a genital ulcer varies depending on the characteristics of a population and location. The most common cause of genital ulcers in the United States is herpes simplex infections, with syphilis the second most common cause, and chancroid the third. These common causes of genital ulcer disease (HSV-1, HSV-2 and treponema pallidum) can all be efficiently transmitted through oral sex. Important signs associated with genital ulcers that may assist in the diagnosis of the cause of the genital ulcer may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of vesicular lesions, which are small, painful, elevated blisters." }, { "id": "wiki20220301en042_58337", "title": "Inguinal lymph nodes", "score": 0.017355371900826446, "content": "Clinical significance The presence of swollen inguinal lymph nodes is an important clinical sign because lymphadenopathy (swelling) may indicate an infection, or spread as a metastasis from cancers, such as anal cancer and vulvar cancer. Inguinal lymph nodes may normally be up to 2 cm. The cut-off value for normal sized inguinal nodes is up to 10 mm. Additional images References Lymphatic organ anatomy" }, { "id": "wiki20220301en393_31405", "title": "Inguinal lymphadenopathy", "score": 0.016993188680570183, "content": "Inguinal lymphadenopathy causes swollen lymph nodes in the groin area. It can be a symptom of infective or neoplastic processes. Infective aetiologies include Tuberculosis, HIV, non-specific or reactive lymphadenopathy to recent lower limb infection or groin infections. Another notable infectious cause is Lymphogranuloma venereum, which is a sexually transmitted infection of the lymphatic system. Neoplastic aetiologies include lymphoma, leukaemia and metastatic disease from primary tumours in the lower limb, external genitalia or perianal region and melanoma. References Further reading Inflammations Diseases of veins, lymphatic vessels and lymph nodes" }, { "id": "wiki20220301en012_95894", "title": "Lymphogranuloma venereum", "score": 0.01359456217512995, "content": "The secondary stage most often occurs 10–30 days later, but can present up to six months later. The infection spreads to the lymph nodes through lymphatic drainage pathways. The most frequent presenting clinical manifestation of LGV among males whose primary exposure was genital is unilateral (in two-thirds of cases) lymphadenitis and lymphangitis, often with tender inguinal and/or femoral lymphadenopathy because of the drainage pathway for their likely infected areas. Lymphangitis of the dorsal penis may also occur and resembles a string or cord. If the route was anal sex, the infected person may experience lymphadenitis and lymphangitis noted above. They may instead develop proctitis, inflammation limited to the rectum (the distal 10–12 cm) that may be associated with anorectal pain, tenesmus, and rectal discharge, or proctocolitis, inflammation of the colonic mucosa extending to 12 cm above the anus and associated with symptoms of proctitis plus diarrhea or abdominal cramps." }, { "id": "InternalMed_Harrison_10857", "title": "InternalMed_Harrison", "score": 0.012859569980666705, "content": "Diagnosis Although most genital ulcerations cannot be diagnosed confidently on clinical grounds alone, clinical findings (Table 163-7) FIGURE 163-5 Chancroid: multiple, painful, punched-out ulcers with undermined borders on the labia occurring after autoinoculation. Sexually Transmitted Infections: Overview and Clinical Approach FIGURE 163-6 Genital herpes. A relatively mild, superficial ulcer is typically seen in episodic outbreaks. (Courtesy of Michael Remington, University of Washington Virology Research Clinic.) FIGURE 163-7 Lymphogranuloma venereum (LGV): striking ten-der lymphadenopathy occurring at the femoral and inguinal lymph nodes, separated by a groove made by Poupart’s ligament. This “sign-of-the-groove” is not considered specific for LGV; for example, lym-phomas may present with this sign. InITIAL MAnAgEMEnT of gEnITAL oR PERIAnAL uLCER" }, { "id": "article-32329_33", "title": "Anatomy, Abdomen and Pelvis: Female External Genitalia -- Clinical Significance -- Sexually Transmitted Infections", "score": 0.012067099567099566, "content": "Treponema pallidum : Syphilis infections result from Treponema pallidum . This infection usually manifests as a painless chancre in the primary stage. If the disease is left untreated, it will progress to the secondary stage. In the secondary stage, it manifests as fever, widespread maculopapular skin rashes involving the palms and soles,  widespread lymphadenopathy (epitrochlear node is pathognomic), and genital lesions similar to genital warts (condylomata lata- has a rounder surface when compared with condylomata acuminata). If there is still no treatment during the secondary stage, the infection will progress into the tertiary stage. The tertiary stage causes necrotic lesions called Gummas, neurological symptoms such as tabes dorsalis, Argyll Robertson pupils, and general paresis, cardiac symptoms such as aortitis. The treatment of syphilis is with the use of penicillin." }, { "id": "Gynecology_Novak_2917", "title": "Gynecology_Novak", "score": 0.011959093982420555, "content": "Several clinical presentations are highly suggestive of specific diagnoses: 1. A painless and minimally tender ulcer, not accompanied by inguinal lymphadenopathy, is likely to be syphilis, especially if the ulcer is indurated. A nontreponemal rapid plasma reagin (RPR) test, or venereal disease research laboratory (VDRL) test, and a confirmatory treponemal test—fluorescent treponemal antibody absorption (FTA ABS) or microhemagglutinin–T. pallidum (MHA TP)—should be used to diagnose syphilis presumptively. Some laboratories screen samples with treponemal enzyme immunoassay (EIA) tests, the results of which should be confirmed with nontreponemal tests. The results of nontreponemal tests usually correlate with disease activity and should be reported quantitatively. 2." }, { "id": "article-28956_50", "title": "Sexually Transmitted Infections -- History and Physical -- Granuloma Inguinale", "score": 0.011150935882118677, "content": "Females and males: Signs and symptoms: Patients will present with highly vascularized lesions over the genitals and perineum that tend to be painless. [37] [38] It can cause severe scarring. Physical Exam: Typical findings include ulcer-like lesions that are beefy red, consistent with high vascularization that bleeds easily with manipulation. Subcutaneous granulomas may be present, but lymphadenopathy is uncommon. The lesions tend to be relatively large and irregular. It is often found to be associated with secondary infections. Four main lesions can be seen on examination: 1. Ulcerovegetative: large painless ulcer on the patient's physical exam. 2. Nodular: soft and erythematous that tend to ulcerate throughout the infectious process. 3. Cicatricial: dry ulcerations that tend to transition into plaques. 4. Hypertrophic: lesions are thick and painless. [37] [39]" }, { "id": "pubmed23n0999_2351", "title": "[A chancre instead of cancer].", "score": 0.010676940011007155, "content": "Syphilis (lues) is a sexually transmitted infection caused by the spirochete Treponema pallidum. In adolescents, the diagnosis of primary syphilis can be made promptly by taking a sexual medical history and inspecting the glans penis. A 17-year-old male was referred to the paediatric oncology centre for additional diagnostics due to inguinal lymphadenopathy, with a strong suspicion of a malignant lymphoma. None of the physicians took a sexual medical history or investigated the glans penis, as a result of which essential information was lacking. The combination of inguinal lymphadenopathy and the ultrasound findings for the inguinal region made the physicians only consider a malignancy. However, it actually concerned a reactive lymphadenopathy associated with primary syphilis. This case demonstrates that a full medical history and thorough physical examination can prevent the need for costly and invasive diagnostics." }, { "id": "article-23529_10", "title": "Anatomy, Abdomen and Pelvis: Inguinal Lymph Node -- Clinical Significance -- Lymphadenopathy", "score": 0.010624538063562453, "content": "Syphilis is a bacterial infection caused by the spirochete Treponema pallidum. Clinical presentation of secondary syphilis can present with diffuse lymphadenopathy along with fever, skin rashes, and condylomata lata. [7] Chancroid" }, { "id": "InternalMed_Harrison_4570", "title": "InternalMed_Harrison", "score": 0.010500868776913199, "content": "node is an enlarged left supraclavicular node infiltrated with metastatic cancer from a gastrointestinal primary. Metastases to supraclavicular nodes also occur from lung, breast, testis, or ovarian cancers. Tuberculosis, sarcoidosis, and toxoplasmosis are nonneoplastic causes of supraclavicular adenopathy. Axillary adenopathy is usually due to injuries or localized infections of the ipsilateral upper extremity. Malignant causes include melanoma or lymphoma and, in women, breast cancer. Inguinal lymphadenopathy is usually secondary to infections or trauma of the lower extremities and may accompany sexually transmitted diseases such as lymphogranuloma venereum, primary syphilis, genital herpes, or chancroid. These nodes may also be involved by lymphomas and metastatic cancer from primary lesions of the rectum, genitalia, or lower extremities (melanoma)." }, { "id": "InternalMed_Harrison_9486", "title": "InternalMed_Harrison", "score": 0.010312093081866678, "content": "Approach to the Patient with an Infectious Disease regions (e.g., popliteal, inguinal, epitrochlear, axillary, multiple cervical regions), with notation of the location, size (normal, <1 cm), presence or absence of tenderness, and consistency (soft, firm, or shotty) and of whether the nodes are matted (i.e., connected and moving together). Of note, palpable epitrochlear nodes are always pathologic. Of patients presenting with lymphadenopathy, 75% have localized findings, and the remaining 25% have generalized lymphadenopathy (i.e., that involving more than one anatomic region). Localized lymphadenopathy in the head and neck region is found in 55% of patients, inguinal lymphadenopathy in 14%, and axillary lymphadenopathy in 5%. Determining whether the patient has generalized versus localized lymphadenopathy can help narrow the differential diagnosis, as various infections present differently." }, { "id": "article-23529_8", "title": "Anatomy, Abdomen and Pelvis: Inguinal Lymph Node -- Clinical Significance -- Lymphadenopathy", "score": 0.010292397660818714, "content": "Swollen lymph nodes usually indicate infection from bacteria or viruses. Swollen inguinal lymph nodes could indicate an infection of areas of the lower body. One of the more concerning causes of inguinal lymphadenopathy is sexually transmitted infections. Sexually transmitted infections that commonly presents with inguinal lymphadenopathy are lymphogranuloma venereum, secondary syphilis, and chancroid caused by Chlamydia trachomatis (L1-L3), Treponema pallidum , and Haemophilus ducreyi , respectively. Lymphogranuloma venereum" }, { "id": "article-28956_39", "title": "Sexually Transmitted Infections -- History and Physical -- Chancroid", "score": 0.010054091009631819, "content": "Females and males: Signs and symptoms: Often occurs in the 20 to 30-year-old age group, frequently among sex workers and their clients. The areas most often affected include the distal portion of the penis in men, while in women, the vagina, labia, and perianal regions are involved. The most significant symptom is the extremely high pain level noted when the lesion reaches the ulcerative stage. [6] Physical Exam: The lesion starts as a reddish papule which rapidly progresses to a pustule followed by an extremely painful ulcer. The ulcer sometimes called a \"soft chancre,\" will have soft and irregular margins with a friable base and a grayish-yellowish exudate. It tends to bleed easily. The ulcers are typically 1 cm to 2 cm in diameter and usually resolve spontaneously within three months, even if left untreated. Close to half of the affected individuals will develop regional lymphadenopathy, which may be tender. A minority (about 25%) of these patients will progress to infected bulla or abscesses, which can rupture and become superinfected leading to significant tissue destruction and damage to the genitalia. It is estimated that 10% of affected individuals will also have syphilis or genital herpes as well." }, { "id": "article-23529_0", "title": "Anatomy, Abdomen and Pelvis: Inguinal Lymph Node -- Introduction", "score": 0.009830940063498203, "content": "The inguinal lymph node can be subdivided into the superficial and deep lymph nodes and collectively drains the anal canal(below the pectinate line), the skin below the umbilicus, lower extremity, scrotum, vulva, glans penis, and clitoris. The lymph node's primary function is to filter for harmful substances as lymphatic fluids travel through its cortex, paracortex, and medulla. Clinical signs of inguinal lymphadenopathy can help to clue physicians in possible diagnoses of sexually transmitted diseases such as syphilis, chancroid, and lymphogranuloma venereum. The lymph node can also serve to assist in the diagnosis of cancer." }, { "id": "wiki20220301en013_140385", "title": "Yaws", "score": 0.00980392156862745, "content": "Serological tests cannot distinguish yaws from the closely related syphilis; no test distinguishing yaws from syphilis is widely available. The two genomes differ by about 0.2%. PCR and DNA sequencing can distinguish the two. There are also no common blood tests which distinguish among the four treponematoses: syphilis (Treponema pallidum pallidum), yaws (Treponema pallidum pertenue), bejel (Treponema pallidum endemicum), and pinta (Treponema carateum). Haemophilus ducreyi infections can cause skin conditions that mimic primary yaws. People infected with Haemophilus ducreyi lesions may or may not also have latent yaws, and thus may or may not test positive on serological tests. This was discovered in the mid 2010s. It seems that a recently diverged strain of Haemophilus ducreyi has evolved from being a sexually transmitted infection to being a skin ulcer pathogen that looks like yaws. Yaws has been reported in nonendemic countries." }, { "id": "pubmed23n0693_21371", "title": "Disseminated lupus vulgaris.", "score": 0.009708737864077669, "content": "A 28-year-old woman presented with reddish raised, shiny lesions over the face and ears present for the past 3 years. Four years ago, she developed in her left axilla a nodule that became fluctuant and tender, which ruptured to discharge seropurulent material. It subsided after the patient had received antibiotics for 6 months, leaving puckered scarring. There was no history of antituberculous treatment. After 1 year, she developed papulonodular lesions on her face, nose, and ears. There was now a history of malaise, fever, dry cough, and anorexia and weight loss for the past 2 months. The patient was fully vaccinated in childhood, including against varicella infection. The general physical examination revealed lymphadenopathy involving cervical, axillary, and inguinal lymph nodes 0.5 x 0.5 cm to 1 x 1.5 cm, firm in consistency, and nontender. They were discrete except in the left axilla where multiple matted lymph nodes were present with overlying scarring and a papule. Her systemic examination was normal. Cutaneous examination showed a shiny erythematous plaque 3x2 cm with central atrophy and scarring on the face (Figure). It was comprised of multiple shiny nontender soft papules arranged in annular configuration. Similar discrete papules and nodules with adherent fine scaling were seen bilaterally on the alar prominence of the nose, lower lip, and post-auricular area. On diascopy, apple jelly nodules were seen. The hemogram, liver function tests, and renal function tests were normal, except for an elevated erythrocyte sedimentation rate. The Mantoux test showed erythema and an induration of 20 x 20 cm. A posteroanterior view on the chest x-ray showed fibrotic changes suggestive of pulmonary tuberculosis. Ultrasonography of the abdomen and pelvis showed no tubercular foci. Human immunodeficiency virus serology by enzyme-linked immunosorbent assay with 3 different kits was nonreactive. Histopathology from a nodule showed a focally thinned-out epidermis with follicular plugging and multiple epithelioid cell granulomas, rimmed by lymphocytes in the deeper portion of the dermis, mainly peri-appendageal. Stain for acid-fast bacteria was negative. Cultures from the skin lesions were negative. The patient was diagnosed as having lupus vulgaris with multiple lesions of varying morphology at different sites with pulmonary tuberculosis and healed lymph node involvement." }, { "id": "article-28956_53", "title": "Sexually Transmitted Infections -- History and Physical -- Lymphogranuloma venereum (LGV)", "score": 0.009708737864077669, "content": "Females and males: Signs and symptoms: Patients will present with painful lymphadenopathy localized to the inguinal area. Patients may note the initial presentation of a pustule that gradually progresses to large painful ulceration. [41] Men tend to present with early or acute stages, while women typically present much later. [19] Physical Exam: Lymphogranuloma venereum presents with two stages: Primary phase is a small painless papule/pustule that will ulcerate and can be visualized throughout the affected genital area. During the secondary phase, patients present with unilateral lymphadenopathy that is fluctuant with palpation or may be suppurative in a presentation known as buboes. [38] Buboes tend to rupture in the acute phase and progress to a thickened mass. [42]" }, { "id": "InternalMed_Harrison_4562", "title": "InternalMed_Harrison", "score": 0.009632616487455198, "content": "Lymphadenopathy may be an incidental finding in patients being examined for various reasons, or it may be a presenting sign or symptom of the patient’s illness. The physician must eventually decide whether the lymphadenopathy is a normal finding or one that requires further study, up to and including biopsy. Soft, flat, submandibular nodes (<1 cm) are often palpable in healthy children and young adults; healthy adults may have palpable inguinal nodes of up to 2 cm, which are considered normal. Further evaluation of these normal nodes is not warranted. In contrast, if the physician believes the node(s) to be abnormal, then pursuit of a more precise diagnosis is needed. APPROACH TO THE PATIENT:" }, { "id": "wiki20220301en302_4978", "title": "Cervical lymphadenopathy", "score": 0.009615384615384616, "content": "Cervical lymphadenopathy is a sign or a symptom, not a diagnosis. The causes are varied, and may be inflammatory, degenerative, or neoplastic. In adults, healthy lymph nodes can be palpable (able to be felt), in the axilla, neck and groin. In children up to the age of 12 cervical nodes up to 1 cm in size may be palpable and this may not signify any disease. If nodes heal by resolution or scarring after being inflamed, they may remain palpable thereafter. In children, most palpable cervical lymphadenopathy is reactive or infective. In individuals over the age of 50, metastatic enlargement from cancers (most commonly squamous cell carcinomas) of the aerodigestive tract should be considered. Classification Cervical lymphadenopathy can be thought of as local where only the cervical lymph nodes are affected, or general where all the lymph nodes of the body are affected. Causes" }, { "id": "InternalMed_Harrison_10874", "title": "InternalMed_Harrison", "score": 0.009615384615384616, "content": "adenopathy that is sometimes mistaken for malignancy; syphilis, LGV, HSV infection, and chancroid involving the anus can produce inguinal adenopathy because anal lymphatics drain to inguinal lymph nodes." }, { "id": "pubmed23n0954_11063", "title": "Unusual Manifestations of Secondary Syphilis: Case Presentations.", "score": 0.009523809523809525, "content": "Dear Editor, Syphilis is an infection caused by Treponema pallidum. Without treatment, it goes through the following stages: primary, secondary, latent, and tertiary (1). The clinical picture of secondary syphilis is very variable (2,3). We present two rare cases of secondary syphilis, one with nodular lesions initially considered to be lymphoma and second with periostitis, which was initially interpreted as an osteoma. To date, only 15 cases with nodular lesions and 10 cases with periostitis in secondary syphilis have been reported in the literature. The first patient was a 59 year old man who presented in a private practice with nodular lesions on the face and axillary and inguinal folds (Figure 1, a, b). The initial diagnostic consideration was lymphoma. A biopsy specimen was taken, and the histopathological features revealed epidermal hyperplasia with papillomatosis, minimal spongiosis with many neutrophils and with a marked inflammatory infiltrate in dermis, consisting of lymphocytes, plasma cells, and neutrophils; the diagnosis of interfaced dermatitis was established (Figure 1, d, e). After one month, the patient presented to our clinic with numerous nodular lesions, some of them painful, located on the trunk and intertriginous folds, including the intergluteal cleft - the lesions in this area being suggestive of condylomata lata (Figure 1, c). The diagnosis of secondary syphilis was taken into consideration, and screening serum tests were performed and found reactive: a Venereal Diseases Research Laboratory (VDRL) titer of 1:64 and Treponema pallidum Hemaglutination Assay (TPHA) titer of 1:80. Hepatitis and anti-human immunodeficiency virus (HIV) antibodies serology was negative. The biopsy was repeated and showed the same histopathological changes. In addition, Warthin-Starry staining was performed, revealing the presence of some spiral micro-organisms in the dermis corresponding to Treponema pallidum (Figure 1, f). A diagnosis of secondary syphilis was established, and the patient was treated with benzathine penicillin G 2.4 million units by intramuscular injection once a week for 2 consecutive weeks. The skin lesions regressed within 1 month, and serological tests showed a VDRL titer of 1:8 3 months after treatment. The second patient was a homosexual male, 35 years old, diagnosed with HIV infection, stage B2. He presented with bone pain in the calves and forearms, with insidious onset. He also presented with an associated erythematous maculo-papular rash on the trunk and limbs and generalized lymphadenopathy (Figure 2, a, b). The tibial crest and radius were sensitive to palpation. A right leg radiography was performed, raising suspicion of osteoid osteoma. The CT scan excluded the diagnosis of osteoma; taking into account the epidemiological context, the diagnosis of syphilis was suspected. The diagnosis was confirmed by leg ultrasound examination (2D US) which showed thickening of the compact tibial bone associated with subperiosteal destructive and proliferative changes (Figure 2, c, d) and by serology for syphilis: the VDRL titer was 1:32 and the TPHA titer was 1:80. The patient was treated with benzathine penicillin 2.4 million units, once a week, for 2 consecutive weeks, with clinical improvement. Syphilis continues to be a serious public health problem worldwide, even if it is a controllable disease due to diagnostic tests and effective and accessible treatment. According to the World Health Organization in 2008, the estimated number of new cases of sexually transmitted diseases in adults with syphilis is 10.6 million cases (4). The cases presented in this paper were characterized by unusual manifestations, requiring good collaboration between the dermatologist and other specialties. In the first case, the diagnosis of secondary syphilis was confirmed by positive serological, clinical, and histopathological findings. The main differential diagnosis of nodular syphilis includes lymphoma, sarcoidosis, Kaposi's sarcoma, atypical mycobacteriosis, deep fungal infections, leprosy, tuberculosis, leishmaniasis, and lymphomatoid papulosis (5). Another important differential diagnosis is between secondary and tertiary syphilis, especially when ulcerating nodules are present. Tertiary syphilis is characterized by unilateral, deep ulcerating nodules with necrotizing granulomas (6). Bone involvement during syphilis is mainly represented by polyarthritis, synovitis, osteitis, and periostitis (7,8). Syphilitic periostitis is characterized by localized or diffuse pain, particularly during the night, which is relieved by movement. The skull, the shoulder girdle, and the long bones are the most common sites of involvement (9). In conclusion, we presented two different cases of secondary syphilis that contribute to the clinical experience of rare cases presented in the literature, raising the awareness of dermatologists and other specialists about less specific clinical aspects of syphilis." }, { "id": "wiki20220301en032_60070", "title": "Lymphadenopathy", "score": 0.009433962264150943, "content": "Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include: Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis, cat-scratch disease). The most distinctive sign of bubonic plague is extreme swelling of one or more lymph nodes that bulge out of the skin as \"buboes.\" The buboes often become necrotic and may even rupture. Infectious mononucleosis is an acute viral infection usually caused by Epstein-Barr virus and may be characterized by a marked enlargement of the cervical lymph nodes. It is also a sign of cutaneous anthrax and Human African trypanosomiasis Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy). Plasma cell variant of Castleman's disease - associated with HHV-8 infection and HIV infection" }, { "id": "wiki20220301en017_7708", "title": "Chancroid", "score": 0.009433962264150943, "content": "About half of infected men have only a single ulcer. Women frequently have four or more ulcers, with fewer symptoms. The ulcers are typically confined to the genital region most of the time. The initial ulcer may be mistaken as a \"hard\" chancre, the typical sore of primary syphilis, as opposed to the \"soft chancre\" of chancroid. Approximately one-third of the infected individuals will develop enlargements of the inguinal lymph nodes, the nodes located in the fold between the leg and the lower abdomen. Half of those who develop swelling of the inguinal lymph nodes will progress to a point where the nodes rupture through the skin, producing draining abscesses. The swollen lymph nodes and abscesses are often referred to as buboes." }, { "id": "wiki20220301en071_45148", "title": "Sézary disease", "score": 0.009345794392523364, "content": "Generalized erythroderma– redness of the skin Lymphadenopathy – swollen, enlarged lymph nodes Atypical T-cells – malignant lymphocytes known as \"Sézary cells\" seen in the peripheral blood with typical cerebriform nuclei (brain-shaped, convoluted nuclei) Hepatosplenomegaly– enlarged liver and spleen Palmoplantar keratoderma – thickening of the palms of the hands, and soles of the feet Diagnosis Those who have Sézary disease often present with skin lesions that do not heal with normal medication. A blood test generally reveals any change in the levels of lymphocytes in the blood, which is often associated with a cutaneous T-cell lymphoma. Finally, a biopsy of a skin lesion can be performed to rule out any other causes." }, { "id": "Gynecology_Novak_2919", "title": "Gynecology_Novak", "score": 0.009345794392523364, "content": "3. One to three extremely painful ulcers, accompanied by tender inguinal lymphadenopathy, are unlikely to be anything except chancroid. This is especially true if the adenopathy is fluctuant. 4. An inguinal bubo accompanied by one or several ulcers is most likely chancroid. If no ulcer is present, the most likely diagnosis is LGV. Recommended regimens for the treatment of chancroid include azithromycin, 1 g orally in a single dose; ceftriaxone, 250 mg intramuscularly in a single dose; ciprofloxacin, 500 mg orally twice a day for 3 days; or erythromycin base, 500 mg orally four times daily for 7 days. Patients should be reexamined 3 to 7 days after initiation of therapy to ensure the gradual resolution of the genital ulcer, which can be expected to heal within 2 weeks unless it is unusually large." }, { "id": "pubmed23n0900_17463", "title": "Scrotal lymphangioma circumscriptum.", "score": 0.009259259259259259, "content": "Lymphangioma circumscriptum (LC) is anuncommon, benign, cutaneous disorder thatinvolves lymphatic dilatation to cause vesicularand papular lesions on the trunk, extremities, andanogenital areas. It may be a diagnostic challengewhen appearing in the anogenital region andoften is misdiagnosed and mistreated as infectiousetiologies, which include molluscum contagiosumand condylomata accuminata. We report a healthy40-year-old man with a six-month history of aneruption of multiple, asymptomatic, scrotal papulesthat were diagnosed as lymphangiomas. Awarenessof scrotal LC in adult men without prior disease orsymptoms is necessary for proper diagnosis andavoidance of unnecessary treatment." }, { "id": "pubmed23n0805_14300", "title": "Primary syphilis of the oropharynx: an unusual location of a chancre.", "score": 0.009174311926605505, "content": "A 33-year-old man presented with a two-week history of an asymptomatic ulcer of the oropharynx and submandibular lymph nodes swelling. Laboratory examinations were normal, but serological tests revealed positivity for rapid plasma reagin, Treponema pallidum haemagglutination assay and anti-T. pallidum IgM antibodies. Since the patient denied any homosexual relationship, a biopsy of the lesion was performed, which confirmed primary syphilis. The patient received an intramuscular injection of Benzathine Penicillin G (2.4 MU) with complete resolution of the lesion. Extragenital chancres occur in at least 5% of patients with primary syphilis, and the oral mucosa is the most frequent location as a consequence of orogenital/oroanal contact with an infectious lesion. Because of their transient nature, these oral ulcerations are often underestimated by the patient or by any unsuspecting clinician. Health professionals should consider the recent sexual history of their patients and should be prepared to recognise oral and systemic manifestations of sexually transmitted infections. " }, { "id": "InternalMed_Harrison_12283", "title": "InternalMed_Harrison", "score": 0.009174311926605505, "content": "The presentation of chancroid does not usually include all of the typical clinical features and is sometimes atypical. Multiple ulcers can coalesce to form giant ulcers. Ulcers can appear and then resolve, with inguinal adenitis (Fig. 182-2) and suppuration following 1–3 weeks later; this clinical picture can be confused with that of lymphogranuloma venereum (Chap. 213). Multiple small ulcers can resemble folliculitis. Other differential diagnostic considerations include the various infections causing genital ulceration, such as primary syphilis, secondary syphilis (condyloma latum), genital herpes, and donovanosis. In rare cases, chancroid lesions become secondarily infected with bacteria; the result is extensive inflammation. FIGURE 182-2 Chancroid with characteristic penile ulcers and associated left inguinal adenitis (bubo)." }, { "id": "pubmed23n0620_7089", "title": "Glandular fever and pulmonary artery thrombosis in a paraplegic patient, who had undergone splenectomy for splenic trauma sustained along with spinal cord injury: misdiagnosed initially as urine infection and later as lymphoma when CT scan revealed enlarged lymph nodes: a case report.", "score": 0.009009009009009009, "content": "A 36-year-old male sustained fracture of first lumbar vertebra, splenic tear and paraplegia in a motorcycle accident in 2001; splenectomy was performed. In 2008, he presented with temperature and feeling rough. With a diagnosis of urine infection, he was prescribed ciprofloxacin, followed by trimethoprim, amoxicillin, and gentamicin, as temperature did not subside. White cell count was 21.2 x 109/L; lymphocytes were 13.05 x 109/L (1.00 - 4.00). Therefore, computerised tomography (CT) of chest and abdomen was performed. Thrombus was present in pulmonary arteries bilaterally involving the lobar and segmental branches. Enlarged lymph nodes were seen in axillae, chest, abdomen and inguinal regions. Radiological diagnosis was lymphoma. Cell marker showed an excess of large granular lymphocytes and activated lymphocytes. The Glandular Fever Slide Test was positive. Subsequently, Paul Bunnell test was also positive. Epstein Barr virus serology was consistent with recent Epstein Barr virus infection. Antibiotic was omitted; enoxaparin was prescribed for pulmonary artery thrombosis. Learning points from this case: (1) Although routine administration of antibiotic to a spinal cord injury patient with pyrexia may be acceptable in outpatient setting, other possibilities such as infection by multi-drug resistant organism, viral infection, venous or, arterial thrombosis should be considered if a patient does not respond promptly to antibacterial therapy. (2) When full blood count showed lymphocytosis (comprising &gt; 50% of white blood cells) with atypical morphology, lymphocyte surface markers, Paul Bunnell test, and Epstein Barr virus serology should be performed. These tests would have led to a diagnosis of infectious mononucleosis, and abdominal imaging studies could have been avoided. (3) Lymphoid hyperplasia is the hallmark of infectious mononucleosis; therefore, we should have suspected glandular fever rather than lymphoma when CT scan revealed enlarged lymph nodes in abdomen, mediastinum, axillae and inguinal regions in this patient, who had lymphocytosis with atypical morphology. (4) A soft tissue mass, situated inferior to left hemidiaphragm in this asplenic patient, was misinterpreted as lymph nodes; review of CT led to the correct diagnosis of splenunculus. (5) Acute infection with Epstein Barr virus may lead to transient induction of anti-phospholipid antibodies, which can cause vascular thrombosis. (6) This case illustrates the value of reviewing test results and discussion with senior doctors, as these measures help to recognize medical errors and improve patient care." }, { "id": "wiki20220301en067_61541", "title": "Sexual health clinic", "score": 0.009009009009009009, "content": "In a private room or space, the patient will partially undress. The clinician may inspect the patient's: Throat and lymph nodes of the neck for inflammation Pubic hair for lice Lymph nodes of the groin for swelling Genitals, anus, and surrounding areas for sores and warts The clinician may swab the patient's: Throat to test for gonorrhea and possibly chlamydia Cheek, inside, to diagnose HIV Sores of the genitals, anus, and surrounding areas to test for herpes Urethra to test for gonorrhea and possibly chlamydia Vagina to test for chlamydia and possibly gonorrhea Cervix to test for cervical intraepithelial neoplasia (a Pap test) Rectum to test for gonorrhea and possibly chlamydia The clinician may take small blood samples by pricking a finger or from a vein to test for HIV, syphilis, and possibly herpes and hepatitis C." }, { "id": "wiki20220301en005_4072", "title": "Infectious mononucleosis", "score": 0.008928571428571428, "content": "Physical examination The presence of an enlarged spleen, and swollen posterior cervical, axillary, and inguinal lymph nodes are the most useful to suspect a diagnosis of infectious mononucleosis. On the other hand, the absence of swollen cervical lymph nodes and fatigue are the most useful to dismiss the idea of infectious mononucleosis as the correct diagnosis. The insensitivity of the physical examination in detecting an enlarged spleen means it should not be used as evidence against infectious mononucleosis. A physical examination may also show petechiae in the palate. Heterophile antibody test" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 77 ] ], "word_ranges": [ [ 0, 10 ] ], "text": "Ivabradine, in fact, is contraindicated in patients with atrial fibrillation." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Ivabradine.", "2": "Angiotensin converting enzyme inhibitors.", "3": "Antialdosterone.", "4": "Beta-blockers.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0506_20517", "title": "[Pharmacotherapy of chronic heart failure in clinical practice].", "score": 0.015396368337544809, "content": "Chronic heart failure affects between 1-5% of the population and rise steeply with age. Most patients with chronic heart failure should be routinely managed with a combination of 4 types of drugs: a diuretic, an angiotensin converting enzyme inhibitors (ACE-I), beta-blocker and usually digitalis. Diuretics are essential for symptomatic treatment when fluid overload is present, and should always be administrated in combination with ACE-I if possible. ACE-I improves survival and symptoms and reduces hospitalization in patients with moderate to severe ventricular systolic dysfunction, and in the absence of fluid retention should be given first. Angiotensin II receptor antagonist could be considered in patients who not tolerate ACE-I. beta-blocking agents are recommended for treatment of patients with stable, mild, moderate and severe heart failure unless there is a contraindication. Bisoprolol, metoprolol and carvedilol have been associated with reduction in total mortality, cardiovascular mortality and sudden death. Cardiac glycosides are indicated in atrial fibrillation and any degree of symptomatic heart failure in order slow ventricular rate. Indications for antiarrhythmic drug therapy include atrial fibrillation, non-sustained or sustained ventricular tachycardia. Oral anticoagulation reduces the risk of stroke in patients with atrial fibrillation, and there is a lack of evidence to support the use of antithrombotic therapy in patients in sinus rhythm." }, { "id": "pubmed23n0507_1094", "title": "[Features of the treatment of heart failure in the elderly].", "score": 0.01484585143803021, "content": "PHARMACOLOGICAL MODIFICATIONS TO BE TAKEN INTO ACCOUNT: In elderly patients, there is a modification in the distribution columns of drugs, an alteration in glomerular filtration (doses require adaptation) and tubular function (greater sensitivity to low salt diet and diuretics), and a reduction in the hepatic elimination capacity. FOR SYSTOLIC HEART FAILURE: The choice of drugs is in practice the same as that for younger patients: diuretics, antialdosterone agents, converting enzyme inhibitors, angiotensin II receptor antagonists, beta-blockers and digitalics. FOR DIASTOLIC HEART FAILURE: The therapeutic approach combines an etiologic treatment (blood pressure, myocardial ischaemia), prevention and the rapid treatment of the decompensation factors (atrial arrhythmia), a pharmacological treatment (converting enzyme inhibitors, angiotensin II receptor antagonists, and bradycardia lowering agents). Non-pharmacological measures include dietary restrictions, regular physical exercise, and education for the patient and the family." }, { "id": "pubmed23n0535_20531", "title": "Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate.", "score": 0.014711409395973155, "content": "Chronic kidney disease is common in older patients with hypertension. To compare rates of coronary heart disease (CHD) and end-stage renal disease (ESRD) events; to determine whether glomerular filtration rate (GFR) independently predicts risk for CHD; and to report the efficacy of first-step treatment with a calcium-channel blocker (amlodipine) or an angiotensin-converting enzyme inhibitor (lisinopril), each compared with a diuretic (chlorthalidone), in modifying cardiovascular disease (CVD) outcomes in high-risk patients with hypertension stratified by GFR. Post hoc subgroup analysis. Multicenter randomized, double-blind, controlled trial. Persons with hypertension who were 55 years of age or older with 1 or more risk factors for CHD and who were stratified into 3 baseline GFR groups: normal or increased (&gt; or = 90 mL/min per 1.73 m2; n = 8126 patients), mild reduction (60 to 89 mL/min per 1.73 m2; n = 18,109 patients), and moderate or severe reduction (&lt; 60 mL/min per 1.73 m2; n = 5662 patients). Random assignment to chlorthalidone, amlodipine, or lisinopril. Rates of ESRD, CHD, stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease). In participants with a moderate to severe reduction in GFR, 6-year rates were higher for CHD than for ESRD (15.4% vs. 6.0%, respectively). A baseline GFR of less than 53 mL/min per 1.73 m2 (compared with &gt;104 mL/min per 1.73 m2) was independently associated with a 32% higher risk for CHD. Amlodipine was similar to chlorthalidone in reducing CHD (16.0% vs. 15.2%, respectively; hazard ratio, 1.06 [95% CI, 0.89 to 1.27]), stroke, and combined CVD (CHD, coronary revascularization, angina, stroke, heart failure, and peripheral arterial disease), but less effective in preventing heart failure. Lisinopril was similar to chlorthalidone in preventing CHD (15.1% vs. 15.2%, respectively; hazard ratio, 1.00 [CI, 0.84 to 1.20]), but was less effective in reducing stroke, combined CVD events, and heart failure. Proteinuria data were not available, and combination therapies were not tested. Older high-risk patients with hypertension and reduced GFR are more likely to develop CHD than to develop ESRD. A low GFR independently predicts increased risk for CHD. Neither amlodipine nor lisinopril is superior to chlorthalidone in preventing CHD, stroke, or combined CVD, and chlorthalidone is superior to both for preventing heart failure, independent of level of renal function." }, { "id": "wiki20220301en159_18160", "title": "TIMI", "score": 0.012952736722429754, "content": "TIMI Risk Score for STEMI Age 65-74 years? Yes (+2) – or – Age ≥75 years? Yes (+3) Diabetes, Hypertension or Angina? Yes (+1) Systolic BP < 100 mmHg? Yes (+3) Heart rate > 100? Yes (+2) Killip Class II-IV (JVD or any pulmonary exam findings of CHF)? Yes (+2) Weight < 67kg (147.7 lbs)? Yes (+1) Anterior ST Elevation or LBBB? Yes (+1) Time to treatment > 4 hours? Yes (+1) What Does This Score Mean? TIMI Risk Score for HF in Diabetes Prior heart failure? Yes (+2) History of atrial fibrillation? Yes (+1) Coronary artery disease? Yes (+1) eGFR < 60 ml/min/1.73*m2? Yes (+1) Urine albumin-to-creatinine ratio >300 mg/g? Yes (+2) – or – Urine albumin-to-creatinine ratio 30-300 mg/g? Yes (+1) What Does This Score Mean?" }, { "id": "pubmed23n0418_20069", "title": "Pharmacotherapy for heart failure in patients with renal insufficiency.", "score": 0.012348417627920733, "content": "Clinical trials have demonstrated that angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and spironolactone improve survival in patients with heart failure. Because patients with heart failure and renal insufficiency have been underrepresented in these trials, little evidence is available to guide clinicians in the optimal management of patients with both conditions. Approximately one third to one half of patients with heart failure have renal insufficiency (estimated glomerular filtration rate [GFR] &lt;60 mL/min per 1.73 m2), and renal insufficiency is among the strongest predictors of mortality in patients with heart failure. Evidence supports the use of ACE inhibitors to improve survival in patients with moderate renal insufficiency (GFR, 30 to 60 mL/min per 1.73 m2), but there is little evidence with which to weigh the risks and benefits in patients with more advanced renal dysfunction. beta-Blockers improve survival in patients with heart failure, and their beneficial effect is unlikely to differ according to renal function. Spironolactone improves outcomes in patients with advanced heart failure, but renal insufficiency appears to increase risk for hyperkalemia and limits the use of the drug in patients with severe renal insufficiency. Future clinical trials in heart failure should include a representative number of patients with renal insufficiency to improve the evidence base and outcomes in this vulnerable population." }, { "id": "wiki20220301en026_111819", "title": "Angiotensin II receptor blocker", "score": 0.011996336996336997, "content": "A 2016 meta-analysis including 148,334 patients found no significant differences in cancer incidence associated with ARB use. Kidney failure Although ARBs have protective effects against developing kidney diseases for patients with diabetes and previous hypertension without administration of ARBs, ARBs may worsen kidney functions such as reducing glomerular filtration rate associated with a rise of serum creatinine in patients with pre-existing proteinuria, renal artery stenosis, hypertensive nephrosclerosis, heart failure, polycystic kidney disease, chronic kidney disease, interstitial fibrosis, focal segmental glomerulosclerosis, or any conditions such as ARBs-treated but still clinically present hypertension that lead to abnormal narrowing of blood vessels to the kidney that interrupts oxygen and nutrient supply to the organ. History" }, { "id": "wiki20220301en024_705", "title": "Antihypertensive drug", "score": 0.011991213335056209, "content": "The ratio of CCBs' anti-proteinuria effect, non-dihydropyridine to dihydropyridine was 30 to -2. ACE inhibitors ACE inhibitors inhibit the activity of angiotensin-converting enzyme (ACE), an enzyme responsible for the conversion of angiotensin I into angiotensin II, a potent vasoconstrictor. captopril enalapril fosinopril lisinopril moexipril perindopril quinapril ramipril trandolapril benazepril A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense. The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of kidney function compared to calcium channel blockers and beta blockers. As such, ACE inhibitors should be the drug treatment of choice for patients with chronic kidney disease regardless of race or diabetic status." }, { "id": "wiki20220301en100_36270", "title": "Ivabradine", "score": 0.011533978199963189, "content": "Chronic heart failure In the SHIFT study, ivabradine significantly reduced the risk of the primary composite endpoint of hospitalization for worsening heart failure or cardiovascular death by 18% (P<0.0001) compared with placebo on top of optimal therapy. These benefits were observed after 3 months of treatment. SHIFT also showed that administration of ivabradine to heart failure patients significantly reduced the risk of death from heart failure by 26% (P=0.014) and hospitalization for heart failure by 26% (P<0.0001). The improvements in outcomes were observed throughout all prespecified subgroups: female and male, with or without beta-blockers at randomization, patients below and over 65 years of age, with heart failure of ischemic or non-ischemic etiology, NYHA class II or class III, IV, with or without diabetes, and with or without hypertension." }, { "id": "wiki20220301en248_20376", "title": "Atrial fibrillation", "score": 0.011236277947008448, "content": "Rate control Rate control to a target heart rate of fewer than 110 beats per minute is recommended in most people. Lower heart rates may be recommended in those with left ventricular hypertrophy or reduced left ventricular function. Rate control is achieved with medications that work by increasing the degree of the block at the level of the AV node, decreasing the number of impulses that conduct into the ventricles. This can be done with: Beta blockers (preferably the \"cardioselective\" beta blockers such as metoprolol, bisoprolol, or nebivolol) Non-dihydropyridine calcium channel blockers (e.g., diltiazem or verapamil) Cardiac glycosides (e.g., digoxin) – have less use, apart from in older people who are sedentary. They are not as effective as either beta-blockers or calcium channel blockers. In those with chronic AF either beta blockers or calcium channel blockers are recommended." }, { "id": "wiki20220301en100_36262", "title": "Ivabradine", "score": 0.011069899051697767, "content": "Medical uses It is used for the symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm who cannot take beta blockers. It is also being used off-label in the treatment of inappropriate sinus tachycardia.Ivabradine stands as a pharmacological option for controlling HR and rhythm without associated side effects in postoperative CABG patients with IST Chest pain It may be as effective as the beta blocker atenolol and comparable with amlodipine in the management of chronic stable angina. Heart failure It is used in combination with beta blockers in people with heart failure with LVEF lower than 35 percent inadequately controlled by beta blockers alone and whose heart rate exceeds 70 beats per minute. In people not sufficiently managed with beta blockers for their heart failure adding ivabradine decreases the risk of hospitalization for heart failure." }, { "id": "wiki20220301en024_723", "title": "Antihypertensive drug", "score": 0.010164525580347082, "content": "Chronic kidney disease. ACE inhibitors or ARBs should be included in the treatment plan to improve kidney outcomes regardless of race or diabetic status. Late-stage Dementia should consider Deprescribing antihypertensives, according to the Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D) Diabetes mellitus. The ACE inhibitors and angiotensin receptor blockers have been shown to prevent the kidney and retinal complications of diabetes mellitus. Gout may be worsened by thiazide diuretics, while losartan reduces serum urate. Kidney stones may be improved with the use of thiazide-type diuretics Heart block. β-blockers and nondihydropyridine calcium channel blockers should not be used in patients with heart block greater than first degree. JNC8 does not recommend β-blockers as initial therapy for hypertension" }, { "id": "wiki20220301en019_111576", "title": "Glomerular filtration rate", "score": 0.009900990099009901, "content": "The severity of chronic kidney disease (CKD) is described by six stages; the most severe three are defined by the MDRD-eGFR value, and first three also depend on whether there is other evidence of kidney disease (e.g., proteinuria): 0) Normal kidney function – GFR above 90 mL/min/1.73 m2 and no proteinuria 1) CKD1 – GFR above 90 mL/min/1.73 m2 with evidence of kidney damage 2) CKD2 (mild) – GFR of 60 to 89 mL/min/1.73 m2 with evidence of kidney damage 3) CKD3 (moderate) – GFR of 30 to 59 mL/min/1.73 m2 4) CKD4 (severe) – GFR of 15 to 29 mL/min/1.73 m2 5) CKD5 kidney failure – GFR less than 15 mL/min/1.73 m2 Some people add CKD5D for those stage 5 patients requiring dialysis; many patients in CKD5 are not yet on dialysis. Note: others add a \"T\" to patients who have had a transplant regardless of stage." }, { "id": "pubmed23n0937_17304", "title": "[Cardiovascular Medication in Elderly Patients].", "score": 0.009900990099009901, "content": "Elderly people show increased probability to develop atherosclerotic diseases; in consequence heart failure - most often following coronary heart disease - as well as atrial fibrillation is more common. Following guidelines may lead to polypharmacy, i. e. use of more than 5 drugs daily. Thus, drug interactions as well as side effects become more likely; especially in elderly patients reduced kidney function has to be taken into account. Only drugs which have shown to prolong life or to reduce symptoms in controlled clinical trials should be used. There is little evidence to use low dose aspirin or lipid lowering agents in primary prevention especially in elderly. ACE inhibitors, β blocker and MRA are effective to improve symptoms and outcome in HFrEF but not in HFmEF or HFpEF. This also holds true for the elderly. Withdrawal of long term diuretic treatment in the elderly patients may lead to symptoms of heart failure or increase in blood pressure to hypertensive values often. In coronary heart disease ß blocker may be used to control symptoms as well as to reduce the need for coronary intervention following 1 year after myocardial infarction. Because the risk of stroke increases with age more than the risk of bleeding, the absolute benefit of oral anticoagulation in atrial fibrillation patients is highest in the elderly. NOAK appear to be safer and at least as efficacious as warfarin." }, { "id": "wiki20220301en012_66472", "title": "Heart failure", "score": 0.009815892168833346, "content": "Beta-adrenergic blocking agents (beta blockers) also form part of the first line of treatment, adding to the improvement in symptoms and mortality provided by ACE-I/ARB. The mortality benefits of beta blockers in people with systolic dysfunction who also have atrial fibrillation is more limited than in those who do not have it. If the ejection fraction is not diminished (HFpEF), the benefits of beta blockers are more modest; a decrease in mortality has been observed, but reduction in hospital admission for uncontrolled symptoms has not been observed. In people who are intolerant of ACE-I and ARBs or who have significant kidney dysfunction, the use of combined hydralazine and a long-acting nitrate, such as isosorbide dinitrate, is an effective alternate strategy. This regimen has been shown to reduce mortality in people with moderate heart failure. It is especially beneficial in the black population." }, { "id": "pubmed23n0717_22083", "title": "Renin-angiotensin inhibition in systolic heart failure and chronic kidney disease.", "score": 0.00980392156862745, "content": "The role of renin-angiotensin inhibition in older patients with systolic heart failure with chronic kidney disease remains unclear. Of the 1665 patients (aged≥65 years) with systolic heart failure (ejection fraction&lt;45%) and chronic kidney disease (estimated glomerular filtration rate&lt;60 mL/min/1.73 m(2)), 1046 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the receipt of these drugs, estimated for each of the 1665 patients, were used to assemble a matched cohort of 444 pairs of patients receiving and not receiving these drugs who were balanced on 56 baseline characteristics. During more than 8 years of follow-up, all-cause mortality occurred in 75% and 79% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.74-0.996; P=.045). There was no significant association with heart failure hospitalization (HR, 0.86; 95% CI, 0.72-1.03; P=.094). Similar mortality reduction (HR, 0.83; 95% CI, 0.70-1.00; P=.046) occurred in a subgroup of matched patients with estimated glomerular filtration rate less than 45 mL/min/1.73 m(2). Among 171 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was associated with a significant reduction in all-cause mortality (HR, 0.72; 95% CI, 0.55-0.94; P=.015) and heart failure hospitalization (HR, 0.71; 95% CI, 0.52-0.95; P=.023). Discharge prescription of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant modest reduction in all-cause mortality in older patients with systolic heart failure with chronic kidney disease, including those with more advanced chronic kidney disease." }, { "id": "pubmed23n0364_14894", "title": "[The use of beta blockers in heart failure: clinical studies].", "score": 0.00980392156862745, "content": "Although inhibitors of angiotensin-converting enzyme (ACE) have improved the treatment of chronic heart failure (CHF), mortality related to this disorder remains unacceptably high. Results from studies started more than 25 years ago in Sweden suggested that long-term therapy with beta-blockers could improve hemodynamics and increase survival in patients with CHF; this hypothesis is confirmed by the results of six double-blind, randomized, placebo-controlled trials (MDC, CIBIS, ANZ, US Carvedilol Study, CIBIS II and MERIT-HF) who enrolled about 9000 patients with CHF. In these trials beta-blockers (metoprolol, bisoprolol or carvedilol) where added to the stable usual treatment of each patient (ACE-inhibitors, diuretics, digoxin). Baseline characteristics of patients enrolled into the beta-blocker or placebo arm were similar in all these studies. Specifically the mean patient's age was &lt; 60 years, with a mean left ventricular ejection fraction of 25-26%, 30% of enrolled patients were in NYHA functional class II and 60% in NYHA functional class III, CHF was due to ischemic heart disease in about 60% of patients. The average follow-up for all the trials was 14.5 +/- 5.6 months. On the whole in patients on beta-blocker treatment there is a 33.3% reduction in total mortality rate, a 34.2% reduction in cardiac death rate, a 37.7% reduction in sudden death rate, and a 41.7% reduction in worsening heart failure mortality rate. Moreover, in beta-blocker patients there is a 31.7% reduction in all-cause readmissions to hospital and a 26% reduction in the combined end point (total mortality and hospital readmission). Beta-blockers improved ventricular function but there was no significant improvement in functional capacity. In conclusion, the results of the six trials considered indicate that there is convincing evidence supporting a favorable effect of beta-blockade on the risk of death and readmission to hospital in patients with dilated cardiomyopathy with systolic dysfunction, aged &lt; 70 years, in NYHA functional class II-III. The effects of these drugs in CHF patients a) with normal left ventricular ejection fraction, b) aged &gt; 65-70 years, c) in NYHA functional class IV, and d) with comorbilities such as obstructive lung disease, diabetes, peripheral arterial diseases, require additional study." }, { "id": "wiki20220301en000_119255", "title": "Digitalis", "score": 0.009708737864077669, "content": "under current regulations by the Food and Drug Administration on the basis of prospective, randomized study and clinical trials. It was also approved for the control of ventricular response rate for patients with atrial fibrillation. American College of Cardiology/American Heart Association guidelines recommend digoxin for symptomatic chronic heart failure for patients with reduced systolic function, preservation of systolic function, and/or rate control for atrial fibrillation with a rapid ventricular response. Heart Failure Society of America guidelines for heart failure provide similar recommendations. Despite its relatively recent approval by the Food and Drug Administration and the guideline recommendations, the therapeutic use of digoxin is declining in patients with heart failure—likely the result of several factors. The main factor is the more recent introduction of several drugs shown in randomised controlled studies to improve outcomes in heart failure. Safety concerns" }, { "id": "pubmed23n0367_10209", "title": "Renal implications of the renin-angiotensin-aldosterone system blockade in heart failure.", "score": 0.009708737864077669, "content": "The renin-angiotensin-aldosterone system actively participates in the derangement of renal function since the early stages of heart failure (HF). A diminished capacity to excrete sodium secondary to increased proximal tubular re-absorption and loss of the renal functional reserve are the two most relevant initial alterations of renal function in which angiotensin II has been proven to act directly. Meanwhile, the octapeptide contributes to maintain glomerular filtration rate (GFR) within normal limits through efferent arteriole vasoconstriction. Administration of angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor antagonists (ARA) may thus be accompanied by a functional fall in that parameter. Advanced age, higher initial serum creatinine, history of hypertension, diabetes and atrial fibrillation predict the onset of GFR impairment associated with blockade of the renin-angiotensin system. Concomitant administration of betablockers may help to protect renal function, and preliminary data indicate that the combination of ACEi and ARA is not accompanied by a higher renal risk. The good prognostic effects of aldosterone antagonists in HF does not seem to be related to intrarenal effects of these compounds with the exception of preventing potassium loss and hypokalemia. The systematic therapeutic use of drug(s) provided with beneficial renal effects, to treat arterial hypertension or myocardial ischemia, may contribute to delay of, or prevent the development of HF." }, { "id": "pubmed23n0053_5142", "title": "Protection: risk ratio of antihypertensive drug treatment in the elderly.", "score": 0.009615384615384616, "content": "In recent controlled trials using clinic-based manometry, thiazides and beta-blockers prevented cerebrovascular and coronary deaths in patients aged 60-79 years with cryptogenic hypertension (diastolic 90-119 mm Hg). Elderly patients should usually take low-dose thiazide with potassium replacement. beta-Blockers also postpone death, but may mask hypoglycaemia. Calcium blockers and low-dose angiotensin-converting enzyme (ACE) inhibitors appear preferable in diabetes, and thiazides or ACE inhibitors in heart failure or peripheral vascular disease. Maintaining average diastolic pressure at 80-84 mm Hg impairs function of the kidneys, and possibly the myocardium. Metabolic reactions worsen with age. Drug treatment should match individual daily function. By clinic manometry, the protection:risk ratio of antihypertensive treatment progressively decreases with age, reaching less than 1.0 in patients over 80-85 years. Twenty-four-hour ambulatory blood pressure information should guide treatment more reliably in patients greater than or equal to 60 years." }, { "id": "wiki20220301en012_66425", "title": "Heart failure", "score": 0.009523809523809525, "content": "Treatment depends on the severity and cause of the disease. In people with chronic stable mild heart failure, treatment commonly consists of lifestyle modifications such as stopping smoking, physical exercise, and dietary changes, as well as medications. In those with heart failure due to left ventricular dysfunction, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or valsartan/sacubitril along with beta blockers are recommended. For those with severe disease, aldosterone antagonists, or hydralazine with a nitrate may be used. Diuretics are useful for preventing fluid retention and the resulting shortness of breath. Sometimes, depending on the cause, an implanted device such as a pacemaker or an implantable cardiac defibrillator may be recommended. In some moderate or severe cases, cardiac resynchronization therapy (CRT) or cardiac contractility modulation may be of benefit. A ventricular assist device (for the left, right, or both ventricles), or" }, { "id": "pubmed23n1072_10876", "title": "Beta-blocker therapy in elderly patients with renal dysfunction and heart failure.", "score": 0.009523809523809525, "content": "To assess the role of beta-blockers (BB) in patients with chronic kidney disease (CKD) aged ≥ 75 years. From January 2008 to July 2014, we included 390 consecutive patients ≥ 75 years of age with ejection fraction ≤ 35% and glomerular filtration rate (GFR) ≤ 60 mL/min per 1.73 m<sup2</sup. We analyzed the relationship between treatment with BB and mortality or cardiovascular events. The mean age of our population was 82.6 ± 4.1 years. Mean ejection fraction was 27.9% ± 6.5%. GFR was 60-45 mL/min per 1.73 m<sup2</sup in 50.3% of patients, 45-30 mL/min per 1.73 m<sup2</sup in 37.4%, and &lt; 30 mL/min per 1.73 m <sup2</sup in 12.3%. At the conclusion of follow-up, 67.4% of patients were receiving BB. The median follow-up was 28.04 (IR: 19.41-36.67) months. During the study period, 211 patients (54.1%) died and 257 (65.9%) had a major cardiovascular event (death or hospitalization for heart failure). BB use was significantly associated with a reduced risk of death (HR = 0.51, 95% CI: 0.35-0.74;<iP</i &lt; 0.001). Patients receiving BB consistently showed a reduced risk of death across the different stages of CKD: stage IIIa (GFR = 30-45 mL/min per 1.73 m <sup2</sup; HR = 0.47, 95% CI: 0.26-0.86,<iP</i &lt; 0.0001), stage IIIb (GFR 30-45 mL/min per 1.73 m <sup2</sup; HR = 0.55, 95% CI: 0.26-1.06,<iP</i = 0.007), and stages IV and V (GFR &lt; 30 mL/min per 1.73 m <sup2</sup; HR = 0.29, 95% CI: 0.11-0.76;<iP</i = 0.047). The use of BB in elderly patients with HFrEF and renal impairment was associated with a better prognosis. Use of BB should be encouraged when possible." }, { "id": "pubmed23n0747_19760", "title": "Renin-angiotensin inhibition in diastolic heart failure and chronic kidney disease.", "score": 0.009433962264150943, "content": "The role of renin-angiotensin inhibition in older patients with diastolic heart failure and chronic kidney disease remains unclear. Of the 1340 patients (age ≥65 years) with diastolic heart failure (ejection fraction ≥45%) and chronic kidney disease (estimated glomerular filtration rate &lt;60 mL/min/1.73 m(2)), 717 received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Propensity scores for the use of these drugs, estimated for each of the 1340 patients, were used to assemble a cohort of 421 pairs of patients, receiving and not receiving these drugs, who were balanced on 56 baseline characteristics. During more than 8 years of follow-up, all-cause mortality occurred in 63% and 69% of matched patients with chronic kidney disease receiving and not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, respectively (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.70-0.97; P = .021). There was no association with heart failure hospitalization (HR, 0.98; 95% CI, 0.82-1.18; P = .816). Similar mortality reduction (HR, 0.81; 95% CI, 0.66-0.995; P = .045) occurred in a subgroup of matched patients with an estimated glomerular filtration rate less than 45 mL/min/1.73 m(2). Among 207 pairs of propensity-matched patients without chronic kidney disease, the use of these drugs was not associated with mortality (HR, 1.03; 95% CI, 0.80-1.33; P = .826) or heart failure hospitalization (HR, 0.99; 95% CI, 0.76-1.30; P = .946). A discharge prescription for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a significant reduction in all-cause mortality in older patients with diastolic heart failure and chronic kidney disease, including those with more advanced chronic kidney disease." }, { "id": "pubmed23n1152_14282", "title": "Already low drug dose antagonism of the renin-angiotensin aldosterone system decreases 1-year mortality and rehospitalization in old heart failure patients.", "score": 0.009433962264150943, "content": "Hospitalization for heart failure treatment (HHF) is an incisive event in the course of HF. Today, the large majority of HHF patients is ≥ 65 years and discharge HF drugs are most often not applied at dose levels acknowledged to provide prognostic benefit. This study therefore aims to investigate the treatment effect size of discharge HF drugs in old HHF patients. Drugs are analyzed according to pharmacological class. Individual discharge HF drug dose is reported as percentage of guidelines-recommended target dose. Primary endpoint was 1-year all-cause mortality (ACM) after discharge; the secondary endpoint combined 1-year ACM and first cardiovascular hospitalization within 1 year after discharge. Comparison between 65-80 years and &gt; 80 years old study participants tested the relative treatment effect size as a function of respective age group. The 875 consecutive HHF patients had a median age of 82 years [76-87 years]; 48.6 % were females. Betablocker and diuretic treatment did not change the incidence of endpoints. Inhibition of the renin-angiotensin system (RASi), when compared to no treatment, decreased the incidence of endpoints both at the 1-25 % and the &gt; 25 % target dose level. Antagonists of the mineralocorticoid receptor (MRA), when compared to no treatment, decreased the secondary endpoint at the 1-25 % target dose level but not at the &gt; 25 % target dose level. The relative treatment effect size of RASi or MRA corresponded between the age strata for both endpoints. Low-dose RASi and MRA had beneficial effects in these old HHF patients." }, { "id": "pubmed23n0943_2340", "title": "Characteristics of clinical drugs for elderly chronic heart failure complicated with different degrees of renal insufficiency.", "score": 0.009345794392523364, "content": "To investigate the characteristics of clinical therapeutic drugs in elderly chronic heart failure (CHF) patients complicated with different degrees of renal insufficiency. The elderly patients who were hospitalized from October 2010 to October 2015 in our hospital due to CHF for the first time were selected by means of retrospective case collection. The glomerular filtration rate was estimated by using the Modification of Diet in Renal Disease (MDRD) Study equation. The patients were divided into a group with normal renal function, a group with slight decrease in renal function, and a group with moderate and severe decrease in renal function. Statistical analysis was made to compare the characteristics of clinical drugs for the three groups. Compared with the normal renal function group and the slight decrease group, ACEIs and β-blockers were less used in the moderate and severe decrease group, but diuretics and spironolactone were more used (P&lt;0.05). Compared with the normal renal function group, the use rate of ACEIs was low whereas that of diuretics was high (P&lt;0.05). ACEIs and β-blockers were barely employed to treat elderly CHF patients complicated with renal insufficiency, but diuretics and spironolactone were frequently utilized." }, { "id": "pubmed23n0371_468", "title": "The management of heart failure--an overview.", "score": 0.009304016768618728, "content": "National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given \"risk reduction\", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies." }, { "id": "pubmed23n0764_21395", "title": "Cardiovascular medication in relation to renal function after coronary artery bypass surgery.", "score": 0.009259259259259259, "content": "Guidelines for recommended medication use for the secondary prevention of coronary heart disease are exceedingly important in patients with chronic kidney disease. Despite a high risk for recurrent cardiovascular events, these patients are less likely to use evidence-based recommended medications. The objective of the current study was to analyze the association between renal function and guideline-recommended drug therapy in patients with coronary heart disease. In this nationwide population-based cohort study, we included 12,332 patients with established coronary heart disease who underwent primary isolated coronary artery bypass grafting in Sweden between 2005 and 2008. Medication use was retrieved from the national Prescribed Drug Register. During the first year after coronary surgery, 94% of patients had at least two dispensed prescriptions for an antiplatelet agent, 68% for an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, 92% for a beta-blocker, and 93% for a statin. Only 57% of all patients had prescriptions for all four medication classes. Reduced renal function (estimated glomerular filtration rate (eGFR) of 30 to 45 mL/min per 1.73 m(2) and &lt;30 mL/min per 1.73 m(2)) was significantly associated with a lower use of all four medication classes (adjusted risk ratio 0.89, 95% confidence interval 0.82 to 0.98; and adjusted risk ratio 0.75, 95% confidence interval 0.62 to 0.90, respectively) as compared to normal renal function (eGFR &gt;60 mL/min per 1.73 m(2)). In patients with established coronary heart disease, moderate to severe renal dysfunction was associated with significantly lower use of guideline-recommend medications as compared to normal renal function." }, { "id": "pubmed23n0872_23161", "title": "Antihypertensive Medication Use in Older Patients Transitioning from Chronic Kidney Disease to End-Stage Renal Disease on Dialysis.", "score": 0.009174311926605505, "content": "The transition from CKD to ESRD can be particularly unstable, with high rates of death and hospitalizations. Few studies have examined medication use during this critical period. We examined patterns of antihypertensive medication use from the four quarters before and eight quarters after incident ESRD treated with maintenance dialysis. We used the US Renal Data System to identify patients aged ≥67 years initiating dialysis for ESRD between January 2008 and December 2010 with Medicare Part D and a low-income subsidy. We ascertained the incidence of AKI and hyperkalemia during each quarter on the basis of having at least 1 payment claim for the condition. We used Poisson regression with robust SEMs to formally test for changes in the trend and level of antihypertensive medication use in a series of intervention analyses. The number of antihypertensive drugs used increased as patients neared ESRD, peaking at an average of 3.4 in the quarter immediately preceding dialysis initiation, then declining to 2.2 medications by 2 years later. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was stable at approximately 40%, even among patients with coronary disease and systolic heart failure, and did not correlate with AKI or hyperkalemia. Dialysis initiation was associated with a 40% (95% confidence interval, 38% to 43%) lower adjusted level of diuretic use, which continued to decline after ESRD. Three- and four-drug combinations that included a diuretic were most common before ESRD, whereas after ESRD, one- and two-drug β-blocker or calcium-channel blocker-based combinations were most common. The use of antihypertensive medications, particularly angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers and diuretics, may be suboptimal during the transition from CKD to ESRD, especially in patients with coronary disease or systolic heart failure. Future studies are needed to identify strategies to increase the appropriate use of antihypertensive medications during this critical transition period." }, { "id": "wiki20220301en370_36970", "title": "Heart failure with preserved ejection fraction", "score": 0.00909090909090909, "content": "Beta-blockers are the first-line therapy: they lower the heart rate and thus give more time for ventricles to fill. They may also improve survival. There is some evidence that calcium channel blockers may be of benefit in reducing ventricular stiffness. In some cases, (verapamil has the benefit lowering the heart rate). Angiotensin converting enzyme (ACE) inhibitors Likewise, treatment with angiotensin converting enzyme inhibitors, such as enalapril, ramipril, and many others, may be of benefit due to their effect on preventing ventricular remodeling but under control to avoid hypotension. ACE inhibitors do not appear to improve morbidity or mortality associated with HFpEF alone. However, they are important in the management of hypertension, a significant player in the pathophysiology of HFpEF. Angiotensin II receptor blockers (ARBs) ARB treatment results in an improvement in diastolic dysfunction and hypertension that is comparable to other anti-hypertensive medication." }, { "id": "pubmed23n0052_89", "title": "[What can be achieved by treatment with antihypertensive agents? Report from a hearing].", "score": 0.00909090909090909, "content": "Today it is considered a primary goal to reduce morbidity and mortality from stroke. It will probably also be possible to reduce other pressure-related illnesses, such as heart failure and renal failure. Coronary morbidity is influenced to some extent only, and involves risk of over-treatment. There is most probably a J-shaped relationship between achieved reduction of pressure and mortality. Treatment with drugs is considered when diastolic pressures exceed 90 mm Hg, provided that the patient has been observed when treated in other ways than by drugs for several months. If no other risk factors are present, 5-10 mm Hg higher diastolic blood pressure levels can be accepted. However, all patients with diastolic pressure above 100 mm Hg should be treated. In patients with coronary disease it is advisable not to lower diastolic blood pressure below 85 mm Hg. One should hesitate to give antihypertensive drugs to individuals with high pressures at the doctor's and normal pressures at home. They should preferably receive intense non-drug treatment aimed at reducing total cardiovascular risk." }, { "id": "wiki20220301en038_67877", "title": "Candesartan", "score": 0.009009009009009009, "content": "Prevention of atrial fibrillation Results from a meta-analysis completed in 2005 demonstrated a reduction in atrial fibrillation in patients with systolic left ventricular dysfunction treated with candesartan, another angiotensin receptor blocker or an angiotensin converting enzyme inhibitor. Evidence for the use of candesartan specifically is also supported by an analysis of the CHARM study which demonstrated a reduction in atrial fibrillation in patients with systolic left ventricular dysfunction. While these studies have demonstrated a potential additional benefit for candesartan when used in patients with systolic left ventricular dysfunction, additional studies are required to further elucidate the role of candesartan in the prevention of atrial fibrillation in other population groups." }, { "id": "pubmed23n1050_25255", "title": "[Association between duration of digoxin use and adverse outcomes among Chinese patients with atrial fibrillation].", "score": 0.009009009009009009, "content": "<bObjective:</b We aimed to explore the impact of digoxin use on outcomes in Chinese patients with atrial fibrillation (AF). <bMethods:</b We used the dataset from the Chinese Atrial Fibrillation Registry, a prospective, multicenter, hospital-based registry study. According to the inclusion and exclusion criteria, 10 472 eligible patients enrolled from August 2011 to December 2016 were included in this ancillary study. The patients were classified into three groups according to the status of digoxin use at study enrollment, patients already receiving digoxin before registry were represented as continuous group, patients initiated on digoxin for the first time were represented as newly group, and patients without digoxin prescription at enrollment were represented as control group. Patients were followed by telephone or outpatient service every 6 months. Kaplan-Meier survival analysis and Cox proportional hazards regression models were used to investigate the association of digoxin use with adverse outcomes (all-cause death, cardiovascular death and cardiovascular hospitalization). <bResults:</b In the overall study population, men accounted for 42.8%, and the average age was (66.9±11.8) years. There were 777（7.42%）patients in continuous group, 375 (3.58%) patients in newly group, and 9 320 (89.00%) patients in control group. Compared with the control group, the patients in the newly group and the continuous group were older, had faster heart rate, lower estimated glomerular filtration rate, higher proportion of persistent atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, ischemic stroke, coronary heart disease, vascular disease and bleeding history. At the same time, the patients in the newly group and the continuous group were treated more often with anticoagulants, antiplatelet drugs, ACE inhibitors or angiotensin receptor blockers, beta-receptor blockers while the proportion of antiarrhythmic drugs was lower as compared to control group (<iP</i&lt;0.05). During a median follow-up of 36 months (interquartile range: 18-48 month), risk of all-cause mortality was significantly higher in newly group compared to control group (7.3% vs. 4.7%, <iP</i&lt;0.05), the rates of all-cause mortality, cardiovascular death and cardiovascular hospitalization were all higher in continuous group than in control group (8.0% vs. 4.7%; 4.7% vs. 3.0%; 16.7% vs<i.</i 11.8%; <iP</i all&lt;0.05). After adjustment for age, male, body mass index, blood pressure, heart rate, renal function, AF type, history of stroke, heart failure, diabetes, coronary artery disease and other drugs treatment, the association between newly group and adverse outcomes was not significant, however, digoxin use was associated with increased all-cause mortality (<iHR</i 1.26; 95%<iCI</i 1.04-1.56; <iP</i=0.019), cardiovascular death (<iHR</i 1.38; 95%<iCI</i 1.08-1.77, <iP</i =0.01), and cardiovascular hospitalization (<iHR</i 1.10; 95%<iCI</i 1.06-1.52, <iP</i=0.02) in continuous group. <bConclusion:</b Continuous digoxin use is associated with a significant increase in adverse outcomes among Chinese patients with atrial fibrillation." }, { "id": "pubmed23n0293_4575", "title": "Current drug treatment and treatment patterns with antihypertensive drugs.", "score": 0.008928571428571428, "content": "The 4 major classes of antihypertensive drugs are diuretics, beta-blockers, ACE inhibitors and calcium antagonists. The diuretics have recently regained prominence, largely due to the results of recent controlled trials. These trials in elderly patients demonstrated that low-dose diuretics were effective not only in preventing stroke but also in greatly reducing coronary-related events. Diuretics also decrease left ventricular mass more than the other major drug classes. In addition, they are the most effective drugs for use in combination therapy. By contrast, the safety of calcium antagonists has recently been questioned because of report of increased coronary morbidity and mortality. However, these adverse events may be restricted to the short-acting preparations, especially nifedipine, which causes cardiac stimulation. ACE inhibitors, like beta-blockers, are not only effective in reducing blood pressure, particularly when combined with a diuretic, but also improve angina and decrease postinfarction mortality. They also benefit congestive heart failure, stabilise or improve renal function in hypertensive and diabetic nephropathy and reduce albuminuria. Beta-Blockers are especially effective in reducing sudden cardiac death in patients with coronary heart disease, particularly in postinfarction patients. Final proof of the relative effectiveness of these drugs in preventing morbidity and mortality must await the outcome of large comparative trials currently under way. A recent national survey in the US found that more than 75% of hypertensive patients did not have their hypertension completely controlled. Possible reasons for this disturbing statistic are discussed along with suggestions for improvement." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 172, 521 ] ], "word_ranges": [ [ 27, 95 ] ], "text": "we have a crossed clinical picture, having to think about brainstem involvement. If we have in a quick diagram where the nuclei of the cranial pairs start from: the first 4 above the pons, the next 4 in the pons, and the last 4 below the pons, we have that the facial nucleus is in the middle 4. That is, left facial nucleus, left pons, so answer 4." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "At the level of the area 4 of Brodmann of the cerebral cortex of the right side.", "2": "In the internal capsule, posterior arm on the right side.", "3": "In the left cerebral peduncle.", "4": "In the medial portion of the caudal protuberance of the left side.", "5": "In the medulla oblongata before decussation of the right cortico-spinal fascicle." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en089_56264", "title": "Facial motor nucleus", "score": 0.01787984742530197, "content": "The neurons in the dorsal aspect of the facial motor nucleus receive inputs from both sides of the cortex, while those in the ventral aspect mainly receive contralateral inputs (i.e. from the opposite side of the cortex). The result is that both sides of the brain control the muscles of the upper face, while the right side of the brain controls the lower left side of the face, and the left side of the brain controls the lower right side of the face. Clinical significance As a result of the corticobulbar input to the facial motor nucleus, an upper motor neuron lesion to fibers innervating the facial motor nucleus results in central seven. The syndrome is characterized by spastic paralysis of the contralateral lower face. For example, a left corticobulbar lesion results in paralysis of the muscles that control the lower right quadrant of the face." }, { "id": "wiki20220301en089_56266", "title": "Facial motor nucleus", "score": 0.01748358528019545, "content": "Branches of the facial nerve leaving the facial motor nucleus (FMN) for the muscles do so via both left and right posterior (dorsal) and anterior (ventral) routes. In other words, this means lower motor neurons of the facial nerve can leave either from the left anterior, left posterior, right anterior or right posterior facial motor nucleus. The temporal branch travels out from the left and right posterior components. The inferior four branches do so via the left and right anterior components. The left and right branches supply their respective sides of the face (ipsilateral innervation). Accordingly, the posterior components receive motor input from both hemispheres of the cerebral cortex (bilaterally), whereas the anterior components receive strictly contralateral input. This means that the temporal branch of the facial nerve receives motor input from both hemispheres of the cerebral cortex whereas the zygomatic, buccal, mandibular and cervical branches receive information" }, { "id": "wiki20220301en089_56270", "title": "Facial motor nucleus", "score": 0.017061679040548255, "content": "A lesion on either the left or right side would affect both the anterior and posterior routes on that side because of their close physical proximity to one another. So, a lesion on the left side would inhibit muscle innervation from both the left posterior and anterior routes, thus paralyzing the whole left side of the face (Bell’s palsy). With this type of lesion, the bilateral and contralateral inputs of the posterior and anterior routes, respectively, become irrelevant because the lesion is below the level of the medulla and the facial motor nucleus. Whereas at a level above the medulla a lesion occurring in one hemisphere would mean that the other hemisphere could still sufficiently innervate the posterior facial motor nucleus, a lesion affecting a lower motor neuron would eliminate innervation altogether because the nerves no longer have a means to receive compensatory contralateral input at a downstream decussation." }, { "id": "article-40985_12", "title": "How to Localize Neurologic Lesions by Physical Examination -- Clinical Significance", "score": 0.015765765765765764, "content": "Hemiplegia can result from a unilateral lesion of the brain stem, internal capsule, or cerebral cortex. Brain stem lesions result in crossed hemiplegia. For example, a left pontine lesion will result in left facial weakness of lower motor neuron type and right-sided hemiplegia. Similarly, a lesion in the left midbrain will result in left-sided oculomotor weakness with right hemiparesis and right facial weakness of upper motor neuron type. This constellation of signs is called Weber syndrome. Lesions above the level of the brainstem result in uncrossed hemiplegia. For example, a lesion in the left internal capsule would result in right hemiplegia and right facial weakness of the upper motor neuron type. A left cortical lesion may also result in cortical dysfunction in addition to right hemiparesis and facial weakness of upper motor neuron type. [5] [6] [7]" }, { "id": "pubmed23n1139_25126", "title": "Contralateral Tongue Deviation Due to Paramedian Pontine Infarction: A Brief Review of Cortico-Hypoglossal Projections.", "score": 0.015306395504415307, "content": "BACKGROUND Motor function of the tongue is controlled by the hypoglossal nucleus (the lower motor neuron) and its supranuclear innervation (the upper motor neuron). Tongue deviation due to muscle weakness on one side is common in brain stem stroke and is usually associated with dysarthria and dysphagia that decrease the patient's quality of life. This case report presents a typical but rarely discussed case of tongue deviation secondary to a brain stem stroke. In addition, it also offers a concise review of both the ipsilateral and the contralateral cortico-hypoglossal fibers that innervate the hypoglossal nucleus. Even though the direction of the tongue deviation offers essential clues to localizing the brain lesion, many providers lack experience and knowledge in this area. CASE REPORT We report the case of an 81-year-old right-handed male patient with right-sided hemiparesis, right lower facial droop, dysarthria, and tongue deviated to the right side without fasciculation or atrophy. The Babinski sign was positive on the right. Magnetic resonance imaging revealed an infarct in the left paramedian pontine. Since both the tongue deviation and the hemiparesis were right-sided, contralateral to the side of the lesion, we concluded that the lesion affected the cortico-hypoglossal fibers and the corticospinal fibers prior to their decussations. CONCLUSIONS The case report reviews the projections of the corticospinal fibers. Each hypoglossal nucleus receives input from both hemispheres, with the contralateral descending fibers passing through the medial part of the ventral pons and the ipsilateral descending fibers passing through the more lateral aspect of the pons. The decussation is generally located at the pontomedullary junction, with exceptions due to individual variance." }, { "id": "pubmed23n0278_1886", "title": "[A case report of Weber's syndrome associated with supranuclear vertical gaze palsy caused by the ipsilateral thalamomesencephalic lesion].", "score": 0.013989953523308764, "content": "We report a rare case showing Weber's syndrome associated with supranuclear vertical gaze palsy caused by the ipsilateral lesion of the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF), which is regarded as the supranuclear control center of vertical gaze. To date, no literature concerning Weber's syndrome associated with the ipsilateral riMLF lesion was documented. The patient was a 53-year-old female, who suddenly developed unconsciousness and left-sided weakness. Neurological findings on admission revealed right third nerve palsy, severe supranuclear vertical gaze palsy, almost complete convergence palsy, left hemiparesis and hyperreflexia with positive Babinski's sign on the left side. There was no sign of pupillary disturbance or no abnormality of the horizontal movements of the left eye. The vestibulo-ocular reflex of the left eye was preserved. There was no sensory disturbance. Cranial MRI had the advantages in demonstrating unilateral ischemic lesions at the cerebral peduncle and the thalamomesencephalic junction involving the unilateral riMLF on the right side. Recent reports have demonstrated that supranuclear vertical gaze palsy is caused by the unilateral riMLF lesion. We confirm that the unilateral riMLF lesion causes supranuclear vertical gaze palsy in our case and that cranial MRI has the advantages in demonstrating the specific lesion." }, { "id": "pubmed23n0600_22104", "title": "[Case of suspected multiple sclerosis with transcallosal lesions involving the upper surface of the corpus callosum].", "score": 0.013588263588263587, "content": "A 26-year-old woman noticed gradually progressive, right lower leg weakness over a 1.5-month period. Neurological examination revealed right hemiparesis with slightly increased deep tendon reflexes, Babinski's sign on the right side, loss of position sense in the right leg, and slight loss of superficial sensation in the right toes. MR FLAIR images showed a high intensity area measuring 5 x 2 x 3 cm in the left frontal lobe, extending to the outer surface of the body of the corpus callosum and the adjacent right cingulate gyrus. Gadolinium enhancement was seen along the cortex and the outer surface of the body of the corpus callosum. CSF findings showed no pleocytosis, a protein content of 32 mg/dl, a sugar level of 85 mg/dl, and an IgG index of 0.46. The biopsy specimen obtained from the superior frontal gyrus showed perivascular cuffing of T-lymphocytes and some B-lymphocytes, as well as multiple small foci of demyelination. Starting on the second day of admission, the patient was treated with methylprednisolone pulse therapy (1,000 mg/day for 3 days); she was then switched to oral prednisolone (20 mg/day). Thereafter, the patient had two clinical relapses: one was due to a lesion in the dorsal part of the medulla oblongata associated with a disturbance of deep sensation in both hands, and the other was due to a lesion involving the right internal capsule, the globus pallidus, and the caudate nucleus associated with left facial nerve palsy. Visual evoked potentials suggested a demyelinating lesion in the right optic nerve. We suspected a diagnosis of multiple sclerosis based on the presence of more than two clinical episodes of neurological deficits with identifiable lesions on MRI. Multiple sclerosis should be considered in the differential diagnosis of lesions located in the outer part of the corpus callosum and transcallosal bilateral hemispheres on MRI, even though inner callosal lesions are common in multiple sclerosis." }, { "id": "wiki20220301en089_56268", "title": "Facial motor nucleus", "score": 0.013511019232898961, "content": "Now, because the anterior FMN receives only contralateral cortical input whereas the posterior receives that which is bilateral, a corticobulbar lesion (UMN lesion) occurring in the left hemisphere would eliminate motor input to the right anterior FMN component, thus removing signaling to the inferior four facial nerve branches, thereby paralyzing the right mid- and lower-face. The posterior component, however, although now only receiving input from the right hemisphere, is still able to allow the temporal branch to sufficiently innervate the entire forehead. This means that the forehead will not be paralyzed. The same mechanism applies for an upper motor neuron lesion in the right hemisphere. The left anterior FMN component no longer receives cortical motor input due to its strict contralateral innervation, whereas the posterior component is still sufficiently supplied by the left hemisphere. The result is paralysis of the left mid- and lower-face with an unaffected forehead." }, { "id": "article-36151_25", "title": "Neuroanatomy, Facial Colliculus -- Clinical Significance -- Lateral Gaze Palsy", "score": 0.012698412698412698, "content": "A lesion located in the abducens nucleus will lead to the paralysis of the ipsilateral lateral rectus. Although the function of the contralateral medial rectus muscle, which is innervated by CN III, will remain intact, interneurons projecting from the damaged CN VI nucleus will no longer be able to send proper signals through the contralateral MLF to the CN III nucleus. As a result, horizontal eye movements are unable to coordinate when both eyes attempt to gaze towards the side of the lesion. For example, if the right nucleus of CN VI is damaged, the right CN VI fibers projecting to the right lateral rectus muscle will be impaired. Since the left CN III nucleus and its nerves are not damaged, there will be no problem contracting the left medial rectus muscle when CN III is activated, and there is no involvement of CN VI. In this example, the lesion of the right nucleus of CN VI impairs the left MLF that projects to the left CN III nucleus, and thus the left CN III nerve cannot stimulate the contraction of the left medial rectus muscle. Ultimately, horizontal eye movements will become disrupted, and both eyes will look straight ahead when instructing the patient to turn their gaze to the right. The patient will have no problem gazing to the left." }, { "id": "wiki20220301en021_62661", "title": "Internal capsule", "score": 0.012685730305578919, "content": "Posterior limb The posterior limb of internal capsule (or occipital part) is the portion of the internal capsule posterior to the genu. The anterior two-thirds of the occipital part of the internal capsule contains fibers of the corticospinal tract, which arise in the motor area of the cerebral cortex and, passing downward through the middle three-fifths of the base of the cerebral peduncle, are continued into the pyramids of the medulla oblongata. The posterior third of the occipital part contains: sensory fibers, largely derived from the thalamus, though some may be continued upward from the medial lemniscus the fibers of optic radiation, from the lower visual centers to the cortex of the occipital lobe; acoustic fibers, from the lateral lemniscus to the temporal lobe fibers that pass from the occipital and temporal lobes to the pontine nuclei" }, { "id": "InternalMed_Harrison_30040", "title": "InternalMed_Harrison", "score": 0.011968423733129615, "content": "Superior cerebellar peduncle Midpontine syndrome: Medial longitudinal fasciculus 5th n. sensory nucleus 5th n. motor nucleus Spinothalamic Medial lemniscus FIGURE 446-12 Axial section at the level of the midpons, depicted schematically on the left, with a corresponding magnetic resonance image on the right. Approximate regions involved in medial and lateral midpontine stroke syndromes are shown. Signs and symptoms: Structures involved 1. Medial midpontine syndrome (paramedian branch of midbasilar artery) On side of lesion Ataxia of limbs and gait (more prominent in bilateral involvement): Pontine nuclei On side opposite lesion Paralysis of face, arm, and leg: Corticobulbar and corticospinal tract Variable impaired touch and proprioception when lesion extends posteriorly: Medial lemniscus 2." }, { "id": "wiki20220301en052_34248", "title": "Precentral gyrus", "score": 0.011690036900369004, "content": "Blood supply Branches of the middle cerebral artery provide most of the arterial blood supply for the primary motor cortex. The medial aspect (leg areas) is supplied by branches of the anterior cerebral artery. Clinical significance Lesions of the precentral gyrus result in paralysis of the contralateral side of the body (facial palsy, arm-/leg monoparesis, hemiparesis) - see upper motor neuron. New research has identified this as the part of the brain that makes sure our words are being properly articulated. This knowledge could help treat speech disorders and neural disorders in the future, the researchers say. Additional images See also Corticospinal tract Motor cortex List of regions in the human brain References Gyri Frontal lobe" }, { "id": "pubmed23n0322_13376", "title": "[Left lateral gaze paresis due to subcortical hematoma in the right precentral gyrus].", "score": 0.011282530777621941, "content": "We report a case of transient left lateral gaze paresis due to a hemorrhagic lesion restricted in the right precentral gyrus. A 74-year-old female experienced a sudden clumsiness of the left upper extremity. A neurological examination revealed a left central facial paresis, distal dominant muscle weakness in the left upper limb and left lateral gaze paresis. There were no other focal neurological signs. Laboratory data were all normal. Brain CTs and MRIs demonstrated a subcortical hematoma in the right precentral gyrus. The neurological symptoms and signs disappeared over seven days. A recent physiological study suggested that the human frontal eye field (FEF) is located in the posterior part of the middle frontal gyrus (Brodmann's area 8) and the precentral gyrus around the precentral sulcus. More recent studies stressed the role of the precentral sulcus and the precentral gyrus. Our case supports those physiological findings. The hematoma affected both the FEF and its underlying white matter in our case. We assume the lateral gaze paresis is attributable to the disruption of the fibers from the FEF. It is likely that fibers for motor control of the face, upper extremity, and lateral gaze lie adjacently in the subcortical area." }, { "id": "wiki20220301en021_62665", "title": "Internal capsule", "score": 0.011168432028977552, "content": "Lesions of the genu of the internal capsule affect fibers of the corticobulbar tract. The primary motor cortex sends its axons through the posterior limb of the internal capsule. Lesions, therefore, result in a contralateral hemiparesis or hemiplegia. While symptoms of weakness due to an isolated lesion of the posterior limb can initially be severe, recovery of motor function is sometimes possible due to spinal projections of premotor cortical regions that are contained more rostrally in the internal capsule. References External links Rostral basal ganglia and associated structures" }, { "id": "wiki20220301en022_111113", "title": "Pyramidal tracts", "score": 0.01081849185297461, "content": "Corticobulbar tract Fibres from the ventral motor cortex travel with the corticospinal tract through the internal capsule, but terminate in a number of locations in the midbrain (cortico-mesencephalic tract), pons (Corticopontine tract), and medulla oblongata (cortico-bulbar tract). The upper motor neurons of the corticobulbar tract synapse with interneurons or directly with the lower motor neurons located in the motor cranial nerve nuclei, namely oculomotor, trochlear, motor nucleus of the trigeminal nerve, abducens, facial nerve and accessory and in the nucleus ambiguus to the hypoglossal, vagus and accessory nerves. These nuclei are supplied by nerves from both sides of the brain, with the exception of the parts of the facial nerve that control muscles of the lower face. These muscles are only innervated by nerves from the contralateral (opposite) side of the cortex." }, { "id": "InternalMed_Harrison_1859", "title": "InternalMed_Harrison", "score": 0.0107992607992608, "content": "Hemiparesis Hemiparesis results from an upper motor neuron lesion above the midcervical spinal cord; most such lesions are above the foramen magnum. The presence of other neurologic deficits helps localize the lesion. Thus, language disorders, for example, point to a cortical lesion. Homonymous visual field defects reflect either a cortical or a subcortical hemispheric lesion. A “pure motor” hemiparesis of the face, arm, and leg often is due to a small, discrete lesion in the posterior limb of the internal capsule, cerebral peduncle, or upper pons. Some brainstem lesions produce “crossed paralyses,” consisting of ipsilateral cranial nerve signs and contralateral hemiparesis (Chap. 446). The absence of cranial nerve signs or facial weakness suggests that a hemiparesis is due to a lesion in the high cervical spinal cord, especially if associated with the Brown-Séquard syndrome (Chap. 456)." }, { "id": "wiki20220301en275_22660", "title": "Primary motor cortex", "score": 0.010564435564435565, "content": "Clinical significance Lesions of the precentral gyrus result in paralysis of the contralateral side of the body (facial palsy, arm-/leg monoparesis, hemiparesis) - see upper motor neuron. Movement coding Evarts suggested that each neuron in the motor cortex contributes to the force in a muscle. As the neuron becomes active, it sends a signal to the spinal cord, the signal is relayed to a motorneuron, the motorneuron sends a signal to a muscle, and the muscle contracts. The more activity in the motor cortex neuron, the more muscle force." }, { "id": "Neurology_Adams_2223", "title": "Neurology_Adams", "score": 0.010474579002497784, "content": "Zee DS, Hain TC, Carl JR: Abduction nystagmus in internuclear ophthalmoplegia. Ann Neurol 21:383, 1987. Figure 13-1. The supranuclear pathways subserving horizontal gaze to the left. The pathway originates in the right frontal cortex, descends in the internal capsule, decussates at the level of the rostral pons, and descends to synapse in the left pontine paramedian reticular formation (PPRF). Further connections with the ipsilateral sixth nerve nucleus and contralateral medial longitudinal fasciculus are also indicated. The right MLF (green line) is labeled between the abducens and oculomotor nuclei and the vestibular nuclei (VN) are shown on the right. LR, lateral rectus; MLF, medial longitudinal fasciculus; MR, medial rectus." }, { "id": "article-30800_4", "title": "Neuroanatomy, Upper Motor Neuron Lesion -- Structure and Function", "score": 0.010403670888752617, "content": "Knowledge about the pathways of the pyramidal tracts is paramount to understanding the clinical presentation of UMN lesions. Lesions above or below the pyramidal decussation will have symptoms on different parts of the body. UMN lesions rostral to the pyramidal decussation will result in symptoms contralateral to the site of the lesion. For example, a unilateral lesion on the right corticospinal tract before the pyramidal decussation would cause weakness and spasticity of musculature on the left side of the body.  UMN lesions caudal to the decussation will cause symptoms ipsilateral to the site of the lesion. This presentation would generally be with lesions to the spinal cord. For example, left-sided lesions of the corticospinal tract in the spinal cord will cause left-sided weakness and spasticity. Unilateral UMN lesions innervating cranial nerves do not manifest with clinically significant symptoms due to their bilateral innervation from the left and right motor areas. Hence, only bilateral lesions to the UMN of cranial nerves would create deficits. Lesions of UMN’s to CN VII and XII are the exceptions because of their unilateral innervation from contralateral motor areas. For example, a right-sided UMN lesion to the motor area that controls CN VII would manifest as a weakness on the left lower face. [5]" }, { "id": "article-40985_6", "title": "How to Localize Neurologic Lesions by Physical Examination -- Function", "score": 0.010357667295993286, "content": "Descending fibers of the corticospinal tract travel from the cerebral cortex to corona radiata, posterior limb of the internal capsule, cerebral peduncles, pons, and medulla. At the lower part of the medulla, most of these fibers cross the midline, continue as the lateral corticospinal tract and descend through the white matter of the cord to innervate the anterior horn cells. This crossing over of corticospinal tract fibers is called pyramidal decussation.  Resultantly, pyramidal cells of the right cerebral cortex innervate left spinal motor nuclei and vice versa. Spinal motor nuclei innervating skeletal muscles of upper and lower limbs receive upper motor neuron innervation only from the contralateral side. Lower motor neurons of cranial nerves, on the other hand, are innervated by corticobulbar fibers from both sides. Therefore despite damage to corticobulbar fibers on one side, cranial motor nuclei will continue to receive upper motor supply from the other side. The nucleus of the facial nerve, however, can be considered a hybrid. Like other cranial motor nuclei, the upper half of the facial nucleus receives bilateral upper motor neuron innervation. On the other hand, the lower half receives innervation only from the contralateral side." }, { "id": "wiki20220301en406_24617", "title": "Alternating hemiplegia", "score": 0.010227504590899817, "content": "Symptoms and signs Superior alternating hemiplegia Superior alternating hemiplegia (also known as Weber syndrome) has a few distinct symptoms: contralateral hemiparesis of limb and facial muscle accompanied by weakness in one or more muscles that control eye movement on the same side. Another symptom that appears is the loss of eye movement due to damage to the oculomotor nerve fibers. The upper and lower extremities have increased weakness. Middle alternating hemiplegia Middle alternating hemiplegia (also known as Foville Syndrome) typically constitutes weakness of the extremities accompanied by paralysis of the extraocular muscle specifically lateral rectus, on the opposite side of the affected extremities, which indicates a lesion in the caudal and medial pons involving the abducens nerve root (controls movement of the eye) and corticospinal fibers (carries motor commands from the brain to the spinal cord)." }, { "id": "article-30800_3", "title": "Neuroanatomy, Upper Motor Neuron Lesion -- Structure and Function", "score": 0.010202918376652987, "content": "The corticobulbar tract fibers originate from the parts of the motor cortex that represent the face. The axons share a similar trajectory to the corticospinal tract descending through the corona radiata and the internal capsule. At the level of the brainstem, the axons will synapse with each cranial nerve nuclei at their respective levels. The upper motor neuron innervation of most cranial nerves is bilateral which means that each cranial nerve receives impulses from the left and right hemisphere. This bilateral innervation pertains to the muscles of the eyes, jaw, pharynx, upper face, larynx, and neck. Two exceptions to this rule are CN VII and XII. The control of tongue protrusion by CN XII and the control of the muscles of the lower face by CN VII only receive contralateral innervation from the pyramidal tract. [4]" }, { "id": "InternalMed_Harrison_30041", "title": "InternalMed_Harrison", "score": 0.009900990099009901, "content": "On side opposite lesion Paralysis of face, arm, and leg: Corticobulbar and corticospinal tract Variable impaired touch and proprioception when lesion extends posteriorly: Medial lemniscus 2. On side of lesion Ataxia of limbs: Middle cerebellar peduncle Paralysis of muscles of mastication: Motor fibers or nucleus of fifth nerve Impaired sensation over side of face: Sensory fibers or nucleus of fifth nerve On side opposite lesion Impaired pain and thermal sense on limbs and trunk: Spinothalamic tract the lateral two-thirds of the pons and middle and superior cerebellar peduncles; and (3) bilateral long circumferential (superior cerebellar and anterior inferior cerebellar arteries), which course around the pons to supply the cerebellar hemispheres." }, { "id": "pubmed23n0063_7190", "title": "[Analysis of hemiparesis with homolateral ataxia by single photon emission CT].", "score": 0.00980392156862745, "content": "Case 1. A 46-year-old man suddenly developed mild gait disturbance and left hemiparesis. On examination, gross strength was slightly reduced in the left extremities. The finger-to-nose and heel-to-knee tests disclosed moderate dyssynergia and dysmetria on the left side that could not be explained by the muscular weakness. Deep tendon reflexes were more brisk in the left extremities. There was no Babinski sign. Magnetic resonance imaging showed a region of high signal intensity in the right posterior limb of internal capsule with extension into lateral thalamus. The lesion involved the cortico-ponto-cerebellar pathway and partly the dentato-rubro-thalamo-cortical pathway. No lesions were seen in the brainstem. Single photon emission CT with 123I-IMP showed left cerebellar hypoperfusion termed crossed cerebellar diaschisis by Baron et al. Case 2. A 65-year-old female developed weakness of the left extremities and gait disturbance. On examination, there was a horizontal nystagmus on lateral gaze to each side. She showed dysarthria, mild left hemiparesis and slight left hypesthesia. The finger-nose and heel-knees tests revealed moderate dysmetria and dyssynergia on the left side. Deep tendon reflexes were hyperactive in the left extremities with left Babinski sign. CT showed a low density area in the right basis pontis at about middle level. Intravenous digital subtraction angiography revealed a slight stenosis of right vertebral artery, but no other abnormality. The lesion involved the cortico-ponto-cerebellar pathway. Single photon emission CT with 123I-IMP showed left cerebellar hypoperfusion. The right cerebellar blood flow was normal.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0400_2286", "title": "Distribution and course of cortico-respiratory projections for voluntary activation in man. A transcranial magnetic stimulation study in healthy subjects and patients with cerebral ischemia.", "score": 0.009615384615384616, "content": "The function and course of the cortico-respiratory projections in man are not yet well established. In 30 normal volunteers respiratory muscles were activated by magnetic stimulation of the motor cortex and the cervical and thoracic spinal roots with bilateral recordings from the respiratory muscles. Following cortical stimulation contralateral responses were obtained in all subjects during voluntary inspiration showing a mean latency and amplitude of 13.4+/-1.4ms/1.6+/-1.2 mV (stimulation of the left hemisphere) and 13.2+/-1.3ms/2.5+/-2.5 mV (stimulation of the right hemisphere). Ipsilateral responses were obtained in only 18 (right side) and 21 (left side) subjects and had a significantly (p &lt; 0.001) longer mean latency and lower mean amplitude than the contralateral responses. In 31 patients with impairment of the cortico-respiratory projections due to cerebral infarction demonstrated by magnetic resonance imaging studies, the responsible lesion topography was analysed. We found that, 1. the voluntary activation of respiratory muscles is mediated predominantly by the contralateral motor cortex, 2. the descending cortico-respiratory projections are located within the pyramidal tract, and 3. the cortico-respiratory projections to the respiratory muscles are frequently affected in patients with hemiparesis due to acute stroke. These findings might explain the increased incidence of pneumonia at the hemiparetic side in patients with cerebral ischemia as shown in previous studies." }, { "id": "article-20041_2", "title": "Corticospinal Tract Lesion -- Introduction", "score": 0.009572253342776813, "content": "The corticospinal tract controls primary motor activity for the somatic motor system from the neck to the feet. It is the major spinal pathway involved in voluntary movements. The tract begins in the primary motor cortex, where the soma of pyramidal neurons are located within cortical layer V. Axons for these neurons travel in bundles through the internal capsule, cerebral peduncles, and ventral pons. They stay in the ventral position within the medulla as the pyramids. A majority of the axons cross the midline at the pyramidal decussation between the brainstem and spinal cord to form the lateral corticospinal tract (Figure 1A). This crossover causes the left side of the brain to control the right side of the spinal cord and the right side of the brain to control the left side of the spinal cord. A small number of axons remain on the ipsilateral side to form the anterior corticospinal tract. Axons of both anterior and lateral corticospinal tracts move into the gray matter of the ventral horn to synapse onto lower motor neurons. These lower motor neurons exit the spinal cord to contract muscle. [1] While the anterior corticospinal tract assists with axial muscle motor control, the lateral corticospinal tract is the primary pathway for motor information to the body. Injuries to the lateral corticospinal tract results in ipsilateral paralysis (inability to move), paresis (decreased motor strength), and hypertonia (increased tone) for muscles innervated caudal to the level of injury. [2] The lateral corticospinal tract can suffer damage in a variety of ways. The most common types of injury are central cord syndrome, Brown-Sequard syndrome, and anterior spinal cord syndrome." }, { "id": "Neurology_Adams_6329", "title": "Neurology_Adams", "score": 0.009529481834425254, "content": "Distinguishing capsular from pontine hemiplegia It is often not possible to distinguish a hemiplegia of pontine origin from one of deep cerebral origin unless there is an associated cranial nerve palsy to triangulate the lesion to a specific part of the brainstem. In both, the face, arm, hand, leg, and foot are affected because of the location of the descending motor fibers into a small segmental region in both structures. With brainstem lesions, as with cerebral ones, a flaccid paralysis gives way to spasticity after a few days or weeks, and there is no satisfactory explanation for the occurrence in some cases of spasticity from the onset of the stroke. There is also may be a combined hemiparesis and ataxia of the limbs on the same side. With a hemiplegia of pontine origin, however, the eyes may deviate to the side of the paralysis, that is, the opposite of what occurs with supratentorial lesions. The pattern of sensory disturbance may also be helpful. A dissociated sensory deficit" }, { "id": "pubmed23n0056_17750", "title": "Structure-function relationships in rat brain stem subnucleus interpolaris. VIII. Cortical inputs.", "score": 0.009523809523809525, "content": "1. Spinal trigeminal (SpV) subnucleus interpolaris (SpVi) receives inputs from trigeminal (V) first- and second-order neurons, monoamine-containing brain stem nuclei, and somatosensory cortex. Prior studies suggest that SpVi receptive-field (RF) properties cannot be predicted solely on the basis of primary afferent inputs. To assess the cortico-V projection and its role in SpVi RFs, anatomic and electrophysiological experiments were conducted. 2. Phaseolus vulgaris leucoagglutinin (PHA-L) or wheat-germ-agglutinized horseradish peroxidase (WGA-HRP) were used as anterograde tracers to study cortico-V axons in 24 normal adult rats. Injections into SI barrel cortex-labeled pyramidal fibers that decussated at all levels of the V brain stem complex, though crossing fibers were most numerous in the pyramidal decussation and pons. A small number of axons projected to ipsilateral V brain stem subnuclei. PHA-L-labeled pyramidal fibers did not give rise to collaterals in their descent through the pons and medulla. 3. Heaviest terminal labeling occurred contralaterally and in the maxillary portion of caudalis laminae III-V. Moderately dense reaction product was seen in ventral portions of all other contralateral V brain stem subnuclei, as well as in laminae I and II of caudalis. Subnucleus oralis contained the least amount of label contralateral to the injection site. Ipsilateral projections were weak and most dense in principalis. 4. Cortico-V projections were topographic between matching whisker representations. Axons most commonly had longitudinal orientations and stringy shapes. Terminal boutons occurred at the ends of short collateral branches. Many of these collaterals were derived from axons that ascended through caudal V brian stem subnuclei after crossing in the lower medulla. 5. Cortico-V labeling was heavier in septal regions between single whisker representations. This \"honeycomb-like\" termination pattern was most pronounced in contralateral caudalis and SpVi and ipsilateral principalis. 6. In 13 other adult rats, right SI cortex was aspirated followed by single-unit recordings in left SpVi under pentobarbital sodium anesthesia. In 9 of these, chronic effects were evaluated by recording the responses of 346 left SpVi cells 4-55 days after the lesion. In the remaining four rats, acute effects were analyzed by recording the responses of 190 SpVi cells on the day of the lesion.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "wiki20220301en100_19999", "title": "Lateral corticospinal tract", "score": 0.009433962264150943, "content": "Damage to different parts of the body will cause deficits, depending on whether the damage is above (rostral) or below (caudal) the pyramidal decussation. Damage to the body above the pyramidal decussation will cause contralateral motor deficits. For example, if there is a lesion at the pre-central gyrus in the right cerebral cortex, then the left side of the body will be affected. Whereas damage below the pyramidal decussation will result in ipsilateral motor deficits. For example, spinal cord damage on the left side of the lateral corticospinal tract at the thoracic level can cause motor deficits to the left side of the body. Clinical significance" }, { "id": "Neurology_Adams_2910", "title": "Neurology_Adams", "score": 0.009433962264150943, "content": "Decorticate posturing, usually, with arm or arms in flexion and adduction and leg(s) extended, signifies lesions at a more rostral level of the nervous system—in the cerebral white matter or internal capsule and thalamus. Bilateral decorticate rigidity is essentially a bilateral spastic hemiplegia. Diagonal postures, for example, flexion of one arm and extension of the opposite arm and leg, usually indicate a supratentorial lesion. Forceful extensor postures of the arms and weak flexor responses of the legs are usually seen with lesions at about the level of the vestibular nuclei. Lesions below this level lead to flaccidity and abolition of all postures and movements. If preceded by decorticate or decerebrate postures, the coma is profound and usually progresses to brain death." }, { "id": "article-36151_26", "title": "Neuroanatomy, Facial Colliculus -- Clinical Significance -- One-and-a-Half Syndrome", "score": 0.00937242975459536, "content": "If a lesion in the dorsal pontine tegmentum is more extensive than the size of the CN VI nucleus and damages both the ipsilateral abducens nucleus and MLF, then the ipsilateral lateral rectus muscle and bilateral medial rectus muscles will be impaired. From the ipsilateral CN VI nucleus, CN VI fibers arise and travel to the ipsilateral lateral rectus muscle. In contrast, the interneuron fibers arising from the ipsilateral nucleus cross the midline and project through the contralateral MLF and synapse to the contralateral CN III nucleus. The ipsilateral MLF, to which the contralateral CN VI fibers project, is responsible for the synapse on the ipsilateral CN III nucleus, which innervates the ipsilateral medial rectus muscle. For example, when the lesion affects both the right CN VI nucleus and MLF fibers, the right lateral rectus and left medial rectus muscles associated with the right CN VI fibers will be impaired. The right medial rectus muscle, which is innervated by the right CN III that can no longer receive signals from the right damaged MLF, will also be impaired. As a result, when the examiner asks a patient to look to the right, the patient will seem to be looking straight ahead. When instructing a patient to look to the left, the patient’s left eye will look to the side, whereas the right eye cannot move to the left and look straight ahead." }, { "id": "wiki20220301en033_62876", "title": "Myelopathy", "score": 0.009345794392523364, "content": "Presentation Clinical signs and symptoms depend on which spinal cord level (cervical, thoracic, or lumbar) is affected and the extent (anterior, posterior, or lateral) of the pathology, and may include: Upper motor neuron signs—weakness, spasticity, clumsiness, altered tonus, hyperreflexia and pathological reflexes, including Hoffmann's sign and inverted plantar reflex (positive Babinski sign) Lower motor neuron signs—weakness, clumsiness in the muscle group innervated at the level of spinal cord compromise, muscle atrophy, hyporeflexia, muscle hypotonicity or flaccidity, fasciculations Sensory deficits Bowel/bladder symptoms and sexual dysfunction Diagnosis" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 152 ] ], "word_ranges": [ [ 0, 24 ] ], "text": "Overuse of the drugs he is taking should be suspected. Olanzapine has no antidote, so, in principle, we should antagonize the effect of benzodiazepines." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Proceed to IOT.", "2": "Perform a skull X-ray.", "3": "Administer flumazenil.", "4": "Administer naloxone.", "5": "Wait until he wakes up." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en191_25038", "title": "Post-acute-withdrawal syndrome", "score": 0.01265167209233501, "content": "Treatment The condition gradually improves over a period of time which can range from six months to several years in more severe cases. People with longer term and heavier substance use have caused damage to the nervous system, where, after cessation of the primary addictive substance, the opioid receptors may become favorable to any potential agonist. This places people with longer term and heavier substance use at risk of becoming addicted to any other agonist with very little use of the secondary agonist. Abstinence from all agonists, sometimes taking multiple years, is required for full recovery. Flumazenil was found to be more effective than placebo in reducing feelings of hostility and aggression in patients who had been free of benzodiazepines for 4 to 266 weeks. This may suggest a role for flumazenil in treating protracted benzodiazepine withdrawal symptoms." }, { "id": "pubmed23n0284_2655", "title": "[Electrophysiologic tests and benzodiazepine hypnosis].", "score": 0.012317137876146442, "content": "The effects of a pure benzodiazepine antagonist (Flumazenil) on the responses R1 and R2 of the blink reflex, psychomotor tests, and Event Related Potentials (ERP), in six healthy volunteers sedated with Midazolam have been compared. Measurements were made during each of four successive phases. Phase 0 corresponded to control recordings. Midazolam was administered rapidly during phase 1 and slowly during phase 2. Phase 3 corresponded to spontaneous waking once the administration of Midazolam had been stopped. Flumazenil was administered during phase 2. As the subjects fell asleep, R1 and R2 were the last parameters to disappear. Under the influence of Flumazenil, R1 was the first to reappear, while R2 did not recur until complete waking, and the other tests were unpracticable. During phase 3, R1 reappeared before R2 once more, the psychomotor test responses and ERP returning only later. The modifications of both R1 and R2 of the blink reflex are a good criterion of the presence of BZD in a toxic coma and a good test to indicate the depth of a coma or a sedation with BZD, whilst ERP, since they require the cooperation of the patient, are a test of vigilance and not of awakening." }, { "id": "pubmed23n0414_11905", "title": "[Catatonia de novo, report on a case: immediate vital prognosis and psychiatric prognosis in longer term].", "score": 0.011173533083645444, "content": "We report on the case of a 20 year old woman with no previous psychiatric history, who displayed a first episode of catatonia with acute onset. Symptoms started plainly with sudden general impairment, intense asthenia, headache, abdominal pain and confusion. After 48 hours, the patient was first admitted to an emergency unit and transferred to an internal medicine ward afterwards. She kept confused. Her behaviour was bizarre with permanent swinging of pelvis, mannerism, answers off the point and increasingly poor. The general clinical examination was normal, except for the presence of a regular tachycardia (120 bpm). The paraclinical investigations also showed normal: biology, EEG, CT Scan, lumbar puncture. Confusion persisted. The patient remained stuporous, with fixed gazing and listening-like attitudes. She managed to eat and move with the help of nurses but remained bedridden. The neurological examination showed hypokinaesia, extended hypotonia, sweating, urinary incontinence, bilateral sharp reflexes with no Babinski's sign and an inexhaustible nasoorbicular reflex. The patient was mute and contrary, actively closed her eyes, but responded occasionally to simple instructions. For short moments, she suddenly engaged in inappropriate behaviors (wandering around) while connecting back to her environment answering the telephone and talking to her parents. The patient's temperature rose twice in the first days but with no specific etiology found. During the first 8 days of hospitalization, an antipsychotic treatment was administered: haloperidol 10 mg per os daily and cyamemazine 37.5 mg i.m. daily. Despite these medications, the patient worsened and was transferred to our psychiatric unit in order to manage this catatonic picture with rapid onset for which no organic etiology was found. On admission, the patient was stuporous, immobile, unresponsive to any instruction, with catalepsy, maintenance of postures, severe negativism and refusal to eat. A first treatment by benzodiazepine (clorazepate 20 mg i.v.) did not lead to any improvement. The organic investigations were completed with cerebral MRI and the ruling out of a Wilson's disease. Convulsive therapy was then decided. It proved dramatically effective from the first attempt; 4 shocks were carried out before the patient's relatives ask for her discharge from hospital. The patient revealed she had experienced low delirium during her catatonic state. The clinical picture that followed showed retardation with anxiety. She was scared with fear both for the other patients and the nursing team. She kept distant and expressed few affects. The treatment at the time of discharge was olanzapine 10 mg per os. She was discharged with a diagnosis of catatonia but with no specific psychiatric etiological diagnosis associated. She discontinued her follow-up a few weeks later. After one year, we had no information about her. Catatonia has now become rare but remains a problem for clinicians. We reviewed data concerning short term vital prognosis and psychiatric long term prognosis in catatonia. Lethal catatonia is associated with acute onset, both marked psychomotor and neurovegetative symptoms. In the light of literature, there is no proband clinical criterion during the episode that is of relevant diagnostic value to ascertain the psychiatric etiology." }, { "id": "Neurology_Adams_9671", "title": "Neurology_Adams", "score": 0.010070694944644524, "content": "Signs of physical dependence and true addiction, although relatively rare, undoubtedly occur in chronic benzodiazepine users, even in those taking therapeutic doses. The withdrawal symptoms are much the same as those that follow the chronic use of other sedative drugs (anxiety, jitteriness, insomnia, seizures) but may not appear until the third day after the cessation of the drug and may not reach their peak of severity until the fifth day (Hollister, 1990). In chronic benzodiazepine users, the gradual tapering of dosage over a period of 1 to 2 weeks minimizes the withdrawal effects. However, we have observed numerous cases over the years in which the cessation of moderate doses of chronically used diazepines has resulted in one or more seizures. This is likely to happen when the patient is hospitalized for other reasons and the accustomed sleeping or anxiolytic medication is omitted." }, { "id": "pubmed23n1165_14784", "title": "Coma, Severe Hypotension, and Pinpoint Pupils After Olanzapine Intoxication in the Intensive Care Unit with Symptom Reversal After Administration of Flumazenil.", "score": 0.009900990099009901, "content": "BACKGROUND Olanzapine is an antipsychotic drug and is used in critical care to treat delirium. There is no known antidote to olanzapine intoxication. Overdosing olanzapine can cause, tremor, bradykinesia, hypotension somnolence, coma, and miosis. CASE REPORT We present the case of a previously healthy 69-year-old man who after routine mitral valve surgery developed pneumonia and severe sepsis requiring several weeks on a ventilator in the Intensive Care Unit. He developed delirium and paranoia and was prescribed olanzapine. After 4 doses, he became hypotensive and nonresponsive and developed pinpoint pupils. The symptoms were reversed minutes after administration of flumazenil. The clinical picture in this case corresponds well with an olanzapine intoxication. No other drugs, such as benzodiazepines or opioids, had been administered that could explain the reaction. Olanzapine intoxication is known to present with hypotension, coma, and miosis. The doses given were normal starting doses for olanzapine in the outpatient setting but much higher than recommended doses in the intensive care setting. CONCLUSIONS This case illustrates a risk for severe adverse effects, even within normal prescription range, when olanzapine is used in the intensive care setting. Finally, it is intriguing that the symptoms were reversed after administration of flumazenil, a selective competitive antagonist of the GABA receptor. Olanzapine mainly effects dopamine, serotonin, a1-adrenergic, histamine, and muscarinic receptors, but a low affinity to GABA and benzodiazepine sites can perhaps explain the observed effect." }, { "id": "pubmed23n0036_7665", "title": "[Sulpiride and drug addiction].", "score": 0.009900990099009901, "content": "The authors carried on their study as presented in Tunis Congress of Psychiatry and Neurology. The results of the administration of Sulpiride with drug-addicts are still difficult to evaluate, because none of the patients are hospitalized and there is no possibility to know the precise doses absorbed by the patients. An improvement is however obvious with patients who spontaneously come to ask for more. They generally present polytoxicomania and use haschisch, opium-derivatives, amphetamines and usually L.S.D. Two recent observations summarize the action of Sulpiride: 1. --A fit of acute depersonnalisation in a young lady was suppressed within eight days with the administration of 1 g p.o. of Sulpiride a day. Recovery without relapse. 2. --An old drug-addict would shoot himself i.v. with at least 1 g of Sulpiride whenever he wanted to stop his intoxication periods. He did not feel any \"flash\" but only could thus obtain a \"soft\" withdrawal without need syndrome. Neither dependence, nor serious side-effects were observed." }, { "id": "wiki20220301en258_12063", "title": "Coma cocktail", "score": 0.00980392156862745, "content": "A coma cocktail is a combination of substances administered in an emergency to comatose individuals when the cause of the coma has not yet been determined. The intention is to work against various causes of a coma seen in an emergency setting including drug overdoses and hypoglycemia. A standard combination included dextrose (1 Amp D50W IV), flumazenil (0.2 mg IV), naloxone (2 mg IV), and thiamine (100 mg IV). It has been suggested that the use of naloxone and flumazenil be administered more selectively than glucose and thiamine. Some have proposed that the concept be abandoned completely because modern EMS providers should be able to determine the likely etiology of the change in mental status. At a minimum, the clinical presentation of the patient should rule in or out some portions of the coma cocktail. For example, with the advent and widespread implementation of glucometers, the indications for administering glucose can be more narrowly defined and its use more regimented." }, { "id": "pubmed23n0126_2947", "title": "Schneiderian first-rank symptoms caused by benzodiazepine withdrawal.", "score": 0.00980392156862745, "content": "Benzodiazepine withdrawal has been found to give rise to numerous physical and psychological symptoms. This paper describes, for the first time, Schneiderian first-rank symptoms of schizophrenia caused by such withdrawal." }, { "id": "wiki20220301en069_15245", "title": "Central nervous system depression", "score": 0.009708737864077669, "content": "There are two antidotes that are frequently used in the hospital setting and these are naloxone and flumazenil. Naloxone is an opioid antagonist and reverses the central nervous depressive effects seen in opioid overdose. In the setting of a colonoscopy, naloxone is rarely administered but when it is administered, its half-life is shorter than some common opioid agonists. Therefore, the patient may still exhibit central nervous system depression after the naloxone has been cleared. Naloxone is typically administered in short intervals with relatively small doses in order to prevent the occurrence of withdrawal, pain, and sympathetic nervous system activation. Flumazenil is a benzodiazepine antagonist and blocks the binding of benzodiazepines to gamma-aminobutyric acid receptors. Similarly to naloxone, flumazenil has a short half-life, and this needs to be taken into account because the patient may exhibit central nervous depression after the antidote has been cleared. Benzodiazepines" }, { "id": "pubmed23n0495_8799", "title": "[The use of olanzapine in sleep disorders. An open trial with nine patients].", "score": 0.009708737864077669, "content": "The impossibility of treating patients with sleep disorders adequately means that, as specialists, we have to look for new pharmacological treatments and for this reason we examined the information in the paper by Salin Pascual (1999) about the increase in deep sleep when olanzapine is used as an antipsychotic drug. We decided to use this medication in six females and three males who were suffering from different sleep disorders that conditioned their chronic insomnia. The dosages of olanzapine used ranged from 2.5 and 10 mg in a single dose. The clinical history and progress were used to elaborate the results and conclusions. The result was positive in eight of the nine patients, five who were administered the medication as monotherapy and three as polytherapy. The population studied is insufficient to prove the effectiveness of the drug, but the fact that in eight of our patients the treatment clearly improved their symptoms leads us to think that this line of research must be continued." }, { "id": "pubmed23n0319_1886", "title": "Profound increase in epinephrine concentration in plasma and cardiovascular stimulation after mu-opioid receptor blockade in opioid-addicted patients during barbiturate-induced anesthesia for acute detoxification.", "score": 0.009615384615384616, "content": "Acute displacement of opioids from their receptors by administration of large doses of opioid antagonists during general anesthesia is a new approach for detoxification of patients addicted to opioids. The authors tested the hypothesis that mu-opioid receptor blockade by naloxone induces cardiovascular stimulation mediated by the sympathoadrenal system. Heart rate, cardiac index, and intravascular pressures were measured in 10 patients addicted to opioids (drug history; mean +/- SD, 71 +/- 51 months) during a program of methadone substitution (96 +/- 57 mg/day). Cardiovascular variables and concentrations of catecholamine in plasma were measured in the awake state, during methohexital-induced anesthesia (dose, 74 +/- 44 microg x kg(-1) x min(-1)) before administration of naloxone, and repeatedly during the first 3 h of mu-opioid receptor blockade. Naloxone was administered initially in an intravenous dose of 0.4 mg, followed by incremental bolus doses (0.8, 1.6, 3.2, and 6.4 mg) at 15-min intervals until a total dose of 12.4 mg had been administered within 60 min; administration was then continued by infusion (0.8 mg/h). Concentration of epinephrine in plasma increased 30-fold (15 +/- 9 to 458 +/- 304 pg/ml), whereas concentration of norepinephrine in plasma only increased to a minor extent (76 +/- 44 to 226 +/- 58 pg/ml, P &lt; 0.05). Cardiac index increased by 74% (2.7 +/- 0.41 to 4.7 +/- 1.7 min(-1) x m(-2)), because of increases in heart rate (89 +/- 16 to 108 +/- 17 beats/min) and stroke volume (+44%), reaching maximum 45 min after the initial injection of naloxone. In parallel, systemic vascular resistance index decreased (-40%). Systolic arterial pressure significantly increased (113 +/- 16 to 138 +/- 16 mmHg), whereas diastolic arterial pressure did not change. Despite barbiturate-induced anesthesia, acute mu-opioid receptor blockade in patients addicted to opioids induces profound epinephrine release and cardiovascular stimulation. These data suggest that long-term opioid receptor stimulation changes sympathoadrenal and cardiovascular function, which is acutely unmasked by mu-opioid receptor blockade. Because of the attendant cardiovascular stimulation, acute detoxification using naloxone should be performed by trained anesthesiologists or intensivists." }, { "id": "pubmed23n0274_21871", "title": "[Flumazenil, a benzodiazepine antagonist, in endoscopic premedication].", "score": 0.009615384615384616, "content": "Midazolam is the benzodiazepine recommended for anaesthesia induction when an early recovering is desirable. Flumazenil, which is also a hydrosoluble imidazobenzodiazepine, improves the safety of the forhere one because it immediately reduces the degree of sedation. With this purpose, this last drug has been studied in 25 patients who had been previously treated with Midazolam in order to carry out different endoscopic studies. The Flumazenil average dose used was 0.276 mg and the conscience recovering after its intravenous injection, evaluated by a simple oral numeric regression test, oscillated between 60 and 300 seconds with an X of 96 seconds. Once the study was finished, all patients were discharged from hospital after two-hour observation, except for one patient (4%) who suffered a complication and so was discharged after a twenty-four-hour control. No doubt the advent of a drug opposed to benzodiazepine receptors used in anaesthetic induction shows the possibility of a quick recovering and moreover. Quicker discharge from hospital." }, { "id": "wiki20220301en053_44285", "title": "Nonbenzodiazepine", "score": 0.009523809523809525, "content": "The Z-drug zaleplon may have fewer side effects compared to benzodiazepines. Dependence and withdrawal management Nonbenzodiazepines should not be discontinued abruptly if taken for more than a few weeks due to the risk of rebound withdrawal effects and acute withdrawal reactions, which may resemble those seen during benzodiazepine withdrawal. Treatment usually entails gradually reducing the dosage over a period of weeks or several months depending on the individual, dosage, and length of time the drug has been taken. If this approach fails, a crossover to a benzodiazepine equivalent dose of a long-acting benzodiazepine (such as chlordiazepoxide or more preferably diazepam) can be tried followed by a gradual reduction in dosage. In extreme cases and, in particular, where severe addiction and/or abuse is manifested, an inpatient detoxification may be required, with flumazenil as a possible detoxification tool." }, { "id": "pubmed23n0823_20973", "title": "\"First Things First\": What is the First Thing?", "score": 0.009523809523809525, "content": "This op-ed piece comments on the down-side of an otherwise useful 12-step slogan, \"First Things First,\" which generally refers to staying sober (not drinking or using no matter what). While important, there are environmental, microsocial, psychiatric, and neurobiological considerations that may place other needs at an equal or higher priority than sobriety per se. That is, other changes may be needed to set the stage for, or enhance efforts at sobriety, prior to or concurrent with attempting to quit one's drug of choice. Perhaps slogans should be considered in a broader context and not be taken too literally. " }, { "id": "pubmed23n0579_3423", "title": "Dextromethorphan poisoning: an evidence-based consensus guideline for out-of-hospital management.", "score": 0.009433962264150943, "content": "The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected ingestion of dextromethorphan by 1) describing the process by which an ingestion of dextromethorphan might be managed, 2) identifying the key decision elements in managing cases of dextromethorphan ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to the ingestion of dextromethorphan alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) Patients who exhibit more than mild effects (e.g., infrequent vomiting or somnolence [lightly sedated and arousable with speaking voice or light touch]) after an acute dextromethorphan ingestion should be referred to an emergency department (Grade C). 3) Patients who have ingested 5-7.5 mg/kg should receive poison center-initiated follow-up approximately every 2 hours for up to 4 hours after ingestion. Refer to an emergency department if more than mild symptoms develop (Grade D). 4) Patients who have ingested more than 7.5 mg/kg should be referred to an emergency department for evaluation (Grade C). 5) If the patient is taking other medications likely to interact with dextromethorphan and cause serotonin syndrome, such as monoamine oxidase inhibitors or selective serotonin reuptake inhibitors, poison center-initiated follow-up every 2 hours for 8 hours is recommended (Grade D). 6) Patients who are asymptomatic and more than 4 hours have elapsed since the time of ingestion can be observed at home (Grade C). 7) Do not induce emesis (Grade D). 8) Do not use activated charcoal at home. Activated charcoal can be administered to asymptomatic patients who have ingested overdoses of dextromethorphan within the preceding hour. Its administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grade D). 9) For patients who have ingested dextromethorphan and are sedated or comatose, naloxone, in the usual doses for treatment of opioid overdose, can be considered for prehospital administration, particularly if the patient has respiratory depression (Grade C). 10) Use intravenous benzodiazepines for seizures and benzodiazepines and external cooling measures for hyperthermia (&gt;104 degrees F, &gt;40 degrees C) for serotonin syndrome. This should be done in consultation with and authorized by EMS medical direction, by a written treatment protocol or policy, or with direct medical oversight (Grade C). 11) Carefully ascertain by history whether other drugs, such as acetaminophen, were involved in the incident and assess the risk for toxicity or for a drug interaction." }, { "id": "wiki20220301en010_137684", "title": "Orbital (band)", "score": 0.009433962264150943, "content": "In late 1992, the Radiccio EP barely reached the UK top 40, although it included one of their most popular songs, \"Halcyon\". The track featured a sample of Kirsty Hawkshaw from \"It's a Fine Day\" (a chart hit for Opus III earlier that year). The B-side \"The Naked and the Dead\" was similarly based on a line from Scott Walker's rendition of Jacques Brel's song \"Next\". \"Halcyon\" was dedicated to the Hartnolls' mother, who was addicted to the tranquiliser Halcion (Triazolam) for many years." }, { "id": "article-21842_9", "title": "Flumazenil -- Administration -- Dosing: Adult", "score": 0.009392057218144175, "content": "FDA Dosage for management of benzodiazepine overdose The clinician should give the initial dosage of 0.2 mg IV for 30 seconds If the desired level of consciousness is not obtained after 30 seconds, the clinician can give an additional dose of 0.3 mg IV over 30 seconds May repeat doses of 0.5 mg IV over 30 seconds at 1-minute intervals to a maximum total cumulative dose of 3 mg Patients with partial response to 3 mg may require additional slow titration up to a total dose of 5 mg. If there is no response after administration of 5 mg, the primary cause of sedation is not benzodiazepine-related, and further treatment with Flumazenil will be ineffective. In reoccurrence, sedations repeat doses may be given at 20-minute intervals, not to exceed 1 mg (0.5 mg/minute) per dose or 3 mg/hour. FDA dosage for benzodiazepine reversal when used in conscious sedation or general anesthesia" }, { "id": "wiki20220301en115_9135", "title": "Chlordiazepoxide", "score": 0.009345794392523364, "content": "Chlordiazepoxide taken during pregnancy can cause a postnatal benzodiazepine withdrawal syndrome. Overdose An individual who has consumed excess chlordiazepoxide may display some of the following symptoms: Somnolence (difficulty staying awake) Mental confusion Hypotension Hypoventilation Impaired motor functions Impaired reflexes Impaired coordination Impaired balance Dizziness Muscle weakness Coma Chlordiazepoxide is a drug that is very frequently involved in drug intoxication, including overdose. Chlordiazepoxide overdose is considered a medical emergency and, in general, requires the immediate attention of medical personnel. The antidote for an overdose of chlordiazepoxide (or any other benzodiazepine) is flumazenil. Flumazenil should be given with caution as it may precipitate severe withdrawal symptoms in benzodiazepine-dependent individuals." }, { "id": "Neurology_Adams_9556", "title": "Neurology_Adams", "score": 0.009345794392523364, "content": "Most patients during withdrawal do not require antiepileptic drugs, as the entire episode of seizure activity—whether a single seizure or a brief flurry of seizures—may have terminated before the patient is brought to medical attention. The parenteral administration of diazepam or sodium phenobarbital early in the withdrawal period does, however, prevent withdrawal fits in patients with a previous history of this disorder, as well as in those who might be expected to develop seizures on withdrawal of alcohol. This approach has been supported by the observations of D’Onofrio and colleagues that intravenous lorazepam (2 mg in 2 mL of normal saline) was highly effective in preventing recurrent seizures after a first seizure in the same withdrawal period. Only 3 of 100 patients so treated had a second seizure within 48 h, compared to 21 of 86 untreated patients. The long-term administration of anticonvulsants is neither necessary nor practical: if such patients remain abstinent, they will" }, { "id": "wiki20220301en027_47850", "title": "Buprenorphine", "score": 0.009259259259259259, "content": "In the years before buprenorphine/naloxone was approved, Reckitt Benckiser had lobbied Congress to help craft the Drug Addiction Treatment Act of 2000, which gave authority to the Secretary of Health and Human Services to grant a waiver to physicians with certain training to prescribe and administer schedule III, IV, or V narcotic drugs for the treatment of addiction or detoxification. Before this law was passed, such treatment was permitted only in clinics designed specifically for drug addiction." }, { "id": "article-36911_8", "title": "Dose Calculation Desired Over Have Formula Method -- Technique or Treatment -- Dimensional Analysis Method", "score": 0.009259259259259259, "content": "An order placed by a provider for lorazepam 4 mg IV PUSH for CIWA score of 25 or higher, follow CAGE Protocol for subsequent dosages based on CIWA scoring. The clinician has 2 mg/mL vials in the automated dispensing unit. How many milliliters are needed to arrive at an ordered dose? The desired dose os placed over 1 remember, (x mL) = 4 mg/1 x 1 mL/2 mg x (4)(1)/2 x 4/2 x 2/1 = 2 mL, keep multiplying/dividing until the desired amount is reached, 2 mL in this example. Notice, the fraction was set up with milligrams and milligrams strategically placed, so units could cancel each other out, making the equation easier to solve for the unit desired or milliliters. The answer makes sense, so work is done. Zeros can be canceled out in the same way as like units. For example: 1000/500 x 10/5 = 2, the 2 zeros in 1000 and 2 zeros in 500 can be crossed out since like units in numerator and denominator, leaving 10/5, a much easier fraction to solve, and the answer makes sense." }, { "id": "pubmed23n1132_2325", "title": "Addiction of High Dose of Benzodiazepine: Verona Detox Approach With Flumazenil.", "score": 0.009174311926605505, "content": "Since the 1990s there has been evidence of the significant role Flumazenil (FLU) has in benzodiazepines (BZD) detoxes. The Verona Detox approach has been developed for high dose BZD and Z-drug detoxification via continuous subcutaneous infusion of FLU, a selective BZD receptor antagonist acting on the BZD subunit of the GABA-A receptor. Flumazenil is licensed in the United Kingdom and other countries to treat only BZD overdose although numerous studies have demonstrated its effectiveness in rapidly resetting GABA-A receptors, quickly reducing tolerance and dependence from BZD, and providing a safe and rapid detox from benzodiazepines. The aim of this article is to provide all healthcare professional who are interested in BZD detoxification with an approach and clear practical information on how to administer FLU. In this article we outline the approach in detail, describing all medical and nursing procedures day by day. This detox treatment is indicated for patients abusing from at least 5 Defined Daily Dose (DDD) of BZDs or Z-drugs. The process lasts 7 days, and is conducted under medical supervision (daily reviews) and continuous nursing (24/7). During this period, 7mg of FLU is administered (1 mg/24) through an elastomeric pump, via continuous subcutaneous infusion. To this day, the largest database of FLU detoxification was published by our group, showing how this treatment is safe, with very little side effects even in patients with significant medical comorbidities." }, { "id": "wiki20220301en577_29631", "title": "Four Good Days", "score": 0.009174311926605505, "content": "antagonist in order to help her on the road to sobriety. However, she must stay off any drugs for an additional four days before it is safe for her to receive the first shot, and then expect an additional shot each month." }, { "id": "pubmed23n0573_15264", "title": "[Prescription of olanzapine in children and adolescent psychiatric patients].", "score": 0.009126984126984128, "content": "A review of the literature from 1996-2004 on the indications and adverse reactions concerning the use of olanzapine, a second generation antipsychotic agent, in children and adolescents with psychiatric illness is made in this article. Studies lasted for 2 to 3 months and a few had a follow up period up to a year. Olanzapine, dosed from 2.5 to 20 mg/day, is shown to be a useful drug in the treatment of child and adolescent onset schizophrenia, bipolar disorder, anorexia nervosa with delusions, pervasive developmental disorder, tic disorders, and aggression. OPEN AND DOUBLE-BLIND STUDIES: In 4 open labeled studies (26, 34, 39, 43) and 2 case reports (25), 53 patients, aged from 6-18 years old, afflicted by child onset schizophrenia, were treated with olanzapine for 1 1/2 weeks to one year; 19 had treatment resistant childhood schizophrenia and 34 a first episode. In the first group 13/19 showed improvement whereas, in the second group 27/34 were considered responders. Four patients in the first group who had responded to clozapine (stopped because of adverse events) did less well on olanzapine. In 5 studies, 4 open labeled (15, 20, 44) and 1 double blind (27), 59 adolescent onset schizophrenic patients were treated by olanzapine from 8 to 26 weeks; 50/59 patients were considered responders. In the open label study (20) comparing 43 adolescents treated by olanzapine (19 patients), risperidone (17 patients), or haloperidol (7 patients), improvement was significant in the three groups after 4 weeks of treatment and continued after 8 weeks. It is most interesting to mention that 2 months after the end of the study 71% (12/17) of the olanzapine group that had completed the study, 10/15 (67%) of the risperidone group, and 43% (3/7) of the haloperidol group had continued their treatment. Dropouts were for inefficacy and non-compliance in the olanzapine and risperidone groups whereas they were also for adverse events in the haloperidol group (2/4). A final double blind study of 263 adult and adolescent schizophrenic patients (latter are not separated from the former) confirmed the superiority of olanzapine compared to haloperidol and its use for a long period: 67% of the olanzapine and 54% of the haloperidol patients completed the 12-week study. 12 case reports of children and adolescents diagnosed with acute mania (8, 25, 46, 47) and 23 in an open labeled study (16) were treated by olanzapine; 26/35 were considered to respond well. Some of the patients were on mood stabilizers before adjunction of olanzapine, others on olanzapine monotherapy; 10 case reports of patients with anorexia nervosa associated with psychotic symptomatology, aged from 10-17 years old, relate the use of olanzapine as adjuvant treatment. Improvement was spectacular in these patients who not only gained considerable weight, but were also more compliant to the therapeutic program and their obsessions, delusions, agitation and anxiety became less intense. In this form of anorexia nervosa, olanzapine appears to have an interesting therapeutic role and, in particular, its most important adverse effect, weight gain, became a therapeutic goal. In 2 preliminary studies (24, 30) 31 children and adolescents diagnosed with pervasive developmental disorder were treated by olanzapine from 6 to 13 weeks; 18/25 had good or moderate symptomatic improvement: they were less irritable and hyperactive, and their speech less excessive. In 17 case reports of children and adolescents with aggression (42, 45), associated with tics in 10 patients (49), treatment with olanzapine from 2 weeks to 10 months lowered the presenting symptoms, enhanced the cooperation, and improved the mood of the patients. Only one patient's treatment was changed for inefficacy. No matter what the disorder treated, when olanzapine was compared to haloperidol and risperidone, it proved to be as effective as risperidone, and as or more effective than haloperidol; but when compared to clozapine, it was less effective. The most prominent adverse reaction was excessive weight gain, even more so than in adult patients treated with olanzapine. Also weight gain was greater in children and adolescents treated by olanzapine than those treated by risperidone or haloperidol. Though few treatments had to be interrupted because of this side effect, child and adolescent psychiatrists are wary of the long-term disease related to obesity and glucose dysregulation. All should be done to under-stand the process of weight gain better and to prevent or stall excessive caloric intake, encourage activity, and eventually treat by corrector drugs. Secondly, sedation may bother up to 50% of patients even at the end of the study periods, as many as those treated by haloperidol and more than those treated by risperidone. Extrapyramidal symptoms were mild or moderate compared to those that appear with haloperidol, but may be more frequent than in adult patients. Liver enzymes and blood sugar may be slightly elevated. Prolactemia may be elevated but less so with risperidone and haloperidol. All the authors emphasized the unfortunate lack of randomized double blind studies for the use of olanzapine in this age group." }, { "id": "pubmed23n1121_20744", "title": "A Case of Phenibut Directed Detoxification Leading to Toxicity During the COVID-19 Pandemic.", "score": 0.00909090909090909, "content": "Phenibut is a non-Food and Drug Administration-approved gamma-aminobutyric acid analog marketed in the United States as an anxiolytic, cognitive enhancer, and alcohol withdrawal treatment through online supplement vendors. In this case report, we describe a woman's self-directed detoxification with phenibut used to manage withdrawal symptoms from fentanyl and benzodiazepines in March 2020 during the height of the COVID-19 pandemic. A 38-year-old woman with severe opioid, benzodiazepine, gabapentin, stimulant use disorders developed altered mental status after oral phenibut ingestion intended to help self-manage opioid and benzodiazepine withdrawal. She chose self-directed detoxification as she feared COVID-19 exposure in detoxification facilities. Her altered mental status drove her to jump out a third-story window causing multiple spinal fractures. After a long hospitalization, she self-directed her discharge home due to concerns about COVID-19. Her premature discharge disrupted opioid and benzodiazepine use disorder treatment plans. This case highlights the risks of phenibut use for selfdirected detoxification. With COVID-19 related changes in the drug supply, people may be more likely to use online pharmaceuticals, therefore, substance use assessments should inquire about the online acquisition of new psychoactive drugs. Public health messaging regarding the risks of infectious disease transmission in addiction care settings is needed to guide addiction treatment choices among people who use substances." }, { "id": "wiki20220301en023_63413", "title": "The Mystery of Edwin Drood", "score": 0.00909090909090909, "content": "Princess Puffer tries to follow Jasper, she suspects him of something because of what he said during his opium intoxication. Jasper says to Puffer at the end of what exists of the book: \"Suppose you had something in your mind; something you were going to do... Should you do it in your fancy, when you were lying here doing this?... I did it over and over again. I have done it hundreds of thousands of times in this room.\" The very first hint (Mr. Jasper being concerned about what he may say while in an opium stupor) occurs in the first pages when Mr. Jasper listens to other opium users and says \"unintelligible!\". On his last opium trip, Puffer says to him, while he sleeps: \"'Unintelligible' I heard you say, of two more than me. But don't ye be too sure always; don't ye be too sure, beauty!\" Lastly, on the day of Edwin's disappearance, Jasper was in an ebullient state of mind all day, performing in the choir with great self-command." }, { "id": "pubmed23n1060_952", "title": "Ivermectin to prevent hospitalizations in patients with COVID-19 (IVERCOR-COVID19): a structured summary of a study protocol for a randomized controlled trial.", "score": 0.009009009009009009, "content": "To assess the efficacy of ivermectin in addition to standard treatment compared to standard treatment alone in reducing hospitalizations in the COVID-19 patient population. IVERCOR-COVID19 will be a single-center, prospective, randomized, double-blind, parallel group (1:1 ratio), placebo-controlled study. Patients who meet the following criteria will be invited to participate: Inclusion criteria: (1) Over 18 years of age who reside in the province of Corrientes at the time of diagnosis. (2) Confirmed diagnosis of COVID-19 by polymerase chain reaction (PCR) test for detection of SARS-CoV2 in the last 48 h. (3) In the case of women of childbearing age, they must be using a contraceptive method of proven efficacy and safety (barrier, hormonal, or permanent contraceptives) for at least 3 months prior to inclusion in the present study and for the entire period of time for the duration of the study and until at least 30 days after the end of this study. A woman will be considered to have no reproductive capacity if she is postmenopausal (at least 2 years without her menstrual cycles) or if she has undergone surgical sterilization (at least 1 month before the time of inviting her to participate in this study). (4) Weight at the time of inclusion greater than 48 kg. (5) That they sign the informed consent for participation in the study. (1) pregnant or breastfeeding women; (2) known allergy to ivermectin or some of the components of ivermectin tablets or placebo; (3) current use of home oxygen; (4) require hospitalization due to COVID-19 at the time of diagnosis or history of hospitalization for COVID-19; (5) presence of mal-absorptive syndrome; (6) presence of any other concomitant acute infectious disease; (7) known history of severe liver disease, for example liver cirrhosis; (8) need or use of antiviral drugs at the time of admission for another viral pathology other than COVID-19; (9) need or use of hydroxychloroquine or chloroquine; (10) use of ivermectin up to 7 days prior to randomization; (11) patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months; and (12) current participation or in the last 30 days in a research study that has included the administration of a drug (Table 1). Table 1 Ivermectin/placebo dose according to patient weight Patient weight Ivermectin/placebo dose Total dose (mg) Equal to or greater than 48 kg and less than 80 kg 2 tablets of 6 mg each at the time of inclusion and 2 tablets 24 h after the first intake 24 Equal or greater than 80 kg and less than 110 kg 3 tablets of 6 mg each at the time of inclusion and 3 tablets 24 h after the first intake 36 Equal or greater than 110 kg 4 tablets of 6 mg each at the time of inclusion and 4 tablets 24 h after the first intake 48 The study will be carried out by the Ministry of Public Health of the Province of Corrientes (Argentina) in coordination with the Institute of Cardiology of Corrientes in the Province of Corrientes, Argentina. Intervention group: patients who are randomized to ivermectin will receive the dose according to their weight (patients up to 80 kg will receive 2 tablets of 6 mg ivermectin; patients with more than 80 kg and up to 110 kg will receive 3 tablets of 6 mg of ivermectin; patients weighing more than 110 kg will receive 4 tablets of 6 mg ivermectin) the day they enter the study and the same dose 24 h after the first dose. patients who are randomized to placebo will receive the dose according to their weight (patients up to 80 kg will receive 2 tablets of 6 mg placebo; patients with more than 80 kg and up to 110 kg will receive 3 tablets of 6 mg of placebo; patients weighing more than 110 kg will receive 4 tablets of 6 mg placebo) on the day they enter the study and the same dose 24 h after the first dose (Table 2). Table 2 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria 1. Over 18 years of age who reside in the province of Corrientes at the time of diagnosis 1. Pregnant or breastfeeding women 2.Confirmed diagnosis of COVID-19 by polymerase chain reaction test for detection of SARS-CoV2 in the last 48 h 2. Known allergy to ivermectin or some of the components of ivermectin tablets or placebo 3. In case of being women of childbearing age, they must be using a contraceptive method of proven efficacy and safety (barrier, hormonal, or permanent contraceptives) for at least 3 months prior to inclusion in the present study, during the entire period of time for the duration of the study, and until at least 30 days after the end of this study. A woman will be considered to have no reproductive capacity if she is postmenopausal (at least 2 years without her menstrual cycles) or if she has undergone surgical sterilization (at least 1 month before the time of inviting her to participate in this study) 3. Current use of home oxygen 4. Weight at the time of inclusion equal to or greater than 48 kg 4. That require hospitalization due to COVID-19 at the time of diagnosis or history of hospitalization for COVID-19 5. That they sign the informed consent for participation in the study 5. Presence of mal-absorptive syndrome 6. Presence of any other concomitant acute infectious disease 7. Known history of severe liver disease, for example liver cirrhosis 8. Need or use of antiviral drugs at the time of admission for another viral pathology other than COVID-19 9. Need or use of hydroxychloroquine or chloroquine 10. Use of ivermectin up to 7 days prior to randomization 11. Patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months 12. Current participation or in the last 30 days in a research study that has included the administration of a drug MAIN OUTCOMES: Primary outcome will be the percentage of hospitalizations in patients with COVID-19 in the intervention and control groups. time to hospitalization in each of the arms of the study: number of days elapsed from the inclusion in the study until the hospitalization of the patient; percentage of use of invasive mechanical ventilation in each of the study arms: every patient who is connected to invasive mechanical ventilation after signing the informed consent and before the final study visit; time to invasive mechanical ventilation in each of the arms of the study: number of days elapsed from inclusion in the study to connection to invasive mechanical ventilation of the patient; percentage of patients requiring dialysis in each of the study arms: all patients who require renal replacement therapy of any kind, temporary or permanent, and which begins after signing the informed consent and before the final visit; mortality from all causes in each of the two trial groups: death of the patient, from any cause. Negative PCR swab at 3 ± 1 and 12 ± 2 days after entering the study. Ivermectin safety: it will be analyzed according to the incidence of adverse events that patients present in the intervention and control groups. The end of study (EOS) is recorded as the day the patient is discharged or death. Discharge will be granted according to the current recommendations of the Ministry of Public Health of the Province of Corrientes. A follow-up visit (EOF) will be made by phone 30 days after the EOS when vital status will be verified. Randomization will be done through a web system with randomly permuted blocks. Randomization will be carried out by one of the investigators who will not participate in the inclusion of patients or in the delivery of medication (Table 3). Table 3 EOS end of study, EOF end of follow-up Visit Basal and randomization, day 0 Day 3 ± 1 Day 12 ± 2 V#1 V#2 V#3 EOS EOF Informed consent X - - - - Inclusion/exclusion criteria X - - - - Demographic data and medical history X - - - - Concomitant medication X - - - - Vital signs* X X - - - Anthropometric data<sup^</sup X - - - - Basal laboratory X - - - - PCR swab - X X - - Assessment of adverse events - X X X - Final objective evaluation - X X X X Randomization X - - - - Adherence to treatment X X - - - *Includes heart rate, temperature, and oxygen saturation by a digital saturometer ^Includes weight and height BLINDING (MASKING): The participants, investigators, care providers, and outcome assessors will be blinded. We will include a total of 500 patients (250 patients in each group). This is version 1.0, 17 August 2020. The recruitment started on 19 August 2020, and we anticipate the trial will finish recruitment on 31 December 2020. ClinicalTrials.gov NCT04529525 . Registered on 26 August 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting the dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol." }, { "id": "wiki20220301en432_16675", "title": "David J. Impastato", "score": 0.009009009009009009, "content": "Zigmond Lebensohn, MD, provides specifics in his account of the event in Comprehensive Psychiatry: \"Dr Impastato's records reveal the following handwritten entry for January 7, 1940: 'Volts 70, T-.1 sec MA 400. Had delayed (15sec?) reaction during apnea, face flushed, eyes opened, normal expression–looking forward, no breathing.' This treatment was administered by Dr. Impastato on a Sunday morning in his office.\"" }, { "id": "pubmed23n0267_21361", "title": "Effect of flumazenil on basal and naloxone-stimulated ACTH and cortisol release in humans.", "score": 0.008928571428571428, "content": "1. Endogenous benzodiazepine receptor ligands are thought to influence the human hypothalamic-pituitary-adrenal (HPA) axis and naloxone, a known stimulator of adrenocorticotropic hormone (ACTH) release, is thought to act via release of hypothalamic corticotropin-releasing hormone. 2. The aim of the present study was to assess the influence of endogenous benzodiazepine-receptor ligands by administering flumazenil (Ro15-1788), a benzodiazepine antagonist, and measuring ACTH and cortisol release, both basal and during naloxone-stimulation. 3. Nine normal volunteers in a placebo-controlled double-blind design were studied. Flumazenil (0.5 mg, i.v. bolus) was given 2 min before naloxone (125 micrograms/kg bodyweight, i.v. bolus) immunoreactive-adrenocorticotropic hormone (IR-ACTH) and cortisol levels were measured at frequent intervals from 60 min before to 120 min after naloxone injection. 4. Flumazenil had no effect on ACTH and cortisol release when given alone; flumazenil area under the ACTH/time curve (pmol/L.min) = -36.5 +/- 63.5 compared with placebo = -53.5 +/- 31.8, flumazenil area under the cortisol/time curve (nmol/L.min x 10(-3)) = - 2.4 +/- 2.4 compared with placebo -0.56 +/- 1.4. Flumazenil did not change the ACTH and cortisol release achieved with naloxone; naloxone area under the ACTH/time curve (pmol/L.min) = 327.8 +/- 61.7 compared with flumazenil/naloxone = 366.3 +/- 88.1, naloxone area under the cortisol/time curve (nmol/L. min x 10(-3) = 12.2 +/- 3.4 compared with naloxone/flumazenil = 10.5 +/- 2.1. 5. The authors conclude that flumazenil dose not modify basal or stimulated ACTH and cortisol release in healthy humans. This would suggest that endogenous benzodiazepine-like ligands and the benzodiazepine/gamma-aminobutyric acid receptor complex do not tonically influence the hypothalamic-pituitary-adrenal axis." }, { "id": "pubmed23n0308_9688", "title": "[Sedation in endoscopic diagnosis: rationale of the use of specific benzodiazepine antagonists].", "score": 0.008928571428571428, "content": "The aim of this study was to evaluate the best clinical use of Flumazenil, a specific antagonist of benzodiazepines, during endoscopic exams. Two-hundred patients were studied: 120 were treated with Flumazenil and 80 with placebo. The patients were prepared for the endoscopic exam with local anaesthesia and i.v. Diazepam administration. Controls performed at the end of the exam and at 5, 30, 120 e 240 minutes from the administration of Flumazenil and placebo, allowed to evaluate the state of awakeness, the level of conscience and the capacity of time-space orientation. Significantly statistical differences between the two groups were obtained at 5, 30 and 120 minutes after Flumazenil administration, while both groups had retrograde amnesia. The drug was well tolerated and there were no undesiderable side effects or reactions. The Authors therefore affirm that Flumazenil, in virtue of its competitive action toward benzodiazepine receptors, interrupts sedation with immediate awakening and improvement of the state of consciousness. Such drug, thus, permits the Day Hospital performance of endoscopic procedures which otherwise would require hospitalization, at the same time allowing the surgeon to use benzodiazepines at doses more adequate for surgical necessities." }, { "id": "pubmed23n1071_16139", "title": "Prompt improvement of difficulty with sleep initiation and waking up in the morning and daytime somnolence by combination therapy of suvorexant and ramelteon in delayed sleep-wake phase disorder: a case series of three patients.", "score": 0.008849557522123894, "content": "Patients with delayed sleep-wake phase disorder (DSWPD) suffer from difficulties in sleep initiation at night, difficulties in waking up at the socially required time, and daytime somnolence. About half of the patients resist conventional light therapy and melatonin therapy. Therapy using hypnotics is not recommended due to its adverse effects. Recently, suvorexant, an orexin receptor antagonist, has become available for clinical use. The drug is relatively safer than traditional hypnotics such as benzodiazepines. We report three DSWPD patients who were successfully treated by the combination therapy of suvorexant and ramelteon. The first case was a 19-year-old woman who was experiencing difficulties in sleep initiation, difficulty in waking up in the morning, and daytime somnolence. She showed a prompt response to the combination therapy of suvorexant and ramelteon. Her sleep phase advanced, and her daytime somnolence reduced. The second and third cases were 21-year-old and 17-year-old men, respectively, who also showed significant sleep phase advances. Although case 2 was resistant to ramelteon treatment, his sleep phase advanced after suvorexant started. His difficulty in falling asleep and his habit of daytime napping disappeared after the combination therapy of suvorexant and ramelteon was started. Case 3 also showed a prompt response. His difficulties in falling asleep and waking up in the morning were ameliorated immediately after suvorexant with ramelteon was started. No obvious side effects were observed. Therapy using the combination therapy of suvorexant and ramelteon might be a reasonable option for DSWPD patients." }, { "id": "First_Aid_Step2_1262", "title": "First_Aid_Step2", "score": 0.008849557522123894, "content": "A schizophrenic patient takes haloperidol for one year and develops uncontrollable tongue movements. Diagnosis? Treatment? A man unexpectedly flies across the country, takes a new name, and has no memory of his prior life. Panic disorder. Agranulocytosis. Schizophreniform disorder (diagnosis of schizophrenia requires ≥ 6 months of symptoms). Weight gain, type 2 DM, QT prolongation. Acute dystonia (oculogyric crisis). Treat with benztropine or diphenhydramine. Neuroleptics. Conduct disorder. Rett’s disorder. Acute mania. Start a mood stabilizer (e.g., lithium). Malingering. Factitious disorder (Munchausen syndrome). Substance abuse. Phencyclidine hydrochloride (PCP) intoxication. Depersonalization disorder. Frotteurism (a paraphilia). Tardive dyskinesia. ↓ or discontinue haloperidol and consider another antipsychotic (e.g., risperidone, clozapine). Dissociative fugue. Risk factors for DVT. Criteria for exudative effusion. Causes of exudative effusion." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 317 ] ], "word_ranges": [ [ 0, 50 ] ], "text": "We are not given any further data on the patient except that she is in shock (tissue hypoperfusion) and on introducing a Swan-Ganz catheter we find a low cardiac index (<2), elevated PCP (25mmHg) and elevated systemic resistances (normal: 600-1200 dyne/m2). These data are compatible with cardiogenic origin of shock." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Cardiogenic.", "2": "Septic.", "3": "Hypovolemic.", "4": "Anaphylactic.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0221_8339", "title": "Cardiac function and peripheral circulatory adjustments in patients with acute myocardial infarction. Observations during the early stage of AMI.", "score": 0.01786843769765971, "content": "Since little is known concerning the effect of different types of cardiac dysfunction on the peripheral circulation in acute myocardial infarction, cardiac and peripheral circulatory hemodynamics were measured simultaneously and sequentially in the Coronary Care Unit in 40 patients with acute myocardial infarction (AMI) using a Swan-Ganz catheter and venous occlusion plethysmography. Patients were classified by clinical assessment (Killip) and into four hemodynamic subsets (HS) according to pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) measures obtained by invasive central hemodynamic monitoring (Forrester): uncomplicated AMI, HS-I (PCWP less than or equal to 18 mmHg, CI greater than 2.2 L/min/m2) 15; pulmonary congestion, HS-II (PCWP greater than 18 mmHg, CI greater than 2.2 L/min/m2) 15; peripheral hypoperfusion, HS-III (PCWP less than or equal to 18 mmHg, CI less than or equal to 2.2 L/min/m2) 4; cardiogenic shock, HS-IV (PCWP greater than 18 mmHg, CI less than or equal to 2.2 L/min/m2) 6. Measurements taken within 48 hours after the onset of AMI showed significantly lower calf blood flow (p less than 0.05) and calf venous capacitance (p less than 0.01) and higher calf vascular resistance (p less than 0.05) in all AMI classifications compared to 10 normal subjects. In uncomplicated AMI group (Killip I and HS-I) calf blood flow and venous capacitance were significantly reduced while calf vascular resistance remained unchanged from normal. In AMI complicated by pulmonary congestion (Killip II and HS-II), in addition to reduced calf venous capacitance, calf blood flow was further significantly reduced (p less than 0.05) due, in part, to a rise in calf vascular resistance (p less than 0.05). In AMI complicated by severe heart failure and shock (Killip III, VI and HS-IV), mean changes in the periphery were not statistically different from those seen in patients with pulmonary congestion alone. In patients with AMI complicated by poor peripheral perfusion (HS-III), the peripheral changes did not show significant differences from those seen in uncomplicated AMI (HS-I). Significant correlations were found between calf blood flow and PCWP (r = -0.37, p less than 0.05) and CVP (r = -0.31, p less than 0.05); calf vascular resistance and PCWP (r = +0.36, p less than 0.05) and systemic vascular resistance (r = +0.43, p less than 0.01). Sequential daily peripheral hemodynamic changes in 14 H-I patients not requiring specific therapy showed that calf blood flow took 5 days, calf vascular resistance 3 days and calf venous capacitance 7 days to return to within normal levels.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0090_12348", "title": "[Use of norepinephrine in the treatment of septic shock].", "score": 0.017252918866661707, "content": "The effects of noradrenaline were studied in 16 patients, with either a hyperkinetic septic shock syndrome or a septic shock resistant to dobutamine treatment. The study aimed to restore normal tissue perfusion pressure, assessed by a return to normal of urine output or blood pressure. An optimal left ventricular filling pressure, estimated by the pulmonary capillary wedge pressure, was obtained for each patient using a Swan-Ganz catheter. The administration of 10.6 +/- 0.5 micrograms.kg-1.min-1 dobutamine (starting dose: 6 micrograms.kg-1.min-1) was started when the cardiac index (CI) was less than 3.3 l.min-1.m-2 after vascular filling with plasma expanders. Patients became eligible for noradrenaline treatment when they fulfilled the following conditions: arterial systolic pressure (Pasys) less than or equal to 90 mmHg; systemic vascular resistances less than or equal to 600 dyn.s.cm-5; CI greater than 3.5 l.min-1.m-2; persistent oliguria (less than 30 ml.h-1). This drug was given at a constant rate with a starting dose of 0.5 micrograms.kg-1.min-1, increased every 10 min by 0.3 to 0.6 micrograms.kg-1.min-1 according to the effects on Pasys and hourly urine output. Eight patients received noradrenaline alone; the efficient dose was 0.9 +/- 0.2 micrograms.kg-1.min-1, and it was used for a mean 5.1 +/- 1 days. CI increased in those patients who were given both noradrenaline and dobutamine. Thirteen out of the 16 patients had a dramatic increase in urine output; only three patients remained oliguric. There were no effects on serum creatinine concentration, anion gap, intrapulmonary shunt and oxygen consumption.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0784_10331", "title": "Increasing mean arterial pressure in cardiogenic shock secondary to myocardial infarction: effects on hemodynamics and tissue oxygenation.", "score": 0.01721132897603486, "content": "There are very few data regarding the effects of norepinephrine uptitration on global and regional hemodynamics in cardiogenic shock. We studied 25 patients with shock secondary to myocardial infarction successfully treated with percutaneous coronary intervention. Before the inclusion, 16 of 25 patients presented a cardiac arrest in the presence of medical staff. Norepinephrine was titrated to increase mean arterial pressure (MAP) from 65 to 85 mmHg during 1 h. Swan-Ganz variables, arterial and mixed venous blood gases, lactate, and thenar near-infrared spectroscopy variables (muscle tissue oxygen saturation [StO2] and its changes during a vascular occlusion test) were measured before, 1 h after norepinephrine uptitration, and 1 h after norepinephrine downtitration. To obtain a MAP at 85 mmHg, norepinephrine was increased from 0.6 (0.28-1.2) to 1.53 µg · kg · min (0.76-2.6 µg · kg · min) (P &lt; 0.00001) (median and interquartile range), with no change in heart rate. Norepinephrine uptitration significantly increased cardiac index (2.3 ± 0.5 to 2.8 ± 0.1 L · min · m), cardiac power index (0.40 ± 0.1 to 0.55 ± 0.1 W/m), mixed venous oxygen saturation (69% ± 9% to 73% ± 9%), and coronary perfusion pressure (32 ± 3 to 43 ± 4 mmHg). Lactate level decreased from 2.6 ± 1.7 to 1.6 ± 0.4 mmol/L (P &lt; 0.05). Pulmonary artery occlusion pressure remained unchanged. Regarding near-infrared spectroscopy variables, all values except StO2 were significantly pathological when compared with healthy volunteers. The StO2 recovery slope and delta StO2, respectively, increased from 3.0% ± 1.3%/s to 3.6% ± 1.3%/s and 10% ± 3% to 14% ± 4%, whereas StO2 did not change (83% ± 6% to 83% ± 7%). After H1, norepinephrine was decreased to basal values, and all variables returned to baseline. In conclusion, a short-term increase in MAP with norepinephrine in resuscitated cardiogenic shock complicated by postreperfusion disease is associated with better cardiac performance and improved microcirculatory variables." }, { "id": "pubmed23n0348_7617", "title": "Dobutamine in severe scorpion envenomation: effects on standard hemodynamics, right ventricular performance, and tissue oxygenation.", "score": 0.016964924838940586, "content": "To document the effects of dobutamine on standard hemodynamics and right ventricular (RV) performance in patients exhibiting pulmonary edema following severe scorpion envenomation, and to characterize the tissue oxygenation profile in patients sustaining scorpion envenomation-related shock. Prospective cohort study. An ICU in a university hospital. Nineteen consecutive patients were admitted to the ICU for severe scorpion envenomation; all 19 patients exhibited hemodynamic pulmonary edema, and 10 patients had peripheral shock. All patients underwent a hemodynamic study with a Swan-Ganz catheter. In 8 of 19 patients, the thermodilution catheter was equipped with a fast-response thermistor. Standard hemodynamic parameters were recorded on admission and following the infusion of dobutamine in all patients at a dosage, from 7 to 20 microg/kg/min, intended to achieve the best hemodynamic and tissue oxygenation compromise. RV ejection fraction (RVEF) and RV volumes were simultaneously recorded in 8 patients, and tissue oxygenation parameters were assessed in the 10 patients with peripheral shock. The clinical signs of tissue hypoperfusion improved, and optimal hemodynamic parameters were achieved at a mean +/- SD dobutamine dosage of 17 +/- 7 microg/kg/min. Dobutamine infusion evoked statistically significant increases in cardiac index, from 2.3 +/- 0.6 to 3.6 +/- 0.7 L/min/m2; stroke volume index, from 18 +/- 5 to 31 +/- 10 mL/m2; and systemic arterial pressure, from 64 +/- 12 to 78 +/- 14 mm Hg. Pulmonary artery occlusion pressure (PAOP) and venous admixture decreased significantly: from 23 +/- 4 to 15 +/- 6 mm Hg and from 29 +/- 7% to 20 +/- 5%, respectively. With respect to RV function, dobutamine infusion significantly increased the RVEF, from 24 +/- 7% to 42 +/- 9%, without significantly changing the RV end-diastolic volume index, reflecting an enhanced RV contractility. In patients with peripheral circulatory failure, the baseline tissue oxygenation profile was consistent with cardiogenic shock, showing increased oxygen extraction as a consequence of a striking depression in oxygen delivery (DO2). After dobutamine infusion, DO2 improved significantly, from 386 +/- 104 to 676 +/- 156 mL/min/m2, with a significant decrease in oxygen extraction, from 34 +/- 8% to 24 +/- 6%. In severe scorpion envenomation, dobutamine infusion improves impaired heart function. The effects involve both left ventricular and RV dysfunction. Impaired tissue oxygenation is also improved." }, { "id": "pubmed23n0497_22832", "title": "[Short term effects of hypertonic saline during severe sepsis and septic shock].", "score": 0.014362023785527112, "content": "Assessment of haemodynamic effects of 250 ml hypertonic saline 7.5% (HS) perfusion in critically ill patients with severe sepsis or septic shock. Observational study. Twelve mechanically ventilated patients with severe sepsis or septic shock requiring a pulmonary artery catheter and volume loading. Two hundred and fifty millilitres HS were given over 15 min. Were measured: heart rate (HR), mean arterial pressure (MAP) and pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), cardiac index (CI), indexed systemic vascular resistance (ISVR), indexed pulmonary vascular resistance (IPVR), plasma sodium, chloride, protein and haemoglobin concentrations and arterial blood lactate. Studied parameters were assessed at baseline (T(0)) and 5 (T(0)) and 105 min (T(120)) after the end of HS infusion. MAP, HR and RAP were not altered. HS increased PAPM (25 +/- 5-30 +/- 6 mmHg), PCWP (13 +/- 3-18 +/- 4 mmHg) and CI (3.5 +/- 1.2-4.6 +/- 1.1 l/min per m(2)) at T(20) (P &lt; 0.05). ISVR and IPVR were decreased at T(20). Protein and haemoglobin were decreased at T(20). Sodium and chloride were increased at T(20) (from 136 +/- 4 to 147 +/- 4 and from 110 +/- 6 to 123 +/- 6 mmol/l, respectively, P &lt; 0.01) and T(120). In patients with severe sepsis or septic shock, 250 ml HS transiently (&lt;120 min) increases CI and PCWP and induces an increase in sodium and chloride concentrations." }, { "id": "pubmed23n0288_6150", "title": "[Comparison of clinical assessment and invasive evaluation of hemodynamic parameters in septic shock].", "score": 0.01420975430876421, "content": "The authors compare, in this prospective study, the accuracy of their own clinical assessment of hemodynamic parameters and severity of disease with the findings obtained by right heart catheterization in 50 patients with septic shock. The purpose of the study was to determine whether Swan-Ganz catheter insertion was necessary in all patients with septic shock. As soon as the diagnosis was established, the value of pulmonary capillary wedge pressure was estimated, as well as presence or absence of pathological uptake/supply dependency in all patients. The latter is an excellent indicator of severity of disease. The accurate assessment was noted in 27 (54%) patients (1. investigator), and in 30 (60%) patients (2. investigator). The sensitivity of detection of pathological uptake/supply dependency amounted to 53% and 65%; specificity was 73% and 79%, respectively. The therapy was altered in 21 patients (42%) after catheter insertion. The results were tested with chi2-test (p &lt; 0.01). The findings of this study warrant catheter insertion in patients with septic shock." }, { "id": "wiki20220301en039_33588", "title": "Cardiogenic shock", "score": 0.013550625135506252, "content": "Swan-Ganz catheter The Swan–Ganz catheter or pulmonary artery catheter may assist in the diagnosis by providing information on the hemodynamics. Biopsy When cardiomyopathy is suspected as the cause of cardiogenic shock, a biopsy of heart muscle may be needed to make a definite diagnosis. Cardiac index If the cardiac index falls acutely below 2.2 L/min/m2, the person may be in cardiogenic shock. Treatment Depending on the type of cardiogenic shock, treatment involves infusion of fluids, or in shock refractory to fluids, inotropic medications. In case of an abnormal heart rhythm immediate synchronized cardioversion or anti-arrhythmic agents may be administered, e.g. adenosine." }, { "id": "pubmed23n0078_7267", "title": "Hemodynamic and oxygen transport variables in cardiogenic shock secondary to acute myocardial infarction, and response to treatment.", "score": 0.012225378447376936, "content": "There are few data on oxygen transport in cardiogenic shock after acute myocardial infarction. This prospective study examined oxygen transport variables in 19 such patients and assessed their responses to treatment. Femoral and pulmonary arterial catheters were inserted before any therapy except correction of hypoxemia by mechanical ventilation in 8 patients, defibrillation (3 patients) or pacing (5 patients). In 3 patients mean arterial pressure was greater than 80 mm Hg and cardiac index greater than 2.1 liters/min/m2 with normal mixed venous oxygen saturation despite simultaneous clinical shock. They recovered with no further treatment. Sixteen patients were treated with varying combinations of intravenous fluids and dobutamine (37 +/- 25 mu/kg/min) and 14 survived long enough for a second set of measurements to be completed. Mean heart rate increased from 83 +/- 22 to 101 +/- 20 beats/min and mean cardiac index from 1.4 +/- 0.5 to 2.5 +/- 0.4 liters/min/m2 (p less than 0.001). Oxygen consumption (VO2) was maintained even when oxygen delivery (DO2) was less than 330 ml/min/m2. After treatment DO2 increased from 230 +/- 69 to 397 +/- 60 ml/min/m2 (p less than 0.001) and VO2 from 103 +/- 31 to 124 +/- 27 ml/min/m2 (p less than 0.05). Mean mixed venous oxygen saturation increased from 54 +/- 16 to 69 +/- 8% (p less than 0.001) and mean oxygen extraction ratio decreased from 48 +/- 16 to 31 +/- 6% (p less than 0.001). There was no correlation between cuff systolic blood pressure and mean arterial pressure before or after resuscitation. Thirteen patients survived to hospital discharge. When cardiogenic shock responds to treatment, large increases in DO2 lead to small increases in VO2 but large increases in mixed venous oxygen saturation, reflecting improved tissue oxygen availability." }, { "id": "article-18914_2", "title": "Cardiogenic Shock -- Introduction", "score": 0.010483834603417955, "content": "Cardiogenic shock is defined as a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion. Clinical criteria include a systolic blood pressure of less than or equal to 90 mm Hg for greater than or equal to 30 minutes or support to maintain systolic blood pressure less than or equal to 90 mm Hg and urine output less than or equal to  30 mL/hr or cool extremities. Hemodynamic criteria include a depressed cardiac index (less than or equal to 2.2 liters per minute per square meter of body surface area) and an elevated pulmonary-capillary wedge pressure greater than 15 mm Hg." }, { "id": "InternalMed_Harrison_20979", "title": "InternalMed_Harrison", "score": 0.01013444170771757, "content": "Cardiogenic shock (CS) is characterized by systemic hypoperfusion due to severe depression of the cardiac index (<2.2 [L/min]/m2) and sustained systolic arterial hypotension (<90 mmHg) despite an elevated filling pressure (pulmonary capillary wedge pressure [PCWP] >18 mmHg). It is associated with in-hospital mortality rates >50%. The major causes of CS are listed in Table 326-1. Circulatory failure based on cardiac dysfunction may be caused by primary myocardial failure, most commonly secondary to acute myocardial infarction (MI) (Chap. 295), and less frequently by cardiomyopathy or myocarditis (Chap. 287), cardiac tamponade (Chap. 288), or critical valvular heart disease (Chap. 283)." }, { "id": "pubmed23n0040_3046", "title": "Hemodynamic patterns in shock and critically ill patients.", "score": 0.009900990099009901, "content": "Nine variables were studied in 56 patients to analyze hemodynamic patterns of critically ill and shock patients. The variables were central venous pressure, mean arterial pressure, heart rate, cardiac index, left ventricular stroke work, strok index, total peripheral resistance, arteriovenous oxygen difference, and oxygen consumption. We observed six patterns; three with low cardiac index (hypodynamic) and three with high cardiac index (hyperdynamic). Group IA: Low cardiac index with increased central venous pressure and arteriovenous oxygen differences associated with myocardial infarction, cardiac insufficiency, and postoperative cardiac surgery: Group IB: Low cardiac index with normal arteriovenous oxygen difference associated with myocardial infarction or hypovolemia. Group IC: Low cardiac index and decreased arteriovenous oxygen difference in patients with hypodynamic septic shock. Group IID: High cardiac index and increased arteriovenous oxygen difference in patients with sepsis and stable hemodynamic conditions. Groups IIE and IIF: Increased cardiac index and normal or increased arteriovenous oxygen difference in septic patients, who were hemodymamically unstable or in shock. These hemodynamic observations were found to be useful for understanding physiological compensations, for deciding on therapy, and in evaluating the effectiveness of therapy." }, { "id": "pubmed23n0225_5367", "title": "[Hemodynamic effects of intravenous clonidine in patients with acute myocardial infarction].", "score": 0.009708737864077669, "content": "To assess the hemodynamic effects of Clonidine in hypertensive patients (pts) with an acute myocardial infarction (AMI), we administered the drug to 12 such patients either in a single bolus (75--150 micrograms in 5 min - 8 pts) or by continuous infusion (0.4--5 micrograms/min - 4 pts). Hemodynamic measurements were obtained by means of a Swan-Ganz thermodilution catheter, before and 60 min after the administration of the drug. Clonidine did not significantly affected Heart Rate (from 80.5 +/- 3.9 to 78.4 +/- 5.9 beats/min), Mean Pulmonary Arterial Pressure (from 18.6 +/- 1.7 to 15.1 +/- 1 mmHg), Mean Pulmonary Wedge Pressure (from 12.5 +/- 1.1 to 10.6 +/- 0.7 mmHg), central Venous Pressure (from 4 +/- 0.8 to 3 +/- 0.9 mmHg), Cardiac Index (from 2.6 +/- 0.07 to 2.6 +/- 0.7 L/min/m2), Stroke Volume (from 65.2 +/- 2.8 to 68.5 +/- 5.5 ml/b). Conversely Mean Arterial Pressure fell significantly from 127 +/- 3.1 to 96.2 +/- 7.2 mmHg (P less than 0.001). Left Ventricular Systolic Work Index was reduced from 62.3 +/- 3.3 to 50.4 +/- 4.4 gm/beats/m2 (P less than 0.025), Total Systemic Resistances from 1888 +/- 50 to 1412 +/- 117 dyne sec cm-5 (P less than 0.005) and Tension Time Index from 3536 +/- 495 to 2389 +/- 385 x 10(3) mmHg x sec/min (p less than 0.05). Clonidine is a safe and useful drug to obtain a fall of high blood pressure often complicating AMI, without depressing left ventricular performance, as suggested by no significant changes of CI, WP and LVSWI. The reduction of TTI suggests a beneficial effect on the balance between myocardial oxygen delivery and demand. Clonidine is a hypotensive drug which can be safely used in patients with AMI, without depressing the left ventricular performance." }, { "id": "pubmed23n0067_3575", "title": "[Hemodynamic effects of dobutamine in hyperkinetic septic shock treated with norepinephrine].", "score": 0.009708737864077669, "content": "A prospective study of the haemodynamic effects of dobutamine was carried out in six men and four women suffering from hyperkinetic septic shock, already treated with noradrenaline and dopamine. All ten patients had septic shock, defined as a mean arterial blood pressure of less than 70 mmHg and an urine output under 15 ml.h-1, persisting despite fluid loading, associated with positive blood cultures, increased white blood cell counts, and a septic area. Initial treatment consisted in fluid loading, so as to increase cardiac output whilst keeping pulmonary wedge pressure (Ppw) between 8 and 10 mmHg. Dopamine was then added, up to a dose of 15-20 micrograms.kg-1.min-1, in an attempt to improve coronary and renal blood flows. In patients in whom this failed, the amounts of dopamine were then decreased, down to 3 micrograms.kg-1.min-1, and replaced by noradrenaline. When patients had as steady cardiac index (CI) greater than 3 l.min-1.m-2 and a systemic arterial resistance index (RsaI) of less than 1,800 dyn.s.cm-5.m-2 for more than 60 min, they were included in the protocol. Dopamine was then replaced by increasing doses of dobutamine (0, 5, 7.5, 10, 15 and again 0 micrograms.kg-1.min-1). The usual haemodynamic parameters were measured and calculated once a steady state had been obtained at each dose (within 20 to 30 min). Ppw was kept between 8 and 10 mmHg by fluid loading with a 4% albumin solution. At the beginning of the study, patients had a mean blood pressure of 78 +/- 6 mmHg, a CI of 4.8 +/- 1.5 l.min-1.m-2 and a RsaI of 1,285 +/- 341 dyn.s.cm-5.m-2 RsaI.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en037_50762", "title": "Cardiac catheterization", "score": 0.009615384615384616, "content": "Right heart catheterization is often done for pulmonary hypertension, heart failure, and cardiogenic shock. The pulmonary artery catheter can be placed, used, and removed, or it can be placed and left in place for continuous monitoring. The latter can be done an intensive care unit (ICU) to permit frequent measurement of the hemodynamic parameters in response to interventions. Parameters obtainable from a right heart catheterization: Right atrial pressure Right ventricular pressure Pulmonary artery pressure Pulmonary capillary wedge pressure Systemic vascular resistance Pulmonary vascular resistance Cardiac output Blood oxygenation Implantation of a CardioMEMS is done during a right heart catheterization. This device is implanted into the pulmonary artery to permit real-time measurement of the pulmonary artery pressure over time. Coronary catheterization" }, { "id": "pubmed23n1008_21163", "title": "A Two Parameters for the Evaluation of Hypovolemia in Patients with Septic Shock: Inferior Vena Cava Collapsibility Index (IVCCI), Delta Cardiac Output.", "score": 0.009615384615384616, "content": "BACKGROUND The aim of this study was to determine the correlation between inferior vena cava collapsibility index and changes in cardiac output measured during passive leg raising test in patients with spontaneous breathing and septic shock. MATERIAL AND METHODS Fifty-six patients were included in the study. All of these 56 patients were diagnosed with septic shock and had spontaneous breathing under continuous positive airway pressure. Patients exclusions included: patients with cardiac pathology, not septic shock, pregnant, spontaneous breathing, increased intra-abdominal pressure, inferior vena cava could not be visualized, arrhythmia and pulmonary hypertension. Exclusion criteria for the study were as follows: 1) left ventricular systolic dysfunction, 2) cardiomyopathy, 3) medium severe heart valve disease, 4) patients with arrhythmia; 5) pulmonary hypertension, 6) patients without spontaneous breathing (for inferior vena cava collapsibility index, it is not evaluated), 7) patients with &gt;60 mmHg CO₂ in arterial blood gas; 8) pregnant patients; 9) patients with neurogenic shock, cerebrovascular incident or traumatic brain injury, 10) patients whose inferior vena cava and parasternal long axis cannot be visualized, and 11) patients with increased intra-abdominal pressure. Patients were placed in neutral supine position, and the inferior vena cava collapsibility index and cardiac output 1 were recorded. In passive leg raising test, after which the cardiac output 2 is recorded in terms of L/min. The percentage increase between the 2 cardiac outputs was calculated and recorded. RESULTS A moderately positive correlation was also observed between the inferior vena cava collapsibility index and delta cardiac output (r=0.459; r2=0.21), which was statistically significant (P&lt;0.001). The cutoff value for the delta cardiac output was 29.5. CONCLUSIONS In conclusion, we found that the inferior vena cava collapsibility index, which is one of the dynamic parameters used in the diagnosis of hypovolemia in patients with septic shock, is correlated with delta cardiac output after leg raising test. We believe that, based on a clinician's experience, looking at 1 of these 2 parameters is sufficient for the identification of hypovolemia in patients diagnosed with septic shock." }, { "id": "pubmed23n0364_2326", "title": "Systemic, pulmonary, and renal hemodynamic effects of endothelin ET(A/B)-receptor blockade in patients with maintained left ventricular function.", "score": 0.009523809523809525, "content": "Endothelin-1 (ET-1) regulates vascular tone in congestive heart failure and modulates renal function. Its role in patients with normal left ventricular (LV) function and its renal effects are unclear. Cardiac and renal hemodynamics were studied in 24 patients with normal LV function and coronary arteries after single-dose, double-blind, randomized administration of TAK-044 (25, 50, or 100 mg, i.v.), an ET(A/B)-receptor antagonist, or placebo. Hemodynamics were monitored using Swan-Ganz and arterial catheters, and ET levels were measured. Renal function was assessed by clearance techniques. In the absence of a dose-response relation, TAK-044 patients were analyzed as a single group. Most hemodynamic effects occurred during the first 4 h. TAK-044 reduced mean arterial (-9.3 mm Hg, p &lt; 0.001), pulmonary (-1.8 mm Hg, p = 0.01), and pulmonary capillary wedge pressure (-1.6 mm Hg, p &lt; 0.001) between 30 min and 4 h. Mean reduction in systemic vascular resistance was 279 dyne/s/cm2 (p &lt; 0.001), whereas heart rate increased 6.1 beats/min (p &lt; 0.001) and cardiac index by 0.37 L/m2 (p = 0.01). Stroke volume index, right atrial pressure, and pulmonary vascular resistance did not change. TAK-044 increased renal plasma flow in proportion to the increase in cardiac output (+119 ml/min, 4 h after TAK-044; p &lt; 0.05) and ET-1 levels (2.5-fold; p &lt; 0.05). No serious side effects were noted. In patients with normal cardiac function, ET-receptor blockade causes vasodilation and reduces systemic but not pulmonary vascular resistance and increases cardiac index and renal plasma flow." }, { "id": "pubmed23n1022_23884", "title": "[Cardiogenic shock].", "score": 0.009523809523809525, "content": "Cardiogenic shock (CS) is defined as end-organ hypoperfusion as the consequence of primary myocardial dysfunction. Among the diagnostic criteria are a systolic blood pressure &lt; 90 mmHg, acute renal failure (oligoanuria), ischemic hepatitis, cyanosis and cold, clammy skin. Accepted hemodynamic cutoffs are a cardiac index &lt; 2,2 (l/min)/m2 and a pulmonary capillary wedge pressure &gt; 15 mmHg. It should be acknowledged, that a normal blood pressure does not rule out CS; there is a nonhypotensive variant of CS demonstrating all the signs mentioned above (including elevated lactate levels) while the blood pressure is compensated due to vasoconstriction.The single most frequent cause of CS is pump failure in the setting of an acute myocardial infarction and its mortality rate has been lowered to 40-50%, owing to the widespread availability of primary PCI. Regarding PCI, it has been demonstrated recently that a \"culprit-lesion only strategy\" should be followed in the setting of CS. Other important causes of CS to take into account are mechanical complications of myocardial infarction (papillary and ventricular septal rupture as well as rupture of the myocardial free wall leading to tamponade), valvular heart disease (mostly decompensated aortic stenosis) as well as myocarditis and end stage cardiomyopathy.The diagnosis of CS is made by patient history, physical examination, ECG, echocardiography and coronary angiography. Echocardiography should always be performed before coronary angiography because, in the case of mechanical complications, it significantly alters the management of the patients. Patients with clinical signs of CS but paradoxically preserved ejection fraction must be thoroughly evaluated for the presence of a papillary muscle rupture, particularly in the setting of a lateral wall infarction.Noradrenaline and dobutamine are the first-line agents for medical stabilization. When such conventional measures fail, extracorporeal support devices such as ECMO or Impella© may be used. Currently, trials are underway to assess wheter these devices confer a survival benefit in this high-risk population." }, { "id": "pubmed23n0299_4908", "title": "[Hemodynamic effects of oral captopril in patients with critical aortic stenosis].", "score": 0.009433962264150943, "content": "To analyse the hemodynamic and ventricular function effects of oral captopril in severe aortic stenosis. inclusion criteria: patients older than 18 years with critical aortic stenosis. angiotensin-converting enzyme inhibitor used previously contraindication to right catheterisation aortic insufficiency, valvular prosthesis in aortic position, or other valvulopathy. As well as the need for immediate valvular aortic replacement arrhythmia, A-V conduction alterations, or ventilatory support. prospective, no randomized. Swan-Ganz catheter was used. Basal hemodynamic measurements were made on 1, 2, 4, 6 and 8 hours during 48 hours. Captopril was administered 12.5 mg first and then 8 mg tid (6 doses). Neuman-Keuls test was used for multivariate comparisons. Statistical significance was determined with P &lt; 0.05. 22 patients were analyzed. Systemic vascular resistance fell from 1750 Dyn/seg/cm-5 to 1200 (P-0.001), cardiac output increased from 4.1l/min to 5.8 (P-0.001), cardiac index increased from 2.4 l/min/m2 to 2.9 (P-0.009), stroke volume from 47 ml to 64 (P-0.04) and stroke volume index from 27 ml/m2 to 36 (P-0.002). In patients with heart failure (n = 7) the systemic vascular resistance fell from 2050 Dyn/seg/cm-5 to 1463 (P-0.04), cardiac output increased from 2.8l/min to 4.1 (P-0.04), cardiac index from 2.07 l/min/m2 to 2.75 (P-0.04), stroke volume from 46 ml to 64 (P-0.03), pulmonary capillary wedge pressure fell from 19 mmHg to 16 (0.04) and the systolic pulmonary arterial pressure fell from 63 mmHg to 42 (P-0.009). captopril improves the hemodynamic parameters in patients with critical aortic stenosis, principally in those with heart failure." }, { "id": "pubmed23n0050_11136", "title": "[Clinical picture of acute pulmonary embolism. Relations to the degree of vascular obstruction].", "score": 0.009433962264150943, "content": "In 132 consecutive patients treated for pulmonary embolism, duration of symptoms, number of embolic episodes before the diagnosis, circulatory affection (stable circulation (n = 61), reversible shock (n = 60), circulatory collapse (n = 11), electrocardiographic findings and systolic pulmonary pressure (n = 60) were analysed in relation to 1) underlying diseases (orthopedic surgical patients (n = 43), gynecological-abdominal surgical patients (n = 22), preembolic healthy patients (n = 42), miscellaneous medical patients (n = 25)), and 2) the obstruction of the pulmonary vascular bed quantified by a scintigraphic or angiographic score. While embolic score did not differ between the groups of underlying diseases, preembolic healthy patients with deep vein trombosis (n = 30) had longer mean duration of symptoms (14 days), more embolic episodes, (1.7 episode) and higher pulmonary pressure (72 mmHg) than the material on an average with values of 7 days, 0.9 episodes and 57 mmHg, respectively (p less than 0.001). Among patients with reversible shock or circulatory collapse, half had at least one previous embolic episode, one fifth from two to four. Embolic score correlated well with the circulatory affection (p less than 0.001). A high pulmonary pressure correlated with long duration of symptoms and a high number of embolic episodes (p less than 0.002). Sinus tachycardia and electrocardiographic signs of acute right ventricular strain (complete and incomplete right bundle branch block, SIQIIITIII-pattern and inverted T-waves in V2-4) correlated positively to the circulatory affection and inversely to duration of symptoms and number of embolic episodes (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0293_104", "title": "Valve replacement for aortic stenosis with severe congestive heart failure and pulmonary hypertension.", "score": 0.009345794392523364, "content": "Significant pulmonary hypertension in aortic stenosis is evidence of severe dysfunction of the left ventricle. It is also a predictor of a bad prognosis in the natural course of the disease. This study was performed to evaluate the changes in the hemodynamic parameters of pulmonary circulation at rest and effort in patients who had significant pulmonary hypertension preoperatively and underwent valve replacement. The study consists of 11 male patients with aortic stenosis with an average peak transvalvular gradient of 68 mmHg and impaired left ventricular function (mean ejection fraction 38%). Six patients were in NYHA functional class III, and five were in class IV. The patients underwent Swan-Ganz catheterization before urgent valve replacement. Significant pulmonary hypertension was found in all subjects, and a below normal cardiac index in eight. Urgent valve replacement was performed in all patients: two of them were operated on during pulmonary edema and cardiogenic shock which developed soon after diagnosis-one of them died. Patients were followed up six months after surgery, and all of them showed major clinical improvement (six in NYHA class I, four in class II). Mean pulmonary artery systolic pressure dropped from 77 mmHg preoperatively to 32 mmHg, and the pulmonary artery mean pressure from 47 mmHg to 17 mmHg, pulmonary wedge pressure from 32 mmHg to 9 mmHg, and pulmonary vascular resistance from 4.74 to 1.8 Wood units. The cardiac index came back to normal in all patients (2.18 vs. 3.0 l/min/m2). Swan-Ganz catheterization was also performed during exercise (work load; 50 Watts in three patients, 100 Watts in six patients). The reaction of the hemodynamic parameters on exercise in most patients was almost normal. Our data indicate that in aortic stenosis, even with severe left heart failure, pulmonary hypertension can be fully reversible and a significant improvement in both rest and effort hemodynamic parameters can be expected." }, { "id": "pubmed23n0244_3043", "title": "[Physiopathology of anaphylactic and anaphylactoid shock. A cooperative retrospective study].", "score": 0.009345794392523364, "content": "The pathophysiology of anaphylactic and anaphylactoid shock states suggests that the rapidly initiated, intensive therapeutic measures to be taken must involve: breathing (ventilation) of (with) 100% oxygen, continuous or semi-continuous sympathicomimetic therapy (epinephrine, isoprenalin, orciprenalin) avoiding excessive single doses, rapid intensive volume substitution, control of metabolic acidosis, bronchospasmolytic therapy, in case of laryngospasm intubation, if not possible coniotomy or transtracheal punction. In case of circulatory arrest possibly also cardiac massage, defibrillation, lidocain, cardioversion. In a retrospective study 91 cases of anaphylactic and anaphylactoid shock were analyzed. Cutaneous vascular changes. Vasodilation was reported in 30 cases, vasoconstriction in 15 cases. Hypovolemia. CVP as measured in 23 cases was less than or equal to 2 cmH2O in 12 cases; in 4 of these cases the early finding and in 2 a rather low hematocrit are in favour of venous blood sequestration. In 2 cases the increase of the hematocrit suggests an extravasation of as much as 1,2 and 1,81 of plasma, respectively. Increase of pulmonary arterial pressure. CVP increased in 2 out of 9 cases suggesting a high pulmonary arterial pressure. Decreased cardiac output (CO). In 3 cases CO as determined in a late shock phase diminished by 37--55%. Blood gas changes. PaO2 was as low as 47--61 mmHg in 4 out of 8 cases, PaCO2 being 29--34 mmHg in 2 of them. It suggests an insufficient oxygen transport. Myocardial involvement. Arrhythmias (non sinus-) were found in 38 cases, of which 14 ventricular arrhythmia and 13 asystole. Serious wave deformation concerned QRS (3), AV-block (2), intraventricular blocks (4). 5 times the reaction resulted in myocardial infarction. A localized coronary spasm in anayphylactic shock was observed during a coronary angiography. Respiratory impairment. Severe respiratory impairment was associated with anaphylactic and anaphylactoid shock in 31 cases (26 bronchospasm, 4 apnea, 1 laryngospasm)." }, { "id": "pubmed23n0069_20584", "title": "[Clinical and hemodynamic efficacy of enalapril in severe congestive heart failure].", "score": 0.009259259259259259, "content": "Evaluate the clinical and hemodynamic efficacy of enalapril in the treatment of severe congestive heart failure, refractory to the classic therapeutics with diuretics and digitalis. Hospitalized patients (pts) of a cardiac department. 10 pts with a mean age of 57.8 years in whom a Swan-Ganz catheter was placed for 72 hours to monitor the right pressures and cardiac output, with regular control of arterial blood pressure and cardiac frequency. Low doses of enalapril (2.5 mg) were utilized at the start of the treatment and this dose was readjusted depending on the clinic and hemodynamic parameters. the 10 pts had the following characteristics: Basal-mean pulmonary arterial pressure (PAP) 34.1 mmHg, Pulmonary wedge pressure (PWP) 21.1 mmHg, cardiac output (CO) 4.8 l/min, cardiac index (CI) 2.8 l/min/m2. After 72 hours with enalapril treatment, these measurements were: PAP-23.8 mmHg, PWP-12.6 mmHg, CO-5.2 l/min and Cl-3.0 ll/min/m2. These differences were statistically significant. With a follow-up of 18.4 months, there was also a clinical improvement; of the 4 pts in class III, 2 moved to class II and 2 to class I; the 4 pts in class IV 4 moved to class II; two pts had died. In severe heart failure, the addition of enalapril to the classic therapy has allowed the immediate improvement of the clinical and hemodynamic indexes and this improvement was maintained in the follow-up period." }, { "id": "InternalMed_Harrison_20701", "title": "InternalMed_Harrison", "score": 0.009182551319648093, "content": "Abbreviations: (A − a) DO2, alveolar-arterial oxygen difference; FIO2, fraction of inspired oxygen; PaO2, partial pressure of oxygen; WBC, white blood cell count. Mortality rate, % FIGURE 321-1 APACHE II survival curve. Blue, nonoperative; green, (See also Chap. 323) During the initial resuscitation of patients in postoperative. shock, principles of advanced cardiac life support should be followed. most common cause of high-cardiac-output hypotension is sepsis (Chap. 325). Other causes include liver failure, severe pancreatitis, burns and other trauma that elicit the systemic inflammatory response syndrome (SIRS), anaphylaxis, thyrotoxicosis, and peripheral arteriovenous shunts. In summary, the most common categories of shock are hypovolemic, cardiogenic, and high-cardiac-output with decreased SVR (highoutput hypotension). Certainly more than one category can occur simultaneously (e.g., hypovolemic and septic shock)." }, { "id": "pubmed23n0356_19489", "title": "Invasive hemodynamic monitoring in the postoperative period of cardiac surgery.", "score": 0.009174311926605505, "content": "To assess the hemodynamic profile of cardiac surgery patients with circulatory instability in the early postoperative period (POP). Over a two-year period, 306 patients underwent cardiac surgery. Thirty had hemodynamic instability in the early POP and were monitored with the Swan-Ganz catheter. The following parameters were evaluated: cardiac index (CI), systemic and pulmonary vascular resistance, pulmonary shunt, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), oxygen delivery and consumption, use of vaso-active drugs and of circulatory support. Twenty patients had low cardiac index (CI), and, 10 had normal or high CI. Systemic vascular resistance was decreased in 11 patients. There was no correlation between oxygen delivery (DO2) and consumption (VO2), p = 0.42, and no correlation between CVP and PCWP, p = 0.065. Pulmonary vascular resistance was decreased in 15 patients and the pulmonary shunt was increased in 19. Two patients with CI &lt; 2 L/min/m2 received circulatory support. Patients in the POP of cardiac surgery frequently have a mixed shock due to the systemic inflammatory response syndrome (SIRS). Therefore, invasive hemodynamic monitoring is useful in handling blood volume, choice of vasoactive drugs, and indication for circulatory support." }, { "id": "pubmed23n0008_12199", "title": "Septic lung and shock lung in man.", "score": 0.009174311926605505, "content": "Two series of patients were studied by serial measurements of blood gas exchange and pulmonarmonary dysfunction and to evaluate the dangers of respiratory failure in post traumatic patients. There were 27 patients who had sustained profound hemorrhagic shock and massive blood replacement averaging 9.7 liters and 38 patients who suffered general peritonitis or other forms of fulminating nonthoracic sepsis. All were supported by endotrachael intubation and volume controlled ventilators. The overall mortality for the post shock patients without sepsis was 12% while in the septic patients it was 35%. The maximal pulmonary arteriovenous shunt encountered in the post hemorrhagic shock patients at 36 hours averaged 20 plus or minus 8% and was accompanied by high cardiac indices (average 5.1 plus or minus 1.3 L/M-2/min) but no significant rise of pulmonary arterial pressure or peak inspiratory pressure (PIP). Severe pulmonary dysfunction subsequently occurred only in those patients who later became septic. The studies on the septic patients were divided according to the magnitude of the cardiac indices (the high indices averaged 4.8 plus or minus 1.6L/M-2/min) and thelow indices averaged 1.9 plus or minus 1.0 L/M-2/min. In the former, the average maximal shunt of 30 plus or minus 6% was sustained for 4 or more days, accompanied by an elevation of PIP to 36 plus or minus 6 cm H2O and by Pa pressure of 28 plus or minus 5 mm Hg. The patients in low output septic shock usually had an associated bronchopneumonia and had an average venous admixture of 34 plus or minus 8% and PIP values of 41 plus or minus 8 cm H2O. The mean Pa pressure in this group was 29 plus or minus 6 mm Hg." }, { "id": "wiki20220301en145_21192", "title": "Cardiac index", "score": 0.009125586854460094, "content": "Cardiac index (CI) is a haemodynamic parameter that relates the cardiac output (CO) from left ventricle in one minute to body surface area (BSA), thus relating heart performance to the size of the individual. The unit of measurement is litres per minute per square metre (L/min/m2). Calculation The index is usually calculated using the following formula: where CI Cardiac index BSA Body surface area SV Stroke volume HR Heart rate CO Cardiac output Clinical significance The normal range of cardiac index at rest is 2.6–4.2 L/min/m2. The cardiac index is frequently measured and used in both intensive care medicine and cardiac intensive care. The CI is a useful marker of how well the heart is functioning as a pump by directly correlating the volume of blood pumped by the heart with an individual's body surface area. If the CI falls acutely below 2.2 L/min/m2, the patient may be in cardiogenic shock. References Cardiovascular physiology Diagnostic intensive care medicine" }, { "id": "pubmed23n0217_5555", "title": "[Cardiogenic shock in acute myocardial infarct patients].", "score": 0.00909090909090909, "content": "To differentiate between various forms of cardiogenic shock (CS) and to elaborate the criteria of its prognosis, the authors examined 284 patients with acute myocardial infarction (MI) and 30 patients of the control group for the peculiarities of the clinical course of the disease in relation to changes in the hemodynamic parameters and oxygen supply to the tissues. CS was shown to develop more frequently in patients over 64 years of age, with a history of MI and with signs of chronic circulation insufficiency of IIA stage. Late CS more commonly took the true form and was associated with a MI relapse. Reflex CS was characterized by the hyperkinetic variant of the hemodynamics while an arrhythmic one by the congestive variant. Patients with the authentic form of CS were divided into 3 subgroups with different hemodynamic reactions to sympathomimetic amines. In the first day of the disease the coefficient of the tissue extraction of oxygen serves as a significant prognostic criterion which should be determined along with the dynamic measurement of the pump and contractile functions of the heart." }, { "id": "pubmed23n0546_6233", "title": "Hemodynamic effects of monomeric nonionic contrast media in pulmonary angiography in chronic thromboembolic pulmonary hypertension.", "score": 0.009009009009009009, "content": "The purpose of this study was to investigate the hemodynamic safety of the monomeric nonionic contrast agent iomeprol for selective pulmonary angiography in chronic thromboembolic pulmonary hypertension (CTPH), and to investigate the effect of periinterventional oxygen administration. Selective pulmonary digital subtraction angiography was performed in 94 patients with CTPH using six bolus injections of iomeprol (posteroanterior, oblique, and lateral projections; both pulmonary arteries; iomeprol, 25 mL at 13 mL/s). Hemodynamics were obtained with Swan-Ganz catheters, and systolic pulmonary artery pressure (PAsyst) was classified into one of three groups: 30 mm Hg or less (control group), greater than 30 but less than or equal to 60 mm Hg (group 1, moderate pulmonary hypertension), and greater than 60 mm Hg (group 2, severe pulmonary hypertension). At baseline, values for PAsyst were 21.4 +/- 2.3 (control group, n = 8), 49.8+/- 8.5 (group 1, n = 18), and 86.5 +/- 18.9 (group 2, n = 68) mm Hg (p &lt; 0.001). Pulmonary vascular resistance indexes (PVRI) were 222 +/- 105 (control), 703 +/- 364 (group 1), and 1,582 +/- 562 (group 2) dyne x s x cm(-5) x m2 (p &lt; 0.001). The mean cardiac indexes were 3.1 (control), 2.8 (group 1), and 2.3 (group 2) L/min/m2 (p &lt; 0.05). Pulmonary capillary wedge pressure (PCw) indicated healthy left heart function. Periinterventional oxygen inhalation improved oxygen saturation in all groups and slightly reduced pulmonary artery pressure and heart rate. Online measurement of pulmonary artery pressure during contrast bolus injection for angiography showed only a minor increase, predominantly in severe pulmonary hypertension (triangle up [difference] PAsyst: 1.3 +/- 1.9 [control], 2.9 +/- 3.4 [group 1], and 3.8 +/- 4.5 [group 2] mm Hg [p &lt; 0.001]). After completion of angiography, right atrial pressure (RAP) and PAsyst were moderately increased: triangle up RAP: 1.4 (control), 2.6 (group 1, p &lt; 0.001), and 3.0 (group 2, p &lt; 0.001) mm Hg; triangle up PAsyst: 3.2 (control), 7.7 (group 1, p &lt; 0.01), and 8.5 (group 2) mm Hg (p &lt; 0.001). PVRI was significantly higher in group 2 (triangle up PVRI: 188 dyne x s x cm(-5) x m2, p &lt; 0.001). Selective pulmonary angiography using iomeprol is safe without critical pressure peaks during selective contrast bolus injection or significant hemodynamic derangement in severe CTPH. Periinterventional oxygen inhalation improved pulmonary circulation." }, { "id": "pubmed23n0117_3128", "title": "Hemodynamic determinants of mortality in human septic shock.", "score": 0.009009009009009009, "content": "To assess the relative importance of cardiac versus peripheral vascular failure in patients dying of septic shock, a series of 42 patients with documented septic shock was retrospectively evaluated. Patients were included in the study if serial hemodynamic and metabolic studies had been performed: the first one within 12 hours after onset of septic shock and the last one within 12 hours (median 2 hours; range 0.1 to 12 hours) before death in nonsurvivors. Nonsurvivors were included only if they died in shock. From the patient records the first, highest, and last measured cardiac indexes (CI) (t = 1, t = 2, and t = 3) with concomitant hemodynamic and metabolic variables were obtained. Group I (n = 21) consisted of survivors and group II (n = 21) of nonsurvivors. Group II was divided into three subgroups: group IIa (n = 4) consisted of nonsurvivors with liver cirrhosis, group IIb (n = 9) patients with final CI less than 4 1 X min-1 X m-2, and group IIc (n = 8) patients with final CI greater than 4 1 X min-1 X m-2. At t = 1 no significant differences in hemodynamic variables were found between groups I and II, and all patients, whether surviving or not, were able to increase CI to similar levels. At t = 3 group II showed a marked decrease in mean arterial pressure and systemic vascular resistance index compared with group I (p less than 0.001), whereas CI did not differ significantly. The nonsurvivors showed progressive lactic acidemia. Even group IIb patients showed persistent vasodilation despite a decrease in CI. Our data suggest that many patients in septic shock die as a result of peripheral vascular rather than cardiac failure, since persistent vasodilation, irrespective of CI, was a major hemodynamic determinant in nonsurvivors, of whom 57% maintained a high CI until shortly before death." }, { "id": "pubmed23n0234_1162", "title": "Effects of propranolol on the cardiovascular and renin-angiotensin systems during hypotension produced by sodium nitroprusside in humans.", "score": 0.008928571428571428, "content": "The authors examined the effects of controlled hypotension induced with sodium nitroprusside (SNP) with and without propranolol on the cardiovascular, pulmonary, and renin-angiotensin systems in 10 consecutive anesthetized patients with kyphoscoliosis undergoing posterior spinal fusion. SNP infusion (4.1 microgram . kg-1 . min-1) alone decreased mean systemic arterial pressure (SAP) by 25 torr +/- 3 SE (P less than 0.001), systemic vascular resistance index (SVRI) by 1113 dyne . sec. cm-5 . m2 +/- 125 SE (P less than 0.001), mean pulmonary artery pressure (PAP) by 6 torr +/- 2 SE (P less than 0.02), pulmonary capillary wedge pressure (PCWP) by 4 torr +/- 1 SE (P less than 0.01), pulmonary vascular resistance (PVR) by 50 dyne . sec . cm-5 +/- 18 (P less than 0.05), and PaO2 by 16 torr +/- 7 SE (P less than 0.05), whereas cardiac index increased by 1.08 l . min-1 . m2 +/- 0.24 SE (P less than 0.01) and heart rate increased 16 beats/min +/- 5 SE (P less than 0.02). After 40 min of hypotension, 0.03 mg/kg propranolol was injected intravenously while the SNP infusion rate was held constant. Ten min later there was a significant decrease in the heart rate (10 beats/min +/- 4 SE, P less than 0.02) and cardiac index (0.65 l . min-1 . m-2 +/- 0.21, P less than 0.02). Plasma renin activity (PRA) increased from 2.37 ng . ml-1 . h-1 +/- 0.7 SE before anesthesia to 6.50 ng . ml-1 . h-1 +/- 1.45 SE (P less than 0.05) after 40 min of nitroprusside infusion. Forty min after propranolol there was a significant reduction in PRA to 4.07 ng . ml-1 . h-1 +/- 0.73 SE (P less than 0.05). Thus propranolol, when given during SNP hypotension, exhibits an early cardiovascular response manifested as a decrease in cardiac output and heart rate and a delayed action of the kidney resulting in an inhibition of renin release." }, { "id": "pubmed23n0259_11066", "title": "[Importance of oximetry parameters in the detection of hypoxia in the early phase of septic shock].", "score": 0.008928571428571428, "content": "The routinely monitored variables in shock stages include: arterial pressure, heart rate, central venous pressure, pulmonary artery wedge pressure and cardiac index. With vigorous therapy it is possible to bring these values back into the normal range in both survivors and nonsurvivors. The therapeutic goal in septic shock stages is to maximize the values of cardiac index, O2 delivery (DO2) and O2 consumption (CO2). The aim of this study is to determine the relationship between O2 delivery and O2 consumption as an early sign of hypoxia. Fifteen patients with septic shock were treated in order to maximize the value of CI, DO2 and VO2. We compared the levels of these parameters between the survivors and nonsurvivors and found no significant differences after 24 hours. High levels of DO2 and VO2 do not exclude tissue hypoxia in the early stage of septic shock." }, { "id": "pubmed23n0053_8559", "title": "Myocardial depression characterizes the fatal course of septic shock.", "score": 0.008849557522123894, "content": "The relationship between cardiac and vascular abnormalities was studied in 68 patients with established septic shock. At time of hemodynamic evaluation, after initial resuscitation, there was no significant difference in arterial pressure, pulmonary artery pressure, cardiac filling pressures, and cardiac index between the 38 survivors of shock and the 30 patients who died of shock, but the left ventricular stroke work index and the right ventricular (RV) stroke work index were higher in survivors than in those who died (mean +/- SD: 25.0 +/- 9.1 vs 20.1 +/- 9.4 gm/m2 [p less than 0.05] and 6.6 +/- 3.6 vs 4.8 +/- 2.8 gm/m2 [p less than 0.05], respectively). Survivors had also higher thermodilution RV ejection fraction and lower RV end-diastolic volumes than had those who died (43.9% +/- 16.3% vs 31.1% +/- 13.7% [p less than 0.01] and 82 +/- 30 vs 99 +/- 31 ml/m2 [p less than 0.05], respectively). Calculated systemic vascular resistance was similar in the two groups, but vasopressors had been required in 22 (58%) of 38 survivors and 25 (83%) of 30 patients who died (p less than 0.01). Moreover, when the patients were separated into two groups according to their cardiac output, higher or lower than 3 L/min/m2, in both subgroups patients who died had lower blood pressure than had survivors. Blood lactate levels were significantly lower in survivors than in nonsurvivors (5.1 +/- 2.1 vs 8.1 +/- 4.7 mEq/L, p less than 0.01). Final data obtained before recovery of shock or death indicated that the survivors had higher arterial pressure, lower pulmonary artery pressure and right atrial pressure, higher stroke volume, and higher RV ejection fraction than had the patients who died. No survivors but all patients who died had been treated with vasopressors. These data therefore indicate that death as a result of septic shock is characterized by both myocardial depression and altered vascular tone and both are probably interrelated." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 181 ] ], "word_ranges": [ [ 0, 29 ] ], "text": "The data provided on the characteristics of the murmur (it DECREASES with Valsalva) and the data on left ventricular hypertrophy, lead us to the diagnosis of severe aortic stenosis." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The clinical picture suggests pulmonary thromboembolism.", "2": "The data provided indicate hypertrophic cardiomyopathy with severe obstruction of the left ventricular outflow tract.", "3": "These data correspond to severe aortic stenosis.", "4": "Aortic dissection should be excluded by contrast-enhanced computed tomography.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0239_7163", "title": "[Differential diagnosis of obstructions to left ventricular outflow (author's transl)].", "score": 0.013817663817663818, "content": "A total of 127 patients with different forms of obstruction to left ventricular outflow are studied. There were eight cases with supravalvular aortic stenosis, 79 with valvular aortic stenosis, 25 with hypertrophic subaortic stenosis, and 15 with subvalvular aortic stenosis. Clinical findings and electrocardiographic, radiographic, and angiohemodynamic data corresponding to these groups are reported, as well as the differential characteristics for each category from a clinical, electrocardiographic and radiographic point of view. The presence of a typical face, asymmetrical carotid and brachial pulses, absence of aortic ejection click and little or no aortic button on the chest roentgenogram reveals a supravalvular aortic stenosis. Valvular aortic stenosis shows aortic ejection click, poststenotic dilation of the ascending aorta, electrocardiographic signs of left ventricular hypertrophy and associated aortic regurgitation. Hypertrophic subaortic stenosis is characterized by a typical arterial pulse, marked \"a\" wave in the jugular venous pulse, double apical impulse on palpation and appearance or modification of the systolic ejection sound with Valsalva's maneuver." }, { "id": "pubmed23n0107_8010", "title": "[Advanced sequelae of apical hypertrophic cardiomyopathy: report of two cases with wall motion abnormalities].", "score": 0.01361875637104995, "content": "In view of the paucity of reports describing symptoms of increased degree, and deterioration of left ventricular systolic function in patients with apical hypertrophic cardiomyopathy (apical HCM), two cases with congestive heart failure and progressive thinning of previously hypertrophied apical portions of the left ventricle are reported. These were among 13 patients observed from eight to 10 years. Case 1: A 56-year-old man was diagnosed as having apical HCM at the age of 49 years. Severe left ventricular hypertrophy and prominent ST-T changes were observed on ECG during his first admission. His left ventricular end-diastolic pressure (LVEDP) was 24 mmHg and a left ventriculo-gram revealed a decrease in the left ventricular cavity in the apex and marked hypertrophy of the apical wall. Moderate interstitial fibrosis without hypertrophy or disarray of myocytes was observed in a left ventricular endomyocardial biopsy specimen. In two episodes of cardiac arrest he was successfully resuscitated at the age of 50 years. At the age of 55 years, two-dimensional echocardiography revealed thinning and abnormal motion in the apical wall, and a defect in 201T1 accumulation was observed in the same region by perfusion scintigraphy. This patient was readmitted with a diagnosis of cerebral embolism at the age of 56 years. Cardiac catheterization revealed normal LVEDP (8 mmHg), and a left ventriculogram revealed an aneurysm in the left ventricular apex with normal major epicardial coronary arteries. He has been under treatment with antiarrhythmic medications, calcium antagonists and anticoagulants, and has become relatively asymptomatic. Case 2: A 69-year-old-man was diagnosed as having apical HCM after a complete evaluation, including cardiac catheterization, at the age of 59 years. His LVEDP was elevated (17 mmHg), and a left ventricular angiogram revealed marked hypertrophy localized to the apex. Ejection fraction was 64%. A left ventricular endomyocardial biopsy revealed interstitial fibrosis without hypertrophy of myocytes. Thereafter, he has been followed as a New York Heart Association functional class III to IV with occasional elevation of cardiac enzymes but without chest pain or acute changes in his ECGs. However, atrial fibrillation with complete right bundle branch block developed at the age of 60 years. Apical wall thinning and dyskinesis were diagnosed by 2D echocardiography and a defect in the 201T1 accumulation was observed at about 65 years of age. He was readmitted in severe cardiac failure at the age of 69 years, and he was diagnosed as having cardiac asthma with pulmonary capillary wedge pressure of 35 mmHg.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0114_8764", "title": "[Hypertrophic cardiomyopathy manifesting different modes of illness: report of three cases].", "score": 0.013469387755102041, "content": "Three cases of hypertrophic cardiomyopathy (HCM) which presented with different modes of appearance of left ventricular hypertrophy are reported. Case 1: A 24-year-old man had three relatives with HCM. At 13 years of age, he showed no electrocardiographic or echocardiographic abnormalities characteristic of HCM. During the ensuing 11 years, he developed asymmetric septal hypertrophy (ASH) and systolic anterior motion of the mitral valve (SAM), with right bundle branch block and T-wave inversion. Cardiac catheterization confirmed the diagnosis of hypertrophic obstructive cardiomyopathy by demonstrating an intraventricular pressure gradient of 25 mmHg. These observations indicate that this case developed abnormal hypertrophy during adolescence on the basis of genetic predisposition of an autosomal dominant trait. Case 2: A 51-year-old woman had three proven and three possibly affected relatives. At 35 years of age, she had a normal electrocardiogram, although the echocardiogram was not available. Now, 16 years later, she had developed ASH with abnormal Q-waves and was diagnosed as having non-obstructive HCM. These suggest that ASH can be manifested as late as during middle-age, even in those with genetic predisposition. Case 3: A 47-year-old woman was diagnosed as having hypertension and her blood pressure was 190/100 mmHg at 40 years of age, though she had no abnormal electrocardiographic findings and heart murmurs. Now, at 47 years of age, she had developed T-wave inversion, ASH, SAM, and an intraventricular pressure gradient of 50 mmHg. Thus, her ASH appeared during middle-age, and was probably provoked by hypertension, though a complete family survey could not be conducted. These three patients' findings indicate that there may be various modes of appearance of left ventricular hypertrophy in HCM. In the majority of patients with genetic predisposition, abnormal hypertrophy may develop during adolescence as in Case 1. In others, it may develop in middle-age, as it did in Case 2. The disease spectrum of HCM may additionally include those who develop abnormal hypertrophy during middle-age, following provocation by hypertension, as in Case 3." }, { "id": "pubmed23n0270_2738", "title": "[Functional maneuvers for the diagnosis of hypertrophic cardiomyopathies with and without left ventricular outflow obstruction].", "score": 0.013462217514124294, "content": "to assess the diagnostic value of the commonly adopted haemodynamic criteria for the diagnosis of obstructive and non-obstructive hypertrophic cardiomyopathy. 16 cases of hypertrophic cardiomyopathy, 7 cases of the non-obstructive form, 16 fixed subaortic stenosis, 8 valvular aortic stenosis, and 7 cases of hypertensive heart disease. left and right heart catheterisation, with particular attention to the pressure gradient and to the aortic pulse pressure by means of simultaneous pressure recording from the left ventricle and aorta under basal conditions, after a ventricular premature beat, during the Valsalva manoeuvre, during amyl nitrite inhalation, and isoproterenol administration. the Valsalva manoeuvre increases significantly (p &lt; 0.001) the pressure gradient, and the aortic pulse pressure in the post-extrasystolic beat decreases significantly (p &lt; 0.001) in patients with hypertrophic obstructive cardiomyopathy. This response is significantly different from that of the other 3 disease groups. If the non-obstructive form is defined by strict criteria (i.e. no gradient above 30 mmHg even after provocative manoeuvres), then it cannot be separated from other forms of secondary left ventricular hypertrophy." }, { "id": "wiki20220301en024_55490", "title": "Aortic regurgitation", "score": 0.012673436167738934, "content": "If there is increased stroke volume of the left ventricle due to volume overload, an ejection systolic 'flow' murmur may also be present when auscultating the same aortic area. Unless there is concomitant aortic valve stenosis, the murmur should not start with an ejection click. There may also be an Austin Flint murmur, a soft mid-diastolic rumble heard at the apical area; it appears when a regurgitant jet of blood from severe aortic regurgitation partially closes the anterior mitral leaflet. Peripheral physical signs of aortic regurgitation are related to the high pulse pressure and the rapid decrease in blood pressure during diastole due to blood returning to the heart from the aorta through the incompetent aortic valve, although the usefulness of some of the eponymous signs has been questioned: Phonocardiograms detect AI by having electric voltage mimic the sounds the heart makes. Characteristics- indicative of aortic regurgitation are as follow:" }, { "id": "wiki20220301en439_14516", "title": "Pressure overload", "score": 0.012419881786667333, "content": "Signs and symptoms A forceful apex beat indicates left ventricular pressure overload, while a right ventricular heave suggests right ventricular pressure overload. Other signs provide evidence for specific causes of pressure overload. Hypertension is diagnosed by sphygmomanometry. A narrow pulse pressure is a sign of aortic stenosis. The chest x-ray may show pulmonary hyperaemia in the case of pulmonary hypertension, and pulmonary oligemia in pulmonary stenosis. Pulmonary hypertension is also associated with chronic lung disease. Coarctation of the aorta presents with a significant difference in blood pressure between the upper and lower limbs, a systolic murmur or radiofemoral delay. Causes Any obstruction to the outflow of one of the chambers of the heart can lead to pressure overload. Left ventricular pressure overload Aortic stenosis Hypertension Coarctation of the aorta Right ventricular pressure overload Pulmonary stenosis Pulmonary hypertension Treatment" }, { "id": "wiki20220301en011_153783", "title": "Heart murmur", "score": 0.01239123912391239, "content": "Tricuspid valve regurgitation presents as a holosystolic (pansystolic) murmur at the left lower sternal border with radiation to the left upper sternal border. Prominent v and c waves may be seen in the JVP (jugular venous pressure). The murmur will increase with inspiration. Hypertrophic obstructive cardiomyopathy (or hypertrophic subaortic stenosis) will be a systolic crescendo-decrescendo murmur best heard at the left lower sternal border. Valsalva maneuver will increase the intensity of the murmur, as will changing positions from squatting to standing. Atrial septal defect will present with a systolic crescendo-decrescendo murmur best heard at the left upper sternal border due to increased volume going through the pulmonary valve, and is associated with a fixed, split S2 and a right ventricular heave." }, { "id": "InternalMed_Harrison_17806", "title": "InternalMed_Harrison", "score": 0.012055821492794366, "content": "and left ventricles with inspiration (right ventricular systolic pressure increases while left ventricular systolic pressure decreases) are observed. The latter hemodynamic phenomenon is the most specific for constriction. Restrictive cardiomyopathy may be distinguished from constrictive pericarditis by a marked increase in right ventricular and pulmonary artery systolic pressures (usually >60 mmHg), a separation of the left and right ventricular diastolic pressures by and magnitude of the pressure waveforms provide important diag->5 mmHg (at baseline or with acute volume loading), and concordant nostic information; an example of normal pressure tracings is shown changes in left and right ventricular diastolic filling pressures with in Fig. 272-1. In the absence of valvular heart disease, the atria and inspiration (both increase). ventricles are “one chamber” during diastole when the tricuspid and mitral valves are open while in systole, when the pulmonary and aortic Cardiac Output" }, { "id": "InternalMed_Harrison_2892", "title": "InternalMed_Harrison", "score": 0.012014080195898377, "content": "CHAPTER 51e Approach to the Patient with a Heart Murmur PART 2 Cardinal Manifestations and Presentation of Diseases FIguRe 51e-2 Maximal intensity and radiation of six isolated systolic murmurs. HOCM, hypertrophic obstructive cardiomyopathy; MR, mitral regurgitation; Pulm, pulmonary stenosis; Aortic, aortic stenosis; VSD, ventricular septal defect. (From JB Barlow: Perspectives on the Mitral Valve. Philadelphia, FA Davis, 1987, p 140.) during the respiratory cycle and the performance of simple bedside maneuvers complete the auscultatory examination. These features, along with recommendations for further testing, are discussed below in the context of specific systolic, diastolic, and continuous heart murmurs (Table 51e-1)." }, { "id": "InternalMed_Harrison_2910", "title": "InternalMed_Harrison", "score": 0.01198512585812357, "content": "The mid-systolic, crescendo-decrescendo murmur of congenital pulmonic stenosis (PS, Chap. 282) is best appreciated in the second and third left intercostal spaces (pulmonic area) (Figs. 51e-2 and 51e-4). The duration of the murmur lengthens and the intensity of P2 diminishes with increasing degrees of valvular stenosis (Fig. 51e1D). An early ejection sound, the intensity of which decreases with inspiration, is heard in younger patients. A parasternal lift and ECG evidence of right ventricular hypertrophy indicate severe pressure overload. If obtained, the chest x-ray may show poststenotic dilation of the main pulmonary artery. TTE is recommended for complete characterization. Significant left-to-right intracardiac shunting due to an ASD (Chap. 282) leads to an increase in pulmonary blood flow and a grade 2–3 mid-systolic murmur at the middle to upper left sternal border CHAPTER 51e Approach to the Patient with a Heart Murmur" }, { "id": "pubmed23n0218_2527", "title": "A catheter-induced syncopal attack in a case of hypertrophic obstructive cardiomyopathy.", "score": 0.011933581097207543, "content": "A 48-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) was studied by serial cardiac catheterization during incidentally induced syncope. His hospital admission was for repeated syncopal attacks and chest pain. His electrocardiogram showed giant negative T waves (greater than 10 mm) in V3, V4 and V5 leads, and his M-mode echocardiogram disclosed typical asymmetric septal hypertrophy, systolic anterior movement of the mitral valve, and a midsystolic semiclosure of the aortic valve. During cardiac catheterization, we incidentally induced syncope and recorded the serial pressure changes. During syncope, systemic blood pressure dropped without appreciable changes in pulmonary arterial and right ventricular pressures. Although blood pressure was maintained by administering etilefrine and hydrocortisone, syncope persisted. After administration of propranolol, he recovered from syncope. He was on sinus rhythm throughout the examinations. The ejection time (ET) obtained from the aortic pressure curve was extremely short (160 msec) during syncope and prolonged (300 msec) after recovery without significant change in the heart rate. We believe that the prompt intravenous administration of propranolol was very effective in relieving myocardial spasm as a possible cause of syncope." }, { "id": "wiki20220301en345_35423", "title": "Handgrip maneuver", "score": 0.011915985753195055, "content": "Murmurs that are due to forward flowing of blood such as aortic stenosis, and hypertrophic cardiomyopathy decrease in intensity. The effect of reducing the intensity in forward flowing murmurs is much more evident in aortic stenosis rather than mitral stenosis. The reason for this is that there is a larger pressure gradient across the aortic valve. A complementary maneuver for differentiating disorders is the Valsalva maneuver, which decreases preload. See also Valsalva maneuver Preload Afterload References Cardiac procedures" }, { "id": "InternalMed_Harrison_17463", "title": "InternalMed_Harrison", "score": 0.01191044436867826, "content": "Systolic murmurs can be early, mid, late, or holosystolic in timing (Fig. 267-5). Acute severe MR results in a decrescendo early systolic murmur, the characteristics of which are related to the progressive attenuation of the left ventricular to left atrial pressure gradient during systole because of the steep and rapid rise in left atrial pressure in this context. Severe MR associated with posterior leaflet prolapse or flail radiates anteriorly and to the base, where it can be confused with the murmur of AS. MR that is due to anterior leaflet involvement radiates posteriorly and to the axilla. With acute TR in patients with normal pulmonary artery pressures, an early systolic murmur that may increase in intensity with inspiration may be heard at the left lower sternal border, with regurgitant cv waves visible in the jugular venous pulse." }, { "id": "InternalMed_Harrison_17466", "title": "InternalMed_Harrison", "score": 0.011882572227399813, "content": "FIGURE 267-5 A. Top. Graphic representation of the systolic pressure difference (green shaded area) between left ventricle and left atrium with phonocardiographic recording of a holosystolic murmur (HSM) indicative of mitral regurgitation. ECG, electrocardiogram; LAP, left atrial pressure; LVP, left ventricular pressure; S1, first heart sound; S2 second heart sound. Bottom. Graphic representation of the systolic pressure gradient (green shaded area) between left ventricle and aorta in patient with aortic stenosis. A midsystolic murmur (MSM) with a crescendo-decrescendo configuration is recorded. AOP, aortic pressure. B. Top. Graphic representation of the diastolic pressure difference between the aorta and left ventricle (blue shaded area) in a patient with aortic regurgitation, resulting in a decrescendo, early diastolic murmur (EDM) beginning with A2. Bottom. Graphic representation of the diastolic left atrial–left ventricular gradient (blue areas) in a patient with mitral stenosis" }, { "id": "pubmed23n0134_16807", "title": "Main systolic blood flow patterns in the left and right ventricular outflow tracts determined by Doppler echocardiography.", "score": 0.011858974358974358, "content": "The main blood flow velocity patterns in the LVOT and RVOT were recorded by pulsed Doppler echocardiography in 28 normal healthy cases, in two athletes, and in 85 patients with atrial septal defects, pulmonary regurgitation, tetralogy of Fallot, aortic regurgitation, mitral stenosis, aortic stenosis, mitral regurgitation, hypertrophic cardiomyopathy, ischemic heart disease, and pulmonary hypertension. Blood flow velocities were displayed using a graphic system to form a real time sonogram, using Fast Fourier Transformation. In the normal group, the blood flow velocity was 1.69 KHz in LVOT, and 1.71 KHz in RVOT. In AR and T/F but not MS, there was high blood flow velocity in the LVOT, and the peak of blood flow velocity was shifted to mid-to late systole. In ASD and VSD with a L-R shunt, high blood flow velocity occurred in the RVOT, and the peak velocity shifted to early systole. Pulmonary hypertension occasionally produced a W- or V-shaped curve. In normal subjects, a small \"a\" wave could be detected in the LVOT recording. The \"a\" wave began at point B on the AML tracer of the M-mode echocardiography, reached maximum velocity at point C, and returned to zero (baseline) at point C'. The \"a\" wave was coincident with the R wave of the ECG, and with the Ia of the phonocardiogram (PCG). The normal velocity of the \"a\" wave was 602 Hz, and the a/H ratio was 0.36. In cases of HCM and IHD, the \"a\" wave velocity and the a/H ratio correlated with the end diastolic pressure and the peak dP/dT. These data suggest that the Doppler blood flow patterns in the LVOT and RVOT can indicate volume overload in the right and left ventricles, and that the \"a\" wave velocity and a/H ratio can provide new information concerning cardiac performance." }, { "id": "wiki20220301en014_34391", "title": "Valsalva maneuver", "score": 0.01178138010452653, "content": "Medical diagnostics Cardiology The maneuver can sometimes be used to diagnose heart abnormalities, especially when used in conjunction with an echocardiogram. For example, the Valsalva maneuver (phase II) increases the intensity of hypertrophic cardiomyopathy murmurs, namely those of dynamic subvalvular left ventricular outflow obstruction. At the same time, the Valsalva maneuver (phase II) decreases the intensity of most other murmurs, including aortic stenosis and atrial septal defect. During the first few seconds of the Valsalva maneuver (phase I) the opposite findings will be the case." }, { "id": "wiki20220301en046_22775", "title": "Exercise intolerance", "score": 0.011690073412065113, "content": "Hazards Certain conditions exist where exercise may be contraindicated or should be performed under the direction of an experienced and licensed medical professional acting within his or her scope of practice. These conditions include: Decompensated heart failure Recent myocardial infarction Hypertrophic cardiomyopathy or cardiomyopathy from recent myocarditis Active or suspected myocarditis or pericarditis Low left-ventricular ejection fraction (LVEF) Severe aortic stenosis Unstable ischemia Unstable arrythmia Irregular or resting pulse greater than 100 bpm Resting systolic blood pressure >200 mm Hg or resting diastolic blood pressure >110 mm Hg Severe pulmonary hypertension Chronic fatigue syndrome Suspected or known dissecting aortic aneurysm Recent systemic or pulmonary embolus Pneumothorax and haemoptysis Thrombophlebitis" }, { "id": "InternalMed_Harrison_17775", "title": "InternalMed_Harrison", "score": 0.011390772757665488, "content": "Figure 271e-12 A 70-year-old patient with known cardiac murmur and progressive shortness of breath and a recent episode of syncope. Echocardiography shows severe calcific aortic stenosis. A heavily calcified aortic valve (arrow) is shown in the parasternal long-axis views (top panels) and short-axis view (bottom left). Doppler interrogation shows a peak transaortic velocity of 5.2 m/s consistent with a peak instantaneous gradient of 109 mmHg and a mean gradient of 66 mmHg, and a corresponding aortic valve area of <0.6 cm2 (lower right). Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle. (See Videos 271e-8, 271e-9, and 271e-10.)" }, { "id": "pubmed23n0111_14265", "title": "Increased intensity of the murmur of hypertrophic obstructive cardiomyopathy with carotid sinus pressure.", "score": 0.011167102152544482, "content": "In a prospective study murmurs increased in intensity with carotid sinus pressure in 18 of 26 patients with hypertrophic obstructive cardiomyopathy (HOCM) (sensitivity, 69.2 percent for the 26 patients, 85.7 percent for the 21 patients in whom heart rate and blood pressure decreased with carotid sinus pressure). On the other hand, the murmur remained constant or decreased in all but one of 104 patients with valvular aortic stenosis, mitral insufficiency, hypertrophic nonobstructive cardiomyopathy, and systolic murmurs of miscellaneous origins (specificity, 99 percent; positive predictive value, 94.7 percent). Catheterization, indirect arterial pressure tracings, and echocardiographic studies indicated that carotid sinus pressure-induced bradycardia was associated with increased left ventricular outflow tract obstruction. The carotid sinus pressure-induced increase in the murmur is probably multifactorial: decreased aortic pressure and impedance; increased contractility immediately on sudden slowing of heart rate; further increase in obstruction as the mitral valve systolic anterior movement is enhanced; and delayed vasodilatation maintaining the obstruction even after return of heart rate to precarotid sinus pressure values. An increase in a systolic murmur with carotid sinus pressure is characteristic of HOCM." }, { "id": "article-41801_10", "title": "Vital Sign Assessment -- Clinical Significance -- Pulse Rate", "score": 0.011051713679102213, "content": "Assessing whether the rhythm of the pulse is regular or irregular is essential. The pulse could be regular, irregular, or irregularly irregular. Changes in the rate of the pulse, along with changes in respiration are called sinus arrhythmia. In sinus arrhythmia, the pulse rate becomes faster during inspiration and slows down during expiration. Irregularly irregular pattern is more commonly indicative of processes like atrial flutter or atrial fibrillation. We should also be checking for the radial and the femoral pulse simultaneously. If there is any delay between the pulses, it could indicate conditions like the coarctation of the aorta. Assessing the volume of the pulse is equally essential. A low volume pulse could be indicative of inadequate tissue perfusion; this can be a crucial indicator of indirect prediction of the systolic blood pressure of the patient. If we can palpate the radial pulse, the systolic blood pressure is generally more than 80 mmHg. If we can palpate the femoral pulse, the systolic blood pressure is more than 70 mmHg, and if we can palpate the carotid pulse, the systolic blood pressure is more than 60 mmHg. [10] Checking for symmetry of the pulses is important as asymmetrical pulses could be seen in conditions like aortic dissection, aortic coarctation, Takayasu arteritis, and subclavian steal syndrome. Besides the above-stated parameters, amplitude and rate of increase is also an important consideration. Low amplitude and low rate of increase could be seen in conditions like aortic stenosis, besides weak perfusion states. High amplitude and rapid rise can be indicative of conditions like aortic regurgitation, mitral regurgitation, and hypertrophic cardiomyopathy." }, { "id": "InternalMed_Harrison_20985", "title": "InternalMed_Harrison", "score": 0.010826947068258777, "content": "Diagnosis Due to the unstable condition of these patients, supportive therapy must be initiated simultaneously with diagnostic evaluation (Fig. 326-2). A focused history and physical examination should be performed, blood specimens sent to the laboratory, and an electrocardiogram (ECG) and chest x-ray obtained. Etiologies of Cardiogenic Shock or Pulmonary Edema Acute myocardial infarction/ischemia LV failure Ventricular septal rupture Papillary muscle/chordal rupture–severe MR Ventricular free wall rupture with subacute tamponade Other conditions complicating large MIs Post-cardiac arrest Post-cardiotomy Refractory sustained tachyarrhythmias Acute fulminant myocarditis End-stage cardiomyopathy LV apical ballooning Takotsubo’s cardiomyopathy Hypertrophic cardiomyopathy with severe outflow obstruction Aortic dissection with aortic insufficiency or tamponade Severe valvular heart disease Other Etiologies of Cardiogenic Shockb RV failure due to:" }, { "id": "wiki20220301en068_46138", "title": "Cardiac examination", "score": 0.010777777777777778, "content": "Finally the sacrum and ankles are checked for pitting edema which is caused by right ventricular failure in isolation or as part of congestive cardiac failure. Auscultation One should comment on S1 and S2 – if the splitting is abnormal or louder than usual. S3 – the emphasis and timing of the syllables in the word Kentucky is similar to the pattern of sounds in a precordial S3. S4 – the emphasis and timing of the syllables in the word Tennessee is similar to the pattern of sounds in a precordial S4. If S4 S1 S2 S3 Also known as a gallop rhythm. diastolic murmurs (e.g. aortic regurgitation, mitral stenosis) systolic murmurs (e.g. aortic stenosis, mitral regurgitation) pericardial rub (suggestive of pericarditis) The base of the lungs should be auscultated for signs of pulmonary oedema due to a cardiac cause such as bilateral basal crepitations." }, { "id": "InternalMed_Harrison_2937", "title": "InternalMed_Harrison", "score": 0.010590673575129534, "content": "It is usually of grade 1 or 2 intensity but may be absent when the cardiac output is severely reduced despite significant obstruction. The intensity of the murmur increases during maneuvers that increase cardiac output and mitral valve flow, such as exercise. The duration of the murmur reflects the length of time over which left atrial pressure exceeds left ventricular diastolic pressure. An increase in the intensity of the murmur just before S1, a phenomenon known as presystolic accentuation (Figs. 51e-1A and 51e-6), occurs in patients in sinus rhythm and is due to a late increase in transmitral flow with atrial contraction. Presystolic accentuation does not occur in patients with atrial fibrillation." }, { "id": "InternalMed_Harrison_19088", "title": "InternalMed_Harrison", "score": 0.010577951364671967, "content": "Palpation may reveal cardiac enlargement and abnormal contraction of the cardiac impulse (left ventricular dyskinesia). Auscultation can uncover arterial bruits, a third and/or fourth heart sound, and, if acute ischemia or previous infarction has impaired papillary muscle function, an apical systolic murmur due to mitral regurgitation. These auscultatory signs are best appreciated with the patient in the left lateral decubitus position. Aortic stenosis, aortic regurgitation (Chap. 283), pulmonary hypertension (Chap. 304), and hypertrophic cardiomyopathy (Chap. 287) must be excluded, since these disorders may cause angina in the absence of coronary atherosclerosis. Examination during an anginal attack is useful, since ischemia can cause transient left ventricular failure with the appearance of a third 1582 and/or fourth heart sound, a dyskinetic cardiac apex, mitral regurgitation, and even pulmonary edema. Tenderness of the chest wall, localization of the discomfort with a single" }, { "id": "wiki20220301en011_153779", "title": "Heart murmur", "score": 0.010549662487945997, "content": "Abrupt standing Squatting, by increasing afterload and increasing preload. Handgrip maneuver, by increasing afterload Valsalva maneuver. One study found the Valsalva maneuver to have a sensitivity of 65%, specificity of 96% in detecting hypertrophic obstructive cardiomyopathy (HOCM). Both standing and Valsalva maneuver will decrease venous return and subsequently decrease left ventricular filling, resulting in an increase in the loudness of the murmur of hypertrophic cardiomyopathy, since outflow obstruction is increased by decreasing preload. Alternatively, squatting increases systemic vascular resistance, increasing afterload and helping to hold the obstruction in a more open configuration, decreasing the murmur. Maximum handgrip exercise also results in a decrease in the loudness of the murmur. Post ectopic potentiation" }, { "id": "pubmed23n0882_5825", "title": "77-year-old female with syncope.", "score": 0.010395414359273292, "content": "A 77-year-old female was referred for evaluation of an episode of syncope while eating breakfast. There was no history of fall, syncope, prodrome, dyspnoea, chest discomfort or palpitations. Medical history was notable for hyperlipidaemia and treated hypertension. Blood pressure was 140/90 mm Hg, pulse 85  beats per minute (BPM). No murmurs were present on cardiac examination. ECG revealed normal sinus rhythm with left ventricular (LV) hypertrophy (see online supplementary figure S1). Holter monitor demonstrated rare premature ventricular complexes (&lt;1% of beats), without heart block or ventricular tachycardia. Transthoracic echocardiogram is shown in figure 1. Which of the following is the explanation for the flow indicated by the yellow arrow? Aortic stenosisCoronary artery flow, indicative of coronary fistulaHypertrophic cardiomyopathy with apical pouchHypertensive heart diseaseMitral stenosis." }, { "id": "InternalMed_Harrison_2904", "title": "InternalMed_Harrison", "score": 0.01020047467555421, "content": "Tricuspid regurgitation (TR) with normal pulmonary artery pressures, as may occur with infective endocarditis, may produce an early systolic murmur. The murmur is soft (grade 1 or 2), is best heard at the lower left sternal border, and may increase in intensity with inspiration (Carvallo’s sign). Regurgitant “c-v” waves may be visible in the jugular venous pulse. TR in this setting is not associated with signs of right heart failure. Mid-Systolic Murmurs Mid-systolic murmurs begin at a short interval after , end before S (Fig. 51e-1C), and are usually crescendo-decrescendo in configuration. Aortic stenosis is the most common cause of a mid-systolic murmur in an adult. The murmur of AS is usually loudest to the right of the sternum in the second intercostal space (aortic area, Fig. 51e-2) and radiates into the carotids. Transmission of the mid-systolic murmur to the apex, where it becomes higher-pitched, is common (Gallavardin effect; see above)." }, { "id": "pubmed23n0087_17839", "title": "[The clinical significance of the audible and mechanographic manifestations of mitral valve prolapse].", "score": 0.009900990099009901, "content": "Graphic techniques were employed to examine 82 patients with mitral valve prolapse verified on echocardiography. In addition to the known acoustic symptoms, enhancement of tones III, IV and V was identified, especially in transmitral regurgitation, together with inverted alternating of the components of tones I and II. Mitral click (OS) was discovered in one third of the examined. Uninterrupted protodiastolic and presystolic murmurs were found more seldom. They were more well-defined on the phonocardiogram recorded from the esophagus, at the level of the mitral valve. The right and left ventricular apex cardiography made it possible to diagnose hyperdynamia of the left atrium, the shortening of isometric relaxation of the left ventricle on elongation of this phase of the right ventricle. Both the curves had the M-like deformation in the systole. On the apex cardiogram of the left ventricle, the O point was always low, and the OF amplitude (rapid ventricular filling) was increased. During regurgitation, the OF transformed to an anomalous positive wave (a \"surge\"). Simultaneous alterations in the jugular phlebogram and in both apex cardiograms reflect changes in all four heart chambers. In part of the examined, pulmonary hypertension was established with the aid of indirect techniques. Esophagoatriography turned out diagnostically instrumental, since in some of the patients it enabled identification of systolic expansion of the entire posterior wall of the left atrium (regurgitation)." }, { "id": "wiki20220301en026_53746", "title": "Cardiac stress test", "score": 0.009819967266775777, "content": "Absolute contraindications to cardiac stress test include: Acute myocardial infarction within 48 hours Unstable angina not yet stabilized with medical therapy Uncontrolled cardiac arrhythmia, which may have significant hemodynamic responses (e.g. ventricular tachycardia) Severe symptomatic aortic stenosis, aortic dissection, pulmonary embolism, and pericarditis Multivessel coronary artery diseases that have a high risk of producing an acute myocardial infarction Decompensated or inadequately controlled congestive heart failure Uncontrolled hypertension (blood pressure>200/110mm Hg) Severe pulmonary hypertension Acute aortic dissection Acutely ill for any reason Indications for termination: A cardiac stress test should be terminated before completion under the following circumstances:" }, { "id": "wiki20220301en083_13382", "title": "Pulsus bisferiens", "score": 0.00980392156862745, "content": "Pulsus bisferiens, also known as biphasic pulse, is an aortic waveform with two peaks per cardiac cycle, a small one followed by a strong and broad one. It is a sign of problems with the aorta, including aortic stenosis and aortic regurgitation, as well as hypertrophic cardiomyopathy causing subaortic stenosis. Pathogenesis In hypertrophic cardiomyopathy, there is narrowing of the left ventricular outflow tract (LVOT) due to hypertrophy of the interventricular septum. During systole, the narrowing of the LVOT creates a more negative pressure due to the Venturi effect and sucks in the anterior mitral valve leaflet. This creates a transient occlusion of the LVOT, causing a midsystolic dip in the aortic waveform. Towards the end of systole, the ventricle is able to overcome the obstruction to cause the second rise in the aortic waveform." }, { "id": "pubmed23n0934_19979", "title": "Man in his 50s with chest pain and dyspnoea.", "score": 0.00980392156862745, "content": "A man in his 50s with sudden-onset chest pain and dyspnoea was transferred to the emergency room. He had a history of aortic valve replacement due to aortic regurgitation with a mechanical valve 6 years previously. Heart rate was 90 bpm, and blood pressure was too low to measure. In the emergency room, he presented with severe dyspnoea and a chest X-ray showed severe lung congestion (figure 1A). ECG showed complete left bundle branch block. His respiratory status rapidly worsened, and he went into cardiopulmonary arrest. After cardiopulmonary resuscitation, transthoracic echocardiography was performed (figure 1B, online supplementary video 1).DC1SP110.1136/heartjnl-2017-312477.supp1Supplementary file 1 heartjnl;104/10/868/F1F1F1Figure 1(A) Chest X-ray. (B) Colour Doppler image from apical five-chamber view. What is the most likely cause of the patient's cardiopulmonary arrest?Myocardial infarction in left main trunkAortic dissectionProsthetic valve thrombosisProsthetic valve embolisationPulmonary embolism." }, { "id": "wiki20220301en042_29388", "title": "T wave", "score": 0.009708737864077669, "content": "Hypertrophic cardiomyopathy is the thickening of the left ventricle, occasionally right ventricle. It may be associated with left ventricular outflow tract obstruction or may not be associated with it in 75% of the cases. ECG would be abnormal in 75 to 95% of the patients. Characteristic ECG changes would be large QRS complex associated with giant T wave inversion in lateral leads I, aVL, V5, and V6, together with ST segment depression in left ventricular thickening. For right ventricular thickening, T waves are inverted from V1 to V3 leads. ST and T waves changes may not be apparent in hypertrophic cardiomyopathy, but if there is presence of ST and T waves changes indicates severe hypertrophy or ventricular systolic dysfunction. According to Sokolow-Lyon criterion, the height of R wave in V5 or V6 + the height of S wave in V1 more than 35 mm would be suggestive of left ventricular hypertrophy." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 39 ] ], "word_ranges": [ [ 0, 4 ] ], "text": "VVI pacemaker (ventricular unicameral)." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "DDD pacemaker (bicameral).", "2": "VVI pacemaker (ventricular unicameral).", "3": "AAI pacemaker (single-chamber atrial pacemaker).", "4": "Ventricular resynchronization therapy (CRT).", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0698_22644", "title": "Current concepts in pacing 2010-2011: the right and wrong way to pace.", "score": 0.018829561527581327, "content": "Over five decades have passed since the first permanent cardiac pacemakers were introduced into clinical medicine. Evolving technology and falling costs have demanded adaptation to clinical practice and implantation trends and, with the advent of evidenced-based medicine, the specific roles and benefits of individual pacemaker technologies have never been so carefully scrutinized. Pacing mode choice continues to be a subject of great controversy, and there are great regional variations in practice. We believe that single chamber atrial pacing use (AAI/R) has become an anachronism that should generally be abandoned (obviously with rare exceptional cases) and be replaced by dual chamber pacemakers (DDD/R) equipped with modern pacing algorithms that minimize patient exposure to ventricular pacing. Also, in patients with atrioventricular (AV) block, randomized clinical trials have failed to show improvement in clinically relevant outcomes such as mortality, stroke, and heart failure, particularly in the elderly, which has led some to advocate that DDD/R devices should never be offered to elderly AV block patients. However, we believe that the elderly, like the young, come in many \"shapes and sizes\" and individualized medicine compels us to consider each pacemaker candidate as unique. Implanting DDD/R devices in chronologically older, yet physiologically younger, patients is justifiable and good medical practice. Where right ventricular (RV) pacing is necessary and unavoidable, physicians should consider routinely placing RV leads on the RV mid- or outflow tract septum because these location are as good, if not better, for patients than the current practice of RV apical lead placement. In patients with AV block and asymptomatic yet moderate to severely depressed left ventricular systolic function, primary cardiac resynchronization therapy (CRT) should be strongly considered. Compelling clinical trial evidence does not yet exist to indicate that CRT should be the standard of care in patients with AV block and intact left ventricular systolic function. Right ventricular septal lead placement remains a reasonable option." }, { "id": "pubmed23n0131_18046", "title": "Pacemakers of the 1980s. An overview.", "score": 0.01838731443994602, "content": "Methods and devices for permanent cardiac pacing remained relatively stable for over two decades with use of the single-chamber ventricular demand (VVI) pacemaker. However, changes have occurred in the 1980s and are expected to continue with the availability of more advanced technology and with increasing knowledge about cardiac pacing. The physiologic benefit of the newer dual-chamber atrial synchronous (VDD) and fully automatic, universal (DDD) pacemakers over the VVI pacemaker in patients with permanent complete heart block and normal sinus node function has been established. These newer units not only reestablish atrioventricular synchrony but also are physiologically rate-responsive. The VDD pacemaker is expected to be phased out in favor of the DDD pacemaker. When the atrial rate or interval is lower than the lower rate limit, the VDD pacemaker functions as a VVI, whereas the DDD pacemaker functions as an atrioventricular sequential (DVI) pacemaker to maintain continuous atrioventricular synchrony. Contrary to general belief, patients with complete heart block and normal sinus node function may gain very little physiologic benefit, if any, from DVI pacing. The sinus node will compete with the pacemaker's atrial stimulation when the sinus rate is faster than the DVI pacemaker rate (which usually occurs during activity). Also, the ventricular pacing rate will not vary with physiologic change. The DVI and atrial demand (AAI) pacemakers have been used in some patients with sinus node dysfunction. Increasing exercise tolerance should not be expected in the majority of patients because they are not pacemaker-dependent during activity, ie, their heart rate is higher than the pacemaker rate. However, these pacemakers appear to help in eliminating pacemaker syndrome, which does not infrequently occur with VVI pacemakers. Patients with sinus node dysfunction but without atrioventricular block do not gain more physiologic benefit with a DDD than with a DVI pacemaker. Whether these patients have severe sinus node dysfunction all the time or adequate sinus node function most of the time during follow-up, the DDD pacemaker will function as a noncommitted DVI with atrial sensing (DDI). The early report of DVI pacemaker-induced atrial fibrillation during follow-up has been refuted by more recent works. If the DDD pacemaker is significantly more expensive than the DVI pacemaker, the latter type may be a good alternative for this condition." }, { "id": "pubmed23n0073_10456", "title": "[30 years cardiac pacemaker therapy: a status evaluation].", "score": 0.017494270435446907, "content": "Antibradycardiac pacemaker therapy has become established as one of the most effective forms of cardiological therapy for the indications AV-block, sick sinus syndrome, bradyarrhythmia, and hypersensitive carotid sinus. About 220,000 systems are implanted per year worldwide, about 32,000 in West Germany. Of the pacing modes, the fixed-rate ventricular single chamber systems (VVI) dominate with a share of almost 90%. Prognostic importance: For AV-block, the improvement of the prognosis by pacemaker therapy is unquestionable, since it increases the cumulative survival rates to 81% and 95% after 1 year and 50% to 65% after 5 years. For sick sinus syndrome, VVI-pacing proves to be a symptomatic measure, no prognostic importance can be proven. It is not conclusively clarified at present whether physiological pacing modes (AAI, DDD) have any such importance. Pacemaker therapy also has no prognostic importance for bradyarrhythmia. Hemodynamic importance: Numerous hemodynamic studies show that fixed-rate VVI-pacing fails to produce a long-term hemodynamic improvement for either an AV-block or a sick sinus syndrome. In sick sinus syndrome hemodynamic improvement can only be achieved by physiological pacing modes (AAI, DVI, DDD), whereby the increase in cardiac output is between 11% to 30%. For AV-block a long-term hemodynamic improvement can only be obtained by atrial triggered pacing modes (VAT, VDD, DDD); this is higher than the values of fixed-rate VVI-pacing by 7-25% at rest, or 10-40% under exercise. Similar results with improvements of the exercise hemodynamics between 22% and 66% are reported for rate-modulated single-chamber pacing (VVIR) for AV-block. Future trends: In the fourth decade of pacemaker therapy, developments point toward the \"smart pacemaker\", toward rate-modulated systems with combinations of parameters, toward rate-modulated dual-chamber systems and universal antibradycardiac and antitachycardiac systems." }, { "id": "pubmed23n0346_11202", "title": "[Use of dual-chamber pacemaker. Short and long-term results].", "score": 0.017185900248647065, "content": "Continuous improvement of dual chamber DDD pacemakers, electrode stability and programmed sequential stimulation changed the prognosis of patients implanted with these devices. To report our experience with the use of dual chamber pacemakers. One hundred seventy six patients (116 male), aged 13 to 91 years old, who received a dual chamber pacemaker implant, are reported. Patients were followed for a mean of 2.6 years. Indications for DDD pacemaker were complete atrioventricular block in 43%, sick sinus syndrome in 32%, paroxysmal A-V block in 24%. All pacemakers were Siemens-Pacesetter and were provided with an automatic sensing and threshold device. J shaped atrium electrodes were used in 78% of patients and screw-in electrodes in 22%. Post operative complications were displacement of atrial electrode in 8 patients, of ventricular electrode in 6 patients, infection in two patients and a hematoma in one. Chronic parameters, measured after six months, were within expected ranges and allowed a good reprogramming of pacemakers. Long term programming aimed to reduce battery depletion, enhance device performance and improve hemodynamic conditions. Normal sequential stimulation was achieved in 154 patients (87%), 14 (85) patients died of cardiovascular disease not related to pacemaker function. Eight patients were in atrial fibrillation and were reprogrammed to VVI and DDI modes. DDD pacemakers are reliable and afford symptomatic relief in a broad spectrum of patients." }, { "id": "pubmed23n0053_7050", "title": "Deleterious effects of long-term single-chamber ventricular pacing in patients with sick sinus syndrome: the hidden benefits of dual-chamber pacing.", "score": 0.017157397310069065, "content": "Nine hundred fifty patients who received three modes of primary pacemaker systems (581 dual-chamber universal [DDD], 84 atrioventricular-sequential ventricular-inhibited [DVI] and 285 ventricular-inhibited [VVI]) over 12 years were studied retrospectively to determine the effect of pacing mode on patient longevity and the subsequent development of chronic atrial fibrillation or flutter. All patients were followed up continuously for 7 to 8 years. Patients were classified according to indication for permanent pacing (sick sinus syndrome or other indication), age at pacemaker implantation (less than or equal to 70 or greater than 70 years) and history of atrial tachyarrhythmia. Fourteen percent of patients developed atrial fibrillation at some time during the study period. Of those, 4% had a DDD pacemaker, 8% had a DVI pacemaker and 19% had a VVI pacemaker. At 7 years, atrial fibrillation was significantly more frequent in the VVI group than in the DDD and DVI groups. In patients with sick sinus syndrome, the incidence rate was even higher in the VVI group but approximately the same in the DDD and DVI groups. Patients in the VVI and DVI groups who had had previous atrial tachyarrhythmia had a significantly higher incidence of atrial fibrillation at 7 years than did those in the DDD group. During the entire period there were 130 deaths in the study group, including 22% of patients with a DDD pacemaker, 38% of those with a DVI pacemaker and 50% of those with a VVI pacemaker. Patient survival at 7 years was lower in the VVI group than in the DDD or DVI groups.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0321_20070", "title": "[Pacemaker therapy in patients with atrial fibrillation].", "score": 0.016508152173913042, "content": "Pacemaker therapy in patients with atrial fibrillation means the best current pacemaker therapy for patients with bradycardias with the aim to avoid the onset of atrial fibrillation and to establish DDD pacing despite of a history of atrial tachyarrhythmias. The newer application of pacing is the suppression of atrial arrhythmias in patients with medical refractory atrial tachyarrhythmias. Patients with slow ventricular rates and permanent atrial fibrillation should receive a VVI-pacemaker, if the bradycardias causes syncope, dizziness or a decrease of their exercise tolerance. In case of chronotropic incompetence the pacemaker should provide rate responsive pacing. Patients with sick sinus syndrome should receive an atrial (AAI) or dual-chamber (DDD) pacemaker, because patients with these in contrast to VVI-pacemakers develop less often atrial fibrillation and subsequent complications such as atrial thromboembolism. A dual-chamber or VDD-pacemaker--the latter connected to a VDD-single-lead--is indicated in patients with advanced AV-block. Atrial fibrillation occurs in 3 to 6% of the patients with no history of arrythmia and is, if pacemakers have no automatic mode switch, an often reason to program the devices to the VVI-pacing mode. Nowadays, most DDD(R)-pacemakers provide an automatic mode switch: During an atrial tachycardia the pacemaker switches to a VVI/VVIR mode and restores the initial DDD(R)-pacing mode with termination of the arrhythmia. In respect to the newer applications, one approach to prevent atrial tachyarrhythmias is permanent atrial pacing. As lower pacing rates of 80 to 90 ppm are usually needed and many patients hardly tolerate these pacing rates, new algorithms are under clinical investigation. Another approach is the simultaneous depolarization of the right and left atrium. Biatrial pacing is performed with one lead in the high right atrium and another lead in the coronary sinus. Another solution is bifocal atrial pacing with leads placed in the high right atrium and in the coronary sinus ostium. One effect of the new pacing techniques is to shorten interatrial conduction times. Therefore, biatrial pacing has become a therapy to prevent atrial arrhythmias deriving from delayed interatrial conduction times. As atrial reentry circuits seem to be important in atrial fibrillation, multisite atrial pacing is also performed in patients with medical refractory paroxysmal atrial fibrillation. Preliminary results suggest a more effective prevention of atrial fibrillation; nevertheless, these techniques should be still restricted to patients enrolled in clinical studies." }, { "id": "pubmed23n0658_1651", "title": "[Retrospective analysis of 1650 permanent pacemaker implantations experience over two different consecutive time periods in a single cardiology clinic].", "score": 0.015756302521008403, "content": "Indications for pacing, pacing modes, and demographics of patients who underwent pacemaker implantation between two different time periods were compared in this study. Pacemaker registry of our cardiology department was used to evaluate these changes from 1986 to 2007 (First period: 1986-1996, second period: 1997-2007) retrospectively. Registry revealed 776 implantations in the first and 874 implantations in the second period. The percentages of first implantation were 89% and 70.1% respectively. Nearly 50% of the patients in both periods were female. Main indications for pacing were atrioventricular (AV) block, sick sinus syndrome (SSS) and slow ventricular rate during atrial fibrillation in both periods. Implantation of VVI-AAI pacemakers have decreased (77.8%/1.5% to 51%/0.3%, p=0.05) and implantation of DDD-VDD pacemakers have increased (19.3%/1.3% to 42.3%/6.3%, p=0.05) during the second period compared to the first period. Permanent pacemaker implantation for SSS has decreased significantly from 31.1% in the first period to 12.0% (p=0.05) in the second period. Implantation for AV block has increased significantly from 63.3% to 79.7% (p=0.05) in the second period. Our data revealed temporal changes in pacemaker implantation practice during last twenty years in the cardiology department of a teaching hospital. Implantation of VVI-AAI pacemakers have decreased significantly during the second period. Permanent pacemaker implantation for AV block has also decreased during the last period." }, { "id": "pubmed23n0053_8642", "title": "[Relative contribution of standard and physiologic stimulation for maximal work capacity in patients with complete atrioventricular block].", "score": 0.015268065268065269, "content": "The influence of heart rate on the maximal work capacity was investigated in 18 patients (mean age 55 years) with a physiological pacemaker implanted on account of chronic complete atrioventricular block of different aetiology. Twelve patients with a dominating atrial sinus activity had a dual chamber DDD pacemaker and six patients with dominating atrial fibrillation or flutter had a single chamber QTVVIR pacemaker. The exercise test was made on a bicycle ergometer using three stimulation regimes in randomized order and without the patient's knowledge of the programmed mode of pacing: 1. VVI pacing with frequency of 30/min exercise on AV block, 2. VVI pacing with a frequency of 70/min, 3. Uhysiological DDD or QT pacing. Patients with atrioventricular block attained an average heart rate of 54 + 9/min and a work capacity of 81 + 31 W. During VVI pacing a mean frequency of 73 +/- 9/min was achieved (+35%, P less than 0.002) and a work capacity of 100 +/- 45 W (+24%, P less than 0.008). The load during physiological stimulation led to an increased heart rate, i.e. to 140 +/- 15/min (+169%, P less than 0.002) and work capacity to 130 +/- 52 W (+61%, P less than 0.002). The increment of work capacity was thus 2.5 times greater during physiological than during standard ventricular pacing (P less than 0.005), when compared with the work capacity of patients during AV block. A more extensive investigation is needed to identify patients who will benefit maximally from physiological pacing." }, { "id": "pubmed23n0371_8675", "title": "[Long-term clinical assessment of single-lead VDD electric stimulation].", "score": 0.015172334821939769, "content": "During the last decade single lead VDD pacing has been progressively affirmed as an electrotherapy of choice in patients with advanced atrioventricular block without alterations of the sinus function. It combines the benefits of P-synchronous ventricular pacing with an easy implant procedure when compared to the conventional DDD approach. The aim of this study was to evaluate the validity of such an approach in a large population of patients, all implanted in a single center. From 1987 up to now, 317 patients, all affected by advanced atrioventricular block and without sinus node dysfunction, were implanted in our center with a single lead VDD pacemaker. During follow-up the persistence of a proper atrioventricular synchronization was assessed and evaluated. The mean follow-up was 3.9 +/- 2.7 years/patient (range 6-138 months). The 94.6% of implanted systems maintained the normal VDD pacing function. Permanent reprogramming in VVI mode was necessary in 17 patients (5.36%); in 12 (3.78%) because of chronic atrial fibrillation and in 5 (1.63%) for loss of atrial sensing. The percentage of atrial synchronization was optimal (&gt; 98%) and acceptable (&gt; 95%) in 81% and 19% of patients, respectively. Episodes of paroxysmal atrial fibrillation occurred in 3 patients. Neither inhibition by myopotentials nor occurrence of sinus node disease was observed during follow-up. These results are in accordance with those reported by previous studies, performed on a smaller population or on a multicenter basis, and are comparable with the results reported for conventional DDD pacemaker. Our results confirm the high reliability of the single lead VDD pacing system concerning the long-term persistence of a proper atrioventricular synchronization. Data showed above enforce our opinion that this pacing approach should be considered the treatment of choice in patients with advanced atrioventricular block and preserved sinus node function." }, { "id": "pubmed23n0721_24287", "title": "Adverse effects of long-term right ventricular apical pacing and identification of patients at risk of atrial fibrillation and heart failure.", "score": 0.015143978334162384, "content": "In patients needing a pacemaker (PM) for bradycardia indications, the amount of right ventricular (RV) apical pacing has been correlated with atrial fibrillation (AFib) and heart failure (HF) in both DDD and VVI mode. RV pacing was linked with left ventricular (LV) dyssynchrony in almost 50% of patients with PM implantation and atrioventricular (AV) node ablation for AFib. In patients with normal systolic function needing a PM, apical RV pacing resulted in LV ejection fraction (LVEF) reduction. These negative effects were prevented by cardiac resynchronization therapy (CRT). Algorithms favoring physiological AV conduction are possible useful tools able to maintain both atrial and ventricular support and limit RV pacing. However, when chronic RV pacing cannot be avoided, it appears necessary to reconsider the cut-off value of basic LVEF for CRT. In HF patients, RV pacing can induce greater LV dyssynchrony, enhanced by underlying conduction diseases. In this context, a more deleterious effect of RV pacing in implantable cardioverter-defibrillator (ICD) patients with low LVEF can be expected. In some major ICD trials, DDD mode was correlated with increased mortality/HF. This negative impact was attributed to unnecessary RV pacing &gt;40-50%, virtually absent in VVI-40 mode. However, some data suggest that avoiding RV pacing may also not be the best option for patients requiring an ICD. In patients with impaired LV function, AV synchrony should therefore be ensured. The best pacing mode in ICD patients with HF should be defined on an individual basis." }, { "id": "pubmed23n0663_23156", "title": "[Atrial fibrillation before and after pacemaker implantation (WI and DDD) in patients with complete atrioventricular block].", "score": 0.01487173816895179, "content": "Atrial fibrillation (AF) is a frequent problem of patients with pacemakers, and depends not only on disease but also on stimulation method. The aim of the study was to estimate the prevalence of AF before and after pacemaker implantation as well as to assess the influence of VVI and DDD cardiac pacing on onset of AF in patients with complete atrioventricularblock (AVB). We included 155 patients controlled between 2000 and 2008 in Pacemaker Clinic because of AVB III degree, treated with VVI or DDD pacemaker implantation. Information about the health status of the patients was gathered from medical documentation and analysis of clinical ambulatory electrocardiograms. The study group comprised of 68 women and 87 men, mean age 68.7 +/- 13.9 years during implantation. 69% of patients had VVI pacemaker. There were 72.3% of patients with sinus rhythm before pacemaker implantation. During follow-up 4 +/- 2.8 years in 19.6% cases onset of atrial fibrillation de novo was diagnosed (in 31.3% in VVI mode vs. 2.2% in DDD mode; p = 0.00014). Mean time to AF since implantation was approximately 2.5 years. In VVI group (21 persons) amounted 32.1 months, while in 1 patient with DDD pacemaker 18 months. Between group with AF after implantation and with sinus rhythm preserved there was no statistically significant difference in age or gender (p = 0.89512 and p = 0.1253, respectively). Prevalence of atrial fibrillation after pacemaker implantation increased to 40%. Atrial fibrillation is frequent in patients before and after pacemaker implantation, especially in patients stimulated in VVI mode. Major possibility of atrial fibrillation onset after pacemaker implantation should result in more attention during routine ECG examination." }, { "id": "wiki20220301en003_179428", "title": "Artificial cardiac pacemaker", "score": 0.01485148514851485, "content": "From this the basic ventricular \"on demand\" pacing mode is VVI or with automatic rate adjustment for exercise VVIR – this mode is suitable when no synchronization with the atrial beat is required, as in atrial fibrillation. The equivalent atrial pacing mode is AAI or AAIR which is the mode of choice when atrioventricular conduction is intact but the natural pacemaker the sinoatrial node is unreliable – sinus node disease (SND) or sick sinus syndrome. Where the problem is atrioventricular block (AVB) the pacemaker is required to detect (sense) the atrial beat and after a normal delay (0.1–0.2 seconds) trigger a ventricular beat, unless it has already happened – this is VDD mode and can be achieved with a single pacing lead with electrodes in the right atrium (to sense) and ventricle (to sense and pace). These modes AAIR and VDD are unusual in the US but widely used in Latin America and Europe. The DDDR mode is most commonly used as it covers all the options though the pacemakers" }, { "id": "pubmed23n0975_1252", "title": "Pacemaker programming in patients with first-degree AV-block: Programming pattern and possible consequences.", "score": 0.014433962264150942, "content": "The optimal way of pacing in patients with an indication for pacing and concomitant first-degree atrioventricular (AV)-block is not known, and consequently, firm guidelines on this topic are lacking. This study explored the current pacemaker programming pattern in patients with first-degree AV-block who have a dual chamber pacemaker without cardiac resynchronization. The study was a retrospective chart review conducted at Duke University Hospital. Patients receiving a pacemaker due to sinus node dysfunction with coexistent first-degree AV-block were studied. Baseline demographics and characteristics, as well as pacemaker programming parameters and follow-up data, were collected through chart review. Preimplantation and postimplantation electrocardiograms were analyzed. A total of 74 patients were included (mean age, 75 ± 11 y; 53% men). The mean ± SD preimplant PR interval and QRS duration was 243 ± 46 and 110 ± 30 milliseconds, respectively. A history of atrial fibrillation was present in 49% of the patients, and 77% had a normal left ventricular ejection fraction. The majority of patients (65%) had their pacemakers programmed to atrial pacing (AAI/DDD +/-R), whereas 32% and 2.7% of the pacemakers were programmed to AV-sequential pacing (DDD) and ventricular pacing (VVI), respectively. There were no significant differences in baseline characteristics or electrocardiogram measures between patients programmed to the 3 pacing modes. Patients with pacemakers programmed to AAI had a lower ventricular pacing percentage at follow-up (8 vs 55, and 46% [DDD and VVI, respectively]; P &lt; .001). There was no evident association between baseline characteristics and programmed pacing mode in patients with first-degree AV-block. The choice of pacing mode affects long-term pacing burden, which in turn has been shown to influence outcome." }, { "id": "pubmed23n0592_5575", "title": "[Clinical efficacy of permanent cardiac pacing in patients with bradysystolic forms of disturbances of cardiac rhythm and conduction].", "score": 0.0142719027669076, "content": "From 1996 to 2002 primary implantations of pacing systems because of bradysystolic disturbances of cardiac rhythm and conduction had been carried out in 311 patients. Indications were disturbances of atrioventricular conduction in 168 and sick sinus syndrome in 143 patients. According to type of permanent pacing patients were divided into 3 groups: with single-chamber ventricular on demand pacing (VVI, n=215), with single-chamber atrial pacing (AAI, n=39), and with dual-chamber pacing (DDD, n=57). As characteristics illustrating long term clinical results of permanent pacing we used development of the pacemaker syndrome; development of permanent atrial fibrillation; risk of thromboembolic complications and strokes; progression of heart failure; total, cardiovascular mortality and their structure; 7 year survival." }, { "id": "pubmed23n0044_23925", "title": "[DDD dual chamber pacemakers. Initial experience].", "score": 0.01417283950617284, "content": "Our preliminary experience with dual-chamber DDD pacemakers is reported. Technological innovations of the device, atrio-ventricular electrode stability and sequential stimulation have contributed to improve the conditions of patients previously submitted to VVI pacemaker implantation. Primary indications for DDD pacemaker implantation in our series included 7 patients with complete atrio-ventricular (A-V) block, 3 with Mobitz type II second-degree A-V block and 2 with sick sinus syndrome. In six of the 12 patients (50%) additional indications included: ventricular tachycardia in 4 patients, atrial fibrillation in one and pacemaker syndrome in one. Other cardiac conditions were diagnosed: dilated cardiomyopathy in 3 patients, ischemic heart disease in 2 patients, valvular heart disease in 2 patients, congenital heart disease in 1 patient and hypertrophic cardiomyopathy in one patient. The implanted pacemakers were: 5 Genesis, 4 Ultra CPI and 3 Versatrax. J-shaped atrial electrodes were used in 8 patients and in 4 instances a screw-in electrode was employed. Improvement of hemodynamic function was achieved by frequent follow up and reprogramming of DDD pacemaker in every patient. While 4 patients died with progressive deterioration of cardiac function, eight patients survived with adequate sequential stimulation. We conclude that DDD pacemakers are reliable and afford symptomatic relief in a broad spectrum of patients." }, { "id": "pubmed23n0408_19660", "title": "[Clinical safety and efficacy of single-chamber atrial pacing in sick sinus syndrome: long-term follow-up].", "score": 0.013951001361073304, "content": "Although atrial pacing is a more physiological mode of stimulation in sinus node dysfunction, the pacing modes most often are used DDD and VVI. The aim of our study was to demonstrate that AAI/AAIR pacing is effective and safe by analyzing the complications and mortality of this pacing mode in a long-term follow-up study. Between 1982 and 2000 definitive AAI-mode pacemakers were implanted for sinus node dysfunction in mode AAI in 160 patients. We analyzed the clinical characteristics, evolution, and complications of the AAI pacing mode during a follow-up of 5.4 4.5 years. The sample was made up of 104 women and 56 men with an average age of 72 12 years. During follow-up, it was necessary to change the pacing mode for symptomatic bradycardia in 11 patients (annual incidence 1.2%), which was caused by second or third-degree atrioventricular block in 7 patients (annual incidence 0.8%), and chronic atrial fibrillation with bradycardia in 4 patients (annual incidence 0.4%). During follow-up, atrial arrhythmias occurred in 32 patients (annual incidence 3.7%), stroke in 4 patients (annual incidence 0.4%), and 27 patients (annual incidence 3.1%) died. The AAI/AAIR pacing mode was safe and effective in sinus node dysfunction, with a low percentage of pacing changes required for progression to atrioventricular block, low incidence of atrial arrhythmias, stroke and low mortality during long term follow-up." }, { "id": "pubmed23n0516_12103", "title": "Atrial pacing should be used more frequently in sinus node disease.", "score": 0.013904871499808208, "content": "Single lead atrial (AAI(R)) pacing for sick sinus syndrome provides physiological pacing and is less expensive than a dual chamber system. Compared with ventricular-based pacing, it maintains the normal cardiac depolarization sequence, is associated with less atrial fibrillation and heart failure, and avoids pacemaker syndrome. We sought whether it is possible to select patients for AAI(R) pacing with a low likelihood of subsequent ventricular pacing, and whether this approach was cost-effective. A retrospective review was conducted of AAI(R) pacemaker implantations. Patients requiring a further procedure for insertion of a ventricular lead (for DDD(R) or VVI(R) pacing) were compared with those who remained atrially paced. 2.7% (117 of 4,366) of implants were AAI(R), compared with less than 1% overall for New Zealand and Australia. During follow-up of 3.5 (2.3, 7.7) years, insertion of a ventricular lead was required in 14 (12%), and was more likely in those with pre-existing PR interval &gt;0.20 seconds (odds ratio 7.8, P = 0.003) or left bundle branch block (LBBB, odds ratio 17, P = 0.037). Right bundle branch block, left anterior fascicular block, or history of paroxysmal atrial fibrillation were not more frequent in the group requiring ventricular pacing, and preimplantation Wenckebach point was not different. The most efficient strategy was initial AAIR implantation in all except those with LBBB or PR interval &gt;0.20 seconds. Compared with routine DDDR implantation, cost was reduced by 20%, with a 1.4% annual incidence of further procedures. AAIR is the appropriate pacing choice for sick sinus syndrome without LBBB or PR interval &gt;0.20 seconds." }, { "id": "wiki20220301en003_179431", "title": "Artificial cardiac pacemaker", "score": 0.013664545602871593, "content": "Biventricular pacing Cardiac resynchronization therapy (CRT) is used for people with heart failure in whom the left and right ventricles do not contract simultaneously (ventricular dyssynchrony), which occurs in approximately 25–50% of heart failure patients. To achieve CRT, a biventricular pacemaker (BVP) is used, which can pace both the septal and lateral walls of the left ventricle. By pacing both sides of the left ventricle, the pacemaker can resynchronize the ventricular contractions." }, { "id": "pubmed23n0273_16113", "title": "[Atrial-triggered and ventricular-inhibited ventricular VDD pacing with atrial and ventricular single catheter electrodes--the Phymos MPS pacemaker].", "score": 0.012828947368421053, "content": "Optimal treatment from the haemodynamic aspect in complete atrioventricular block is dual-chamber DDD pacing. It makes possible atrioventricular sequence and adaptability of the frequency of ventricular pacing to the load under the control of the sinoatrial node. DDD pacing calls, however, for an atrial and ventricular electrode on two leads. Italian authors developed in 1984 a pacemaker (PM) PHYMOS (MEDICO ITALIA) which makes possible atrial triggered ventricular VDD pacing by means of a single pass lead with a tripolar electrode. As the first ones in the post-communist countries the authors implanted to six patients a PM PHYMOS MPS. They confirmed that the advantages of the VDD system, as compared with DDD, are the use of a single pass lead. This makes the implantation quicker, simpler and safer and reduces the time of X-ray irradiation and the incidence of electrodes dislocations. Another advantage is the lower incidence of atrial fibrillation and probably also pacemaker mediated tachycardias. The disadvantages of the VDD system are that atrial stimulation is impossible and that the diameter of the single pass lead is somewhat larger. According to data in the literature and the so far small experience of the authors, when the indication is correct--atrioventricular block grade III or II with intact function of the sinoatrial node--the advantages of VDD pacing with a single pass lead, as compared with DDD pacing, predominate over disadvantages." }, { "id": "pubmed23n0490_23783", "title": "Development of atrial fibrillation in patients with atrioventricular block after atrioventricular synchronized pacing.", "score": 0.01276179291446467, "content": "Many studies have evidenced an increased incidence of AF in patients receiving single chamber ventricular pacing (VVI) when compared with those undergoing an atrial-based system (AAI or DDD). However, the difference in incidence of AF between two atrial-based systems (VDD, DDD) in patients with AV block was still controversial. This study was conducted to compare the development of AF between different modes of pacemakers (VDD and DDD) in patients with symptomatic AV block. A retrospective review was conducted of the detailed records of all consecutive patients who received permanent pacemakers due to symptomatic bradycardia from March 1995 to March 2000. The occurrence of AF was documented when there was presence of AF in the free-run or 12-lead ECG, any ECG strips, or persistent AF on 24-hour Holter ECG during the follow-up. The study included 152 patients (44 women, 108 men; mean age 73). The patients were divided into two groups: VDD (n = 100) and DDD (n = 52). The mean follow-up was 48.9 +/- 22.9 months. The incidence of AF was 7.9%. A higher incidence of AF was noted in the DDD group (15.4%) when compared with the VDD group (4.0%, P = 0.023). The incidence of development of AF in patients with AV block was higher in those receiving DDD cardiac pacing when compared with those who received the VDD system. The authors suggest that VDD pacing may be a better choice than the DDD system for patients with AV block, but without clinical evidence of sinus node dysfunction, and if an atrial lead is required, it should be placed close to the Bachmann's bundle." }, { "id": "pubmed23n0781_13775", "title": "Managed ventricular pacing compared with conventional dual-chamber pacing for elective replacement in chronically paced patients: results of the Prefer for Elective Replacement Managed Ventricular Pacing randomized study.", "score": 0.01275369185816947, "content": "Several studies have shown that unnecessary right ventricular pacing has detrimental effects. To evaluate whether minimization of ventricular pacing as compared with standard dual-chamber pacing (DDD) improves clinical outcomes in patients referred for pacemaker or implantable cardioverter-defibrillator (ICD) replacement. In an international single-blind, multicenter, randomized controlled trial, we compared DDD with managed ventricular pacing (MVP), a pacing mode developed to minimize ventricular pacing by promoting intrinsic atrioventricular conduction. We included patients referred for device replacement with &gt;40% ventricular pacing, no cardiac resynchronization therapy upgrade indication, no permanent atrial fibrillation (AF), and no permanent complete atrioventricular block. Follow-up was for 2 years. The primary end point was cardiovascular hospitalization. The intention-to-treat analysis was performed by using Kaplan-Meier method and the log-rank test. We randomized 605 patients (556 referred for pacemaker and 49 referred for ICD replacement; mean age 75 ± 11 years; 365 [60%] men, at 7.7 ± 3.3 years from first device implantation) to MVP (n = 299) or DDD (n = 306). We found no significant differences in the primary end point cardiovascular hospitalization (MVP: 16.3% vs DDD: 14.5%; P = .72) and the secondary end point persistent AF (MVP: 15.4% vs DDD: 11.2%; P = .08), permanent AF (MVP: 4.1% vs DDD: 3.1%; P = .44), and composite of death and cardiovascular hospitalization (MVP: 23.9% vs DDD: 20.2%; P = .48). MVP reduced right ventricular pacing (median 5% vs 86%; Wilcoxon, P &lt; .0001) as compared with DDD. In patients referred for pacemaker and ICD replacement with clinically well-tolerated long-term exposure to &gt;40% ventricular pacing in the ventricle, a strategy to minimize ventricular pacing is not superior to standard DDD in reducing incidence of cardiovascular hospitalizations." }, { "id": "pubmed23n0812_19446", "title": "[The pacemaker and implantable cardioverter-defibrillator registry of the Italian Association Arrhythmology Cardiac Pacing and cardiac pacing - annual report 2013].", "score": 0.012301957129543337, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2013 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 25 419 PM implantations were collected (19 134 first implant and 6285 replacements). The number of collaborating centers was 275. Median age of treated patients was 80 years (74 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 43.6% of first PM implants, sick sinus syndrome in 24.7%, atrial fibrillation plus bradycardia in 12.9%, other in 18.8%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (23.2% of first implants). Use of single-chamber PMs was reported in 27.2% of first implants, of dual-chamber PMs in 62.6%, of PMs with cardiac resynchronization therapy (CRT) in 1.8%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 8.4%. ICD Registry: data about 16 519 ICD implantations were collected (11 474 first implants and 5045 replacements). The number of collaborating centers was 430. Median age of treated patients was 71 years (63 quartile I; 77 quartile III). Primary prevention indication was reported in 76% of first implants, secondary prevention in 24.0% (cardiac arrest in 7.8%). A single-chamber ICD was used in 27.2% of first implants, dual-chamber in 35.9% and biventricular in 36.8%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a constant increase in prophylactic and biventricular ICD use, reflecting a favorable adherence to trials and guidelines in clinical practice." }, { "id": "pubmed23n0258_11335", "title": "Pacing for sinus node disease: a therapeutic rationale.", "score": 0.01200042858673524, "content": "Symptomatic sinus node disease is a common indication for permanent pacemaker implantation. Single-chamber ventricular (VVI) pacing, single-chamber atrial (AAI) stimulation, and dual-chamber (DDD or DDI) systems are used to a varying extent at different implanting centers. Hemodynamic and clinical studies relevant to the choice of pacing mode in these patients are reviewed. The data currently available strongly support the use of pacing systems providing atrial stimulation. The choice between single-chamber atrial or dual-chamber pacing can be based on the relative importance assigned to a number of factors: Hemodynamic aspects, the risk of ventricular lead problems, cost, and complexity aspects favor AAI pacing, whereas patients with a substantial risk of developing atrioventricular block should receive a DDD or DDI unit." }, { "id": "wiki20220301en322_28452", "title": "Pacemaker crosstalk", "score": 0.011608944415268526, "content": "Cause Crosstalk can only occur in dual chamber or biventricular pacemaker. It happens less often in more recent models of dual chamber pacemakers due to the addition of a ventricular blanking period, which coincides with the atrial stimulus. This helps to prevent ventricular channel oversensing of atrial output. Newer dual chamber pacemakers also use bipolar leads with a smaller pacing spike, and steroid eluting leads with lower pacing thresholds. Crosstalk is more common in unipolar systems since they require a larger pacing spike. Crosstalk is sometimes referred to as crosstalk inhibition, far-field sensing, or self-inhibition. In some cases, crosstalk can occur in the pulse generator circuit itself, though more common causes include atrial lead dislodgement into the ventricle, ventricular lead dislodgement into the atrium, high atrial output current, high ventricular sensitivity, and short ventricular blanking period." }, { "id": "pubmed23n0884_8530", "title": "[Predictors for need of antibradycardia and antitachycardia pacing after ICD implantation : Implications for the subcutaneous ICD].", "score": 0.011595547309833025, "content": "Little is known about the incidence and risk factors for progression to pacemaker dependency or the need for cardiac resynchronization in typical patients with an implanted defibrillator with regard to an alternative implantation of a subcutaneous ICD (S-ICD). After retrospective analysis of 291 patients with first implantation of a transvenous single chamber ICD (VVI-ICD) from 2010-2016 and excluding those with an indication for pacemaker or lack of follow-up data, 121 patients were included and investigated with regard to the following endpoints: need for pacemaker stimulation, upgrade for cardiac resynchronization (CRT), and secondary occurrence and effectiveness of antitachycardia pacing (ATP). We compared the results with those of fundamental S‑ICD studies and tried to determine risk factors on the basis of medical history and pre-implant data. The study population and the rate of endpoints were significantly different to those of fundamental S‑ICD studies. Within a 2.2-year follow-up, 14.9 % of the patients developed a need for pacemaker stimulation and 0.8 % the need for cardiac resynchronization. Excluding patients who at implantation were already at high risk for pacemaker dependency, 7.4 % remained with a reached endpoint. We identified atrial fibrillation and bundle-branch-block as risk factors. All episodes of ventricular tachycardia (VT) could be terminated by ATP in 9.9 % of the patients. They more often had ischemic heart disease and a secondary prophylactic indication for an ICD. The low rate of conversions from S‑ICD to a transvenous ICD in case of pacemaker-dependency as stated in fundamental S‑ICD studies should not be transferred to other typical collectives of ICD recipients. The latter group is at significantly higher risk for developing pacemaker-dependency." }, { "id": "pubmed23n0863_3873", "title": "[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing--Annual report 2014].", "score": 0.01109006476842234, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2014 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 24 680 PM implantations were collected (19 480 first implant and 5200 replacements). The number of collaborating centers was 208. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 45.3% of first PM implants, sick sinus syndrome in 23.1%, atrial fibrillation plus bradycardia in 11.7%, other in 19.9%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (22.7% of first implants). Use of single-chamber PMs was reported in 26.9% of first implants, of dual-chamber PMs in 63.6%, of PMs with cardiac resynchronization therapy (CRT) in 1.7%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 7.8%. ICD Registry: data about 17 116 ICD implantations were collected (11 274 first implants and 5842 replacements). The number of collaborating centers was 424. Median age of treated patients was 71 years (62 quartile I; 77 quartile III). Primary prevention indication was reported in 72.3% of first implants, secondary prevention in 27.7% (cardiac arrest in 10.1%). A single-chamber ICD was used in 32.2% of first implants, dual-chamber in 37.1% and biventricular in 30.7%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice." }, { "id": "pubmed23n0778_16851", "title": "[The pacemaker and implantable cardioverter-defibrillator registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual Report 2012].", "score": 0.010839079116512797, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2012 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 25 611 PM implantations were collected (18 870 first implant and 6741 replacements). The number of collaborating centers was 245. Median age of treated patients was 80 years (74 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 41.9% of first PM implants, sick sinus syndrome in 26.0%, atrial fibrillation plus bradycardia in 13.7%, other in 18.4%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (21.7% of first implants). Use of single-chamber PMs was reported in 29.0% of first implants, of dual-chamber PMs in 61.3%, of PMs with cardiac resynchronization therapy (CRT) in 1.7%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 8.0%. ICD REGISTRY: data about 16 606 ICD implantations were collected (11 393 first implants and 5213 replacements). The number of collaborating centers was 427. Median age of treated patients was 71 years (62 quartile I; 77 quartile III). Primary prevention indication was reported in 68.6% of first implants, secondary prevention in 31.4% (cardiac arrest in 9.0%). A single-chamber ICD was used in 29.4% of first implants, dual-chamber in 37.6% and biventricular in 32.9%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a constant increase in prophylactic and biventricular ICD use, reflecting a favorable adherence to trials and guidelines in clinical practice." }, { "id": "pubmed23n0939_15587", "title": "[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2016].", "score": 0.010694119660069583, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2016 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 23 496 PM implantations were collected (19 003 first implant and 4493 replacements). The number of collaborating centers was 204. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 39.8% of first PM implants, sick sinus syndrome in 22.1%, atrial fibrillation plus bradycardia in 14.1%, other in 24.0%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (22.18% of first implants). Use of single-chamber PMs was reported in 26.9% of first implants, of dual-chamber PMs in 65.0%, of PMs with cardiac resynchronization therapy (CRT) in 1.5%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 6.6%. ICD Registry: data about 20 350 ICD implantations were collected (14 763 first implants and 5587 replacements). The number of collaborating centers was 430. Median age of treated patients was 72 years (63 quartile I; 78 quartile III]. Primary prevention indication was reported in 79.0% of first implants, secondary prevention in 21.0% (cardiac arrest in 7.9%). A single-chamber ICD was used in 32.2% of first implants, dual-chamber in 31.1% and biventricular in 36.7%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice." }, { "id": "pubmed23n0899_7592", "title": "[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2015].", "score": 0.010606060606060607, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2015 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 24 285 PM implantations were collected (19 194 first implant and 5091 replacements). The number of collaborating centers was 218. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 42.8% of first PM implants, sick sinus syndrome in 22.9%, atrial fibrillation plus bradycardia in 15.1%, other in 19.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (23.8% of first implants). Use of single-chamber PMs was reported in 26.9% of first implants, of dual-chamber PMs in 63.4%, of PMs with cardiac resynchronization therapy (CRT) in 1.8%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 7.9%. ICD Registry: data about 15 363 ICD implantations were collected (11 453 first implants and 3910 replacements). The number of collaborating centers was 434. Median age of treated patients was 71 years (63 quartile I; 78 quartile III]. Primary prevention indication was reported in 77.3% of first implants, secondary prevention in 22.7% (cardiac arrest in 8.0%). A single-chamber ICD was used in 29.3% of first implants, dual-chamber in 34.6% and biventricular in 36.1%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice." }, { "id": "pubmed23n1021_13866", "title": "[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2018].", "score": 0.010453622207176709, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2018 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 23 912 PM implantations were collected (20 084 first implants and 3828 replacements). The number of collaborating centers was 180. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 34.5% of first PM implants, sick sinus syndrome in 18.3%, atrial fibrillation plus bradycardia in 13.0%, other in 34.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (19.2% of first implants). Use of single-chamber PMs was reported in 24.9% of first implants, of dual-chamber PMs in 67.6%, of PMs with cardiac resynchronization therapy (CRT) in 1.6%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 5.9%. ICD Registry: data about 18 353 ICD implantations were collected (13 944 first implants and 4359 replacements). The number of collaborating centers was 433. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 84.3% of first implants, secondary prevention in 15.7% (cardiac arrest in 5.3%). A single-chamber ICD was used in 27.9% of first implants, dual-chamber ICD in 31.9% and biventricular ICD in 40.2%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale." }, { "id": "wiki20220301en003_179430", "title": "Artificial cardiac pacemaker", "score": 0.010198135198135198, "content": "Automatic pacemakers are designed to be over-ridden by the heart's natural rate at any moment that it gets back to a non-pathologic normal sinus rhythm and can reinitiate influencing the electric activity in the heart when the pathologic event happens again. A \"ventricular-demand pacemaker\" produces a narrow vertical spike on the ECG, just before a wide QRS. The spike of an \"atrial-demand pacemaker\" appears just before the P wave. Comparably, a Triggered Pacemaker is activated immediately after an electrical activity is commenced in the heart tissue by itself. A \"ventricular triggered pacemaker\" produces the impulse just after a pulse is created in the ventricular tissue and it appears as a simultaneous spike with QRS. An \"atrial triggered pacemaker\" is the mode in which an impulse is produced immediately after an electrical event in the atrium. It appears as a discharge following the p wave but prior to the QRS which is commonly widened. Biventricular pacing" }, { "id": "pubmed23n0981_13566", "title": "[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2017].", "score": 0.00994325191216383, "content": "The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2017 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. PM Registry: data about 23 457 PM implantations were collected (19 378 first implant and 4079 replacements). The number of collaborating centers was 185. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 37.1% of first PM implants, sick sinus syndrome in 19.5%, atrial fibrillation plus bradycardia in 13.2%, other in 30.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (21.0% of first implants). Use of single-chamber PMs was reported in 25.6% of first implants, of dual-chamber PMs in 66.7%, of PMs with cardiac resynchronization therapy (CRT) in 1.4%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 6.3%. ICD Registry: data about 19 023 ICD implantations were collected (13 898 first implants and 5125 replacements). The number of collaborating centers was 437. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 81.8% of first implants, secondary prevention in 18.2% (cardiac arrest in 6.4%). A single-chamber ICD was used in 27.0% of first implants, dual-chamber in 33.6% and biventricular in 39.3%. The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 633, 942 ] ], "word_ranges": [ [ 91, 137 ] ], "text": "In case of an unresectable situation, chemotherapy treatment would be considered with the intention of converting the single metastatic lesion into a resectable one. Since more than 12 months have passed since FOLFOX treatment, the same scheme could be used, although FOLFIRI+bevacizumab would also be useful." }, "2": { "exist": true, "char_ranges": [ [ 943, 1140 ] ], "word_ranges": [ [ 137, 165 ] ], "text": "Capecitabine monotherapy, in the patient's current situation, would also not be a good starting option, since the responses are lower compared to FOLFOX or FOLFIRI plus antiangiogenic combinations." }, "3": { "exist": true, "char_ranges": [ [ 232, 495 ] ], "word_ranges": [ [ 37, 78 ] ], "text": "As this is a situation of oligometastasis and the treatments for advanced colon adenocarcinoma allow prolonged survival with good quality of life in these patients, if there is nothing to contraindicate surgery, this should be the first option (correct answer 3)." }, "4": { "exist": true, "char_ranges": [ [ 1141, 1378 ] ], "word_ranges": [ [ 165, 207 ] ], "text": "Hepatic radiotherapy could be considered, since there are SBRT techniques that achieve very good results, but in this case it is best to start by asking for an assessment by the surgeons and if they rule out surgery we would consider RT." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Chemotherapy with FOLFIRI (fluorouracil, leucovorin and irinotecan) plus bevacizumab.", "2": "Monochemotherapy with capecitabine.", "3": "Assessment for surgical resection of the hepatic lesion.", "4": "Hepatic radiotherapy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0822_10693", "title": "[Resection of a left obturator lymph node recurrence five years five months after surgery for rectal cancer].", "score": 0.018329427519250083, "content": "A 62-year-old man with lower rectal cancer underwent abdominoperineal resection and dissection of the lateral pelvic lymph nodes. The cancer was staged at pT3pN0cM0, pStage II and did not show recurrence. Two years later, the patient had dysphagia and was diagnosed with esophageal cancer based on upper gastrointestinal endoscopy. Positron emission tomography-computed tomography (PET/CT) performed to detect distant metastasis revealed fluorodeoxyglucose (FDG) uptake in the left obturator lymph nodes, indicating rectal cancer recurrence. The patient received radiation therapy (60.4 Gy) for the recurrence. A PET/CT scan obtained 2 years 6 months after the initial rectal cancer resection revealed no FDG uptake. Uraciltegafur plus Leucovorin (UFT+LV) was started and continued for 6 months, but tumor enlargement was noted. Treatment was changed to LV, 5-fluorouracil, and irinotecan (FOLFIRI), but after 4 courses, the patient's carcinoembryonic antigen (CEA) levels rose. The patient then received 4 courses of bevacizumab plus FOLFIRI. A CT scan revealed tumor shrinkage, so the patient received 4 more courses of this regimen. Five years postoperatively, the patient's CEA levels rose again. A PET/CT scan 4 months later revealed FDG uptake in the left obturator lymph nodes, indicative of rectal cancer recurrence. One month later, the lymph nodes were resected. The patient was subsequently recurrence free. Tumor marker measurement and PET/CT helped to assess the patient's condition. When cancer recurs in the lateral pelvic lymph nodes with no involvement of the pelvis and R0 resection is possible, resection should be considered if the patient is capable of undergoing surgery." }, { "id": "pubmed23n0727_11079", "title": "The utility of FDG-PET/CT as an effective tool for detecting recurrent colorectal cancer regardless of serum CEA levels.", "score": 0.014802950883323627, "content": "Tumor recurrence of colorectal cancers (CRC) is generally followed up by analyses of the serum carcinoembryonic antigen (CEA) levels. However, recent evidence suggests that tumor recurrence can also be visualized by 18F-fluoro-deoxyglucose emission tomography/computed tomography (FDG-PET/CT) in patients with normal CEA levels. We retrospectively evaluated the diagnostic performance of FDG-PET/CT in patients with suspected recurrence of CRC by comparing PET/CT performance in patients with normal CEA levels with PET/CT performance in patients with elevated CEA levels. A total of 235 patients with CRC who had been treated with surgery and/or chemotherapy/radiotherapy underwent PET/CT for the detection of tumor recurrence. The patients [96 females and 139 males; age (mean ± SD) 59.9 ± 12.6 years; range 18-85] were divided into 2 groups based on whether their CEA levels were normal (&lt;5 ng/ml) (Group 1, n = 118) or elevated (&gt;5 ng/ml) (Group 2, n = 117). All of the patients had suspected recurrence based on raised CEA levels, clinical symptoms, and/or tumor detection using other imaging modalities. Of the 235 patients, 172 (73.1 %) had disease recurrence confirmed by a pathological examination (either biopsy or surgical exploration) or clinical follow-up studies. The FDG-PET/CT study yielded a true positive in detecting recurrence in 169 (71.9 %) patients, a true negative in 53 (22.5 %) patients, a false negative in 3 (1.2 %) patients and a false positive in 10 (4.2 %) patients. CRC recurrence was detected in 64.4 % (76/118) and 88 % (103/117) patients in Group 1 and Group 2 with FDG-PET/CT, respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of the FDG-PET/CT study for establishing recurrence were 100, 84, 89.4, 100 and 93.2 %, respectively, for Group 1; by contrast, these parameters were 97.1, 84.6, 98, 78.5 and 95.7 %, respectively, for Group 2. The number of patients with hepatic and extra-hepatic metastases, such as lung and abdominal lymph node metastasis, detected with FDG-PET/CT was significantly different in Group 1 than in Group 2; however, the number of patients with local recurrence and peritoneal implants detected with FDG-PET/CT was not different between the two groups. FDG-PET/CT can accurately detect tumor recurrence in patients with suspected recurrent CRC, even for patients with normal CEA levels." }, { "id": "pubmed23n0687_15810", "title": "Scan? Cure? Sure!", "score": 0.013527620704654197, "content": "A 61-year-old man undergoes a sigmoid colectomy for a T3N1 (two of 18 nodes) adenocarcinoma of the sigmoid colon. He recovers well and receives 6 months of adjuvant FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) uneventfully. At his first follow-up visit, the oncologist recommended every 3 month visits for a physical, liver function tests, and carcinoembryonic antigen (CEA) measurement; every 6 month chest, abdomen, and pelvic computed tomography (CT) scans for 3 years; and aspirin, vitamin D supplementation, and exercise. Is CT scanning appropriate in the follow-up of colon cancer patients? (This case was presented at Massachusetts General Hospital Cancer Center.)." }, { "id": "wiki20220301en220_29197", "title": "Metastatic liver disease", "score": 0.013068651778329199, "content": "Diagnosis Hemoglobin decrease Liver function test: ALP elevated, bilirubin elevated, albumin decrease Carcinoembryonic antigen for colorectal secondaries Ultrasound scan CT scan Biopsy under ultrasound control Treatment Treatment can consist of surgery (hepatectomy), chemotherapy and/or therapies specifically aimed at the liver like radiofrequency ablation, transcatheter arterial chemoembolization, selective internal radiation therapy and irreversible electroporation. For most patients no effective treatment exists because both lobes are usually involved, making surgical resection impossible. Younger patients with metastases from colorectal cancer confined to one lobe of the liver and up to 4 in number may be treated by partial hepatectomy. In selected cases, chemotherapy may be given systemically or via hepatic artery." }, { "id": "article-137650_18", "title": "Carcinoembryonic Antigen -- Clinical Significance -- Post Resection Detection of Liver Metastasis/Oligometastases", "score": 0.011245346098320797, "content": "CEA measurement is the most sensitive detector of liver metastasis from colorectal cancers that can be resected surgically. [23] There is evidence that colon cancer patients with liver metastasis with preoperative CEA less than or equal to 30 µg/L have more likelihood of having resectable metastatic lesions and hence more prolonged survival. [24] When monitored along with CT scans, CEA has proven to detect the metastasis in surgically curable stage than either modality alone." }, { "id": "pubmed23n0822_10752", "title": "[A case of rectal cancer with multiple liver metastases successfully treated by repeated hepatectomy].", "score": 0.009900990099009901, "content": "A 61-year-old man was diagnosed with rectal cancer with multiple liver metastases in December 2009, and low anterior resection of the rectum was performed. Postoperative adjuvant chemotherapy with 6 courses of oxaliplatin, Leucovorin, and 5-FU (FOLFOX4) and bevacizumab was initiated, followed by 5 courses of fluorouracil, Leucovorin, and irinotecan (FOLFIRI) and bevacizumab. Right posterior segment (S6, S7) hepatectomy with enucleation of S2, S3 and S5 was performed, and chemotherapy with FOLFOX4 (11 courses) was administered. New metastases in the S5 segment were observed in August 2011 and right hepatic lobectomy was performed. The patient then underwent 8 courses of adjuvant chemotherapy with FOLFOX4. However, left hepatic lobe lateral segment and caudate lobe metastases then appeared. Subsequent repeated chemotherapy with FOLFIRI plus cetuximab (3 courses) and irinotecan plus cetuximab was interrupted in August 2013 owing to adverse events resulting in rapid growth of hepatic metastases. The patient underwent hepatic left lateral segmentectomy and left caudate lobectomy. The postoperative course was uneventful and the patient has currently survived 4 years and 7 months after the initial surgery." }, { "id": "pubmed23n0523_2051", "title": "Oncologic emergencies secondary to advanced colorectal cancer successfully treated with oxaliplatin/5-fluorouracil/leucovorin: report of three cases.", "score": 0.00980392156862745, "content": "Metastatic/advanced colorectal cancer is considered a resistant disease and oncologic emergencies secondary to advanced disease may be regarded with a nihilistic attitude. The objective of this report is to emphasize the efficacy of the oxaliplatin/5-fluorouracil/leucovorin regimen (FOLFOX-4) in three patients presenting oncologic emergencies secondary to advanced colon cancer. The first case was a 40-year-old man with severe respiratory insufficiency due to massive carcinomatous lymphangitis; subsequently a cecal adenocarcinoma was diagnosed. The patient's conditions became life-threatening and he was admitted to the intensive care unit. The second case was a 41-year-old woman presenting with fever, abdominal mass and pain. Ultrasound and CT-scan revealed two hepatic masses (13 x 15 and 15 x 20 cm), diagnosed as liver metastases from colon cancer. The patient's condition deteriorated with intestinal obstruction secondary to the large left liver mass. The third case was a 58-year-old woman presenting with hepatic mass, fever and weight loss. Ultrasound and CT-scan showed a liver lesion occupying the right lobe (12 x 14 cm). Ultrasonically-guided biopsy and colonoscopy showed liver metastases from cecal cancer. A 5-fluorouracil/leucovorin regimen failed to improve her clinical condition and she had disease progression, inferior vena cava neoplastic thrombosis and right hydronephrosis. All three patients rapidly improved after a few cycles of oxaliplatin-containing chemotherapy. These cases demonstrate that even patients with advanced colorectal cancer presenting with oncologic emergencies and life-threatening conditions can be successfully treated with the FOLFOX-4 regimen." }, { "id": "pubmed23n0736_65", "title": "Detection of recurrences during follow-up after liver surgery for colorectal metastases: both carcinoembryonic antigen (CEA) and imaging are important.", "score": 0.00980392156862745, "content": "The follow-up of patients treated for colorectal liver metastases (CRLM) is not standardized. The accuracy of an increase in carcinoembryonic antigen (CEA) levels for finding recurrences after treatment for CRLM is compared in this retrospective cohort study with the accuracy of routine imaging modalities of liver and chest. Data from all patients in follow-up after intentionally curative treatment for CRLM from 1990 to 2010 were analyzed. All patients underwent the same follow-up schedule. The way in which recurrences became apparent (i.e., CEA increase, routine imaging, or both) was registered. The specificity and sensitivity of increases in CEA before finding recurrent disease were calculated by receiver operating characteristic (ROC) curves. An economic evaluation of the cost per resectable tumor recurrence was performed. ROC curves showed that a significant CEA increase was defined as a 25 % increase from the previous value. Recurrences were detected in 46 % of the procedures through CEA increase concomitant with positive imaging, in 23 % through CEA increase without positive findings on routine imaging, and in 31 % through positive imaging without an increase in CEA. The resectability of recurrences did not differ between triggers. Cost per curable recurrence was &lt;euro&gt;2,196 for recurrences found via CEA alone and &lt;euro&gt;6,721 for recurrences found with imaging and CEA. In the follow-up of patients after liver surgery for CRLM, a 25 % increase in CEA serum level can accurately detect recurrences, but routine imaging is indispensable. In patients with CRLM, we advocate both CEA monitoring and imaging in the follow-up after liver surgery." }, { "id": "wiki20220301en225_16352", "title": "Metastasectomy", "score": 0.009732878658709861, "content": "Preoperative evaluation involves imaging of the liver and its metastases, for example with ultrasound, computed tomography or magnetic resonance imaging. Positron emission tomography can be useful to check the entire body for metastases, although the test can be falsely normal with small lesions or preoperative chemotherapy. Baseline blood tests typically include liver function tests and tumour markers. During surgery, intraoperative ultrasound can aid the surgeon to find additional metastases. A clinical risk score first proposed by Fong et al. is often used to assess the risk of recurrence after hepatic resection. The score assigns one point to each of the following: CEA level >200 ng/ml Disease-free interval from primary to metastasis <12 months Node-positive primary More than one liver metastasis Largest hepatic tumor >5 cm The median survival for each score is:" }, { "id": "pubmed23n0596_24814", "title": "Yield of routine imaging after curative colorectal cancer treatment.", "score": 0.009708737864077669, "content": "The use of imaging in the follow-up of patients after curative colorectal cancer resection is much debated. The American Society of Colon and Rectal Surgeons did not recommend routine imaging. This retrospective study assesses the yield of routine imaging to detect recurrent disease. In 1998, 108 consecutive patients underwent curative resection for colorectal carcinoma. Minimum followup in our institution was 3 years. Multidisciplinary follow-up at a joint clinic consisted out of a history, clinical examination, serum carcinoembryonic antigen (CEA), chest X-ray and abdominal ultrasound, at least every 6 months. Colonoscopy was performed within 1 year after operation and every 3 to 5 years thereafter. The incidence, timing, means of detection and resectability of recurrence were studied. The recurrence rate was 22% (24 patients): liver metastases (11), extra-hepatic recurrence (10) and combined recurrence (3). Recurrent disease occurred in stage II or III cancer, except for two patients. It was diagnosed at a median of 21.5 months (range 4-79) after surgery. Means of detection were: symptoms in 2 (peritoneal disease, 8%), increasing CEA in 15 (63%), routine imaging in 6 (25%), and abdominal CT-scan in one patient. Curative resection of recurrent disease was possible in ten patients (42%): in 6/15 recurrences detected by CEA, in 3/6 recurrences detected by routine imaging, in 1 liver metastasis detected by CT and in none of the symptomatic patients. A CEA level increasing above 5.0 microg/L was the most important diagnostic tool. However, one quarter of the recurrences were detected by routine imaging and half of them could be resected for cure. These data support routine imaging during follow-up." }, { "id": "pubmed23n1051_8731", "title": "Staged Double Hepatectomy, Double Total Vascular Exclusion, and Double Venous Reconstruction by Peritoneal Patches in One Patient with Colorectal Liver Metastases.", "score": 0.009615384615384616, "content": "Surgical resection is the best treatment for colorectal liver metastases with good response to chemotherapy and in the absence of extrahepatic disease.1 With the amelioration of surgical technique, primary and recurrent colorectal liver metastases with venous invasion can be resected safely under short total vascular exclusion (TVE), and associated right thoracotomy can have a major benefit if resection at the hepato-caval junction is planned.2 The availability of the peritoneum as an autologous graft for venous reconstruction considerably facilitates the task of the surgeon.3 In this video, we present a patient who had staged double liver resection, double TVE, and double venous reconstruction by a peritoneal graft on the vena cava and the hepatic vein. In March 2017, a 47-year-old female was diagnosed with rectal cancer and synchronous liver metastases, microsatellite stability, and Kras mutation. The patient received folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy, with good response and a decrease in tumor markers. After chemotherapy, a computed tomography (CT) scan showed one lesion located on the right liver with lateral invasion of the vena cava, and another lesion located in segment I. A liver-first strategy was decided and, in October 2017, the patient had a right hepatectomy extended to segment I and partially on the diaphragm, with lateral resection of the vena cava under isolated clampage of the vena cava and reconstruction with a peritoneal graft (60 mm). The patient received FOLFOX adjuvant chemotherapy for 3 months, and, while under radiotherapy for the rectal cancer, recurrence was diagnosed on the left liver lobe (two lesions), with lateral invasion of the left hepatic vein. Chemotherapy was shifted to folinic acid, fluorouracil, and irinotecan (FOLFIRI)-Avastin, with good response, allowing resection of the primary (T3N0M1), followed by adjuvant chemotherapy. In May 2019, the patient underwent two large resections on the left liver, including one under TVE, with opening of the diaphragm and intrathoracic control of the vena cava. The left hepatic vein was reconstructed laterally with a peritoneal graft (30 mm). Postoperative outcome was uneventful and the two hospital stays were 12 and 15 days, respectively. For the first hepatectomy, pathological examination showed two lesions (80 and 50 mm) with a residual tumor at 10% and R0 resection, and, for the second resection, pathological examination showed two lesions (18 and 20 mm) with residual tumor at 40-60% and R0 resection. In both cases, the tumor was in contact with the resected vein without wall infiltration. The reconstructed vena cava and hepatic vein were patent without stenosis. The patient is disease-free 3 years after the diagnosis. Improvements in surgical technique combined with short TVE and associated thoracotomy allow some complicated liver resections to be performed safely. The use of the peritoneum for venous reconstruction is of great benefit in relation to safety and availability, especially in 'redo' liver surgery where intense adhesions can be encountered." }, { "id": "pubmed23n0490_21719", "title": "The value of routine serum carcino-embryonic antigen measurement and computed tomography in the surveillance of patients after adjuvant chemotherapy for colorectal cancer.", "score": 0.009615384615384616, "content": "This analysis aims to evaluate routine carcino-embryonic antigen (CEA) and computed tomography (CT) of thorax, abdomen, and pelvis as part of protocol-specified follow-up policy for colorectal cancer (CRC). Patients with resected stage II and III CRC were randomly assigned to bolus fluorouracil/leucovorin or protracted venous infusion fluorouracil. Following completion of chemotherapy, patients were seen in clinic at regular intervals for 5 years. CEA was measured at each clinic visit, and CT of thorax, abdomen, and pelvis was performed at 12 and 24 months after commencement of chemotherapy. Between 1993 and 1999, 530 patients were recruited. The median follow-up was 5.6 years. Disease relapses were observed in 154 patients. Relapses were detected by symptoms (n = 65), CEA (n = 45), CT (n = 49), and others (n = 9). Fourteen patients, whose relapses were detected by CT, had a concomitant elevation of CEA and were included in both groups. The CT-detected group had a better survival compared with the symptomatic group from the time of relapse (P =.0046). Thirty-three patients (21%) proceeded to potentially curative surgery for relapse and enjoyed a better survival than those who did not (P &lt;.00001). For patients who underwent hepatic or pulmonary metastatic resection, 13 (26.5%) were in the CT group, eight (17.8%) in the CEA group, and only two (3.1%) in the symptomatic group (CT v symptomatic, P &lt;.001; CEA v symptomatic, P =.015). Surveillance CT and CEA are valuable components of postoperative follow-up in stage II and III colorectal cancer." }, { "id": "pubmed23n0860_10618", "title": "A 5-year recurrence-free survivor with over ten colorectal liver metastases undergoing FOLFOX plus bevacizumab followed by two-stage hepatectomy.", "score": 0.009523809523809525, "content": "A 62-year-old male was admitted because of lower left abdominal pain and diarrhea. The patient was diagnosed with rectal cancer and multiple liver metastases. First, the laparoscopic Hartmann operation with a D3 lymph node dissection was performed. After five cycles of folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX) and bevacizumab, and one additional FOLFOX, the tumor markers dramatically decreased; with carcinoembryonic antigen levels ranging from 1096.3 to 7.6 ng/ml and carbohydrate antigen 19-9 levels ranging from 3248.0 to 42.1 U/ml. Computed tomography showed a bilateral 14 colorectal liver metastases which indicated stable disease by the Response Evaluation Criteria In Solid Tumors (RECIST) criteria and optimal morphologic response. A two-stage hepatectomy was performed to complete a curative resection because of the insufficient remnant liver volume. Five partial hepatic resections in the left liver and the right portal vein ligation were performed during the first operation. Thirty-four days later, a right hepatectomy was successfully performed. Pathologically, there was tumor necrosis in 90 percent of the area of the metastasized liver, and viable cells were detected in only a marginal part of the liver. The patient had an uneventful postoperative course and was discharged fifteen days after the second operation. Uracil-tegafur plus leucovorin was administered for 6 months as an adjuvant chemotherapy treatment. The patient is currently alive and has remained disease-free for more than 5 years. In conclusion, an ideal combination of perioperative chemotherapy and curative resection may provide a chance of long-term survival without recurrence of disease for selected patients with more than ten bilateral colorectal liver metastases. " }, { "id": "pubmed23n0134_14659", "title": "CEA-directed second-look surgery in the asymptomatic patient after primary resection of colorectal carcinoma.", "score": 0.009523809523809525, "content": "Since 1971, serial carcinoembryonic antigen (CEA) levels have been measured to monitor patients after primary resection of colorectal cancer. Based solely on a rise in CEA level above the baseline established after primary resection, 146 patients were readmitted to the hospital. Chest films, liver-spleen scan, colonoscopy, bone scan, abdominal and pelvic CAT scan, and hepatic arteriograms were performed, and elevated CEA levels were confirmed before reexploration was undertaken. In the 146 patients, 139 (95%) had recurrences, and 81 (58%) of these were resectable for potential cure. Two of the first 22 patients re-explored between 1971 and 1975 are still living 11 and 14 years after second look; of 45 patients reoperated upon from 1976 through 1979 and followed for at least 5 years, 14 (31%) are still living. A rise in CEA above the baseline established after primary resection proved to be a sensitive indicator of recurrence and prompted reexploration before symptoms developed. Early alternative therapy was begun in patients with unresectable recurrences." }, { "id": "pubmed23n0929_173", "title": "Natural killer cells activity in a metastatic colorectal cancer patient with complete and long lasting response to therapy.", "score": 0.009433962264150943, "content": "Here we report a case of a 70-year-old man who received adjuvant chemotherapy with fluorouracile, folinic acid and oxaliplatin after a left hemicolectomy for a stage IIIb adenocarcinoma in May 2009. During follow-up he de-veloped abdominal lymphnodes metastases evidenced by positron emission tomography- computed tomography (PET-CT) scan and increase of carcinoembryonic antigen (CEA) level. Chemotherapy with capecitabine, oxaliplatin and bevacizumab was started in April 2012. Restaging showed a complete response and normalization of CEA. The patient received maintenance therapy with bevacizumab which was stopped in December 2013 for patient choice. In October 2014, a new increase in CEA was documented and PET-CT scan showed lung metastases. Analysis of RAS status revealed the absence of mutations, then the patient started a second-line chemotherapy with fluorouracile, folinic acid, irinotecan (folfiri) and panitumumab achieving, in January 2015, a complete response and normalization of CEA. Thereafter, folfiri was discontinued for toxicity; furthermore, upon the third occurrence of a grade 3 dermatologic toxicity, panitumumab was continued from June 2015 at 60% of the original dose and it was administered every three weeks. Until presentation of this case, the patient maintains a complete response, has no symptoms of disease and CEA is normal. Interestingly, this patient presented a high proportion of circulating natural killer (NK) cells (35.1%) with high cytotoxic activity against tumor cells. Study on the role of NK in patients with advanced colorectal cancer are ongoing." }, { "id": "pubmed23n0905_15588", "title": "Application and Indication of Carcinoembryonic Antigen Triggered 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Scanning in the Detection of Relapse of Colorectal Cancer Patients After Curative Therapy.", "score": 0.009433962264150943, "content": "This study aimed to explore the characteristics of patients with colorectal cancer (CRC) following curative therapy that may benefit from fluorine-18-2-uoro-2-deoxy-D-glucose positron emission tomography/computed tomography (F-FDG PET/CT) scanning, evaluate the application of carcinoembryonic antigen (CEA)-triggered F-FDG PET/CT scanning, and provide referential indicators. This retrospective study included 56 CRC patients who received a PET/CT scan as a primary examination because of rising CEA levels after curative therapy and who had not received any other radiological examinations previously. The rate of recurrence or metastasis was 75.0% by PET/CT scan but was 69.6% with follow-up treatment. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 94.9%, 70.6%, 87.5%, 88.1%, and 85.7%, respectively. TNM (tumor, node, metastasis) stage, body mass index, and CEA level were significant prognostic factors. Positron emission tomography/CT can be selectively applied as a primary examination in CRC patients with asymptomatic elevation of CEA. High CEA levels, increased body mass index, and advanced TNM staging are risk factors for relapse." }, { "id": "pubmed23n0903_9600", "title": "A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis Treated with Preoperative FOLFOX Chemotherapy Followed by Radical Subtotal Gastrectomy and D2 Lymph Node Dissection.", "score": 0.009345794392523364, "content": "We report the case of a 73-year-old female who was diagnosed with advanced gastric cancer. Esophagogastroduodenoscopy was used to diagnose Borrmann type 3 advanced gastric cancer located at the gastric antrum. A biopsy revealed poorly differentiated adenocarcinoma. Abdominopelvic computed tomography (CT) and <sup18</supF-fluorodeoxyglucose positron emission tomography-CT (FDG-PET-CT) scans demonstrated multiple lymph node metastases, including the para-aortic lymph nodes. Systemic chemotherapy with 5-fluoruracil (5-FU), oxaliplatin, and leucovorin (FOLFOX) was initiated. An abdominopelvic CT scan taken after 4 cycles of chemotherapy showed improvement in the ulceroinfiltrative gastric lesion and marked regression of several enlarged lymph nodes. Consequently, we performed a subtotal gastrectomy with D2 lymphadenectomy. The postoperative histopathological report was early gastric carcinoma with no lymph node metastasis in the 48 resected lymph nodes. Another 4 cycles of FOLFOX chemotherapy were performed after surgery. A FDG-PET-CT scan taken 12 months postoperatively showed no definite evidence of local recurrence or distant metastasis, and the previously noted retroperitoneal lymph nodes had disappeared. A FDG-PET-CT taken 16 months postoperatively showed multiple lymph node metastases, including the left supraclavicular lymph node. Despite 8 cycles of secondary chemotherapy with 5-FU, irinotecan, and leucovorin (FOLFIRI) and radiotherapy, the patient died 38 months after the operation." }, { "id": "pubmed23n0097_7500", "title": "Assessment of serial carcinoembryonic antigen: determinations to monitor the therapeutic progress and prognosis of metastatic liver disease treated by regional chemotherapy.", "score": 0.009345794392523364, "content": "It is difficult, time-consuming, and expensive to evaluate the therapeutic efficacy of regional chemotherapy of metastatic liver disease by means of imaging procedures. Therefore it was the aim of this study to find out whether serial carcinoembryonic antigen (CEA) determinations yield reliable data on the therapeutic progress and the individual prognosis of these patients. Since there exists no generally accepted modality to assess CEA curves of patients receiving chemotherapy, we developed our own criterion and tested it in a group of 35 patients. For each patient an individual reference level (CEA-means) was fixed which was obtained as the arithmetical mean of serial CEA values taken during the first three courses of chemotherapy (reference time). On the basis of CEA-means the marker curves of the 35 patients could be divided into two groups. After the reference time the CEA values of group 1 (12 patients) never decreased below CEA-means. Survival of these patients was significantly (P = 0.00001) shorter than that of the 23 patients (group 2) who showed a decrease in their CEA curves below CEA-means after the reference time. Beyond this it could be observed that the improvement in survival was significantly greater in those patients who showed a CEA decrease below CEA-means for a prolonged period (3 months). This difference in prognosis is not an artefact due to different pretherapeutic conditions but is a sign of different responses to therapy. The decrease in CEA values below the individual reference level (CEA-means) is a certain sign of the efficacy of the chosen chemotherapy. A continuous rise of the CEA curve above CEA-means signifies an ineffective intrahepatic chemotherapy or extrahepatic tumor manifestation. In this case an intensive diagnostic workup of the patient and possibly a modification of the therapy are indicated." }, { "id": "wiki20220301en010_160873", "title": "Colorectal cancer", "score": 0.009259259259259259, "content": "If cancer has spread to the lymph nodes or distant organs, which is the case with stage III and stage IV colon cancer respectively, adding chemotherapy agents fluorouracil, capecitabine or oxaliplatin increases life expectancy. If the lymph nodes do not contain cancer, the benefits of chemotherapy are controversial. If the cancer is widely metastatic or unresectable, treatment is then palliative. Typically in this setting, a number of different chemotherapy medications may be used. Chemotherapy drugs for this condition may include capecitabine, fluorouracil, irinotecan, oxaliplatin and UFT. The drugs capecitabine and fluorouracil are interchangeable, with capecitabine being an oral medication and fluorouracil being an intravenous medicine. Some specific regimens used for CRC are CAPOX, FOLFOX, FOLFOXIRI, and FOLFIRI. Antiangiogenic drugs such as bevacizumab are often added in first line therapy. Another class of drugs used in the second line setting are epidermal growth factor" }, { "id": "pubmed23n0691_7674", "title": "What is the most accurate whole-body imaging modality for assessment of local and distant recurrent disease in colorectal cancer? A meta-analysis : imaging for recurrent colorectal cancer.", "score": 0.009259259259259259, "content": "The objective of this study was to compare the diagnostic performance of positron emission tomography (PET), PET/CT, CT and MRI as whole-body imaging modalities for the detection of local and/or distant recurrent disease in colorectal cancer (CRC) patients who have a (high) suspicion of recurrent disease, based on clinical findings or rise in carcinoembryonic antigen (CEA). A meta-analysis was undertaken. PubMed and Embase were searched for studies on the accuracy of whole-body imaging for patients with suspected local and/or distant recurrence of their CRC. Additionally, studies had to have included at least 20 patients with CRC and 2 × 2 contingency tables had to be provided or derivable. Articles evaluating only local recurrence or liver metastasis were excluded. Summary receiver-operating characteristic (ROC) curves were constructed from the data on sensitivity and specificity of individual studies and pooled estimates of diagnostic odds ratios (DORs) and areas under the ROC curve (AUCs) were calculated. To test for heterogeneity the Cochran Q test was used. Fourteen observational studies were included which evaluated PET, PET/CT, CT and/or MRI. Study results were available in 12 studies for PET, in 5 studies for CT, in 5 studies for PET/CT and in 1 study for MRI. AUCs for PET, PET/CT and CT were 0.94 (0.90-0.97), 0.94 (0.87-0.98) and 0.83 (0.72-0.90), respectively. In patient based analyses PET/CT had a higher diagnostic performance than PET with an AUC of 0.95 (0.89-0.97) for PET/CT vs 0.92 (0.86-0.96) for PET. Both whole-body PET and PET/CT are very accurate for the detection of local and/or distant recurrent disease in CRC patients with a (high) suspicion of recurrent disease. CT has the lowest diagnostic performance. This difference is probably mainly due to the lower accuracy of CT for detection of extrahepatic metastases (including local recurrence). For clinical practice PET/CT might be the modality of choice when evaluating patients with a (high) suspicion of recurrent disease, because of its best performance in patient based analyses and confident prediction of disease status." }, { "id": "wiki20220301en056_41696", "title": "FOLFOX", "score": 0.009174311926605505, "content": "FOLFOX is a chemotherapy regimen for treatment of colorectal cancer, made up of the drugs folinic acid (leucovorin, FOL), fluorouracil (5-FU, F), and oxaliplatin (Eloxatin, OX). FOLFOX4 Adjuvant treatment in patients with stage III colon cancer is recommended for 12 cycles, every two weeks. The recommended dose schedule is as follows: Day 1: Oxaliplatin 85 mg/m2 intravenous (IV) infusion in 250-500 mL D5W and leucovorin 200 mg/m2 IV infusion in D5W administered concurrently over 120 minutes in separate bags using a Y-line, followed by fluorouracil (5-FU) 400 mg/m2 IV bolus given over 2–4 minutes, followed by 5-FU 600 mg/m2 IV infusion in 500 mL D5W (recommended) as a 22-hour continuous infusion. Day 2: Leucovorin 200 mg/m2 IV infusion over 120 minutes, followed by 5-FU 400 mg/m2 IV bolus given over 2–4 minutes, followed by 5-FU 600 mg/m2 IV infusion in 500 mL D5W (recommended) as a 22-hour continuous infusion." }, { "id": "pubmed23n0369_16117", "title": "16. FDG-PET in the Detection of Recurrence in Colorectal Cancer Based on Rising CEA Level. Experience in 72 Patients.", "score": 0.009174311926605505, "content": "Purpose: A rising CEA level after the resection of colorectal cancer is an early indicator of tumour recurrence. However, conventional imaging techniques have limited sensitivity for detecting recurrent disease in such patients. Our group has evaluated the role of Positron Emission Tomography with 18F-Fluorodeoxiglucose (FDG-PET) in this clinical situation.Material and Methods: Seventy-two patients with abnormal CEA levels and normal results of conventional methods of tumour detection were studied with FDG-PET. The PET results were compared with pathologic findings (n = 25) long-term radiological (n = 9) and clinical follow-up (n = 38). Influence of PET findings in therapeutic management was also considered in this study.Results: PET detected lesions in 63/72 patients (87.1%). Metabolic imaging showed metastases in the liver (44.1%), ganglionar nodes (27.5%), local recurrence (20.4%) and lung metastases (8%). Overall, the sensitivity of PET was 94.4%, specificity was 83.3%, the positive-predictive value was 97.1%, the negative-predictive value was 71.4% and the diagnostic accuracy was 92.8%. FDG-PET findings change therapeutic decision in 68/72 patients (94.1%)Conclusion: When conventional examinations are normal, FDG-PET is a valuable imaging tool in patients who have rising CEA level after colorectal surgery. Metabolic imaging represents a very cost-effectiveness diagnostic procedure in this clinical situation, avoiding unnecessary invasive techniques." }, { "id": "pubmed23n0822_10843", "title": "[A case of hepatic resection after chemotherapy for metastatic colon cancer of the liver with invasion of the inferior vena cava and hepatic vein].", "score": 0.00909090909090909, "content": "A 61-year-old man presented with lower abdominal pain. Further examination revealed descending colon cancer and multiple liver metastases (S1, S2, and S5). The largest metastatic lesion in S1 showed massive invasion to the inferior vena cava (IVC) and was considered unresectable. Resection of the primary colon cancer was performed in January 2011, followed by several types of systemic chemotherapy(12 courses of capecitabine plus oxaliplatin [XELOX] + bevacizumab[Response Evaluation Criteria In Solid Tumors{RECIST}: PD], 5 courses of folinic acid, fluorouracil, and irinotecan [FOLFIRI] + bevacizumab[RECIST: SD], and 13 courses of FOLFIRI+ panitumumab). After these regimens, the lesions in S1 and S2 substantially decreased in size (RECIST: PR), and the lesion in S5 was no longer visible. The extent of invasion to the IVC significantly reduced, and liver resection(extended left lobectomy)and partial IVC resection were performed in November 2013 without reconstruction of the IVC by using a vascular prosthesis. The patient was discharged uneventfully on postoperative day 16, and administration of tegafur-uracil-Leucovorin (UFT/UZEL) was initiated. After 4 months, a recurrent lesion was found in S5, and partial liver resection was performed. In addition, FOLFIRI+panitumumab was reinitiated for the multiple lung metastases. The patient is alive without progression of disease 3 years and 4 months after colectomy." }, { "id": "pubmed23n0012_9151", "title": "Carcinoembryonic antigen assay: an adjunct to liver scanning in hepatic metastases detection.", "score": 0.00909090909090909, "content": "The radionuclide liver scan is a valuable study for detection of hepatic metastases; however, it has a false-negative rate of between 10 and 30%. In a double-blind study involving 377 patients, we assessed the value of CEA assay as an adjunct to liver scanning for detection of hepatic metastases. Fifty-seven patients studied by both methods were ultimately proven to have liver metastases. All patients with CEA levels above 9 ng/ml and focal defects on liver scan had hepatic tumor involvement, while only 4 of 291 patients with CEA values less than 9 ng/ml and negative scans were later shown to have liver metastases. CEA and liver scan results were discordant for 29 patients with proven hepatic metastases: the radionuclide study was positive in 21 cases with false-negative CEA results, while the CEA assay suggested the presence of metastatic disease in eight of the 12 patients with false-negative liver scans." }, { "id": "pubmed23n1032_21407", "title": "A Randomized Phase II Study of Perioperative Chemotherapy Plus Bevacizumab Versus Postoperative Chemotherapy Plus Bevacizumab in Patients With Upfront Resectable Hepatic Colorectal Metastases.", "score": 0.009009009009009009, "content": "Whether patients with resectable colorectal liver metastases (CRLM) gain a survival benefit from perioperative chemotherapy remains controversial. The benefit of including bevacizumab in chemotherapy also remains unclear. Seventy-six patients with CRLM were randomly assigned to either 6 cycles of FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin)/FOLFIRI (folinic acid, 5-fluorouracil, and irinotecan) with bevacizumab before and after surgery or 12 cycles after surgery. Progression-free survival (PFS) was estimated using the Kaplan-Meier method and compared by the log-rank test. The median PFS of all patients was 37.4 months at 5.4 years follow-up, and the median overall survival (OS) was not reached. The PFS between the perioperative group and the postoperative group did not reveal a statistical difference (P = .280). The OS was significantly better in the perioperative group (hazard ratio [HR], 0.60; 95% confidence interval [CI],) 0.35-1.02; P = .049). In subgroup patients with carcinoembryonic antigens (CEA) ≥ 5 ng/mL or those with over 2 liver metastases, perioperative group had longer OS than postoperative group (CEA: HR, 0.49; 95% CI, 0.25-0.93; P = .030; number of liver metastases: HR, 0.55; 95% CI, 0.30-0.99; P = .049). The largest liver metastases size, disease-free interval, and sidedness did not affect PFS or OS. There was no difference between the 2 groups in postoperative complications with bevacizumab or adverse events during chemotherapy. In patients with resectable CRLMs, perioperative chemotherapy had no effect on PFS, but improved OS. Patients with high CEA levels or over 2 liver metastases may benefit from perioperative chemotherapy." }, { "id": "pubmed23n0333_2489", "title": "Is carcino-embryonic antigen useful in the follow-up management of patients with colorectal liver metastases?", "score": 0.009009009009009009, "content": "The role of carcino-embryonic antigen (CEA) in monitoring early detection of recurrent or metastatic colorectal cancer, and its impact on resectability rate and patient survival remains controversial. Our objective was to determine any association between the preoperative level of CEA and prognosis, and the resectability and survival by method of diagnosis of colorectal hepatic metastases. We analyzed patients who underwent exploration for hepatic resection for metastatic colorectal cancer over a 15-year period. The patient population consisted of those patients who had undergone primary colon or rectal resection and were followed up with serial CEA levels and of patients who were followed up with physical examination, liver function tests (LFTs) or computed tomography (CT) of the abdomen and pelvis that led to the diagnosis of liver metastases. Also included in the study were patients who were diagnosed with liver metastases at the time of the primary colon or rectal resection and underwent planned hepatic resection at a later time. Three hundred and one (301) patients who underwent a total of 345 planned hepatic resections for metastatic colorectal cancer between January 1978 and December 1993 were included in this analysis. The median preoperative CEA level was 24.8 ng/mL in the resected group, 53.0 ng/mL in the incomplete resection group, and 49.1 ng/mL in the nonresected group (P = 0.02). More of the patients who had a preoperative CEA &lt; or =30 ng/mL were in the resected group, while those who had a preoperative CEA &gt;30 ng/mL were likely to be in the nonresected group (P = 0.002). The median survival was 25 months for patients with a preoperative CEA level &lt; or =30 ng/mL and 17 months for patients with a preoperative CEA &gt;30 ng/mL (P = 0.0005). The resectability rate and the survival of patients by method of diagnosing liver metastases-rising CEA versus history and physical, elevated LFTs, CT scan versus diagnosis at the time of primary resection-was not significant (P = 0.06 and P = 0.19, respectively). Given the nonstandardized retrospective nature of the study cohort and relative small groups of patients, the power to detect small differences in survival by method of diagnosis is limited. In the complete resection group of patients with unilobar liver disease (5-year survival of 28.8%) there was no difference in survival between those patients who had normal preoperative CEA and those who had elevated preoperative CEA, and approximately 90% of them had an abnormal preoperative serum CEA level. CEA is useful in the preoperative evaluation of patients with hepatic colorectal metastases for assessing prognosis and is complimentary to history and physical examination in the diagnosis of liver metastases. Patients with colorectal liver metastases and preoperative CEA &lt; or =30 ng/mL are more likely to be resectable, and they have the longest survival." }, { "id": "pubmed23n1062_16158", "title": "Chemotherapy rechallenge in metastatic colon cancer: A case report and literature review.", "score": 0.008928571428571428, "content": "Colorectal cancer (CRC) is the third leading cause of cancer-related death in males and females in the United States. Approximately, 20%-22% of patients have metastatic disease at the time of presentation, and 50%-60% will develop metastasis over the course of their disease. Despite advances in systemic therapies, there remains a paucity of effective third- and later-line therapies for patients with ongoing disease progression. However, rechallenging chemo-resistant CRC tumors with previously administered therapies is an emerging concept that may be a life-prolonging option for heavily treated metastatic colorectal cancer (mCRC). A 41-year-old man with no previous medical history initially presented with worsening diffuse abdominal tenderness. Computed tomography was significant for a splenic flexure mass and hepatic lesions concerning for metastatic disease. He underwent a colectomy with anastomosis. Postoperative pathology was diagnostic for moderately to well-differentiated adenocarcinoma (T4bN1bM1a). He received adjuvant 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX), but therapy was discontinued due to the development of atrial fibrillation. Additional workup indicated a carcinoembryonic antigen level of 508.2 ng/mL, and mutational analysis found that the tumor was microsatellite instability-high and <iKRAS</i/<iBRAF</i wild-type. He was started on irinotecan with oxaliplatin (IROX), and bevacizumab (14 cycles), developed disease progression, was transitioned to FOLFOX and cetuximab, and then eventually three cycles of pembrolizumab. Following disease progression, he was rechallenged with IROX therapy, as he previously responded well to oxaliplatin-based therapy. The IROX rechallenge provided this patient with a ten-month survival benefit, decreased metastatic burden, and marked improvement in his clinical condition. Rechallenge of previous lines of well-tolerated systemic chemotherapy regimens may be a valuable therapeutic strategy in patients with heavily-treated mCRC." }, { "id": "pubmed23n0400_18523", "title": "Positron emission tomography for evaluation of colorectal carcinoma.", "score": 0.008928571428571428, "content": "Evaluation of patients with known or suspected recurrent colorectal carcinoma is now an accepted indication for FDG PET imaging. FDG PET does not replace imaging modalities such as CT for preoperative anatomic evaluation but is indicated as the initial test for diagnosis and staging of recurrence and for preoperative staging (N and M) of known recurrence that is considered to be resectable. FDG PET imaging is valuable for differentiation of posttreatment changes from recurrent tumor, differentiation of benign from malignant lesions (indeterminate lymph nodes, hepatic and pulmonary lesions), and evaluation of patients with rising tumor markers in the absence of a known source. Addition of FDG PET to the evaluation of these patients reduces overall treatment costs by accurately identifying patients who will and will not benefit from surgical procedures. Although initial staging at the time of diagnosis is often performed during colectomy, FDG PET imaging is recommended for a subgroup of patients at high risk (with elevated CEA levels) and normal CT and for whom surgery can be avoided if FDG PET shows metastases. Screening for recurrence in patients at high risk has also been advocated. FDG PET imaging seems promising for monitoring therapy, but larger studies are necessary." }, { "id": "pubmed23n0853_12027", "title": "[A CASE OF ASCENDING COLON CANCER RECURRENCE WITH INTRALUMINAL URETERAL DISSEMINATION MIMICKING PRIMARY URETERAL CANCER, DETECTED DURING INVESTIGATION FOR FEVER].", "score": 0.008849557522123894, "content": "A 69-year-old woman visited our hospital with a chief complaint of fever. Five years ago, she was diagnosed as ascending colon cancer and received right hemi-colectomy. One year later, local recurrence with right hydronephrosis was detected, and she received chemotherapy -4 cycles of modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) plus bevacizumab, and 12 cycles of fluorouracil, leucovorin, and irinotecan (FOLFIRI) plus bevacizumab- for two years. Local recurrence and right hydronephrosis disappeared on positron emission tomography performed 4 years postoperatively. This time, abdominal computed tomography for investigation of fever showed a relapse of right hydronephrosis and pyonephrosis. Cystoscopy revealed non-papillary tumor from the right ureteral orifice. Pelvic magnetic resonance imaging showed multiple tumors in the right ureter, and the distal lesion projecting into the bladder. After the general condition became well by right nephrostomy for infection control, transurethral resection of bladder tumor was performed. Histological examination of the specimen revealed a metastatic tubular adenocarcinoma (colon origin). Although right nephrectomy was performed for pyonephrosis control, she died of local progression of ascending colon cancer 10 months after first visit. Intraluminal ureteral progression of carcinoma originating from organs other than urinary tract is very rare. To our knowledge, this is the 9th report in the English or Japanese literature. In this case we could not rule out primary ureteral cancer preoperatively, and histological examination revealed intraluminal ureteral dissemination of ascending colon cancer." }, { "id": "pubmed23n0408_9311", "title": "Positron emission tomography for the evaluation of patients with colorectal cancer.", "score": 0.008849557522123894, "content": "Approximately 40% of patients treated with curative intent for colorectal carcinoma eventually recur. In about one third of these patients, the lesion is localized and potentially resectable. Typically, the recurrence is characterized by findings on diagnostic imaging studies and may be accompanied by a rise in the serum carcinoembryonic antigen (CEA) levels. In a few patients, however, the asymptomatic rise in CEA is not accompanied by diagnostic findings on computed tomography (CT). We report a case herein, of a patient with rising CEA, noted 1 year after completion of adjuvant chemotherapy for node-positive colorectal cancer. CT and laparoscopic exploration were nondiagnostic. In order to further evaluate the rise in CEA, positron emission tomography (PET) was performed. PET revealed an area of increased uptake in the right lobe of the liver. Resection of the metastatic liver lesion resulted in a subsequent drop in the CEA levels." }, { "id": "pubmed23n0755_1767", "title": "Response to chemotherapy in metastatic colorectal cancer after exposure to oxaliplatin in the adjuvant setting.", "score": 0.008771929824561403, "content": "Oxaliplatin with 5-fluorouracil (5-FU) and leucovorin (FOLFOX and FLOX) or capecitabine (XELOX) is the standard adjuvant treatment for colonic cancer. In metastatic disease, 5-FU/leucovorin/irinotecan (FOLFIRI) and FOLFOX are equivalent in respect to response rates, progression-free and overall survival. Little data are available to compare their efficacy after exposure to oxaliplatin-containing adjuvant chemotherapy. We carried out a retrospective study of patients who underwent surgery and FOLFOX adjuvant chemotherapy, followed by FOLFIRI or FOLFOX for metastatic disease. Exclusion criteria were: metastatic disease at presentation and no oxaliplatin in adjuvant chemotherapy. The end-point was the overall response rate (ORR) to first-line chemotherapy for metastatic disease after three months, as assessed by computed tomography (CT). A total of 205 patients received FOLFOX as adjuvant treatment for colorectal adenocarcinoma between 2006 and 2010. Metastatic disease was diagnosed later in 32 cases after a median follow-up of three years (range=1-5.5 years). The median time between the beginning of adjuvant chemotherapy and onset of metastatic disease was 1.7 years (range=0.5-5.5 years). Twenty-eight patients were evaluable for effects of treatment: six patients received FOLFOX plus bevacizumab and 22 FOLFIRI plus bevacizumab. The ORR was 17% in the FOLFOX group versus 36% in the FOLFIRI group (p=0.22). This difference was not statistically significant, despite a trend in favor of FOLFIRI. Metastatic disease after exposure to oxaliplatin in the adjuvant setting tends to occur early and can be characterized by partial resistance to this agent. Despite insufficient statistical power, our results suggest that FOLFIRI may result in higher response rates than FOLFOX in this situation. However, oxaliplatin re-challenge can also lead to radiological responses and disease stabilization." }, { "id": "pubmed23n0796_23587", "title": "Value of ¹⁸F-FDG PET-CT in surveillance of postoperative colorectal cancer patients with various carcinoembryonic antigen concentrations.", "score": 0.008771929824561403, "content": "To evaluate the value of positron emission tomography (PET)/computerized tomography (CT) in surveillance of colorectal cancer (CRC) patients with different carcinoembryonic antigen (CEA) concentrations. One hundred and six postoperative CRC patients who had suspected recurrence or metastasis and received fluorodeoxyglucose (FDG) PET/CT within one week were included in this study. The final diagnosis was confirmed by histological examination or clinical follow-up over at least six months. The sensitivity, specificity, and accuracy of FDG PET/CT were 95.2%, 82.6%, and 92.5%, and 94.8%, 81.4% and 92.8%, respectively, in the case- and lesion-based analyses. The sensitivity and accuracy of FDG PET/CT significantly differed from CT in both analyses (χ(2) = 8.186, P = 0.004; χ(2) =6.201, P = 0.013; χ(2) =13.445, P = 0.000; χ(2) =11.194, P = 0.001). In the lesion-based analysis, the sensitivity, specificity, and accuracy of FDG PET/CT in the abnormal CEA group were 97.8%, 82.6%, and 95.6%, compared with 81.3%, 80%, and 80.6% for patients with normal CEA levels. In case-based analysis, the sensitivity, specificity, and accuracy of FDG PET/CT were 97.2%, 77.8%, and 95% in abnormal CEA group. Only in lesion-based analysis, the sensitivity and accuracy of FDG PET/CT in the abnormal CEA group were significantly superior to those in the normal CEA group (χ(2) =6.432, P = 0.011; χ(2) =7.837, P = 0.005). FDG PET/CT changed the management in 45.8% of patients with positive scans. FDG PET/CT showed superior diagnostic value and is an advisable option in surveillance of postoperative CRC patients with a vague diagnosis." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 243, 376 ] ], "word_ranges": [ [ 41, 64 ] ], "text": "Among the basic initial treatment measures would be the administration of oxygen therapy with FiO2 1 (not 0.5 as stated in option 1)," }, "2": { "exist": true, "char_ranges": [ [ 243, 423 ] ], "word_ranges": [ [ 41, 71 ] ], "text": "Among the basic initial treatment measures would be the administration of oxygen therapy with FiO2 1 (not 0.5 as stated in option 1), and an antidote, in this case hydroxycobalamin" }, "3": { "exist": true, "char_ranges": [ [ 462, 579 ] ], "word_ranges": [ [ 77, 94 ] ], "text": "Ventilation with hyperbaric chamber would only be indicated in case of coexistence of carbon monoxide (CO) poisoning." }, "4": { "exist": true, "char_ranges": [ [ 580, 759 ] ], "word_ranges": [ [ 94, 127 ] ], "text": "What is stated in option 4 about fluid therapy is not indicated; in case of associated shock, volume would be administered, but in any case not at that rate, but in rapid boluses." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Administration of oxygen by means of a 50% Venturi type mask.", "2": "Administration of intravenous hydroxycobalamin.", "3": "Ventilation with hyperbaric chamber.", "4": "Fluid therapy with infusion of physiological saline solution at 21 ml/h.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en019_108042", "title": "Decompression illness", "score": 0.013540260908681961, "content": "First aid First aid is common for both DCS and AGE: Monitor the patient for responsiveness, airway, breathing and circulation, resuscitate if necessary. Treat for shock. Lay the patient on their back, or for drowsy, unconscious, or nauseated victims, on their side. Administer 100% oxygen as soon as possible. Seek immediate medical assistance, locate a hospital with hyperbaric facilities and plan for possible transport. Allow the patient to drink water or isotonic fluids only if responsive, stable, and not suffering from nausea or stomach pain. Administration of intravenous saline solution is preferable. Record details of recent dives and responses to first aid treatment and provide to the treating medical specialist. The diving details should include depth and time profiles, breathing gases used and surface intervals. Prognosis" }, { "id": "wiki20220301en570_2947", "title": "Demand valve oxygen therapy", "score": 0.012274871355060033, "content": "When used in diving recompression chambers and multi-place medical hyperbaric chambers, a built-in breathing system venting to the exterior is generally used to avoid buildup of oxygen partial pressure in the chamber to dangerous levels which would otherwise require more frequent venting. Procedure Contraindications Hazards and precautions High oxygen concentrations in the surroundings constitute a fire hazard. Oxygen therapy should be accompanied by good ventilation and avoidance of ignition sources, and where reasonably practicable, removal of combustible materials. Oxygen firebreaks are a requirement in some countries for patients using oxygen therapy. See also Oxygen for cluster headaches - Information for cluster headache patients, carers, and clinicians References Diving medicine Medical treatments Oxygen Respiratory therapy" }, { "id": "InternalMed_Harrison_32368", "title": "InternalMed_Harrison", "score": 0.012255762255762255, "content": "Use of low-flow oxygen if available Treatment with acetazolamide (250 mg q12h) and/or dexamethasone (4 mg q6h)c Administration of oxygen (2–4 L/min) Treatment with dexamethasone (8 mg PO/IM/IV; then 4 mg q6h) Hyperbaric therapy if descent is not possible Minimization of exertion while patient is kept warm Administration of oxygen (4–6 L/min) to bring O2 saturation to >90% Adjunctive therapy with nifedipinee (30 mg, extended-release, q12h)" }, { "id": "article-36940_24", "title": "Chokes -- Treatment / Management", "score": 0.01084010840108401, "content": "At the emergency department (ED), the patient must be given high-flow oxygen at 100% or the maximum possible concentration, which addresses hypoxemia and accelerates the reabsorption of extra-alveolar gas. Intravenous cannulation must be started for fluid resuscitation and medication administration. If the patient deteriorates, the medical team must be ready to administer basic (BLS) and advanced cardiac (ACLS) life support. Once stable, the patient must be immediately evacuated to a hyperbaric chamber and placed in the care of the hyperbaric team. If the patient was initially taken to a hospital without a hyperbaric chamber, they must be transferred to an appropriately equipped facility with staff capable of treating patients with pulmonary DCS." }, { "id": "wiki20220301en040_16516", "title": "Saline (medicine)", "score": 0.010243592632808178, "content": "Hypertonic saline may be used in perioperative fluid management protocols to reduce excessive intravenous fluid infusions and lessen pulmonary complications. Hypertonic saline is used in treating hyponatremia and cerebral edema. Rapid correction of hyponatremia via hypertonic saline, or via any saline infusion > 40 mmol/L (Na+ having a valence of 1, 40 mmol/L = 40 mEq/L) greatly increases risk of central pontine myelinolysis (CPM), and so requires constant monitoring of the person's response. Water privation combined with diuretic block does not produce as much risk of CPM as saline administration does; however, it does not correct hyponatremia as rapidly as administration of hypertonic saline does. Due to hypertonicity, administration may result in phlebitis and tissue necrosis. As such, concentrations greater than 3% NaCl should normally be administered via a central venous catheter, also known as a 'central line'. Such hypertonic saline is normally available in two strengths, the" }, { "id": "InternalMed_Harrison_15801", "title": "InternalMed_Harrison", "score": 0.010033375052148519, "content": "Management of HPS during the first few hours after presentation is critical. The goal is to prevent severe hypoxemia by oxygen therapy, with intubation and intensive respiratory management if needed. During this period, hypotension and shock with increasing hematocrit invite aggressive fluid administration, but this intervention should be undertaken with great caution. Because of low cardiac output with myocardial depression and increased pulmonary vascular permeability, shock should be managed expectantly with pressors and modest infusion of fluid guided by pulmonary capillary wedge pressure. Mild cases can be managed by frequent monitoring and oxygen administration without intubation. Many patients require intubation to manage hypoxemia and developing shock. Extracorporeal membrane oxygenation is instituted in severe cases, ideally before the onset of shock. The procedure is indicated in patients who have a cardiac index of 2.3 L/min/m2 or an arterial oxygen tension/fractional" }, { "id": "wiki20220301en211_14097", "title": "Volume expander", "score": 0.009971615451067506, "content": "Normal saline Normal saline (NS) is the commonly used term for a solution of 0.9% w/v of NaCl, about 300 mOsm/L. Less commonly, this solution is referred to as physiological saline or isotonic saline, neither of which is technically accurate. NS is used frequently in intravenous drips (IVs) for patients who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia. NS is typically the first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation, and has long been believed to be the safest fluid to give quickly in large volumes. However, it is now known that rapid infusion of NS can cause metabolic acidosis. Ringer's solution Lactated Ringer's solution contains 28 mmol/L lactate, 4 mmol/L K+ and 1.5 mmol/L Ca2+. It is very similar – though not identical – to Hartmann's Solution, the ionic concentrations of which differ slightly." }, { "id": "wiki20220301en060_49284", "title": "Diving chamber", "score": 0.009900990099009901, "content": "A hyperbaric oxygen therapy chamber is used to treat patients, including divers, whose condition might improve through hyperbaric oxygen treatment. Some illnesses and injuries occur, and may linger, at the cellular or tissue level. In cases such as circulatory problems, non-healing wounds, and strokes, adequate oxygen cannot reach the damaged area and the body's healing process is unable to function properly. Hyperbaric oxygen therapy increases oxygen transport via dissolved oxygen in serum, and is most efficacious where the haemoglobin is compromised (e.g. carbon monoxide poisoning) or where the extra oxygen in solution can diffuse through tissues past embolisms that are blocking the blood supply as in decompression illness. Hyperbaric chambers capable of admitting more than one patient (multiplace) and an inside attendant have advantages for the treatment of decompression sickness (DCS) if the patient requires other treatment for serious complications or injury while in the chamber," }, { "id": "pubmed23n0563_18650", "title": "[Base excess. Parameter with exceptional clinical significance].", "score": 0.009900990099009901, "content": "The base excess of blood (BE) plays an important role in the description of the acid-base status of a patient and is gaining in clinical interest. Apart from the Quick test, the age, the injury severity score and the Glasgow coma scale, the BE is becoming more and more important to identify, e. g. the risk of mortality for patients with multiple injuries. According to Zander the BE is calculated using the pH, pCO(2), haemoglobin concentration and the oxygen saturation of haemoglobin (sO(2)). The use of sO(2 )allows the blood gas analyser to determine only one value of BE, independent of the type of blood sample analyzed: arterial, mixed venous or venous. The BE and measurement of the lactate concentration (cLac) play an important role in diagnosing critically ill patients. In general, the change in BE corresponds to the change in cLac. If DeltaBE is smaller than DeltacLac the reason could be therapy with HCO(3)(-) but also with infusion solutions containing lactate. Physician are very familiar with the term BE, therefore, knowledge about an alkalizing or acidifying effect of an infusion solution would be very helpful in the treatment of patients, especially critically ill patients. Unfortunately, at present the description of an infusion solution with respect to BE has not yet been accepted by the manufacturers." }, { "id": "pubmed23n0422_5703", "title": "Description and evaluation of a delivery system for aerosolized prostacyclin.", "score": 0.00980392156862745, "content": "Inhaled vasodilators such as nitric oxide and aerosolized prostacyclin (PGI(2)) are used to treat severe hypoxemia in acute respiratory distress syndrome. Preferential distribution of nitric oxide and PGI(2) to ventilated areas of the lung causes selective pulmonary vasodilation, improved ventilation/perfusion matching, and decreased hypoxemia. Because of the technical limitations of previously described methods, we developed a PGI(2) delivery technique that allows the aerosolized drug dose to be easily calculated, set, and adjusted. A 50 mL solution of PGI(2) (3.0x10(4) ng/mL) and a 500 mL normal saline solution were infused by a dual-channel volumetric infusion pump into a MiniHEART jet nebulizer that has a manufacturer-specified output of 8 mL/h at a set flow of 2 L/min. By adjusting the pump infusion rate to achieve a total output of 8 mL/h, the PGI(2) concentration was altered to deliver a calculated aerosolized dose of 10-50 ng/kg/min. The effectiveness of the delivery system was retrospectively evaluated by way of the responses of 11 severely hypoxemic acute respiratory distress syndrome patients who received PGI(2) via the system we describe. The MiniHEART nebulizer output, particle size, and dose delivery were evaluated in a laboratory bench study, using a set flow of 2 L/min. Aerosolized PGI(2) therapy (mean dose 28 +/- 17 ng/kg/min, range 10-50 ng/kg/min) significantly increased the ratio of P(aO)(2) to fraction of inspired oxygen (P(aO)(2)/F(IO)(2)) (60 +/- 11 mm Hg vs 80 +/- 17 mm Hg, p = 0.003) and arterial oxygen saturation measured via pulse oximetry (86 +/- 8% vs 94 +/- 3%, p = 0.005) (differences evaluated with the Wilcoxon signed rank test). There was no difference in positive end-expiratory pressure, mean airway pressure, or F(IO)(2), before and after aerosolized PGI(2) (p &gt; 0.05). Nebulizer output was 6.8 +/- 0.9 mL/h, range 6.0-7.8 mL/h. The inhaled aerosol particles had a mass median diameter of 3.1 micro m. Emitted dose was 67 +/- 13% (range 57-81%) of the calculated dose. Our system is effective in delivering aerosolized PGI(2) to the alveolar-capillary interface, as indicated by significant oxygenation improvements soon after therapy commenced. The performance of the MiniHEART nebulizer varies from the manufacturer's specifications, which may alter the delivered dose." }, { "id": "pubmed23n0268_1474", "title": "[What's new in cardiopulmonary resuscitation? American Heart Association].", "score": 0.00980392156862745, "content": "A strong consensus was reached for several changes in the guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) in the 1992 conference on CPR and ECC held by the Emergency Cardiac Care Committee of the American Heart Association. These new recommendations, together with differing recommendations of the European Resuscitation Council, are described. An unresponsive person with spontaneous respirations should be placed in the recovery position if no cervical trauma is suspected. Compared with endotracheal intubation, other airway-protecting devices such as combination esophageal-tracheal tubes are of minor acceptance. During ventilation, the time for filling the lungs is increased to 1.5-2 s to decrease the likelihood of gastric insufflation. Delivery of i.v. drugs can be enhanced by an i.v. flush of sodium chloride. In endotracheal drug administration, higher doses and drug dilution are recommended. In infants and children up to 6 years of age, the value of intraosseous drug administration is emphasized. For pulseless adult victims, the initial dosage of epinephrine of 1 mg i.v. remains unchanged. For repeat doses, high-dose epinephrine up to 0.1 mg/kg is classified as of uncertain but possible efficacy. For lidocaine, the recommended i.v. dosage is 1.5 mg/kg. Sodium bicarbonate and calcium are not routinely recommended for resuscitation. For atropine, the maximum dose is 0.04 mg/kg. If hypomagnesaemia is present in recurrent and refractory ventricular fibrillation, it should be corrected by administration of 1 to 2 g magnesium sulfate i.v. Thrombolytic agents are classified as useful and effective in acute myocardial infarction and should be administered as early as possible. Glucose-containing fluids are discouraged for resuscitative efforts." }, { "id": "wiki20220301en031_37332", "title": "Hypovolemic shock", "score": 0.009708737864077669, "content": "Hypothermia increases the mortality rate of patients suffering hypovolemic shock. It is advised to keep the patient warm for the sake of maintaining the temperatures of all kinds of fluids inside the patient. Monitoring parameters Oxygen saturation by pulse oximetry (SpO2). Respiratory rate. Pulse rate. Arterial blood pressure. Pulse pressure. Central venous pressure. Urine output. Base deficit and/or lactic acid. Temperature. Mental state. Changes in the electrocardiogram. Prognosis If the vital organs are deprived of perfusion for more than just a short time, the prognosis is generally not good. Shock is still a medical emergency characterized by a high mortality rate. Early identification of patients who are likely to succumb to their illness is of utmost importance. Epidemiology Blood loss" }, { "id": "pubmed23n0572_18695", "title": "[Can modern infusion solutions cause serious disruption of inner environment of an organism?].", "score": 0.009708737864077669, "content": "The article brings a description of a patient case when an application of mineral balanced infusion solutions led to a disruption of inner environment, beginning of a combined failure of the acid-base balance with a serious metabolic acidosis. Patient J. was artificially respirated after a CPR. During the therapy the patient was given basically without any changes a combination of mineral solution Plasma-Lyte 148, amino-acid and 20% glucose. During 8 days a serious metabolic alkalosis had developed (caused by a lack of chlorides, phosphates and other reasons), combined with respirational acidosis. Hydrogencarbonate level was increased to 47.2 mmo/l (at norm of 24 mmol/l), base excess level to 21.4 mmol/l (at norm of 0 mmol/l). Metabolic acidosis led to reduction of sensibility of the respiratory centers and therefore it was not possible to restore spontaneous respiration. After the therapy change and reduction of metabolic acidosis the state of the patient got better. Application of acidifying solutions, supplementation of phosphate and potassium levels and replenishment of actual losses of phosphates led to regulation of the inner environment. Together with the application of sufficient amount of basic nutrients was the improvement of acid-base balance the key factor which enabled the restoration of spontaneous respiration and disconnection of the patient from the ventilator. In short summary you can see reasons which cause different effect of identical infusions to acid-base balance of the inmates in different situations. The article points to a necessity of controlling groovy medical procedures according to actual patient's needs." }, { "id": "wiki20220301en014_110267", "title": "Hyperbaric medicine", "score": 0.009615384615384616, "content": "In the larger multiplace chambers, patients inside the chamber breathe from either \"oxygen hoods\" – flexible, transparent soft plastic hoods with a seal around the neck similar to a space suit helmet – or tightly fitting oxygen masks, which supply pure oxygen and may be designed to directly exhaust the exhaled gas from the chamber. During treatment patients breathe 100% oxygen most of the time to maximise the effectiveness of their treatment, but have periodic \"air breaks\" during which they breathe chamber air (21% oxygen) to reduce the risk of oxygen toxicity. The exhaled treatment gas must be removed from the chamber to prevent the buildup of oxygen, which could present a fire risk. Attendants may also breathe oxygen some of the time to reduce their risk of decompression sickness when they leave the chamber. The pressure inside the chamber is increased by opening valves allowing high-pressure air to enter from storage cylinders, which are filled by an air compressor. Chamber air" }, { "id": "pubmed23n0082_20880", "title": "[Iso- and hypervolemic hemodilution with hydroxyethyl starch (HES 200/.05 10%) in patients with II b peripheral arterial occlusive disease].", "score": 0.009615384615384616, "content": "The basic therapy in stage IIb of peripheral arterial occlusive disease (PAOD) according to Fontaine is exercise. The aim of this study was to test whether (given initial physiological hematocrit values of 43 to 46%) a mild hypervolemic to isovolemic to hematocrit values of 40% with HES 200/0.5 10% or Ringer lactate in combination with exercise is even more favorable. In order to answer this question, 3 groups of 25 patients each were formed. One group exercised three times weekly and the second group, in addition to exercise, underwent a mild, hypervolemic to isovolemic 6-week dilution therapy with HES. In the final group the hematocrit value was reduced to the same extent by means of venesection and volume substitution with Ringer lactate. The walking distance increased in the HES group from 216 to 311 m (44%), in the Ringer lactate group from 214 to 258 m (20%), and in the exercise group from 213 to 242 m (14%). In comparison of the groups, the increase in pain-free walking distances in the HES group is found to differ significantly from those in the other groups. It was clearly demonstrated that hemodilution with HES in combination with exercise brings about a clinical effect of an order three times of that achieved by exercise alone. Venesection with subsequent administration of Ringer lactate and exercise is superior to exercise alone, but is markedly inferior to the combination therapy with HES." }, { "id": "wiki20220301en057_29614", "title": "Crush syndrome", "score": 0.009523809523809525, "content": "Intravenous hydration of up to 1.5 L/h should continue to prevent hypotension. A urinary output of at least 300 mL/h should be maintained with IV fluids and mannitol, and hemodialysis considered if an increase in urine is not achieved. Use intravenous sodium bicarbonate to keep the urine pH at 6.5 or greater, to prevent myoglobin and uric acid deposition in kidneys. To prevent hyperkalemia/hypocalcemia, consider the following adult doses: calcium gluconate 10% 10 mL or calcium chloride 10% 5 mL IV over 2 minutes sodium bicarbonate 1 meq/kg IV slow push regular insulin 5–10 U 50% glucose 1–2 ampules IV bolus kayexalate 25–50 g with sorbitol 20% 100 mL by mouth or rectum. Even so, abnormal heart rhythms may develop; electrocardiographic monitoring is advised, and specific treatment begun promptly. References External links Life or Limb: What happens when your leg gets trapped under a building? Injuries Early complications of trauma Nephrology Syndromes" }, { "id": "pubmed23n0678_10748", "title": "[Basis for the clinical management of fire smoke poisoning \"Docohumo Madrid 2010\"].", "score": 0.009523809523809525, "content": "Poisoning by smoke is the main cause of morbidity and mortality in fires. Smoke is a mixture of carbonaceous particles suspended in hot air and toxic gases. Of these, carbon monoxide (CO) and primarily hydrocyanic acid (CNH), are those that provoke tissue anoxia. The clinical manifestations of smoke poisoning are variables. Some of the potential manifestations could be: eye irritation, sore throat, laryngeal stridor, dysphagia, carbonaceous sputum, cough, dyspnea, laryngospasm, bronchospasm, coronary syndrome, coma, hypoxemia, lactic acidosis, cyanosis and death. In the assessment of these patients the presence of soot in the nose, mouth or sputum suggests serious poisoning. Lactate levels higher than 10mmol/L indicates levels of cyanide major than 40micromole/L. The pulse co-oximetry has assumed an important step forward for the diagnosis, appraisal and monitoring of these patients. In the treatment it will be essential to assess the need of an early intubation. The administration of oxygen to the 100% will be essential. As an antidote to the cyanide, the first-choice is the hydroxocobalamin. Its administration has to be early. Its administration criteria are: patient who has inhaled smoke (remnants of soot in the mouth, pharynx or sputum) and has neurological disorder (confusion, coma, agitation, seizures) and also presents one of the following circumstances: bradypnea, respiratory arrest, cardiorespiratory arrest, shock, hypotension, lactate ≥8mmol/L or lactic acidosis. Logically, the rest of the management will be conventional depending on symptoms or complications." }, { "id": "pubmed23n0256_5439", "title": "[Hypertonic solutions in the intensive care unit].", "score": 0.009433962264150943, "content": "The use of small volumes of hypertonic saline (HTS) 7.2-7.5% (small volume resuscitation) in combination with colloidal solutions has been proved to be of value in stabilizing oxygen transport in hemorrhagic shock. The specific effects of HTS lead to an improvement in tissue oxygenation by increasing the cardiac preload, decreasing the afterload and endothelial and interstitial edema within the microcirculation. This study investigates whether the use of HTS combined with hydroxyethylstarch (HAES) leads to a significant increase in the O2 delivery (DO2) and O2 consumption (VO2) in hyperdynamic critically ill patients. A total of 41 patients, 20 septic patients and 21 patients without sepsis were investigated. When a hyperdynamic circulation (DO2 &gt; 700 ml/min/m2) was attained, 2-4 ml/kg 7.5% HTS in 6% HAES were infused over 15 minutes. In the septic patients this leads to a significant increase in the DO2 of 14% (p &lt; 0.001). The VO2 (calculated from the cardiovascular Fick) increased by 7% (p &lt; 0.05). The VO2 calculated from the respiratory gases increased by 4% (n.s.). This &lt; 10% increase in VO2 does not seem to be due to a relevant tissue oxygen debt. This is supported by the fact that in the non septic group the DO2 and VO2 increased by the same extent, there was no significant difference between the two groups. Further there was an equal increase in the O2 extraction ratio of 10% (septic patients) and 9.5% (non septic patients). In both groups the mean plasma lactate levels before and 90 min after the HTS/HAES infusion were within normal range so that a wash-out phenomenon was not discernible.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en020_52706", "title": "Oxygen therapy", "score": 0.009345794392523364, "content": "Medical uses Oxygen is widely used by hospitals, EMS, and first-aid providers in a variety of conditions and settings. A few indications frequently requiring high-flow oxygen include resuscitation, major trauma, anaphylaxis, major bleeding, shock, active convulsions, and hypothermia. Acute conditions In context of acute hypoxemia, oxygen therapy should be titrated to a target level based on pulse oximetry (94–96% in most patients, or 88–92% in people with COPD). This can be performed by increasing oxygen delivery, described as FIO2(fraction of inspired oxygen). In 2018, the British Medical Journal recommended that oxygen therapy be stopped for saturations greater than 96% and not started for saturations above 90 to 93%. This may be due to an association between excessive oxygenation in the acutely ill and increased mortality. Exceptions to these recommendations include carbon monoxide poisoning, cluster headaches, sickle cell crisis, and pneumothorax." }, { "id": "pubmed23n0309_22406", "title": "Using blood gases for the v.i.p..", "score": 0.009345794392523364, "content": "We have tried to expand the routine analysis of blood gases to include some fine-tuning aspects of critical care. Test your understanding by answering the following question: A 70-year-old smoker falls into Lake Dillon (outside Denver) suffering a near-drowning episode. The pulse oximeter shows 93% on 6L nasal oxygen. His pulse and blood pressure are normal. Because you've read this article, you know that the patient's smoking habit and the city's elevation can affect the pulse oximeter's accuracy, leading one to underestimate the severity of the problem. So, you draw labs and note that his hemoglobin is 12, with blood gases showing PaO2 of 90, PaCO2 of 30 and a pH of 7.36. The lab forgot to calculate the base excess for you and his temperature is 89 degrees F rectally. A diagnosis of life-threatening inadequate oxygenation is supported by which of the following astute observations: a) An abnormal base deficit is proven by the borderline acidic pH and the low PaCO2. b) His anemia reduces both his buffer base and his oxygen carrying capacity. c) His hypothermia overstates his PO2 because the blood was heated up before measurement. d) His smoking makes a CO level likely, worsening his anemia and ignored by the pulse oximeter. e) The high level of supplemental oxygen has minimal effect on his arterial oxygen tension, showing severe pulmonary gas transfer problems (shunting). f) The measurement of his PaO2 is artificially high because he is at altitude. All of the following except (f). Measuring his oxygen tension at altitude actually works in his favor, since the barometric effect will be to reduce the PaO2 at a given level of sea level pathology. Now you are ready to give your patients the V.I.P. treatment!" }, { "id": "wiki20220301en334_29038", "title": "Hyperbaric nursing", "score": 0.009259259259259259, "content": "Hyperbaric nurses are responsible for administering hyperbaric oxygen therapy to patients and supervising them throughout the treatment. These nurses must work under a supervising physician trained in hyperbarics who is available during the treatment in case of emergency. Hyperbaric nurses either join the patient inside the multiplace hyperbaric oxygen chamber or operate the machine from outside of the monoplace hyperbaric oxygen chamber, monitoring for adverse reactions to the treatment. Patients can experience adverse reactions to the hyperbaric oxygen therapy such as oxygen toxicity, hypoglycemia, anxiety, otic barotrauma, or pneumothorax. The nurse must know how to handle each adverse event appropriately. The most common adverse effect is otic barotrauma, trauma to the inner ear due to pressure not being released on descent. Since hyperbaric oxygen therapy is usually administered daily for a set number of treatments, adverse effects must be prevented in order for the patient to" }, { "id": "pubmed23n0521_21408", "title": "[Acute dyspnea--what should I not forget?].", "score": 0.009259259259259259, "content": "Acute dyspnea represents a diagnostic challenge even for the experienced physician. There are no prospectively evaluated diagnostic algorithms dealing with this frequent clinical problem. First of all, the emergency has to be assessed and life supporting measures have to be considered. In addition to a thorough medical history and clinical examination, chest X-ray, spirometry, ECG, hemoglobin measurement, BNP and D-dimer testing represent valuable diagnostic tools and are available to GP's. Most commonly, acute dyspnoea is pulmonary or cardiac in origin. Up to one third of all cases will have several causes. Functional dyspnea is difficult to diagnose but should be taken into consideration after excluding any somatic cause. Hyperventilation is found in both, organic and non organic diseases, and is therefore an inappropriate criterion to differentiate between the two. The mainstay in the management of any symptom is to primarily treat the underlying disease. A significant hypoxemia (SO2 &lt; 90%, pO2 &lt; 60 mmHg) ought to be corrected by supplemental oxygen. It is inappropriate to withhold oxygen from patients with COPD and severe hypoxemia just to avoid hypercapnia. Besides oxygen, opiates efficiently relief dyspnoea but harbour the risk of respiratory depression, altered mental status or aspiration." }, { "id": "wiki20220301en053_51834", "title": "Ringer's lactate solution", "score": 0.009174311926605505, "content": "Ringer's lactate solution is used because the byproducts of lactate metabolism in the liver counteract acidosis, which is a chemical imbalance that occurs with acute fluid loss or kidney failure. The IV dose of Ringer's lactate solution is usually calculated by estimated fluid loss and presumed fluid deficit. For fluid resuscitation the usual rate of administration is 20 to 30 mL/kg body weight/hour. RL is not suitable for maintenance therapy (i.e., maintenance fluids) because the sodium content (130 mEq/L) is considered too low, particularly for children, and the potassium content (4 mEq/L) is too low, in view of electrolyte daily requirement. Moreover, since the lactate is converted into bicarbonate, long-term use will cause patients to become alkalotic. Ringer's lactate and other crystalloids are also used as vehicles for the IV delivery of medications. In a large-volume resuscitation over several hours, LRS maintains a more stable blood pH than normal saline." }, { "id": "pubmed23n0360_3548", "title": "[Treatment of 522 patients with sudden deafness performed oxygenation at high pressure].", "score": 0.009174311926605505, "content": "Oxygenation at high pressure (OHP) is thought to be useful, even though regional blood flow is decreased, because increasing dissolved oxygen prevents the death of nerve tissue. In this report, we retrospectively investigated the effect of OHP on sudden deafness. We reviewed 522 patients treated with OHP at Kagawa Rosai Hospital over a ten-year period (January 1989 to December 1998). We discussed some prognostic factors: comparison between cases which had been treated with OHP previously and those which had not, number of days between onset and beginning of the treatment which included OHP, age, initial averaged five-frequency hearing level, vertigo, tinnitus, complications of OHP, cases of relapse and the time of the onset, which is about season, month and week. OHP was administered at a pressure of 2.5 atmospheres for 80 minutes a day from 10 to 15 times. All patients also received a course of intravenous administration of steroid, vitamin B12, Prostaglandin E1, ATP, and low-molecular dextran. Overall, complete recovery occurred in 19.7% of the patients, definite improvement in 34.9% (complete recovery included), and slight improvement in 58.1% (definite improvement included). Most of the patients (78.0%) were referred by other hospitals, because our hospital was the only one in the Sikoku area which had a big equipment of OHP. All 161 patients had already been treated in other hospitals over 8 days, but they had shown little improvement after the initial therapy. Of this group, complete recovery after the second course of treatment occurred in 13.0% of the patients, definite improvement in 19.3%, and slight improvement in 39.1%. OHP was thus effective for about 40% of patients who had been unresponsive to the initial therapy. Delay in treatment usually produces poor hearing recovery. There was a significant difference between those patients treated within 14 days and those treated 15 days or more after onset. The improvement rate also decreased with age. The prognosis of patients with vertigo was worse than those without vertigo. Tinnitus had no influence on the prognosis. There were no severe complications during the course of OHP, but otitis media with effusion occurred in 90 patients, and paracentesis was performed for 53 patients. The treatment of sudden deafness with OHP has been discussed in this report. Important prognostic factors were time between onset and beginning of the treatment which included OHP, age, vertigo, and the initial averaged five-frequency hearing level. We conclude that OHP should be performed within 14 days from onset, and that OHP was able to achieve hearing improvement in many cases unresponsive to the initial therapy if it was performed very early." }, { "id": "pubmed23n0323_15316", "title": "Hemodynamic and metabolic responses to repeated hemorrhage and resuscitation with hypertonic saline dextran in conscious swine.", "score": 0.00909090909090909, "content": "Previous work in our laboratory has demonstrated that HSD is an effective small-volume resuscitation fluid for the treatment of hemorrhagic hypotension, but limitations to its usefulness in severe hemorrhage have not been explored. In the present study, animals (N = 12) were bled from an arterial line at a rate of 1 mL/kg/min until continuously monitored aortic blood flow was reduced to one-half its baseline value, and then they were immediately resuscitated with 7.5% NaCl/6% dextran 70 (hypertonic saline dextran, 4 mL/kg) administered intravenously over 3 min. After recording the maximum improvement in blood pressure, blood samples were obtained and the hemorrhage-resuscitation sequence was repeated until no further measurable increase in cardiac index or blood pressure could be elicited by resuscitation. In the majority of the animals, cardiac index and right and left ventricular stroke work could be improved at least through two bleedings and resuscitation. These improvements sufficed to increase oxygen delivery and consumption, despite the decreases in hematocrit induced by bleeding, transcapillary refill, and asanguinous fluid administration. Under these severe hemorrhage conditions, the acid-base imbalance was not improved by hypertonic saline dextran, and the rate of increase in acidosis was not affected by its administration. We observed a progressive decrease in base excess from +1.35+/-3.19 (mean +/- standard error) to -12.9+/-2.1 mEq/L even when resuscitation improved oxygen consumption significantly by 95+/-20%. In animals that survived as many as three bleedings and resuscitation, the depletion of buffering capacity of the blood was most predominant, and bicarbonate reached a nadir of 7.62 mEq/L with a base excess of -22.4 mEq/L. It is evident that restoration of perfusion in shock treats only a portion of the physiologic dysfunction, leaving major metabolic derangements uncorrected." }, { "id": "pubmed23n0056_19865", "title": "[Hyperosmolar volume replacement in heart surgery].", "score": 0.00909090909090909, "content": "The ideal solution for use in volume therapy is still a matter of debate. Hypertonic sodium (HS) solutions have been advocated for resuscitation from hemorrhagic shock (small volume resuscitation). As hypertonic fluids may also be of interest in cardiac surgery, the effects of a new HS solution were studied. METHODS. In 90 patients undergoing aorto-coronary bypass grafting studies were performed at three different periods: I (n = 30) after induction of anesthesia (before onset of the operation); II (n = 30) during cardiopulmonary bypass (CPB); III (n = 30) after termination of bypass. During these periods the patients were randomly allocated to one of three groups with 10 patients in each group: group 1 received a new hypertonic solution prepared in hydroxyethyl starch (HES) solution (72 g/l NaCl, 60 g/l HES, 2400 mosmol/l; HS-HES patients), group 2 received a 6% HES solution (200/0.5; HES patients), and group 3 received no volume infusion and served as controls. RESULTS. After the induction of anesthesia, significantly less HS-HES solution (4.5 +/- 0.5 ml/kg) than 6% HES solution (10.1 +/- 1.4 ml/kg) was necessary to double the baseline PCWP. The fluid balance during CPB was negative in the patients who had received HS-HES preoperatively (-0.03 +/- 0.01 ml/kg.min CPB), whereas 6% HES (+0.06 +/- 0.02 ml/kg.min CPB) and control patients (+0.13 +/- 0.03 ml/kg.min CPB) had a positive fluid balance. Both after the induction of anesthesia and after termination of bypass, CI increased more in the HS-HES group than in the HES patients, and it even decreased in the control group. SVR decreased in the HS-HES patients, whereas it increased in the control group. Rapid infusion of HS-HES during CPB was followed by a significant, but short-lasting decrease in MAP (-40 mmHg) and an increase in the oxygenator volume. Pulmonary gas exchange (= paO2) was least compromised in the HS-HES patients; the sodium concentration increased only in the HS-HES patients, but never exceeded 150 mmol/l. DISCUSSION. Cardiac surgery procedures offer a special situation for volume therapy as there is a possibility of deterioration in the macro- and microcirculation before, after, and during the period of CPB. Hemodynamic effects of the new HS-HES solution included an increase in CI and a decrease in SVR, which were not merely transient as has been reported which hypertonic saline solution used alone. It was also observed that HS-HES patients required significantly smaller volumes of fluids, both during CPB and during the early postoperative period. This effect seems to be due to a redistribution of interstitial fluid to the intravascular space, possibly decreasing tissue edema. CONCLUSION. The hypertonic saline HES solution adds a new dimension to volume therapy for cardiac surgery patients. The improvement in hemodynamics was effective and not only transient. Fluid requirements were significantly reduced during as well as after CPB, and pulmonary gas exchange was least compromised in these patients." }, { "id": "pubmed23n0853_11905", "title": "[Effect of 3% hypertonic saline as early fluid resuscitation in pediatric septic shock].", "score": 0.009009009009009009, "content": "The mainstay of therapy in patients with septic shock is early and aggressive intravenous fluid resuscitation. However the type of intravenous fluid that would be ideal for managing septic shock has been intensely debated. In this study, the authors observed the effects of 3% hypertonic saline solution compared with normal saline solution as early fluid resuscitation in children with septic shock. In this prospective study, 44 septic shock children seen in the intensive care unit (ICU) of the Children's Hospital Affiliated to Capital Institute of Pediatrics were enrolled from January 2012 to January 2014, of whom 33 were male and 11 were female. Patients were randomly divided into two groups: normal saline group (NS group, 24 patients) and 3% hypertonic saline group (HS group,20 patients). There were no significant differences between the 2 groups of patients in age, gender, pediatric critical illness score (PCIS), oxygenation index (OI = PaO2/FiO2), arterial lactate, initial hemodynamic parameters, serum sodium and treatment at time of admission. Patients in NS group received normal saline guided by standard therapy. Those in HS group received 6 ml/kg 3% hypertonic saline as a single bolus over 10 min to 15 min with a maximum of 2 boluses and other standard therapy. Heart rate (HR), mean arterial blood pressure (MAP), arterial lactate, oxygenation index, urine output, serum sodium, lactate clearance rate, PCIS, fluid infusion volume, vasoactive - inotropic score, mechanical ventilation time , as well as incidence of multiple organ dysfunction syndrome (MODS), and 28 days in - hospital mortality were recorded for all patients. (1) HR, MAP in both groups were significantly higher after infusion than those on admission. There were no significant difference in HR and MAP at 1h, 3h, 6h and 24h after infusion between NS group and HS group. (2) OI in HS group was significantly higher than that on admission at 3 hours after infusion [(321. 8 ± 50. 7) vs. (296. 5 ± 58. 2) mmHg, t = -2. 50, P = 0. 018 ]), and it was significantly higher at 24 hours after infusion in NS group (325. 7 ± 62. 6) vs. (304. 2 ± 70. 4) mmHg, t = -2.60, P=0.016]. There were no significant differences in OI at 1h, 3h, 6h and 24h after infusion between NS group and HS group. (3) At 1 hour after infusion, serum sodium in HS group was significantly higherthan that in NS group [(138.3 ± 3.8)vs. (135.0 ± 3.5) mmol/L, t=8.77, P=0.005], and then no significant difference at 3h, 6h and 24h after infusion between two groups. (4) At 6 hours and 24 hours after treatment, fluid infusion volume in HS group was markedly less than that in NS group [6 h: (39. 2 13. 9) vs. (60. 8 ± 22. 4) ml/kg, t = 14. 21, P =0. 000; 24 h: (102. 9 ± 27. 7) vs. (130. 6 ± 33. 2 ) ml/kg, t= 8. 85, P = 0. 005]. Urine output had not significant different between the two groups. (5) There were no significant differences in 24h PCIS, 24h lactate clearance rate, vasoactive - inotropic score and mechanical ventilation time between the two groups. The incidence of MODS (80. 0% in HS group, 70. 0% in NS group) and mortality rate(5. 0% in HS group, 8. 3% in NS group) were similar in both groups. The 3% hypertonic saline was effective as resuscitation fluid in pediatric septic shock with respect to restoration of hemodynamic stability without obvious side effects. Hypertonic saline could more rapidly improve oxygenation and need less fluid infusion volume compared with normal saline." }, { "id": "wiki20220301en013_139381", "title": "Fluid replacement", "score": 0.009000072144866894, "content": "Optimisation phase - In this phase, the goal is to increase the oxygen delivery to tissues in order to meet the oxygen demands of the tissues. Oxygen delivery can be improved by increasing stroke volume of the heart (through fluid challenge), haemoglobin concentration (through blood transfusion), and arterial oxygen saturation (through oxygen therapy). Fluid challenge is the procedure of giving large amounts of fluid in a short period of time. However, 50% of patients do not respond to fluid challenge. Additional fluid challenges only causes fluid overload. However, there is no gold standard on determining the fluid responsiveness. Among other ways of determining the fluid responsiveness and the end point of fluid resuscitation are: Central venous oxygen saturation (ScvO2), passive leg raising test, ultrasound measurements of pulse pressure variation, stroke volume variation, and respiratory variations at superior vena cava, inferior vena cava and internal jugular vein." }, { "id": "pubmed23n1052_18491", "title": "Elevated Methemoglobin Levels in a Patient Treated with Hydroxocobalamin After Suspected Cyanide Exposure.", "score": 0.008928571428571428, "content": "Cyanide (CN) toxicity commonly occurs during enclosed-space fires. Historically, the first step in treating CN toxicity utilized amyl nitrite and sodium nitrite to induce methemoglobinemia, which can be dangerous in this population. Hydroxocobalamin (OHCob), which binds to CN to form the nontoxic metabolite cyanocobalamin, is now the first-line antidote for CN toxicity, and has the advantage of not inducing methemoglobinemia. A 62-year-old man presented to the Emergency Department (ED) after a house fire. He was intubated for respiratory distress and hypoxia with an initial carboxyhemoglobin of 1.3%, methemoglobin 0.3%, and anion gap 19. Eleven hours after presentation, his serum lactic acid was 9 mmol/L. Given his continued deterioration, 14 h after arrival he received OHCob 5 g i.v. for presumed CN toxicity. Methemoglobin concentration 4 min prior to OHCob administration was 0.7%, and 2 h after administration was 4.2%. This subsequently increased to 14.3% (16 h after OHCob administration) and peaked at 16.3% (47 h after OHCob administration), at which time he was administered a dose of methylene blue 50 mg i.v., 60 h after ED arrival. His methemoglobin concentrations fluctuated until a consistent downward trend starting at 92 h from ED arrival. He continued to deteriorate and expired on hospital day 5 with a methemoglobin concentration of approximately 6.0%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CN toxicity requires immediate recognition and treatment. The antidote, OHCob, is believed to not induce methemoglobinemia. However, this potential side effect must be considered by emergency physicians when treating suspected CN toxicity, especially if the patient does not improve after antidotal therapy." }, { "id": "pubmed23n0680_16690", "title": "[Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council].", "score": 0.008928571428571428, "content": "Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O₂ if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice i.v., second choice intraosseous (i.o.). Vasopressors: 1 mg epinephrine every 3-5 min i.v. After the third unsuccessful defibrillation amiodarone (300 mg i.v.), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children &gt;1 year). Treatment of potentially reversible causes: (\"4 Hs and 4 Ts\") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW i.v. or i.o. every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. NEWBORNS: Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH₂O). If heart rate remains &lt;60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. POSTRESUSCITATION PHASE: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (&lt;0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome &lt;72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. ACUTE CORONARY SYNDROME: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg p.o. or i.v.) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg p.o.). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. TRAUMA: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. Any CPR training is better than nothing; simplification of contents and processes is the main aim." }, { "id": "pubmed23n0478_12215", "title": "[Haemodynamic effects following preoperative hypervolemic haemodilution with hypertonic hyperoncotic colloid solutions in coronary artery bypass graft surgery].", "score": 0.008878048780487806, "content": "Using hyperoncotic colloids as volume replacement to provide haemodynamic stability appears to be a suitable approach to diminish fluid overload and subsequent interstitial edema during cardiac surgery. The aim of the present study was to investigate for the first time the haemodynamic effects following preoperative haemodilution with different hypertonic hyperoncotic colloid solutions in patients undergoing coronary artery bypass grafting. A total of 43 patients with normal left ventricular ejection fraction, undergoing elective coronary artery bypass grafting received preoperatively after induction of anaesthesia according to randomisation the following solutions: 1: 750 ml/m(2) (body surface area) NaCl 0.9% ( n=10, control group, NACL), 2: 250 ml/m(2) 10% HES 200/0.5 plus 400 ml/m(2) NaCl 0.9% ( n=9, HES), 3: 250 ml/m(2) 10% dextran 40 plus 300 ml/m(2) NaCl 0.9% ( n=8, DEX), 4: 150 ml/m(2) hypertonic NaCl (7.2%) 10% HES 200/0.5 (n=8, HYPER-HES), 5: 150 ml/m(2) hypertonic NaCl (7.2%) 10% dextran 60 ( n=8, HYPER-DEX). Haemodynamic measurements were performed immediately before and 15 min after haemodilution and up to 60 min after termination of extracorporeal circulation in 10 min intervals. Fluid balances were calculated separately, during the time period of surgery, postoperatively up to 24 h after termination of surgery, and during the course of extracorporeal circulation. After haemodilution with colloid solutions, a marked increase was observed in all patients and with HYPER-HES and HYPER-DEX a statistically significant increase in cardiac index (CI: +38%, +54%), stroke volume index (SVI: +42%, +40%), and oxygen availability (DO2: +34%; +41%), respectively, was observed during the pre-bypass period. At the same time right and left ventricular filling pressures increased slightly in all patients but these changes did not differ among the treatment groups. Heart rate and mean arterial pressure remained almost unchanged in all groups. The amount of crystalloid solutions required by the patients during surgery was markedly decreased with HES and DEX and significantly decreased with HYPER-HES and HYPER-DEX (1,013+/-341 ml/m(2), 1,096+/-234 ml/m(2)) compared to the control group NACL (1629+/-426 ml/m(2)). Serum sodium concentrations increased with HYPER-HES and HYPER-DEX to maximal values of 150+/-3 mmol/l and 149+/-4 mmol/l, respectively (baseline 141+/-3 mmol/l, 141+/-1 mmol/l) Compared to isotonic saline solution, preoperative volume replacement with hyperoncotic colloids improves haemodynamic conditions during the pre-bypass period in patients with normal left ventricular function undergoing coronary artery bypass grafting. Additionally intraoperative crystalloid solution requirements are reduced. The volume saving effects are increased with administration of hyperoncotic colloids in a preparation with hypertonic saline solution, whereas the choice of the colloid, either hydroxyethyl starch or dextran seems to be of minor importance." }, { "id": "wiki20220301en478_888", "title": "Hyperbaric treatment schedules", "score": 0.008849557522123894, "content": "Built in breathing system Treatment gases are generally oxygen or oxygen rich mixtures which would constitute an unacceptable fire hazard if used as the chamber gas. Chamber oxygen concentration is limited due to fire hazard and the high risk of fatality or severe injury in the event of a chamber fire. US Navy specifications for oxygen content of chamber air allow a range from 19% to 25%. If the oxygen fraction rises above this limit the chamber must be ventilated with air to bring the concentration to an acceptable level. To minimize the requirement for venting, oxygen-rich treatment gases are usually provided to the patient by built in breathing system (BIBS) masks, which vent exhaled gas outside the chamber. BIBS masks are provided with straps to hold them in place over the mouth and nose, but are often held in place manually, so they will fall away if the user has an oxygen toxicity convulsion." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 0, 228 ] ], "word_ranges": [ [ 0, 26 ] ], "text": "Spontaneous reports of serotonergic syndrome associated with concomitant administration of linezolid and serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), have been reported." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Doxycycline.", "2": "Amoxicillin-Clavulanic acid.", "3": "Daptomycin.", "4": "Linezolid.", "5": "Vancomycin." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0622_7622", "title": "Serotonin toxicity as a consequence of linezolid use in revision hip arthroplasty.", "score": 0.019246784491533265, "content": "Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicrobial, it has activity against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, penicillin-resistant Streptococcus pneumoniae, and macrolide-resistant streptococci. There are several documented case reports of serotonin toxicity when used with selective serotonin reuptake inhibitors. The symptoms of serotonin syndrome are alteration of mental state, autonomic dysfunction, and neuromuscular disorders. This article presents a case of an interaction of the serotonin reuptake inhibitor venlafaxine and linezolid and the possible diagnostic problems that can occur. A 58-year-old woman presented with signs of systemic infection. Her medical history included bladder resection for transitional cell carcinoma, bilateral total hip arthroplasty (THA), and depression, for which she was on venlafaxine. Serological and imaging investigations revealed MRSA infection of the bilateral THA. The patient was started on vancomycin and rifampicin intravenously. As intravenous access was becoming problematic and long-term antibiotics were needed, treatment was changed to oral linezolid and oral rifampicin. Four days after the commencement of linezolid, the patient was acutely disorientated with generalized cerebellar signs and no autonomic dysfunction. A computed tomography scan of the head and lumbar puncture revealed no abnormal findings. A diagnosis of serotonin toxicity was made. The patient recovered when linezolid and venlafaxine were discontinued and supportive measures were provided. Linezolid is a popular choice of antibiotic, especially for the treatment of orthopedic-related MRSA infections. Patients who commonly require linezolid as an antimicrobial are those with complex infections where other antibiotic treatment has failed. It is therefore important to be vigilant with linezolid use. Physicians should be aware of the nonspecific presentation of serotonin symptoms and the treatment." }, { "id": "pubmed23n0689_16720", "title": "Linezolid interaction with serotonin reuptake inhibitors: report of two cases and incidence assessment.", "score": 0.015936507936507936, "content": "Prompted by the advent of potentially life-threatening neuromuscular symptoms following initiation of linezolid therapy in two patients receiving treatment with a serotonin reuptake inhibitor antidepressant, an evaluation was conducted to determine the incidence and characteristics of symptomatic serotonin toxicity among hospitalized patients receiving combined treatment with these medications. Patients admitted between January 1, 2006 and August 30, 2008 who received linezolid concurrently with citalopram or escitalopram were identified and their medical records were examined. Patients were judged to have serotonin toxicity if their records contained documentation of clinical evidence adequate to fulfill requisites of the Hunter Serotonin Toxicity Criteria. Severity of serotonin-related symptoms was graded according to previously established criteria. During the period of observation, 24 patients received concurrent treatment with linezolid and citalopram or escitalopram. Of these, one patient (4%) treated with citalopram met evidentiary requirements for diagnosis of serotonin toxicity. The severity of symptoms in this patient was graded as mild. No evidence of serious harm related to a possible drug interaction was identified. Severe symptoms associated with serotonin toxicity were shown to be uncommon in patients receiving linezolid and selected serotonin reuptake inhibitors. Nonetheless, serious interaction-related toxicity has been observed at our institution and reported in detail by others. Accordingly, concurrent use of these medications is categorized as contraindicated. Alternative antimicrobial therapy should be instituted in most cases. If no suitable alternative is available, recipient patients should be hospitalized for expectant observation and rigorous monitoring." }, { "id": "pubmed23n0535_23820", "title": "Drug interactions between linezolid and selective serotonin reuptake inhibitors: case report involving sertraline and review of the literature.", "score": 0.014756135445790618, "content": "A 47-year-old woman developed confusion, incoordination, and hypertension after she was given linezolid in addition to sertraline for 5 days. Her symptoms resolved within 4 days of discontinuing linezolid. One and a half months later, she received a second course of linezolid; sertraline was discontinued on day 1 of linezolid therapy. On day 9 of therapy, the patient developed confusion, myoclonus, and incoordination, and cardiopulmonary arrest occurred, leaving the patient in a coma. Diarrhea, hypertension, and tachycardia developed after cardiopulmonary arrest. Linezolid was discontinued on day 10, and cyproheptadine was given. Linezolid is a weak monoamine oxidase inhibitor and has been reported to interact with selective serotonin reuptake inhibitors (SSRIs). Several cases of serotonin syndrome in patients taking linezolid and SSRIs have been reported, including two reports with sertraline, one with paroxetine, four with citalopram, and two with fluoxetine. One abstract of a retrospective analysis reported that serotonin syndrome did not occur in patients who received linezolid and fluoxetine, paroxetine, or sertraline. Because of several limitations, however, no conclusions can be drawn from that retrospective analysis. A drug interaction involving escitalopram and linezolid has not been documented. Caution should be used when linezolid is used in patients receiving an SSRI. Other antibiotic options should be considered first, and linezolid should be reserved as the last resort if possible. If the infection requires linezolid, the SSRI should be discontinued, and the patient should be monitored closely for serotonin syndrome." }, { "id": "pubmed23n0691_400", "title": "Linezolid-associated hypoglycemia in a 64-year-old man with type 2 diabetes.", "score": 0.01407199625993455, "content": "Older diabetic patients are at increased risk for skin infections, often with methicillin-resistant Staphylococcus aureus (MRSA). Linezolid offers oral therapy with MRSA coverage. We present a case of linezolid-associated hypoglycemia in a 64-year-old diabetic patient with presumed MRSA cellulitis. A 64-year-old man with diabetes was treated for cellulitis. Linezolid was started when amoxicillin/clavulanate failed. Within 7 days, he developed frequent diaphoresis and tremulousness, with glucoses of 30 to 60 mg/dL. Hypoglycemia worsened despite decreasing insulin use, discontinuing glyburide, and increasing caloric intake. The day of admission, he awoke with a glucose level of 30 mg/dL. He took no medications, ate a large breakfast, and presented to clinic. He was symptomatic with a glucose level of 35 mg/dL. Hypoglycemia persisted despite IV dextrose. Linezolid was discontinued immediately in favor of vancomycin. Dextrose was weaned and his diabetes medications were resumed without further hypoglycemia. Linezolid has monoamine oxidase (MAO) inhibitory properties, and MAO inhibitors have been reported to contribute to hypoglycemia. The use of linezolid in older diabetic patients, especially those patients already taking agents with the potential to cause hypoglycemia, represents an area of concern. Increased comorbidities and polypharmacy in geriatric patients adds to this concern." }, { "id": "pubmed23n0416_21057", "title": "Serotonin syndrome after concomitant treatment with linezolid and citalopram.", "score": 0.013554891710231515, "content": "Linezolid, a new synthetic antimicrobial, is an important weapon against methicillin-resistant Staphylococcus aureus (MRSA). Although there are reports of serotonin syndrome developing after concomitant use of linezolid and the selective serotonin reuptake inhibitor paroxitene, this report concerns a patient receiving citalopram who developed thrombocytopenia, serotonin syndrome, and lactic acidosis and died following long-term linezolid therapy." }, { "id": "pubmed23n0915_17722", "title": "Incidence of Serotonin Syndrome With Combined Use of Linezolid and Serotonin Reuptake Inhibitors Compared With Linezolid Monotherapy.", "score": 0.01301865775549986, "content": "Linezolid is a monoamine oxidase inhibitor that may increase the risk of serotonin syndrome in patients receiving combination selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs). The objective of this study was to compare the incidence of serotonin syndrome when linezolid was administered alone and in combination with SSRIs or SNRIs. This was a retrospective case-control study of adult inpatients admitted to the University of Iowa Hospitals and Clinics who received linezolid between January 2010 and December 2014. Patients who received linezolid with or within 14 days of an SSRI or SNRI were eligible for inclusion in the combination therapy group. Patients who received linezolid alone were matched by age and gender to patients in the combination therapy group, and 3 monotherapy patients were included for each combination therapy patient. Clinical features consistent with serotonin syndrome were assessed using the Sternbach and Hunter criteria. A total of 348 patients were included in this study, of which 87 received combination therapy and 261 received linezolid monotherapy. One patient given combination therapy (1.1%) and 1 patient given linezolid monotherapy (0.4%) were determined to have a diagnosis of serotonin syndrome (P = 0.438; relative risk, 3.00; 95% confidence interval, 0.19-47.45). In both cases, signs and symptoms of serotonin syndrome reversed upon discontinuation of linezolid therapy. There was no significant difference in the incidence of serotonin syndrome when linezolid was used alone or in combination with an SSRI or SNRI, and the overall incidence of serotonin syndrome was low." }, { "id": "InternalMed_Harrison_13653", "title": "InternalMed_Harrison", "score": 0.010486156042926307, "content": "Linezolid is a weak monoamine oxidase inhibitor and can be associated with the serotonin syndrome when given concomitantly with serotonergic drugs (primarily antidepressants such as selective serotonin-reuptake inhibitors). A recent meta-analysis showed that ~80% of patients with MDRor XDR-TB can be successfully treated with linezolid-containing anti-TB regimens; however, significant adverse events attributed to linezolid were reported. For MDR-TB treatment, linezolid is usually administered at a dose of 600 mg (or less in some cases) once daily, which appears to be effective. The single daily dose is associated with fewer adverse events than twice-a-day dosing." }, { "id": "InternalMed_Harrison_11565", "title": "InternalMed_Harrison", "score": 0.010373272839760776, "content": "Linezolid is a bacteriostatic agent and is indicated for serious infections due to resistant gram-positive bacteria, such as MRSA and VRE. The intrinsic resistance of gram-negative bacteria is mediated primarily by endogenous efflux pumps. Linezolid has excellent oral bioavailability. Adverse effects include myelosuppression and ocular and peripheral neuropathy with prolonged therapy. Peripheral neuropathy may be irreversible. Linezolid is a weak, reversible monoamine oxidase inhibitor, and coadministration with sympathomimetics and foods rich in tyramine should be avoided. Linezolid has been associated with serotonin syndrome when coadministered with selective serotonin-reuptake inhibitors. Tedizolid has properties similar to those of linezolid, but with lower dosing it may be less likely to cause adverse hematologic and neuropathic effects." }, { "id": "Obstentrics_Williams_7020", "title": "Obstentrics_Williams", "score": 0.010277653381101657, "content": "For women with severe disease according to criteria in Table 51-3, Mandell and associates (2007) summarized IDSAI ATS guidelines, which call for either: (1) a respiratory luoroquinolone-Ievofloxacin, moxifloxacin, or gemiloxacin; or (2) a macrolide plus a preferred �-lactam-either high-dose amoxicillin or amoxicillin-clavulanate. �-Lactam alternatives include ceftriaxone, cefpodoxime, or cefuroxime (see Table 51-4). In areas in which the resistance of pneumococcal isolates to macrolides is great, these latter regimens are preferred. he teratogenicity risk of luoroquinolones is low, and these should be given if indicated (Briggs, 2015). IfCA-MRSA is suspected, then vancomycin or linezolid is added (Mandell, 2015; Moran, 2013; Wunderink, 2013)." }, { "id": "wiki20220301en521_16277", "title": "WHO Model List of Essential Medicines for Children", "score": 0.009900990099009901, "content": "Antifilarials Albendazole Diethylcarbamazine Ivermectin Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquine Antibiotics Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidime Meropenem Vancomycin Reserve group antibiotics Ceftazidime/avibactam (ceftazidime + avibactam) Colistin Fosfomycin Linezolid Polymyxin B Antileprosy medicines Clofazimine Dapsone Rifampicin" }, { "id": "wiki20220301en023_84999", "title": "Serotonin–norepinephrine reuptake inhibitor", "score": 0.00980392156862745, "content": "Contraindications SNRIs are contraindicated in patients taking MAOIs within the last two weeks due to the increased risk of serotonin syndrome, which can be life-threatening. Other drugs and substances that should be avoided due to increased risk of serotonin syndrome when combined with an SNRI include: other anti-depressants, anti-convulsants, analgesics, antiemetic agents, anti-migraine medications, methylene blue, linezolid, Lithium, St. John's worts, ecstasy, and LSD. Signs and symptoms of serotonin syndrome include: hyperthermia, rigidity, myoclonus, autonomic instability with fluctuating vital signs, and mental status changes that include extreme agitation progressing to delirium and coma." }, { "id": "pubmed23n0397_14943", "title": "Serotonin syndrome and linezolid.", "score": 0.00980392156862745, "content": "We present a case of serotonin syndrome in a patient who initiated linezolid therapy shortly after discontinuation of therapy with a selective serotonin reuptake inhibitor (paroxetine)." }, { "id": "wiki20220301en017_112809", "title": "Linezolid", "score": 0.009708737864077669, "content": "In the treatment of diabetic foot infections, linezolid appears to be cheaper and more effective than vancomycin. In a 2004 open-label study, it was as effective as ampicillin/sulbactam and amoxicillin/clavulanic acid, and far superior in patients with foot ulcers and no osteomyelitis, but with significantly higher rates of adverse effects. A 2008 meta-analysis of 18 randomized controlled trials, however, found that linezolid treatment failed as often as other antibiotics, regardless of whether patients had osteomyelitis. Some authors have recommended that combinations of cheaper or more cost-effective drugs (such as co-trimoxazole with rifampicin or clindamycin) be tried before linezolid in the treatment of SSTIs when susceptibility of the causative organism allows it." }, { "id": "wiki20220301en071_56095", "title": "Ventilator-associated pneumonia", "score": 0.009615384615384616, "content": "Risk factors for infection with an MDR strain include ventilation for more than five days, recent hospitalization (last 90 days), residence in a nursing home, treatment in a hemodialysis clinic, and prior antibiotic use (last 90 days). Possible empirical therapy combinations include (but are not limited to): vancomycin/linezolid and ciprofloxacin, cefepime and gentamicin/amikacin/tobramycin vancomycin/linezolid and ceftazidime Ureidopenicillin plus β-lactamase inhibitor such as piperacillin/tazobactam or ticarcillin/clavulanate a carbapenem (e.g., imipenem or meropenem) Therapy is typically changed once the causative bacteria are known and continued until symptoms resolve (often 7 to 14 days). For patients with VAP not caused by nonfermenting Gram-negative bacilli (like Acinetobacter, Pseudomonas aeruginosa) the available evidence seems to support the use of short-course antimicrobial treatments (< or =10 days)." }, { "id": "pubmed23n0598_9732", "title": "Antibiotic-induced serotonin syndrome.", "score": 0.009615384615384616, "content": "Due to its broad spectrum of clinical presentations and to the large number of available serotonergic medications, serotonin syndrome (SS) remains an elusive diagnosis to many clinicians. SS results from the over-stimulation of serotonin receptors by a variety of mechanisms. New medications with the potential to cause SS are released regularly, and among them is the antibiotic linezolid. We present a case of SS in a 36-year-old woman that occurred after linezolid was added to a drug regimen that included lithium, venlafaxine, and imipramine." }, { "id": "wiki20220301en012_37390", "title": "Lyme disease", "score": 0.009523809523809525, "content": "Antibiotics are the primary treatment. The specific approach to their use is dependent on the individual affected and the stage of the disease. For most people with early localized infection, oral administration of doxycycline is widely recommended as the first choice, as it is effective against not only Borrelia bacteria but also a variety of other illnesses carried by ticks. People taking doxycycline should avoid sun exposure because of higher risk of sunburns. Doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding; alternatives to doxycycline are amoxicillin, cefuroxime axetil, and azithromycin. Azithromycin is recommended only in case of intolerance to the other antibiotics. The standard treatment for cellulitis, cephalexin, is not useful for Lyme disease. When it is unclear if a rash is caused by Lyme or cellulitis, the IDSA recommends treatment with cefuroxime or amoxicillin/clavulanic acid, as these are effective" }, { "id": "pubmed23n0528_10130", "title": "Linezolid-associated serotonin syndrome: what we can learn from cases reported so far.", "score": 0.009523809523809525, "content": "To study the characteristics of the linezolid-associated serotonin syndrome cases. Database search for linezolid-associated serotonin syndrome. Twelve cases were found. The mean age of patients was 52.8 years. All patients received linezolid concomitantly with selective serotonin re-uptake inhibitor drugs (SSRID). The onset of syndrome was 9.5 days after linezolid introduction and was directly correlated to patients' age (P = 0.024). The symptoms resolved in 2.9 days. Citalopram was associated with a delayed resolution (P = 0.018). A trend was observed towards longer resolution time the longer the half-life of the interacting drug (P = 0.096). Patients are at risk when receiving SSRID concomitant with linezolid. The syndrome onset could be delayed in older patients. The resolution could be delayed when citalopram is involved in the syndrome." }, { "id": "wiki20220301en023_85003", "title": "Serotonin–norepinephrine reuptake inhibitor", "score": 0.009433962264150943, "content": "Serotonin Syndrome A serious, but rare, side effect of SNRIs is serotonin syndrome, which is caused by an excess of serotonin in the body. Serotonin syndrome can be caused by taking multiple serotonergic drugs, such as SSRIs or SNRIs. Other drugs that contribute to serotonin syndrome include MAO inhibitors, linezolid, tedizolid, methylene blue, procarbazine, amphetamines, clomipramine, and more. Early symptoms of serotonin syndrome may include nausea, vomiting, diarrhea, sweating, agitation, confusion, muscle rigidity, dilated pupils, hyperthermia, rigidity, and goose bumps. More severe symptoms include fever, seizures, irregular heartbeat, delirium, and coma. If signs or symptoms arise, discontinue treatment with serotonergic agents immediately. It is recommended to washout 4 to 5 half-lives of the serotonergic agent before using an MAO inhibitor." }, { "id": "pubmed23n0835_11779", "title": "Linezolid-Associated Serotonin Syndrome. A Report of Two Cases.", "score": 0.009433962264150943, "content": "Linezolid, a mild monoamine oxidase inhibitor, is a commonly used antibiotic drug for the treatment of complicated skin and skin structure infections, including diabetic foot infections. Use of linezolid has been associated with serotonin syndrome, a potentially life-threatening condition typically caused by the combination of two or more medications with serotonergic properties, due to increased serotonin release. The goals of this article are to highlight the risk factors associated with the development of serotonin syndrome related to the use of linezolid and to aid in its prevention and early diagnosis. In this case series we report on two hospitalized patients who, while being treated with linezolid for pedal infections, developed serotonin syndrome. Both individuals were also undergoing treatment with at least one serotonergic agent for depression and had received this medication within 2 weeks of starting the antibiotic drug therapy. In these individuals, we noted agitation, confusion, tremors, and tachycardia within a few days of initiation of linezolid therapy. Owing to the risk of serotonin toxicity, care should be taken when prescribing linezolid in conjunction with any other serotonergic agent. Although serotonin syndrome is an infrequent complication, it can be potentially life threatening. Therefore, risks and benefits of therapy should be weighed before use. " }, { "id": "pubmed23n1129_6397", "title": "The challenge of antibiotic selection in prosthetic joint infections due to Corynebacterium striatum: a case report.", "score": 0.009389365946742997, "content": "Corynebacterium striatum is a gram-positive facultative anaerobe found in the environment and human flora that has historically been considered a contaminant. More recently, Corynebacterium striatum has been implicated in human infections, including respiratory infections, endocarditis, and bone and joint infections, particularly those involving hardware or implanted devices. A 65-year-old man presented for washout of his left total knee arthroplasty following a revision 20 days prior. The patient underwent debridement of his left total knee and revision of the left total femur arthroplasty. Daptomycin was initiated empirically due to a previous rash from vancomycin. Operative tissue cultures grew Staphylococcus haemolyticus, Staphylococcus epidermidis and Corynebacterium striatum. Given concern for daptomycin resistance and the reliability of vancomycin susceptibility, daptomycin was discontinued and vancomycin initiated following a graded challenge. Within a few days, the patient developed a diffuse, blanching, erythematous, maculopapular rash and daptomycin was restarted. Over the next 72 h, his rash progressed and he met criteria for drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Daptomycin was stopped and oral linezolid initiated; rash improved. C. striatum returned with susceptibility to gentamicin, linezolid, vancomycin and daptomycin. Due to concern for adverse effects on long-term linezolid, daptomycin was restarted and was tolerated for 20 days, at which point purulent drainage from incision increased. The patient underwent another arthroplasty revision and washout. Operative cultures from this surgery were again positive for C. striatum. Repeat C. striatum susceptibilities revealed resistance to daptomycin but retained susceptibility to linezolid. Daptomycin was again changed to linezolid. He completed six weeks of linezolid followed by linezolid 600 mg daily for suppression and ultimately opted for disarticulation. C. striatum has historically been regarded as a contaminant, particularly when grown in tissue culture in the setting of prosthetic joint infection. Based on the available literature and susceptibility patterns, the most appropriate first-line therapy is vancomycin or linezolid. Treatment with daptomycin should be avoided, even when isolates appear susceptible, due to the risk of development of high-level resistance (MIC &gt; 256 µg/mL) and clinical failure." }, { "id": "pubmed23n0603_12348", "title": "Serotonergic antidepressants and linezolid: a retrospective chart review and presentation of cases.", "score": 0.009345794392523364, "content": "To report the results from a retrospective chart review looking at the combination of linezolid and serotonergic antidepressants and to report two cases of serotonin syndrome which were identified at our hospital. During the retrospective chart review one case of serotonin syndrome was identified. A 65-year-old female was receiving escitalopram for the treatment of depression prior to admission. Linezolid therapy was initiated on admission and two days later the patient had a tonic-clonic seizure. Escitalopram was discontinued and the patient did not have any further seizure activity. In a second case, a 37-year-old male was receiving citalopram during hospitalization and was started on concomitant linezolid. The patient had myoclonus and was observed to be tremulous throughout therapy with linezolid. Ten days after discontinuation of linezolid the patient continued to have symptoms until the withdrawal of citalopram. The Naranjo probability scale scores the first case as possibly related and the second case as probably related to the combination. It has been well documented in the literature that the combination of linezolid and serotonergic antidepressants may cause serotonin syndrome. In this retrospective chart review only one patient of 53 (1.8%) had symptoms highly suggestive of serotonin syndrome. A second patient continued to have symptoms of serotonin syndrome even after withdrawal of linezolid. This retrospective review and subsequent case reports confirm the rare, but serious, potential of serotonin syndrome associated with the combination of linezolid and serotonergic antidepressants." }, { "id": "article-28852_12", "title": "Selective Serotonin Reuptake Inhibitors -- Contraindications", "score": 0.009286412512218964, "content": "SSRIs are contraindicated with the concurrent use of MAOIs, linezolid, and other medications that increase serotonin levels and could put patients at risk for life-threatening serotonin syndrome." }, { "id": "wiki20220301en166_44924", "title": "WHO Model List of Essential Medicines", "score": 0.009259259259259259, "content": "Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquineα Cysticidal medicines Albendazoleα Mebendazoleα Praziquantelα Antibacterials Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Spectinomycin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Trimethoprim Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidimeα Meropenemα Vancomycinα" }, { "id": "pubmed23n0810_17030", "title": "Dermabacter hominis: a usually daptomycin-resistant gram-positive organism infrequently isolated from human clinical samples.", "score": 0.009174311926605505, "content": "During a 12-year period, Dermabacter hominis was isolated from 21 clinical samples belonging to 14 patients attending a tertiary hospital in León, Spain. Samples included blood cultures (14), peritoneal dialysis catheter exit sites (three), cutaneous abscesses (two), an infected vascular catheter (one) and a wound swab (one). Identification was made by API Coryne™ V2.0, Biolog™ GP2 and 16S rRNA gene amplification. Six febrile patients had positive blood cultures (one, two or three sets) and all of them were treated with teicoplanin (two patients), vancomycin, ampicillin plus gentamicin, amoxicillin/clavulanic acid and ciprofloxacin (one each). An additional patient with a single positive blood culture was not treated, the finding being considered non-significant. In the remaining seven patients the organism was isolated from a single specimen and three of them received antimicrobial treatment (ciprofloxacin, ceftriaxone plus vancomycin and amoxicillin/clavulanic acid). At least ten patients had several underlying diseases and conditions, and no direct mortality was observed in relation to the isolated organism. All isolates were susceptible to vancomycin, rifampin and linezolid. Resistance to other antibiotics varied: erythromycin (100%), clindamycin (78.5%), ciprofloxacin (21.4%) and gentamicin, quinupristin-dalfopristin, benzylpenicillin and imipenem 7.1% each. Thirteen isolates were highly resistant to daptomycin with MICs ranging from 8 to 48 (MIC90 = 32 mg/L); only one was daptomycin-sensitive (MIC = 0.19 mg/L). " }, { "id": "InternalMed_Harrison_11518", "title": "InternalMed_Harrison", "score": 0.009174311926605505, "content": "Ceftriaxone and calcium-containing solutions can be given to infants >28 days of age provided they are given sequentially and the lines are thoroughly flushed between infusions. Decreased levels of valproic acid. Monitor valproic acid levels closely if drugs are given concomitantly. Increased levels of serotonergic and adrenergic agents. Monitor for serotonin syndrome. Tedizolid may have less potential than linezolid to cause this drug interaction. Can result in increased levels of interacting drug. Erythromycin and clarithromycin are more potent CYP3A4 inhibitors than azithromycin. Avoid concomitant administration if possible. Can result in subtherapeutic fluoroquinolone levels. Administer fluoroquinolone 2 h before or 6 h after interacting drug. Can result in increased levels of tizanidine and hypotensive, sedative effects. Monitor for side effects if drugs are given concomitantly." }, { "id": "InternalMed_Harrison_9510", "title": "InternalMed_Harrison", "score": 0.00913900913900914, "content": "Cefoxitin, 2 g q6h; A combination of metronidazole (500 mg q8–12h) plus cefazolin (1–2 g q8h) or cefuroxime (1.5 g q8h) or ceftriaxone (1–2 g q12–24h) or cefotaxime (1–2 g q6–8h) A carbapenem (imipenem, 1 g q8h; meropenem, 1 g q8h; doripenem, 500 mg q8h); Piperacillin-tazobactam, 3.375 g q6hf; A combination of metronidazole (500 mg q8–12h) plus an antipseudomonal cephalosporin (cefepime, 2 g q8–12h; ceftazidime, 2 g q8h) or an antipseudomonal fluoroquinolone (ciprofloxacin, 400 mg q12h; levofloxacin, 750 mg q24h) — Dexamethasone (0.15 mg/ kg IV q6h for 2–4 d) should be added for patients with suspected or proven pneumococcal meningitis, with the first dose administered 10–20 min before the first dose of antibiotics. If MRSA is a consideration, add vancomycin (15 mg/kg q12hb) or linezolid (600 mg q12h); daptomycin should not be used in patients with pneumonia. If MRSA is a consideration, add vancomycin (15 mg/kg q12hb). 159, 201, and pathogen-specific chapters" }, { "id": "wiki20220301en028_42913", "title": "Triptan", "score": 0.00909090909090909, "content": "There is a theoretical risk of coronary spasm in patients with established heart disease, and cardiac events after taking triptans may rarely occur. Interactions Combination of triptans with other serotonergic drugs such as ergot alkaloids, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs) or St John's wort has been alleged to induce symptoms of a serotonin syndrome (a syndrome of changes in mental status, autonomic instability, neuromuscular abnormalities, and gastrointestinal symptoms), whereas scientific studies indicate there is no potential for life-threatening serotonin syndrome in patients taking triptans and SSRI or SNRIs at the same time, although the FDA has officially stated otherwise. Combining triptans with ergot alkaloids is contraindicated because of the danger of coronary spasms." }, { "id": "pubmed23n0545_20207", "title": "Linezolid and serotonergic drug interactions: a retrospective survey.", "score": 0.00909090909090909, "content": "Linezolid is a reversible, nonselective monoamine oxidase inhibitor. There are currently 11 published case reports of serotonin syndrome being associated with linezolid and selective serotonin reuptake inhibitors (SSRIs). Controversy exists regarding whether linezolid and SSRIs can be given concomitantly. The purpose of this study was to report the incidence of serotonin syndrome in patients receiving linezolid and SSRIs. This study was a retrospective chart review of inpatients at the Mayo Clinic (Rochester, MN) with concomitant orders or therapy within 14 days for linezolid and an SSRI from 2000 to 2004. The Sternbach criteria and Boyer criteria for diagnosis of serotonin syndrome were used to identify clinical features of serotonin syndrome. Seventy-two patients received linezolid and an SSRI or venlafaxine within 14 days of each other. Fifty-two patients (72%) received concomitant therapy with linezolid and an SSRI or venlafaxine, and 20 patients (28%) did not receive concomitant therapy but received linezolid and an SSRI within a 14-day period. Overall, only 2 patients (3%) had a high probability of serotonin syndrome. In both patients with high probability, symptoms reversed rapidly on discontinuation of serotonergic therapy. The Boyer criteria were much more specific than the Sternbach criteria for identification of serotonin syndrome. On the basis of our experience, we suggest that, if the clinical situation warrants use of linezolid in a patient receiving an SSRI, linezolid may be used concomitantly with SSRIs, without a 14-day washout period and with careful monitoring for signs and symptoms of serotonin syndrome. Serotonergic agents should be promptly discontinued if serotonin syndrome is suspected." }, { "id": "wiki20220301en521_16278", "title": "WHO Model List of Essential Medicines for Children", "score": 0.009009009009009009, "content": "Reserve group antibiotics Ceftazidime/avibactam (ceftazidime + avibactam) Colistin Fosfomycin Linezolid Polymyxin B Antileprosy medicines Clofazimine Dapsone Rifampicin Antituberculosis medicines Ethambutol Isoniazid Isoniazid/pyrazinamide/rifampicin (isoniazid + pyrazinamide + rifampicin) Isoniazid/rifampicin (isoniazid + rifampicin) Pyrazinamide Rifampicin Rifapentine Amikacin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Bedaquiline Clofazimine Cycloserine Delamanid Ethionamide Levofloxacin Linezolid Meropenem Moxifloxacin P-aminosalicylic acid Streptomycin Antifungal medicines Amphotericin B Fluconazole Flucytosine Griseofulvin Itraconazole Nystatin Voriconazole Potassium iodide Antiviral medicines Antiherpes medicines Aciclovir Antiretrovirals Nucleoside/nucleotide reverse transcriptase inhibitors Abacavir (ABC) Lamivudine (3TC) Zidovudine (ZDV or AZT)" }, { "id": "InternalMed_Harrison_13652", "title": "InternalMed_Harrison", "score": 0.008933211601938338, "content": "NEWER ANTITUBERCULOSIS DRUGS Oxazolidinones Linezolid is an oxazolidinone used primarily for the treatment of drug-resistant gram-positive bacterial infections. However, this drug is active in vitro against M. tuberculosis and NTM. Several case series have suggested that linezolid may help clear mycobacteria relatively rapidly when included in a regimen for the treatment of complex cases of MDRand XDR-TB. Linezolid’s mechanism of action is disruption of protein synthesis by binding to the 50S bacterial ribosome. Linezolid has nearly 100% oral bioavailability, with good penetration into tissues and fluids, including CSF. Clinical resistance to linezolid has been reported, but the mechanism is unclear. Adverse effects may include optic and peripheral neuropathy, pancytopenia, and lactic acidosis. Linezolid is a weak monoamine oxidase inhibitor and can be associated with the serotonin syndrome when given concomitantly with serotonergic drugs (primarily antidepressants such as selective" }, { "id": "pubmed23n0843_7406", "title": "Efficacy of Single and Combined Antibiotic Treatments of Anthrax in Rabbits.", "score": 0.008928571428571428, "content": "Respiratory anthrax is a fatal disease in the absence of early treatment with antibiotics. Rabbits are highly susceptible to infection with Bacillus anthracis spores by intranasal instillation, succumbing within 2 to 4 days postinfection. This study aims to test the efficiency of antibiotic therapy to treat systemic anthrax in this relevant animal model. Delaying the initiation of antibiotic administration to more than 24 h postinfection resulted in animals with systemic anthrax in various degrees of bacteremia and toxemia. As the onset of symptoms in humans was reported to start on days 1 to 7 postexposure, delaying the initiation of treatment by 24 to 48 h (time frame for mass distribution of antibiotics) may result in sick populations. We evaluated the efficacy of antibiotic administration as a function of bacteremia levels at the time of treatment initiation. Here we compare the efficacy of treatment with clarithromycin, amoxicillin-clavulanic acid (Augmentin), imipenem, vancomycin, rifampin, and linezolid to the previously reported efficacy of doxycycline and ciprofloxacin. We demonstrate that treatment with amoxicillin-clavulanic acid, imipenem, vancomycin, and linezolid were as effective as doxycycline and ciprofloxacin, curing rabbits exhibiting bacteremia levels of up to 10(5) CFU/ml. Clarithromycin and rifampin were shown to be effective only as a postexposure prophylactic treatment but failed to treat the systemic (bacteremic) phase of anthrax. Furthermore, we evaluate the contribution of combined treatment of clindamycin and ciprofloxacin, which demonstrated improvement in efficacy compared to ciprofloxacin alone. " }, { "id": "pubmed23n0591_14420", "title": "[Serotonin syndrome as a result of escitalopram and cyclosporin combination in an 84-year-old woman].", "score": 0.008928571428571428, "content": "Due to the stimulation of central and peripheral 5-hydroxytryptamine receptors, the serotonin syndrome is a potentially lethal situation. The large variety of its clinical manifestations leads to a difficult diagnosis. We describe the case of a serotonin syndrome induced by the combined escitalopram and cyclosporine administration. An 84-year-old woman was hospitalized with a history of delirium associated with hyperthermia. The diagnosis of serotonin syndrome was suspected with the combination of the clinical features: the absence of infection, the selective serotonin reuptake inhibitor administration, and the absence of other metabolic and cerebral aetiology. After the discontinuation of escitalopram, the patient's condition improved rapidly. This report is a reminder of the clinical and pharmacological features of the serotonin syndrome from a recent literature review." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 443, 557 ] ], "word_ranges": [ [ 69, 87 ] ], "text": "Persistent hypotension in PTE is the most widely accepted indication for fibrinolysis, so the correct option is 1." }, "2": { "exist": true, "char_ranges": [ [ 126, 188 ] ], "word_ranges": [ [ 18, 29 ] ], "text": "Option 2 would be correct if the patient were not hypotensive." }, "3": { "exist": true, "char_ranges": [ [ 189, 329 ] ], "word_ranges": [ [ 29, 50 ] ], "text": "Option 3 is not correct since diagnostic confirmation is not necessary to initiate anticoagulant therapy in case of PTE without hypotension." }, "4": { "exist": true, "char_ranges": [ [ 330, 356 ] ], "word_ranges": [ [ 50, 55 ] ], "text": "Option 4 is not indicated." }, "5": { "exist": true, "char_ranges": [ [ 357, 442 ] ], "word_ranges": [ [ 55, 69 ] ], "text": "Option 5 would be correct only if the patient had a contraindication to fibrinolysis." } }

{ "1": "Unfractionated heparin, 10,000U iv on clinical suspicion. Fibrinolysis with tPA 100 mg iv once the diagnosis is confirmed.", "2": "Enoxaparin: 80 mg sc every 12 hours, starting upon diagnostic suspicion.", "3": "Enoxaparin; 80 mg sc every 12 hours, starting upon diagnostic confirmation.", "4": "Fondaparinux: 7.5 mg sc daily.", "5": "Emergency pulmonary thromboendarterectomy." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1085_24991", "title": "Case 294.", "score": 0.016845434543454343, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, 150-400 × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L) and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0290_5299", "title": "[Pulmonary thromboembolism. A clinical case with unusual presentation].", "score": 0.015425531914893617, "content": "The authors describe a rare case of pulmonary thromboembolism with unusual clinical findings and emphasized the large difficulty encountered in formuling a correct diagnosis in a reasonable time. A man, 60 years old, was admitted to a Medical Division of our hospital for the appearance of chest pain and epigastric pain during effort in the last year. He smoked 20 cigarettes a day and drank wine (1 or 2 litres a day). He was affected by hypercholesterolemia and in the past reported relapsed thrombophlebitis in the left leg. Four years before admission to our hospital he underwent large and small left saphenectomy. He had no cardiac events in the past. After a non significant exercise stress test the patient was treated with nitrates and asa and was discharged from the hospital. At home the symptoms increased and after 8 months the patient was admitted again to the Cardiologic Division of the hospital. At admission he reported dyspnea and chest pain at rest, not only during effort and the ECG showed negative T waves in anterior and inferior leads. Intravenous heparine, nitrates and calcium antagonists stabilized the clinical picture. The following examinations revealed: reduction of the T wave negativity at the ECG registered during chest pain; mild enlargement of the heart at the chest roentgenogram; normal value of the left ventricle and apical and midseptal by ipokinesia at the transthoracic echocardiogram; normal coronary artery at the coronary arteriography. \"Vasospastic angina\" was diagnosed and the patient was discharged after 20 days, asymptomatic. After 15 days he returned to the hospital again for chest pain, dyspnea, hypotension and syncope despite therapy. At physical examination he showed a painful left tibio-tarsal tumefaction, an increased and splitting second heart sound in the pulmonary area and a systolic murmur in the third and fourth left interspace. The ECG showed a severe anterior ischemia, while a new transthoracic echocardiogram revealed a considerable dilatation of the right atrium, right ventricle and the main pulmonary artery with severe tricuspid regurgitation and pulmonary hypertension (mean PAP about 50 mmHg). The following pulmonary perfusion scintigraphy confirmed the diagnosis of pulmonary embolism and the selective right and left pulmonary arteriography exhibited multiple thrombi and large intravascular filling defects. The right heart catheterization confirmed a chronic precapillary pulmonary hypertension (mean PAP = 55 mmHg). About 24 hours after these examinations the patient died because of a cardiac arrest with electromechanical dissociation. Pulmonary thromboembolism is a potentially fatal disease characterized by a largely variable clinical presentation. Frequently pulmonary embolism diagnosis is difficult especially when clinical findings are unusual. In the case observed the \"typical\" chest and epigastric pains associated with the electrocardiographic findings directed diagnosis towards myocardial ischemia. Also after the coronary arteriography that showed normal coronary artery, the erroneous diagnosis persisted. Pulmonary embolism was correctly diagnosed too late to begin an effective therapy. These unusual clinical findings and diagnostic mistakes are stressed and critically reviewed in the article." }, { "id": "pubmed23n0945_14122", "title": "High-risk pulmonary embolism assessed by transthoracic echocardiography: A case report.", "score": 0.015181848515181848, "content": "Acute pulmonary embolism (APE) as a life-threatening illness may present with a wide range of manifestations. APE was diagnosed using computed tomographic pulmonary angiography (CTPA); however, transthoracic echocardiography (TTE) can reveal hemodynamic status. Early thrombolysis is the most effective therapy for the treatment of massive pulmonary embolism. Herein, we report a case of high-risk APE with a wide range of manifestations, including chest pain, dyspnea, low-blood pressure, and syncope. A 55-year-old, previously healthy woman, complained of dyspnea and pleuritic chest pain for 40 days, along with transitory (10 minutes) episodes of syncope that had occurred 2 days previously. Because of the high-risk APE, the patient received intravenous thrombolytic therapy with low-dose recombinant tissue plasminogen activator (rt-PA, 50 mg over 30 minutes) and an anticoagulant (subcutaneous low-molecular-weight heparin, once every 12 hours for 5 days). Five days after thrombolysis, bedside TTE revealed RV diastolic dimension decreased to 22 mm. Color ultrasonography revealed a significant decrease in systolic and mean pulmonary artery pressure. TTE may provide initial suspicion of APE and may help identify patients with unstable hemodynamic status before the onset of shock. Moreover, concomitant TTE signs of decreased RV load may predict better prognosis for high-risk APE patients." }, { "id": "Anatomy_Gray_562", "title": "Anatomy_Gray", "score": 0.013411600062198725, "content": "A 53-year-old man presented to the emergency department with a 5-hour history of sharp pleuritic chest pain and shortness of breath. The day before he was on a long haul flight, returning from his holidays. He was usually fit and well and was a keen mountain climber. He had no previous significant medical history. On physical examination his lungs were clear, he was tachypneic at 24/min, and his saturation was reduced to 92% on room air. Pulmonary embolism was suspected and the patient was referred for a CT pulmonary angiogram. The study demonstrated clots within the right and left main pulmonary arteries. There was no pleural effusion, lung collapse, or consolidation. He was immediately started on subcutaneous enoxaparin and converted to oral anticoagulation over the course of a couple of days. The whole treatment lasted 6 months as no other risk factors (except immobilization during a long haul flight) were identified. There were no permanent sequelae." }, { "id": "pubmed23n0540_2525", "title": "Acute venous thromboembolism.", "score": 0.013385262780911452, "content": "To review the recent advances in management of acute venous thromboembolism. Articles and published reviews on venous thromboembolism, pulmonary embolism and deep vein thrombosis. Acute venous thromboembolism describes a group of disorders that include venous thrombosis (usually deep vein thrombosis) and pulmonary thromboembolism. Ultrasound supplemented by Doppler flow detection imaging has become the investigation of choice in the diagnosis of deep vein thrombosis and spiral volumetric computed tomography or ventilation perfusion scan (if the patient is haemodynamically stable) or bedside echocardiography (if the patient is hypotensive) are often the initial investigations in a patient who has a suspected pulmonary thromboembolism. Magnetic resonance venography has only recently been evaluated and may prove in future to be a valuable diagnostic test for both deep vein thrombosis and pulmonary thromboembolism. Treatment requires immediate anticoagulation using either subcutaneous low molecular weight heparin (e.g. enoxaparin 1 mg/kg 12-hourly or dalteparin 100 IU anti Xa/kg twice daily) or intravenous unfractionated heparin (80 U/kg as a bolus then 18 U/kg/hr and adjusted to keep the APTT 1.5-2x the control value). Oral anticoagulation using warfarin is started simultaneously with heparin. Fibrinolytic therapy is considered in all patients with pulmonary thromboembolism in whom there are no contraindications, as the improvement in right ventricular function is greater and the pulmonary artery perfusion defect is less compared with patients treated by anticoagulation alone. Fibrinolytic therapy is usually only considered in patients with deep vein thrombosis if severe limb oedema is present. While streptokinase, urokinase and alteplase have been recommended, alteplase (100 mg over two hours with heparinisation) may be the treatment of choice as alteplase has a shorter half life, has a more rapid effect and may be more effective in lysing older clots, when compared with streptokinase or urokinase. Reteplase (10 U over 2 minutes followed by 10 U 30 minutes later) may be as effective as alteplase. Acute venous thromboembolism is a disorder that carries a high morbidity and mortality. Anticoagulation with or without fibrinolysis is the treatment of choice." }, { "id": "pubmed23n1122_24551", "title": "EkoSonic™ Endovascular System-Directed Thrombolysis in a Patient With COVID-19 Infection Presenting With Bilateral Large Pulmonary Embolism Causing Right Ventricular Strain: A Case Report.", "score": 0.012420757776794928, "content": "We discuss a case of a 31-year-old male patient who presented to the accident and emergency department with shortness of breath and chest pain since the morning of the day of presentation. His polymerase chain reaction (PCR) test had returned positive for severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), which causes coronavirus disease 2019 (COVID-19), two weeks ago and his main symptoms had been shortness of breath, dry cough, generalized body pain, and fever. He was not vaccinated against the COVID-19 virus. He had not required hospitalization for COVID-19 and his symptoms had improved on day 10 from the date of diagnosis; however, he developed pleuritic chest pain with shortness of breath on the day of presentation. He was found to have tachypnoea, hypoxia, and tachycardia on assessment. His electrocardiogram showed a right bundle branch block with sinus tachycardia. He underwent a CT pulmonary angiography (CTPA) that showed bilateral large pulmonary emboli extending from the main pulmonary arteries bilaterally extending to the sub-segmental level. There was evidence of right heart strain on the scan. He also had a bedside echocardiogram performed after the CT scan, which showed an enlarged right ventricle but no left ventricular thrombus. His blood results showed D-dimer levels of 14,000 ng/mL and troponin T of 255 ng/L. He received treatment with low molecular weight heparin (LMWH) and underwent emergency EkoSonic™ Endovascular System (EKOS) thrombolysis (Boston Scientific, Marlborough, MA). He remained on ultrasound-accelerated thrombolysis (USAT) for the next 12 hours and showed significant improvement and was taken off oxygen post-EKOS thrombolysis. He was discharged home on oral rivaroxaban after 48 hours of hospital stay; follow-up after two months showed normal-sized right ventricle with no evidence of pulmonary hypertension." }, { "id": "pubmed23n0581_21052", "title": "Impending paradoxical embolism presenting as a pulmonary embolism, transient ischemic attack, and myocardial infarction.", "score": 0.011312217194570135, "content": "A 25-year-old man presented with complaints of nonpleuritic, substernal chest pain, dyspnea, and decreasing exercise tolerance. His vital signs were normal, with the exception of an oxygen saturation level of 93% while breathing room air. During his assessment, he developed transient left facial droop, left arm and leg weakness, and an ataxic gait, which lasted 15 min then resolved spontaneously. Cardiac enzyme levels were elevated, and an ECG revealed T-wave inversion in leads III, aVF, V1, and V2 with evolving ST-segment elevation in leads V3 through V5. The findings of a CT scan and MRI of the head were negative; a Doppler ultrasound of the right lower extremity revealed a thrombus extending from the common femoral vein to the popliteal vein. Cardiac catheterization revealed no evidence of epicardial coronary artery disease. CT pulmonary angiography revealed bilateral pulmonary emboli. Transesophageal echocardiography (TEE) showed a 4-cm, dumbbell-shaped mass lodged in a patent foramen ovale, confirming the diagnosis of an impending paradoxical embolism. The patient was started on therapy with unfractionated heparin, and his thrombus resolved spontaneously by hospital day 5. An impending paradoxical embolism is rare but should be suspected in anyone presenting with evidence of both venous and arterial emboli. The therapeutic options include anticoagulation, thrombolysis, and surgical embolectomy. We would propose that initial treatment with anticoagulation therapy and following with serial TEEs may be appropriate therapy in an otherwise stable patient, with surgical embolectomy or thrombolysis reserved for the treatment of thrombi that do not resolve with anticoagulation therapy or for patients with clinical deterioration." }, { "id": "article-17662_23", "title": "Anteroseptal Myocardial Infarction -- Treatment / Management", "score": 0.010206705059646236, "content": "Enoxaparin is given as an initial intravenous dose of 30 mg in all patients followed by 1 mg/kg subcutaneously every 12 hours dosing (can be used as 1 mg/kg SC once daily dose if creatinine clearance is less than 30 mL/min). It is given for the duration of hospitalization or until PCI is completed. Unfractionated heparin is dosed at an initial loading dose of 60 IU/kg (maximum 4000 IU) followed by infusion of 12 IU/kg per hour (maximum 1000 IU/h) with close monitoring of the activated partial thromboplastin time, continued for 48 hours or until PCI is performed. Fondaparinux administration is a 2.5 mg SQ daily dose that is usually maintained for the duration of hospitalization or until PCI. Fondaparinux should always be used in addition to another anticoagulant such as intravenous heparin or bivalirudin to reduce the risk of catheter thrombosis. Bivalirudin is administered as 0.10 mg/kg initial loading dose, followed by 0.25 mg/kg per hour (only to be used in patients managed with an early invasive strategy) and is continued until diagnostic angiography or PCI. The anticoagulant effect of bivalirudin is monitored by measuring the activated clotting time." }, { "id": "pubmed23n0359_10660", "title": "[The cardiologist facing pulmonary embolism. The experience of 160 cases of acute cor pulmonale].", "score": 0.009900990099009901, "content": "The results of recent multicenter studies dealing with pulmonary embolism often reveal remarkable discrepancies in terms of diagnosis, prognosis and treatment, partly due to the heterogeneity of study patients and of evaluation criteria. Our prospective study focused exclusively on patients affected by pulmonary embolism with a hemodynamic pattern of acute cor pulmonale, investigated at a single center. Particular attention was paid to in-hospital mortality, embolic recurrences, major bleeding and underlying pathologies. This study includes 160 cases (103 women with a median age of 71 years and 57 men with a median age of 65 years) in whom the clinical and echocardiographic findings suggestive of acute pulmonary embolism were confirmed by lung perfusion scan, pulmonary angiography, techniques for the detection of deep vein thrombosis and/or autopsy. The most common clinical manifestations were: dyspnea (92% of cases), tachycardia (80%), syncope (44%), cardiac arrest (22%), and shock (20%). Thoracic pain was present in only 27% of patients. None of the patients showed a normal ECG; a right bundle branch block was found in 47% of cases. T-wave inversion in the precordial leads (32%) was not related to the severity and outcome of pulmonary embolism. Present or previous deep vein thrombosis was found in 53 and 26% of cases, respectively. Only in 2 patients pulmonary embolism was secondary to a deep vein thrombosis of the upper limbs. Intravenous heparin alone was used in 36% of cases, whereas 56% were treated with thrombolytic agents + heparin. Major bleeding occurred in 9% of patients treated with heparin alone, and in 16% of those who received heparin + thrombolytic drugs. Death occurred in 17% of the former, and in 27% of the latter patients. The in-hospital mortality rate was related not only to the presence of cardiac arrest and--to a lower degree--of shock, but also to the recurrence of pulmonary embolism and to the underlying heart disease. No relationship was found between mortality and age, intracardiac thrombi or malignancy. Prognosis was quite different depending on clinical presentation, with a death rate ranging from 11% in the absence of systemic hypertension, and 77% in the presence of cardiac arrest. Even the \"massive\" pulmonary embolism that is observed in a cardiac department represents a true \"spectrum\" of pathological conditions, a spectrum that should be taken into account not only in order to evaluate prognosis and treatment in a particular case, but also when meta-analyses are performed." }, { "id": "pubmed23n1102_22675", "title": "Case 294: Catastrophic Antiphospholipid Syndrome.", "score": 0.00980392156862745, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, [150-400] × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L), and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L]). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/ day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n1068_13411", "title": "Case 290.", "score": 0.00980392156862745, "content": "History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism (PE). He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a D-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range, &lt;0.46 mg/L) and an international normalized ratio of 2.45 (therapeutic range, 2.0-3.0 for a patient taking warfarin), except the prothrombin time was 28.2 seconds (reference range, 9.6-12.8 seconds) and the activated partial thromboplastin time was 52.2 seconds (reference range, 24.8-33.8 seconds). Echocardiography, chest radiography, chest CT, and contrast-enhanced CT revealed no abnormalities. The patient underwent right lower extremity vascular conventional US (Philips IU22; Philips) with an L9-3 probe (3-9 MHz, venous condition) and contrast-enhanced US (1.5-2.0 mL, SonoVue; Bracco) with an intravenous bolus injection at the initial evaluation. Two days later, noncontrast and contrast-enhanced CT images of the lower abdomen (1.5 mL per kilogram of body weight, 300 mg/mL iomeprol, Iomeron; Bracco) were acquired for further evaluation (Figs 1-3)." }, { "id": "pubmed23n0595_3713", "title": "[Extracorporeal membrane oxygenation treatment of a neonate with severe low cardiac output syndrome following open heart surgery].", "score": 0.009708737864077669, "content": "To summarize the experience of extracorporeal membrane oxygenation (ECMO) to rescue a neonate with severe low cardiac output syndrome following open heart surgery. The patient was a male, 2 d, 2.8 kg, G3P2 full-term neonate with gestational age 40 weeks, born by Cesarean-section with Apgar score of 10 at 1 min. He was admitted due to severe dyspnea with oxygen desaturation and heart murmur on the second day after birth. Physical examination showed clear consciousness, cyanosis, dyspnea, RR 70 bpm and a grade II/6 heart murmur. Bp was 56/45 mm Hg (1 mm Hg = 0.133 kPa) and SpO2 around 65%. Blood WBC 13.1 x 10(9)/L, N 46.1%, Hb 238 g/L, Plt 283 x 10(9)/L, CRP &lt; 1 mg/L. Echocardiographic findings: TGA + ASD + PDA with left ventricular ejection fraction (LVEF) of 60%. After supportive care and prostaglandin E1 (5 ng/kg/min) treatment, his condition became stable with SpO2 85 - 90%. On the 6(th) day of life, the baby underwent an arterial switch procedure + ASD closing and PDA ligation. The time of aorta clamp was 72 mins. The cool 4:1 blood cardioplegia was given for 2 times during aortal clamp. Ultrafiltration was used. The internal and external volumes were almost equal and the electrolytes and blood gas and hematocrit (36%) were normal during extracorporeal bypass. Due to a failure (severe low cardiac output) to wean from cardiopulmonary bypass (263 min) with acidosis (lactate 8.8 mmol/L), low blood pressure (&lt; 39/30 mm Hg), increased LAP (&gt; 20 mmHg), bloody phlegm, decreased urine output [&lt; 1 ml/(kg.h)], a V-A ECMO was used for cardio-pulmonary support. ECMO setup: Medtronic pediatric ECMO package (CB2503R1), carmeda membrane oxygenator and centrifugal pump (bio-console 560) were chosen. Direct cannulation of the ascending aorta (Edward FEM008A) and right atrium (TF018090) was performed using techniques that were standard for cardiopulmanory bypass. The ECMO system was primed with 400 ml blood, 5% CaCl(2)1g, 5% sodium bicarbonate 1.5 g, 20% mannitol 2 g, albumin 10 g, and heparin 5 mg. The blood was re-circulated until the temperature was 37 degrees C and blood gases and the electrolytes were in normal range. The patient was weaned from bypass and connected to V-A ECMO. Management of ECMO: the blood flow was set at 150 - 200 ml/kg/min. Venous saturation (SvO2) was maintained at the desired level (75%) by increasing and decreasing extracorporeal blood flow. Systemic blood pressure was maintained at 76/55 - 80/59 mm Hg by adjusting blood volume. Hemoglobin was maintained between 120 - 130 g/L. Platelet count was maintained at &gt; 75,000/mm3 and ACT was maintained at 120 - 190 s. The mechanical ventilation was reduced to lung rest settings (FiO2 35%, RR 10 bpm, PIP 16 cm H(2)O, PEEP 5 cm H2O) to prevent alveolar collapse. Inotropic drug dosages were kept at a low level. The patient was successfully weaned from ECMO following 87 hours treatment. LVEF on day 1, 2 and 3 following ECMO were 20%, 34% and 43% respectively. The circulation was stable after weaning from ECMO with Bp 75/55 mm Hg, HR 160 bpm and LAP 11 mm Hg under inotropic drug suppor with epinephrine [(0.2 microg/(kg.min)], dopamine [(8 microg/(kg.min)], milrinone [(0.56 microg/(kg.min)]. The blood gases after 1 h off-ECMO showed: pH 7.39, PaO2 104 mm Hg, PaCO2 45 mm Hg, lactate 3.8 mmol/L, Hct 35%, K(+) 3.8 mmol/L, Ca(++) 1.31 mmol/L. The serum lactate was normal after 24 h off-ECMO. On day 22 off-ECMO, the baby was successfully extubated and weaned from conventional ventilator. On day 58, the patient was discharged. Serial ultrasound imaging studies revealed no cerebral infarction or intracranial hemorrhage during and after ECMO. At the time of hospital discharge, the patient demonstrated clear consciousness with good activity, normal function of heart, lung, liver and kidney. However, more subtle morbidities, such as behavior problems, learning disabilities should be observed ria long term follow-up. The main ECMO complications were pulmonary hemorrhage, bleeding on the sternal wound, tamponade, hemolysis and hyperbilirubinemia. ECMO is an effective option of cardio-pulmonary support for neonate with low cardiac output syndrome following open heart surgery." }, { "id": "pubmed23n0747_25138", "title": "Pulmonary embolism hotline 2012. Recent and expected trials.", "score": 0.009708737864077669, "content": "Management of acute pulmonary embolism (PE) has advanced considerably in the past year, and progress is expected to continue in 2013. To help determine the optimal management strategy for normotensive patients with intermediate-risk PE, the Pulmonary Embolism Thrombolysis (PEITHO) study completed enrolment of 1006 patients with evidence of right ventricular dysfunction (by echocardiography or computed tomography) plus a positive troponin test. Patients have been randomised to thrombolytic treatment with tenecteplase versus placebo, and the effects on clinical end points (death or haemodynamic collapse) assessed at 7 and 30 days. The results are expected in spring 2013; long-term follow-up is also being performed. The results of a randomised trial on ultrasound-enhanced low-dose catheter-delivered thrombolysis will also become available soon. While optimisation of treatment with vitamin K antagonists incorporating pharmacogenetic testing is still being pursued, new oral anticoagulants are entering the field of PE treatment and secondary prophylaxis. Following the successful use of rivaroxaban as single oral drug therapy in the EINSTEIN-PE trial, the approval of this drug has recently been extended to cover, apart from deep vein thrombosis, PE as well. The apixaban (AMPLIFY) and edoxaban (HOKUSAI) trials have finished recruitment of PE patients, and their results will become available shortly. In the meantime, the AMPLIFY-EXT trial showed that both the therapeutic (5 mg twice daily) and the prophylactic dose (2.5 mg twice daily) of apixaban are effective and safe for long-term secondary prophylaxis after PE. For the extended prophylaxis (after the reommended initial anticoagulation period) of the (few) patients who are unable to tolerate any form of anticoagulation, low-dose asprin may be a safe albeit moderately efficacious option, as indicated by two recent investigator-initiated trials with a total of 1224 patients." }, { "id": "pubmed23n0853_10392", "title": "An 88-year-old man with syncope and an alternating axis.", "score": 0.009615384615384616, "content": "An 88-year-old man, admitted to the emergency room (ER) after three episodes of syncope within 1 day, reported a precursory of syndrome of light-headedness with rapid palpitations that led to an abrupt loss of consciousness. After undergoing percutaneous and surgical revascularisation, he started complaining of chest and back discomfort for the past 20 years and searching for help from Chinese medicine, Fuzi. He had history of chronic renal failure and heart failure, but denied neither taking digitalis nor having family history related to sudden death.On arrival, heart rate was 150 bpm and blood pressure (BP) by cuff was 91/81 mm Hg (non-invasive BP could not be accurately obtained during tachycardia) plus oedema on both lower extremities. There were diffuse crackles and indistinct heart sounds on auscultation.The admission ECG was performed in the ER (figure 1). His serum creatinine was 139.7 mmol/L, serum K(+) was 4.7 mmol/L, N-terminal of the prohormone brain natriuretic peptide was highly elevated (12 000 pg/mL) and troponin I was negative. What is the most likely diagnosis suggested based on the patient's ECG and history? Aconite poisoningDigitalis toxicityCatecholaminergic polymorphic ventricular tachycardia (CPVT)Andersen-Tawil syndrome (ATS)." }, { "id": "pubmed23n0420_4415", "title": "[Acute pulmonary embolism emergency. Confirming diagnosis, administering heparin, begin thrombolysis].", "score": 0.009615384615384616, "content": "In suspected acute pulmonary embolism, the measurement of the d-dimer is now an established screening method. Further diagnostic measures include the electrocardiogram, echocardiography and conventional chest radiography, as well as the analysis of blood gases. The specific demonstration of a pulmonary embolism is achieved with a helical CT of the thorax, pulmonary angiography and ventilation/perfusion scanning. Apart from continuous (infusion) of unfractionated heparin, the low molecular weight heparins also are of potential value in the treatment of pulmonary embolism. A larger percentage of patients benefit from the use of fibrinolytic agents than was previously thought, so that the indication for fibrinolytic therapy should not be made dependent on the presence of hemodynamic instability." }, { "id": "pubmed23n0357_17206", "title": "Low-molecular-weight heparin in thrombotic disease in children and adolescents.", "score": 0.009523809523809525, "content": "The use of unfractionated heparin (UFH) in children is problematic. In adults, subcutaneous low-molecular-weight heparin (LMWH) is as effective as UFH in the treatment of thrombosis. Because pediatric data are limited, the authors studied the use of enoxaparin in children. Nineteen children (ages 18 days to 19 years; median age, 40 months) with indications for thrombosis treatment or prophylaxis were studied. Six patients (median age, 33 months), treated on a protocol that included pharmacokinetic studies, initially received enoxaparin 1 mg/kg subcutaneously every 12 hours; doses then were adjusted until target plasma levels of 0.5 to 1.2 anti-Xa U/mL were achieved. The records of 13 additional patients treated with enoxaparin off study were reviewed. In the first six patients, enoxaparin pharmacokinetics was found to be similar to that in adults; once targeted levels were achieved, these remained stable. Among all 19 subjects, 14 had treatment of active thrombosis and 5 underwent thrombosis prophylaxis. For treatment of thrombosis, enoxaparin 1 mg/kg initially was administered subcutaneously every 12 hours. Target anti-Xa levels were achieved with 0.55 to 1.5 mg/kg every 12 hours (mean, 0.98 mg/kg; median, 1.0 mg/kg) in 1 to 7 days (median, 1 day). All patients in the treatment group had clinical improvement within 2 to 5 days, and 12 had follow-up radiological studies that confirmed this. For prophylaxis, enoxaparin was given at 1 mg/kg subcutaneously every 24 hours. No new thrombi were clinically evident in this group. There was no major bleeding with enoxaparin; one patient had transient mild mucosal oozing. In this limited population, enoxaparin seems to be a safe, effective, and convenient alternative to UFH in children and adolescents. The adult therapeutic target range of 0.5 to 1.2 anti-Xa U/mL is readily achievable with a starting dose of 1 mg/kg every 12 hours in most children. Initial close monitoring with plasma anti-Xa activity should be done and doses adjusted to achieve target range, particularly in neonates. In the population of this study, enoxaparin seems as effective as UFH in the period immediately thrombotic episode. These results should be confirmed in the ongoing randomized trial comparing LMWH with UFH in children." }, { "id": "pubmed23n1157_1471", "title": "Acute Pulmonary Embolism: A Review.", "score": 0.009523809523809525, "content": "Pulmonary embolism (PE) is characterized by occlusion of blood flow in a pulmonary artery, typically due to a thrombus that travels from a vein in a lower limb. The incidence of PE is approximately 60 to 120 per 100 000 people per year. Approximately 60 000 to 100 000 patients die from PE each year in the US. PE should be considered in patients presenting with acute chest pain, shortness of breath, or syncope. The diagnosis is determined by chest imaging. In patients with a systolic blood pressure of at least 90 mm Hg, the following 3 steps can be used to evaluate a patient with possible PE: assessment of the clinical probability of PE, D-dimer testing if indicated, and chest imaging if indicated. The clinical probability of PE can be assessed using a structured score or using clinical gestalt. In patients with a probability of PE that is less than 15%, the presence of 8 clinical characteristics (age &lt;50 years, heart rate &lt;100/min, an oxygen saturation level of &gt; 94%, no recent surgery or trauma, no prior venous thromboembolism event, no hemoptysis, no unilateral leg swelling, and no estrogen use) identifies patients at very low risk of PE in whom no further testing is needed. In patients with low or intermediate clinical probability, a D-dimer level of less than 500 ng/mL is associated with a posttest probability of PE less than 1.85%. In these patients, PE can be excluded without chest imaging. A further refinement of D-dimer threshold is possible in patients aged 50 years and older, and in patients with a low likelihood of PE. Patients with a high probability of PE (ie, &gt;40% probability) should undergo chest imaging, and D-dimer testing is not necessary. In patients with PE and a systolic blood pressure of 90 mm Hg or higher, compared with heparin combined with a vitamin K antagonist such as warfarin followed by warfarin alone, direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior for treating PE and have a 0.6% lower rate of bleeding. In patients with PE and systolic blood pressure lower than 90 mm Hg, systemic thrombolysis is recommended and is associated with an 1.6% absolute reduction of mortality (from 3.9% to 2.3%). In the US, PE affects approximately 370 000 patients per year and may cause approximately 60 000 to 100 000 deaths per year. First-line therapy consists of direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg." }, { "id": "wiki20220301en085_59103", "title": "Contrast-induced nephropathy", "score": 0.009433962264150943, "content": "Roxana Mehran score The Roxana Mehran score is a clinical prediction rule to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h): Risk Factors: Systolic blood pressure <80 mm Hg - 5 points (if systolic BP less than 80 mmHg for at least one hour requiring inotropic support) Intra-arterial balloon pump - 5 points Congestive heart failure, counting as NYHA class III (marked limitation in activity due to symptoms, even during less-than-ordinary activity) or worse, or history of pulmonary edema - 5 points Age >75 y - 4 points Hematocrit level <39% for men and <35% for women - 3 points Diabetes mellitus- 3 points Contrast media volume - 1 point for each 100 mL Decreased kidney function: Serum creatinine level >1.5 g/dL - 4 points or Estimated Glomerular filtration rate (online calculator) 2 for 40–60 mL/min/1.73 m2 4 for 20–40 mL/min/1.73 m2 6 for < 20 mL/min/1.73 m2" }, { "id": "pubmed23n0818_16733", "title": "[Pulmonary embolism].", "score": 0.009433962264150943, "content": "Acute pulmonary embolism is an important differential diagnosis of acute chest pain. The clinical signs are often non-specific. However, diagnosis and therapy must be done quickly in order to reduce morbidity and mortality. The new (2014) European guidelines for acute pulmonary embolism (PE) focus on risk-adapted diagnostic algorithms and prognosis adapted therapy concepts. According to the hemodynamic presentation the division in a high-risk group (unstable patient with persistent hypotension or shock) or in non-high-risk groups (hemodynamically stable) was proposed. In the high-risk group the immediate diagnosis is usually done by multidetector spiral computed tomography (MDCT) and primarily the medical therapy of right ventricular dysfunction and thrombolysis is recommended.In the non-high-risk group, this is subdivided into an intermediate-risk group and low-risk group, the diagnosis algorithm based on the PE-pretest probability--determined by validated scores. Moreover, the diagnosis is usually secured by MDCT--the new gold standard in the PE-diagnosis, scores, or it can be primarily ruled out due to the high negative predictive value of D-dimer determination. To improve the prognostic risk stratification in non-high-risk group patients the additional detection of right ventricular dysfunction (MDCT, echocardiography), cardiac biomarkers (troponin, NT proBNP) and validated scores (e.g. Pulmonary Embolism Severity Index) is recommended. Therefore, the intermediate-risk group can be further subdivided. For treatment of non-high-risk group patients, the initial anticoagulation (except those with severe renal insufficiency) using low molecular weight heparin/fondaparinux and conversion to vitamin-K antagonists or alternatively with direct oral anticoagulants (DOAK) is recommended. Hemodynamically stable patients with right ventricular dysfunction and myocardial ischemia (Intermediate-high-risk group patients) but with clinically progressive hemodynamic decompensation may benefit from systemic thrombolysis as well. Due to the high risk of bleeding in the PEITHO study, however, a critical individual risk-benefit evaluation should be done. A dose reduced systemic or local ultrasound-assisted thrombolysis could gain importance in the future. For very selected patients in the low-risk group early outpatient treatment could be considered.The diagnosis and treatment of pulmonary embolism remains complex. Improved algorithms support the diagnosis procedures and therapy decisions. Direct oral anticoagulants are a new first-line therapy alternative for hemodynamically stable non-high-risk patients." }, { "id": "article-21136_10", "title": "Enoxaparin -- Administration", "score": 0.00936773193212163, "content": "Treatment of Acute Deep Vein Thrombosis with or without Pulmonary Embolism: The recommended dose of enoxaparin is 1 mg/kg SC every 12 hours or 1.5 mg/kg SC daily. Anticoagulation should be started immediately in the case of suspected or proven pulmonary embolism. Patients with pulmonary embolism usually require inpatient therapy, according to the PERT Consortium. [14] [15]" }, { "id": "pubmed23n0498_10724", "title": "Infectious disease capsules: a pox on your house.", "score": 0.009345794392523364, "content": "A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a \"rash.\" His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with \"chickenpox\" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy." }, { "id": "pubmed23n0730_19787", "title": "[Role of thrombolysis in massive pulmonary embolism].", "score": 0.009345794392523364, "content": "Massive pulmonary embolism is a life threatening pathology with a high mortality over 20%. Thrombolysis is one of therapy ways that leads to a lower rate of death. The aim of the study is to show interest, limits and complications of thrombolytic therapy in massive pulmonary embolism. This descriptive study presents 8 cases of pulmonary embolism admitted to the Cardiology Division of Grand-Yoff from March 2003 to March 2006. All cases confirmed by Tomodensitometry (TDM) with massive pulmonary embolism were included in this study. We used thrombolytic only in 8 cases of massive pulmonary embolism about 32. In-hospital prevalence was 25%. The average age was 49.8 ± 19.1 (from 15 to 72) and sex-ratio 0.33. Seven patients had a moderate clinical probability Well's score and one of them 1 had a high clinical probability. The clinical signs were: cardio-vascular collapse (7 cases), syncope (1) and cardio-vascular arrest. The electrocardiogram showed a sub-epicardial ischemia (4 cases), a right bundle branch block and a Mac Ginn White's sign. Two patients had a right-basal opacification at the chest X ray. The echocardiography found 5 cases of right ventricular dilatation, 1 case of paradoxal septum, 1 case of multiple thrombi in the right ventricule. The TDM confirmed diagnosis with 3 cases of bilateral pulmonary embolism, 1 case of pulmonary aneurysm. The treatment used thrombolytic : 1,500,000 IU of streptokinase, sympathomimetic drugs, anticoagulation with heparins and vitamin K antagonists." }, { "id": "pubmed23n0886_6897", "title": "Miliary tuberculosis in an immunocompetent male with a fatal outcome.", "score": 0.009259259259259259, "content": "A man aged 33 years, born in Nepal, but resident in the UK for 7 years presented to the emergency department with a 4-day history of general malaise, fever (temperature 38.6°C) and a non-productive cough. His medical history was unremarkable and no high-risk behaviour was identified. Clinical examination confirmed decreased air entry bilaterally with bibasal crackles. He was tachycardic, with a heart rate of 120 bpm. Further investigation with a 12-lead ECG confirmed supraventricular tachycardia (SVT) which was terminated with vagal manoeuvres. His chest radiograph demonstrated left basal consolidation. His white cell count was 11×10<sup9</sup/L and his C reactive protein was 43.2 mg/L. His blood cultures revealed no growth. He was diagnosed with community-acquired pneumonia and started treatment with amoxicillin and clarithromycin. 3 days post admission, he was intubated for 24 hours in the Department of Intensive Care Medicine. Further episodes of SVT were observed and an ECHO showed a severely dilated and impaired left ventricle. Further chest radiographs illustrated diffuse consolidation with evidence of pulmonary oedema. HIV serology was negative. He developed transaminitis and thrombocytopenia. An ultrasound scan of his liver showed no obvious liver pathology. He remained tachypnoeic and due to worsening pulmonary oedema and extensive consolidation, he was readmitted to the intensive care unit. A CT abdomen with contrast showed an unusual pattern of lymphadenopathy with disproportionately enlarged coeliac axis nodes (5×7×5 cm) and minor para-aortic adenopathy, suspicious for lymphoma. On inserting his central venous catheter in his right internal jugular vein, pus was inadvertently aspirated from his right neck. Acid alcohol fast bacilli (AAFFB) were isolated from the pus and was subsequently identified as Mycobacterium tuberculosis He started treatment with antitubercular medication rifater: a combination of rifampicin 720 mg od, isoniazid 300 mg po od and pyrazinamide 1750 mg. In addition, he received ethambutol 1000 mg po od and pyridoxine 5 mg. He developed worsening metabolic acidosis, pH 7.19, loss of respiratory compensation and pancytopenia. Right heart strain was evident on his Focused Intensive Care Echo. He developed an increased oxygen requirement and respiratory distress on the ventilator. An erect chest radiograph showed bilateral pneumothoraces and bronchopleural fistulae. A chest drain was inserted. Following discussion with the Cardiothoracic Surgeons, pleurodesis was not deemed possible. He developed inotropic-dependent shock with worsening lung compliance. As a result of his deteriorating ventilation, acidosis and hyperkalaemia, he started treatment with continuous veno-venous haemofiltration. With a diagnosis of miliary tuberculosis and SVT causing cardiogenic pulmonary oedema, this man sadly died with his family at his bedside 10 weeks following initial hospital presentation." }, { "id": "pubmed23n0354_2204", "title": "[Massive pulmonary embolism--echocardiographic diagnosis and thrombolytic therapy].", "score": 0.009259259259259259, "content": "Thrombolysis is widely accepted as the treatment of choice for acute massive life-threatening pulmonary embolism. Several trials have shown that thrombolytic treatment has reduced morbidity and mortality in this condition, compared to heparin therapy. Rapid diagnosis and treatment start is mandatory for improving the prognosis. Clinical presentation, ECG, arterial blood gas analysis and D-dimer are non-specific tests. Additional tests like ventilation/perfusion lung scan, spiral-computed tomography or pulmonary angiography are needed. In an emergency situation a non-invasive and bedside technique is preferred, and several studies have demonstrated the accuracy of echocardiography in pulmonary embolism. Acute right ventricular overload is indicated by different echocardiographic findings. Three cases with the echocardiographic method as the initial technique for the diagnosis of massive pulmonary embolism are described as well as the treatment consequence and practical administration of thrombolysis. Our patients had presenting features suggestive of massive pulmonary embolism, a clinical situation where an echocardiographic evaluation is appropriate. All presented with typical echocardiographic features. Thrombolytic treatment was initiated immediately after echocardiographic diagnosis. Different thrombolytic regimens were used. Echocardiography may be used as the initial imaging technique for the diagnosis of massive pulmonary embolism. The advantages are obvious, and thrombolytic treatment can be initiated without delay." }, { "id": "wiki20220301en055_62424", "title": "Acute coronary syndrome", "score": 0.00922364142562642, "content": "NSTEMI and NSTE-ACS If the ECG does not show typical changes, the term \"non-ST segment elevation ACS\" is applied. The patient may still have suffered a \"non-ST elevation MI\" (NSTEMI). The accepted management of unstable angina and acute coronary syndrome is therefore empirical treatment with aspirin, a second platelet inhibitor such as clopidogrel, prasugrel or ticagrelor, and heparin (usually a low-molecular weight heparin), with intravenous nitroglycerin and opioids if the pain persists. The heparin-like drug known as fondaparinux appears to be better than enoxaparin. A blood test is generally performed for cardiac troponins twelve hours after onset of the pain. If this is positive, coronary angiography is typically performed on an urgent basis, as this is highly predictive of a heart attack in the near-future. If the troponin is negative, a treadmill exercise test or a thallium scintigram may be requested." }, { "id": "Obstentrics_Williams_7176", "title": "Obstentrics_Williams", "score": 0.00920581419844112, "content": "TABLE 52-5. Anticoagulation Regimen Definitions Prophylactic LMWHa Enoxaparin,n40 mg SC once daily Dalteparin, 5,000 units SC once daily Tinzaparin, 4,500 units SC once daily Therapeutic LMWHb Enoxaparin, 1 mg/kg every 12 hours Dalteparin, 200 units/kg once daily Tinzaparin, 175 units/kg once daily Dalteparin, 100 units/kg every 12 hours May target an anti-Xa level in the therapeutic range of 0.6-1.0 units/mL for twice daily regimen; slightly higher doses may be needed for a once-daily regimen. Minidose prophylactic UFH UFH, 5,000 units SC every 12 hours Prophylactic UFH UFH, 5,000-10,000 units SC every 12 hours UFH, 5,000-7,500 units SC every 12 hours in first trimester UFH 7,500-10,000 units SC every 12 hours in the second trimester UFH, 10,000 units SC every 12 hours in the third trimester, unless the aPTI is elevated Therapeutic UFHb UFH, 10,000 units or more SC every 12 hours in doses adjusted to target aPTI in the therapeutic range (1n.5-2.5) 6 hours after injection" }, { "id": "pubmed23n0684_23532", "title": "Anaphylactic shock due to intravenous amiodarone.", "score": 0.009174311926605505, "content": "A 24-year-old male patient was admitted to the coronary intensive care unit with atrial fibrillation with rapid ventricular response. He was given amiodarone (Cordarone 150 mg i.v., Sanofi-Aventis) intravenous loading dose of 300 mg in 100 mL dextrose 5% in water (D5W) over 1 hour, followed by a maintenance dose of 900 mg in 500 mL D5W for infusion up to 24 hours. At the emergency department, the patient was conscious and cooperative; his pretreatment arterial blood pressure was 120/80 mm Hg, and the arrhythmic tachycardia was 145 per minute. After intravenous amiodarone loading and half an hour into maintenance infusion, extreme perspiration, hypotension (blood pressure immeasurable), and mild cyanosis developed. The patient was conscious; his auscultation and pulse were normal. He was given physiologic serum and dopamine support. Approximately an hour later, the blood pressure was measurable. Infusion was terminated because of suspicion of an allergic reaction to acetylsalicylic acid or amiodarone. The allergic reaction observed was attributed to acetylsalicylic acid and amiodarone; infusion was resumed when the clinical situation worsened during the maintenance infusion. Once again, the patient was given physiologic serum (2000 mL), dopamine (20 mg/kg per minute), and, additionally, 250 mg of methyprednisolone sodium succinate intravenous, whereby the clinical condition improved within 20 minutes. Anaphylactic shock cases due to amiodarone are rare; it is important to take a history of drug-mediated anaphylaxis before prescribing amiodarone. An addition to a review of the literature regarding treatment of amiodarone-related anaphylactic shock cases had not been reported before." }, { "id": "pubmed23n0712_25047", "title": "Diagnosis and management of carbon monoxide poisoning in the emergency department.", "score": 0.00909090909090909, "content": "An 89-year-old female is found by her family, lying unconscious on her kitchen floor after they had been unable to reach her by phone for several hours. EMS is activated and when the paramedics arrive, they note that the gas oven is on, and there is thin, gray smoke coming from around the door. The house gas supply is turned off, windows are opened, and the family and the patient are immediately evacuated from the home. En route to the hospital, the patient is placed on high-flow oxygen at 15 liters per minute by non-rebreather mask. Her bedside glucose determination is 229 mg/dL. Vital signs are within normal limits during transport. She opens her eyes to sternal rub, and makes spontaneous movements of all extremities. Upon arrival to the ED, the patient becomes more alert and is able to respond to your questions. She tells you that she remembers putting a tray of calzones into the oven, after which she has no recall of the day's events. She has a past medical history of \"well-controlled\" hypertension, hyperlipidemia, and non-insulin-dependent diabetes. Her medications include hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, simvastatin 20 mg daily, and metformin 1000 mg twice daily. On physical examination, weight is 65 kg, blood pressure is 97/50 mm Hg, heart rate is 113 beats per minute, respiratory rate is 22 breaths per minute, temperature is 37.1 degrees C (98.8 degrees F), and oxygen saturation is 99% on 15 liters per minute via non-rebreather mask. She appears her stated age. Cardiopulmonary examination is remarkable only for tachycardia. Her abdomen is soft and non-tender with normal bowel sounds. Her skin is warm and dry, and there is no peripheral edema. Her cranial nerves are intact, with briskly reactive, symmetric pupils. Motor and sensory examination is non-focal, and cerebellar testing is notable only for an intention tremor on finger-nose-finger test. Gait is normal and speech is fluent and without errors. Laboratory testing shows a hemoglobin of 10.3 g/dL and a leukocyte count of 11.7 x 10(9)/L. Electrolyte results fall within the normal range, and her serum creatinine is 1.7 mg/dL. Qualitative CK-MB and troponin I tests are positive, and the sample has been sent to the STAT lab for quantitative testing. Serum carboxyhemoglobin level is 15% with normal serum pH on an arterial blood gas. An ECG reveals deep, down-sloping inferior and lateral ST-segment depressions which were not present on a routine cardiogram 1 month prior. You have many questions about this patient's care. What symptoms and physical signs need to be addressed and treated? What additional diagnostic testing should be performed? What treatment regimen is appropriate and what should be avoided? What are the risks or delayed complications from her illness? Are there special considerations for this or other patient populations?" }, { "id": "pubmed23n0687_17072", "title": "[Diagnosis and treatment of acute pulmonary embolism in 2010].", "score": 0.00909090909090909, "content": "Diagnostic approaches in acute pulmonary embolism include evaluation of clinical likelihood, D-dimers, echocardiography and spiral CT angiography and pulmonary scintigraphy. Determination of D-dimers is only meaningful in patients with low or intermediate clinical likelihood. It is safe not to initiate anticoagulation treatment (or to discontinue such treatment) in patients with low clinical likelihood of acute pulmonary embolism and negative D-dimer test (only if methods with 99-100% sensitivity are used). Duplex sonography and pulmonary scintigraphy are only necessary at the centres with a first generation spiral CT and not those with multidetector devices. Investigations in normotensive patients should include echocardiography that should also include assessment of the right ventricular function using echocardiography and determination of biomarkers of pulmonary embolism. Right ventricular dysfunction together with elevated troponins identifies a normotensive group at an increases risk. Highly sensitive troponin T (hsTnT) appears to be particularly valuable. Echocardiography reading might the decisive factor for treatment initiation in patients with massive acute pulmonary embolism. Negative or unclear echocardiography finding warrants spiral CT angiography (CTA). Ventilation/perfusion scan or pulmonary arteriography are recommendable in patients with unclear CTA finding and patients with high clinical likelihood of pulmonary embolism and negative CTA finding. A combination of CTA and CTV also appears useful as it increases the overall sensitivity of the investigation and enables imaging of pelvic veins. Thrombolytic treatment is indicated in haemodynamically unstable patients, patients with a high risk of a massive pulmonary embolism associated with cardiogenic shock or hypotension (systolic pressure below 90 mmHg or a decrease in systolic pressure by &gt; 40 mmHg) or symptoms of acute right-sided heart failure. Thrombolytic treatment is also indicated in pulmonary embolism not receding following heparin treatment, in recurring or expanding pulmonary embolism, in the presence of thrombi in the right heart and in patients with right-to-left shunting through patent foramen ovale. This treatment should also be considered in patients with submassive pulmonary embolism associated with a dysfunction of the right ventricle and increased troponins, and particularly in patients lacking even a relative contraindication of thrombolytic treatment. A thrombolytic of choice is alteplase. Embolectomy or catheterization should be used if thrombolytic treatment is contraindicated or ineffective. Long-term monitoring of massive and submassive acute pulmonary embolism is highly recommended. Low molecular weight heparins or unfractioned heparin or fondaparinux are used in haemodynamically stable patients." }, { "id": "pubmed23n0973_2746", "title": "Myocarditis in a patient treated with Nivolumab and PROSTVAC: a case report.", "score": 0.009009009009009009, "content": "Immune checkpoint inhibitors have revolutionized treatment and improved survival in many cancers. However, since immune-related adverse events (irAEs) are potentially fatal, early recognition and prompt treatment are warranted. One of the rarest but most dramatic irAE is myocarditis, which has significant morbidity and mortality if not recognized and treated early. To report the first case of myocarditis in a patient with metastatic castration-resistant prostate cancer (mCRPC) treated with a combination of nivolumab, an anti-programmed cell death protein 1 antibody, and PROSTVAC, a vector-based therapeutic prostate cancer vaccine. A 79-year-old man with mCRPC metastatic to bone and lymph nodes and a history of atrial fibrillation presented with blurred vision and pain and stiffness in the upper back after 8 weeks on a clinical trial with nivolumab (1 mg/kg) and PROSTVAC, both given every 2 weeks. Eye exam was within normal limits, while musculoskeletal exam revealed tenderness in trapezius muscles and decreased motor strength in arms (III/V) and neck (IV/V). The rest of the physical exam was within normal limits, with the exception of an irregular heart rhythm. Laboratory tests were as follows: creatinine kinase (CK) 3200 U/L (normal: 39-308 U/L), CK-MB 65.7 mcg/L (normal: 0-7.6 mcg/L), troponin I 0.209 ng/mL (normal: 0-0.056 ng/mL). Electrocardiogram (ECG) revealed atrial fibrillation with QT prolongation (QTc 514 msec) and left anterior fascicular block, unchanged from baseline. 2D-echocardiogram showed a left ventricular ejection fraction of 65% with an enlarged left atrium, dilated right ventricle, and increased pulmonary artery pressure (45 mmHg). ProBNP was elevated at 1463 pg/mL and peaked at 3066 pg/mL one day after hydration. With a presumed diagnosis of autoimmune myositis and possible myocarditis, the patient was admitted and started on methylprednisolone 1 mg/kg/day. Cardiac MRI showed elevated native myocardial T1 values consistent with myocarditis (Fig. 1). The patient was discharged on a prednisone taper after normalization of cardiac enzymes on day 4. Treatment with PROSTVAC continued for three more months; nivolumab was discontinued. Six months later, patient is doing well, with no residual cardiac damage. Cardiovascular irAEs are relatively rare (&lt; 1%) and have a variety of clinical presentations. Myocarditis is potentially life-threatening and can range from subclinical to fulminant. Therefore, clinical suspicion, early detection, and prompt treatment are imperative (1). The initial diagnostic workup should include cardiac enzymes, ECG, and 2D-echocardiogram. The most commonly observed ECG changes are generalized repolarization abnormalities, prolonged QT interval, and conduction abnormalities (2). An elevated troponin I in the absence of overt coronary artery disease is suggestive of myocarditis and should be evaluated further. Myocardial biopsy is the standard diagnostic procedure; however, a cardiac MRI can achieve a diagnosis when biopsy is not feasible (3). Advancements in parametric mapping techniques have allowed the use of native myocardial T1 in the detection of myocarditis, as it has superior diagnostic performance and higher sensitivity than older parameters (3). Our patient had been treated with an immune checkpoint inhibitor and a therapeutic cancer vaccine to induce effective antitumor activity through immunogenic intensification and presented with muscle stiffness and elevated CK. Although he had no new cardiovascular symptoms, cardiac enzymes were tested to rule out myocardial involvement. MRI with gadolinium confirmed the diagnosis of myocarditis. To date, none of the 1360 patients treated with PROSTVAC as a single agent have developed myocarditis, while myocarditis has been rarely reported in patients treated with nivolumab (&lt; 1%) (1). Whether the combination of PROSTVAC and nivolumab presents an additional risk of myocarditis is unclear. To our knowledge, this is the first case of myocarditis in a patient with mCRPC receiving simultaneous treatment with an immune checkpoint inhibitor and a prostate cancer vaccine. Our experience highlights the importance of suspicion and early intervention in patients who present with cardiac abnormalities after receiving cancer immunotherapy. We propose following protocol: baseline troponin, ECG, and 2D-echocardiogram prior to treatment, then repeated troponin at 2, 4, and 12 weeks post-treatment, then monthly. If troponin becomes positive without alternative explanation, myocarditis should be ruled out with cardiac MRI or myocardial biopsy, and patient should be admitted for treatment with high-dose steroids as early intervention may minimize myocardial injury." }, { "id": "pubmed23n0564_24292", "title": "Is it a pheochromocytoma?", "score": 0.008928571428571428, "content": "The patient is a 44-year-old man with a 4-year history of intermittently elevated blood pressure (BP) controlled by diet and exercise. Three months before evaluation he described daily \"spikes\" of BP with sharp unilateral headaches. He was seen in the emergency department with a BP of 212/106 mm Hg and was started on hydrochlorothiazide 25 mg daily. He denied palpitations, diaphoretic episodes, pallor, and tremor. The patient did not want to take medication and specifically requested an evaluation to rule out pheochromocytoma. Results from 24-hour urine tests for total metanephrines was 812 mg/24 h (normal, 130-520 mg/24 h), for total catecholamines was 53 mg/24 h (normal, 0-135 mg/24 h), and for vanillylmandelic acid was 4.7 mg/24 h (normal, &lt;7 mg/24 h). Thyroid-stimulating hormone was 0.87 (normal, 0.4-4.0 IU/mL). Physical examination revealed normal optic fundi, negative cardiac examination results, and presence of peripheral pulses without bruits. His BP was now 136/74 mm Hg, with a heart rate of 76 beats per minute." }, { "id": "pubmed23n0335_1047", "title": "[Thrombolysis in pulmonary embolism - initial experience].", "score": 0.008928571428571428, "content": "Pulmonary embolism (PE) is a clinical situation difficult to diagnose, at times of great clinical instability, above all when it is massive, which leads to difficulties in the approach and treatment of patients. The treatment has not had any major innovations in recent years, being conventional the use of heparin and more rarely embolectomy. Recently, some clinical trials have defended the use of thrombolytics. The objéctive of this paper is to present our experience, although the series is still small. From April 1996 to November 1997, 11 patients were admitted to our Cardiac Intensive Care Unit with the clinical suspicion of PE, 5 of which with great hemodynamic instability and suspicion of massive PE. The clinical presentation was sudden dyspnea and loss of consciousness in 2 patients, dyspnea and hypotension in 2 patients and shock and respiratory arrest in one case. Gasimetry revealed acute hypoxemia and hypocapnia in all cases, average partial blood pressure in O2 (pO2) of 59 mm Hg and CO2 (pCO2) of 19 mm Hg. ECC and thorax x-ray contributed to the diagnosis in 3 patients, transthoracic echocardiography was decisive for the diagnosis in 5 cases, with visualisation of the thrombus by transesophageal echocardiography in 3 patients. All patients were monitored by Swan-Ganz catheter, the average systolic pulmonary artery pressure (PAP) was 74 mm Hg. Thrombolysis with rTPA (10 mg bolus followed by 90 mg in perfusion in 2 hrs) was administered in 6 episodes in 5 patients. Only in the case of the patient in shock were other complications related to the use of thrombolytics namely high digestive hemorrhage. There was a clear clinical improvement in all cases with great relief of dyspnea reduction of cyanosis and jugular engurgitation. The patient in shock recovered systemic pressures and improved the hemodynamic state. A significant reduction in PAP was observed (average of 32.5 mm Hg). PE recurred in two cases: with one death and therapeutic thrombolytic was repeated in the other patient with good results. After discharge, all patients remained asymptomatic under oral anticoagulation. Despite this small series, the results favour the use of thrombolytics in PE with a clear clinical and hemodynamic improvement." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 184, 297 ] ], "word_ranges": [ [ 29, 50 ] ], "text": "The rotator cuff is undamaged in the MRI, ruling out option 1 (it would show us tendinopathy of the teres major)." }, "2": { "exist": true, "char_ranges": [ [ 298, 419 ] ], "word_ranges": [ [ 50, 67 ] ], "text": "Adhesive capsulitis presents with pain and stiffness of the shoulder, especially on active and passive external rotation." }, "3": { "exist": true, "char_ranges": [ [ 420, 621 ] ], "word_ranges": [ [ 67, 97 ] ], "text": "The suprascapular nerve innervates the supraspinatus muscle, which contributes to the first 15º of shoulder abduction (preserved in the statement) and does not innervate the skin of the reflected area." }, "4": { "exist": true, "char_ranges": [ [ 0, 183 ] ], "word_ranges": [ [ 0, 29 ] ], "text": "Dysesthesia of the lateral aspect of the deltoid region of the shoulder (area innervated by the axillary nerve) and paralysis of the deltoid (primary muscle for abduction beyond 15°)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Tendinopathy of the teres major.", "2": "Adhesive capsulitis.", "3": "Suprascapular nerve neuropathy.", "4": "Axillary nerve injury.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0960_2019", "title": "Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tear and Axillary Nerve Palsy Associated with Anterior Dislocation of the Shoulder.", "score": 0.01951637471439452, "content": "This report describes a case of irreparable massive rotator cuff tear and axillary nerve palsy associated with shoulder dislocation successfully treated by arthroscopic superior capsule reconstruction (ASCR), with a favorable post-operative outcome. A 76-year-old man, injured from a fall while walking, presented to another hospital with right shoulder pain and a limited range of motion (ROM) 3 days after the injury. Given a diagnosis of right shoulder dislocation, he received manual reduction followed by immobilization with a sling. He continued to experience difficulty in performing active ROM exercises of the shoulder and underwent magnetic resonance imaging, which revealed an irreparable extensive rotator cuff tear involving the supraspinatus and infraspinatus muscles. He was then referred to our hospital 2 months after the injury. Examination revealed atrophy of the supraspinatus and infraspinatus muscles, atrophy of the deltoid muscle and hypoesthesia, likely due to axillary nerve palsy, and a marked limitation of active ROM with flexion, abduction and lateral rotation angles of 10°each. ASCR was considered for treating the irreparable rotator cuff tear. Since the technique is not indicated for patients with deltoid paralysis, the operation was delayed until signs of improved axillary nerve palsy were observed at 6 months after the injury. The patient started passive ROM training the day after the operation while wearing a shoulder abduction orthosis for 3 weeks, followed by immobilization with a sling for 2 weeks. Thereafter, he started active exercise. The axillary nerve palsy was almost completely resolved 3 months after the operation. He achieved a ROM comparable to that of the unaffected side at 1 year after operation. He has had an uneventful post-operative course for 2 years after operation. We encountered a rare, difficult-to-treat case of irreparable extensive rotator cuff tear with axillary nerve palsy after a shoulder dislocation. ASCR, although not indicated for patients with deltoid muscle dysfunction, provided a favorable post-operative outcome when performed after confirmation of signs of improved palsy." }, { "id": "pubmed23n0302_11924", "title": "[Lesions to the axillary nerve].", "score": 0.018362533692722373, "content": "The authors have reviewed 67 axillary nerve lesions from 1987 to 1993. 35 times the lesion was isolated; 20 times it was associated to other nerve lesions (9 times supra scapular nerve, 3 times musculocutaneous nerve, 8 times posterior cord) and 12 times lesions were associated to rotator cuff injury. Injury corresponded 9 times to stretching mechanism in upper limb traction and came 58 times with osteoarticular lesions (30 anterior dislocations and 28 shoulder fractures). In 11 cases, shoulder active abduction was normal, inspite of deltoïd's complete palsy and this accounted for diagnosis delay. Concerning axillary nerve isolated lesions (35 cases), 7 recovered spontaneously and 28 have been operated. Surgical operation was undertaken 9 months after injury using a combined anterior and posterior approach. Rupture was located in the quadrilateral space and 23 nerve grafts, 4 neurolysis and 1 direct suture were performed. Results were good (muscle measured to M4) and excellent (muscle measured to M5) in 57 per cent of cases. Concerning axillary nerve lesions associated to suprascapular nerve lesions (9 cases) and musculocutaneous nerve (3 cases), all axillary nerve lesions were grafted with 50 per cent of good and very good results. The scapular nerve was neurolysed 6 times with 4 good and excellent results and evaluated irreparable in 3 cases. Musculocutaneous nerve was grafted in all cases with 2 good results out of 3. Posterior cord lesions (8 cases) required an osteotomy of the clavicle. Five grafts and 3 neurolysis were performed with aleatory results. At last, when associated lesions of the rotator cuff muscle were found (12 cases), 6 cases recovered spontaneously and 3 times cuff rupture was small enough to be reinserted with 2 good results. The 6 other cases corresponded to an axillary nerve rupture which were all grafted with 2 good results. On the cuff, result was in relation with lesion's type. Twice a supraspinatus tendon rupture was reinserted with 1 good result and 1 fair result. In 3 older patients, there was a small size rupture which has been reinserted with 1 good result, 1 fair result and 1 failure. At last, one surgical repair of a large rupture couldn't be justified. These encouraging results suggest to propose repair of axillary nerve when deltoid muscle palsy does not recover until 3 to 6 months. Rupture diagnosis is then suspected and the best surgical technique is a nerve graft." }, { "id": "pubmed23n0376_3085", "title": "[Acute anterior instability of the shoulder: short- and mid-term outcome after conservative treatment].", "score": 0.018031189083820662, "content": "We assessed short and mid-term outcome after emergency care for acute anterior instability of the shoulder. Between October 1990 and May 1996, 233 shoulders (206 anteromedial dislocations, 21 dislocations with spontaneous reduction, and 6 painful shoulders with unknown instability) were treated, mainly orthopedically. The series included 165 men and 68 women, mean age 42 years (range 13-95 years). One hundred fifty-eight practiced sports more or less regularly (73% of the 216 patients) and a sports accident was involved in 121 cases (52.8%). Besides the usual lesions secondary to bone displacement, there were 51 fracture-avulsions of the greater tuberosity, 7 major fractures of the anteroinferior border of the glenoid cavity, 2 fractures of the coracoid process, 10 nerve lesions (6 axillary nerve palsies and 4 partial palsies of the brachial plexus) and 10 rotator cuff tears. Orthopedic reduction was performed in the emergency room in all patients with a dislocated shoulder (82%). Immobilization, elbow to body, was prescribed for 8 to 15 days. Sixteen patients (6.8%) underwent surgery during the days following reduction, 8 for displaced fracture of the greater tuberosity, 7 for important fracture of the glenoid cavity and 1 for avulsion of the rotator cuff. Patient files (n=210) or phone interviews (n=185) were used to assess outcome. Mean follow-up was 38 months (12 - 72 months). All nerve lesions regressed within a few weeks without sequelae. We had 6 cases of retractile capsulitis and 4 cases of reflex dystrophy that regressed totally in 3 to 6 months. Recurrent dislocation was observed in 52 cases (24.7% recurrence rate) with 29 occurring within one year (55.8%). Among the 145 other shoulders, 84 recovered completely (58%), 52 were occasionally bothersome (36%), 8 exhibited repeated subdislocation (5.5%) and one remained pseudoparalytic. Among the factors favoring recurrence, we found patient age (higher risk in younger subjects) and lack of rehabilitation (p&lt;0.05). Acute anterior dislocation of the shoulder is frequent, but emergency surgical repair is rarely needed (15 cases in our series, 6.9%). Mid-term recurrence is not as frequent as is often thought, warranting the choice of first intention orthopedic care. Our findings demonstrated that emergency surgery is not indicated in most cases of anterior shoulder instability, even with the arthroscopic approach, especially since the results of this method remain unclear." }, { "id": "pubmed23n0990_5869", "title": "Isolated Radial Nerve Palsy as a Complication After Anterior Dislocation of the Glenohumeral Joint: A Case Report and Clinical Review.", "score": 0.018000642880102863, "content": "Shoulder dislocation is the most common feature in emergencies, while the anterior dislocation of the glenohumeral joint is the most frequent and requires reduction. Accompanied nerve injury is common with an incidence of 21%, while radial nerve palsy is very rare. We describe the case of a 56-year-old man who presented with an anterior dislocation of the left shoulder due to a fall on an outstretched hand with wrist drop 8 hours after injury. Neurological examination revealed loss of sensation along the radial border of the forearm. Closed reduction with Kocher procedure was performed. Magnetic resonance image demonstrated a rotator cuff tear, and 3 weeks after the injury electromyography showed complete radial nerve palsy. A physiotherapy program was applied to the wrist and fingers with the goal of maintaining a full passive range of motion in all joints affected while shoulder rehabilitation started 6 weeks after his fall. Isolated radial nerve palsy associated with an anterior dislocation of the shoulder is very rare but not impossible to occur. Correct diagnosis of the nerve injury associated with the anterior dislocation is very important because it has serious implications on the management and activity morbidity." }, { "id": "wiki20220301en134_9545", "title": "Dislocated shoulder", "score": 0.016420147260050824, "content": "A dislocated shoulder is a condition in which the head of the humerus is detached from the shoulder joint. Symptoms include shoulder pain and instability. Complications may include a Bankart lesion, Hill-Sachs lesion, rotator cuff tear, or injury to the axillary nerve. A shoulder dislocation often occurs as a result of a fall onto an outstretched arm or onto the shoulder. Diagnosis is typically based on symptoms and confirmed by X-rays. They are classified as anterior, posterior, inferior, and superior with most being anterior. Treatment is by shoulder reduction which may be accomplished by a number of techniques. These include traction-countertraction, external rotation, scapular manipulation, and the Stimson technique. After reduction X-rays are recommended for verification. The arm may then be placed in a sling for a few weeks. Surgery may be recommended in those with recurrent dislocations." }, { "id": "pubmed23n0073_10096", "title": "[Incisura scapulae syndrome].", "score": 0.016129032258064516, "content": "The suprascapular nerve may rarely be entrapped in the suprascapular notch. This causes weakness of the supra- and infraspinatus muscles and pain in the glenohumeral and acromioclavicular joints, which are innervated by this nerve. The entrapment syndrome may result from direct or indirect trauma, fracture of the neck of the scapula, kinking or traction on a sling affecting the nerve, from the shape of the notch, compression by a ganglion, or its cause may be idiopathic. Diagnosis of the syndrome is based upon deep unceasing pain reported at the postero-lateral shoulder, atrophy of the supra- and infraspinatus muscles, and impaired shoulder external rotation and a lidocaine test. The final proof is taken from polyphasic EMG potentials which are decreased in amplitude and increased in distal latency. Initially the entrapment neuropathy may be treated by immobilization, analgesics, and physiotherapy. A tear of the rotator cuff as well as a frozen shoulder have to be excluded by arthrography. In persistent cases of pain and pathologic EMG findings surgical decompression of the nerve should be done. The trapezius muscle is approached by a postero-superior incision. Via the suprascapular fossa the notch may be reached. Then the nerve is decompressed by removing the transverse scapular ligament. Reports of the cases operated so far are promising, though their number is small." }, { "id": "pubmed23n1016_21395", "title": "Shoulder Terrible Triad: Classification, Functional Results, and Prognostic Factors.", "score": 0.015556691080451938, "content": "The shoulder terrible triad (STT) is a traumatic anterior shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the functional results and prognostic factors of surgery in patients with STT. Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity fracture. Variables registered on the day of surgery were preoperative Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator. Twenty-seven patients underwent a complete follow-up. The dominant arm was affected in 50% of cases. The mean follow-up was 27 (12 to 43) months. The mean WORC and Constant scores improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), respectively. The ASES and subjective shoulder value scores at the end of the follow-up were 60 and 56 points, respectively. RC tears and nerve injuries that did not involve the axillary or suprascapular nerves were associated to better results than greater tuberosity fractures and injuries to the axillary or suprascapular nerves, respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES scores (P = 0.035). Preoperative WORC and Constant scores were independent prognostic factors. The most frequent patterns include complete RC tears, anterior capsular injuries, and an axillary nerve injury. Patients had improved functional scores at the end of follow-up after surgery. Better functional results were correlated to RC tears, injuries to nerves with innervation distal to the shoulder, and higher preoperative Constant and WORC scores." }, { "id": "wiki20220301en200_11151", "title": "Injury of axillary nerve", "score": 0.015460621912234816, "content": "Injury of axillary nerve (axillary neuropathy) is a condition that can be associated with a surgical neck of the humerus fracture. It can also be associated with a dislocated shoulder or with traction injury to the nerve, which may be caused by over-aggressive stretching or blunt trauma that does not result in fracture or dislocation. One form of this injury is referred to as axillary nerve palsy. Injury most commonly occurs proximal to the quadrangular space. Injury in this nerve causes paralysis (as always) to the muscles innervated by it, most importantly deltoid muscle. This muscle is the main abductor of the shoulder joint from 18 to 90 degrees (from 0 to 18 by supraspinatus). Injury can result in a reduction in shoulder abduction. So a test can be applied to a patient with injury of axillary nerve by trying to abduct the injured shoulder against resistance." }, { "id": "pubmed23n0352_6594", "title": "Neurologic complications of shoulder surgery.", "score": 0.015082337249268968, "content": "Nerve injuries do occur during shoulder surgery. Studies of regional anatomy have defined the nerves at risk. The suprascapular nerve may lie no more than 1 cm from the glenoid rim. The axillary nerve may run no more than 3 mm from the inferior shoulder capsule and passes near the lower extent of the deltoid split used as an approach to the shoulder. The musculocutaneous nerve passes as near as 3.1 cm below the coracoid. Interscalene nerve block is not commonly implicated in nerve injuries. Three-dimensional knowledge of nerve anatomy is essential during arthroscopy for safe portal placement and trochar direction. Nerve injuries are reported to occur in 1% to 2% of patients undergoing rotator cuff surgery, 1% to 8% of patients undergoing surgery for anterior instability, and 1% to 4% of patients undergoing prosthetic arthroplasty. Surgical techniques for the shoulder are improving and nerves seldom are injured by direct laceration or incorporation in suture repair. Commonly, the nerve injuries occur secondary to traction or contusion. These are avoided best by careful attention to patient positioning, retractor placement, and arm manipulation during surgery. Because of the contemporary nature of these nerve injuries, observation is almost always the treatment of choice, with delayed electrodiagnostic testing should nerve recovery not occur within a 3 to 6-week period." }, { "id": "wiki20220301en012_18491", "title": "Axillary nerve", "score": 0.01498526871888652, "content": "Clinical significance The axillary nerve may be injured in anterior-inferior dislocations of the shoulder joint, compression of the axilla with a crutch or fracture of the surgical neck of the humerus. An example of injury to the axillary nerve includes axillary nerve palsy. Injury to the nerve results in: Paralysis of the teres minor muscle and deltoid muscle, resulting in loss of abduction of arm (from 15-90 degrees), weak flexion, extension, and rotation of shoulder. Paralysis of deltoid and teres minor muscles results in flat shoulder deformity. Loss of sensation in the skin over the regimental badge area. Direct trauma to the nerve can also lead to paralysis and loss of sensation. Additional images See also Axillary nerve dysfunction References External links Nerves of the upper limb" }, { "id": "pubmed23n0800_9007", "title": "Concurrent rotator cuff tear and axillary nerve palsy associated with anterior dislocation of the shoulder and large glenoid rim fracture: a \"terrible tetrad\".", "score": 0.014677501269680041, "content": "We present a case of concurrent rotator cuff tear and axillary nerve palsy resulting from anterior dislocation of the shoulder and a large glenoid rim fracture-a \"terrible tetrad.\" A 61-year-old woman fell on her right shoulder. Radiographs showed anterior dislocation of the shoulder with a glenoid rim fracture, and an MRI two months after injury revealed a rotator cuff tear. Upon referral to our hospital, physical and electrophysiological examinations revealed axillary nerve palsy. The axillary nerve palsy was incomplete and recovering, and displacement of the glenoid rim fracture was minimal and already united; therefore, we surgically repaired only the rotator cuff tear three months after injury. The patient recovered satisfactorily following the operation. In patients whose axillary nerve palsy is recovering, surgeons should consider operating on rotator cuff tears in an attempt to prevent rotator cuff degeneration. " }, { "id": "pubmed23n0989_19397", "title": "Axillary artery laceration after anterior shoulder dislocation reduction.", "score": 0.014646464646464647, "content": "Glenohumeral dislocation is the most commonly encountered dislocation in the emergency department. The most frequent complications of glenohumeral dislocation are rotator cuff tears and an increase in the risk of recurrent dislocation. Less common acute complications include fractures, neurological complications and vascular injuries. The incidence of axillary artery injury associated with shoulder dislocation is reported to be about 1-2%. An 81-year-old male presented to the emergency department with pain in the right shoulder after a fall. On physical examination, the shoulder was in slight abduction and external rotation. Shoulder movements were painful and there was a swelling in the axillary region which was tender to palpation. There was no sensory or motor deficit and the peripheral pulses were equal and palpable. Following the administration of analgesics, shoulder reduction was performed using the flexion-adduction-external rotation method. After reduction, the patient started complaining of axillary pain. On control examination, the patient did not have any motor or sensory deficits, but peripheral pulses were not palpable on the right arm. The right upper extremity computed tomography angiography, which was performed with the suspicion of vascular injury, revealed a right axillary artery rupture. Axillary artery injury accompanying anterior shoulder dislocation is a rare but serious condition which may result in limb loss and death." }, { "id": "pubmed23n0675_11384", "title": "[Damage of teres minor branch of axillary nerve].", "score": 0.014578408195429472, "content": "Atrophy demarcating to musculus teres minor is seen in magnetic resonance imaging of the shoulder region in 3 to 5.5% of investigations. We describe seven patients with prolonged or recurrent pain of the shoulder region, who were diagnosed in ENMG with damage of the axillary nerve brand to m. teres minor. Probable causes included tear of the rotator cuff, luxation of the shoulder joint, nerve entrapment in the quadrilateral space, neuritis of the brachial plexus and iatrogenic damage associated with shoulder arthroscopy. This nerve damage cannot be proved clinically." }, { "id": "wiki20220301en070_42985", "title": "Shoulder joint", "score": 0.014565879664889567, "content": "Anterior dislocation of the glenohumeral joint occurs when the humeral head is displaced in the anterior direction. Anterior shoulder dislocation often is a result of a blow to the shoulder while the arm is in an abducted position. In younger people, these dislocation events are most commonly associated with fractures on the humerus and/or glenoid and can lead to recurrent instability. In older people, recurrent instability is rare but people often suffer rotator cuff tears. It is not uncommon for the arteries and nerves (axillary nerve) in the axillary region to be damaged as a result of a shoulder dislocation; which if left untreated can result in weakness, muscle atrophy, or paralysis. Subacromial bursitis is a painful condition caused by inflammation which often presents a set of symptoms known as subacromial impingement. Additional images See also Shoulder girdle Sternoclavicular joint References External links" }, { "id": "pubmed23n0889_10913", "title": "Treatment of Combined Injuries of the Axillary and Suprascapular Nerves with Scapulothoracic Dissociation.", "score": 0.014197151105011595, "content": "A 20-year-old man suffered the combined axillary and suprascapular nerve palsies associated with scapulothoracic dissociation by motorcycle accident. The dislocated shoulder girdle was reduced and stabilized with osteosynthesis of the fractured clavicle and reattachment of the trapezius avulsed from the scapular spine for removal of continuous traction force to these damaged nerves. Because of no evidence of recovery on manual muscle test and electromyogram, exploration for these nerves was administered 6 weeks after injury. Although neurolysis of both nerves revealed neural continuity, excessive tension still existed on the suprascapular nerve. It was thought that previous operation in which the shoulder girdle had been reduced and stabilized as much as possible could not achieve complete anatomical reduction of the scapula. As an additional treatment, medial walls of the suprascapular and spinoglenoid notches were shaven to relax the suprascapular nerve. After a year, complete recovery of both the axillary and suprascapular nerve was identified. Although scapulothoracic dissociation is commonly recognized as massive injury of the shoulder girdle with poor prognosis because of existence of accompanied severe neurovascular injuries, there are more than a few cases in which partial damage on the infraclavicular brachial plexus is only accompanied. In case of them, there is the possibility of lesions in continuity of the nerves in which good prognosis might be expected with surgical intervention including early reduction of the shoulder girdle for removal of excessive tension to the damaged nerve." }, { "id": "pubmed23n0320_13989", "title": "Shoulder impingement syndromes.", "score": 0.014142928535732135, "content": "Not all shoulder pain conditions are a consequence of rotator cuff injuries secondary to anterior subacromial impingement. Additional causative forms have been identified and classified as posterosuperior glenoid rim, subcoracoid and suprascapular nerve (at spinoglenoid notch) impingement syndromes. We reviewed 206 consecutive magnetic resonance examinations carried out with conventional T1- and T2-weighted spin-echo and gradient-echo sequences in patients complaining of shoulder pain. Adjunctive sequences were acquired with the involved arm positioned in abduction and external rotation. Anterior subacromial impingement is only one of the possible causes of shoulder disorders. Posterosuperior glenoid rim impingement is the most frequent cause of shoulder pain in young throwers. Subcoracoid and spinoglenoid notch suprascapular nerve impingement are additional forms that must be considered in the differential diagnosis because of their frequent occurrence in routine clinical practice. Magnetic resonance imaging is the most useful diagnostic modality for shoulder disorders." }, { "id": "pubmed23n0738_4615", "title": "Trapezius tendon transfer according to Saha after neglected complete axillary nerve injury.", "score": 0.01352508132169149, "content": "Traumatic axillary nerve injury represents less than 1% of all nerve injuries.It is often subclinical because it is masked by the pain due to a shoulder fracture or dislocation, so that treatment is neglected for a long period. When nerve repair and physiotherapy are unsuccessful, trapezius tendon transfer may be considered. Between March 2008 and May 2009, 10 patients with neglected deltoid paralysis were treated by trapezius tendon transfer at Mansoura University hospital and in a private hospital. All patients were males. Their mean age was 27.8 years (range: 17-35). The mean follow-up period was 30 months (range: 24 to 36 months). The operations were performed according to the method described by Saha in 1967, involving transfer of the lateral extremity of the clavicle, the acromioclavicular joint and the acromion, with the insertion of the trapezius, to the proximal humerus. The authors retrospectively assessed the results according to the 5 items (a-e) of the Rowe and Zarins score: all 10 patients had (a) improved shoulder function with (e) a more stable shoulder. The mean active abduction (b) was 76 degrees (range: 50-100 degrees) and the mean active flexion (c) 78 degrees (range: 45-110 degrees). However, most authors report lower values: from 34 to 76 degrees of abduction, and from 30 to 78 degrees of flexion. Arthrodesis results in 59 to 71.43 degrees of abduction. The abduction power (d) was improved: it reached grade 3 in 7 cases and grade 4 in 3 cases. In this study, trapezius tendon transfer provided satisfactory functional improvement for paralysis of shoulder abduction after neglected complete axillary nerve injury, with improvement in shoulder stability, power and range of motion." }, { "id": "pubmed23n0771_10451", "title": "Neuropathy of the suprascapular nerve and massive rotator cuff tears: a prospective electromyographic study.", "score": 0.013056189675197245, "content": "An association between massive rotator cuff tear (RCT) and suprascapular nerve neuropathy has previously been suggested. The anatomic course of the suprascapular nerve is relatively fixed along its passage. Thus, injury to the nerve by trauma, compression, and iatrogenic reasons is well documented. However, the association between retraction of the RCT and development of neuropathy of the suprascapular nerve remains unclear. We aimed to prospectively evaluate the suprascapular nerve for preoperative neurodiagnostic abnormalities in shoulders with massive RCT. A prospective study was performed in 2 centers. Fifty patients with retracted tears of both supraspinatus and infraspinatus were evaluated. This was confirmed with preoperative computed tomography arthrography, and the fatty infiltration of the affected muscles was graded. Forty-nine preoperative electromyograms were performed in a standardized fashion and the results analyzed twice. Of 49 shoulders, 6 (12%) had neurologic lesions noted on electromyography: 1 suprascapular nerve neuropathy, 1 radicular lesion of the C5 root, 1 affected electromyogram in the context of a previous stroke, and 3 cases of partial axillary nerve palsy with a history of shoulder dislocation. No difference or diminution of the latency or amplitude of the electromyographic curve was found in the cases that presented significant fatty infiltration. This study did not detect a suprascapular lesion in the majority of cases of massive RCT. With a low association of neuropathy with massive RCT, we find no evidence to support the routine practice of suprascapular nerve release when RCT repair is performed." }, { "id": "pubmed23n0565_14011", "title": "Insidious onset of shoulder girdle weakness.", "score": 0.012861604207758053, "content": "Resident's case problem. An 18-year-old man presented to physical therapy 3 days after insidious onset of painless left shoulder girdle weakness. Decreased light touch sensation was noted on the lateral left shoulder. In addition, weakness was present with shoulder abduction, flexion, external rotation, and internal rotation. Results of magnetic resonance imaging and radiography of the cervical spine, brachial plexus, and left shoulder were normal, Electromyography and nerve conduction velocity study findings were consistent with axillary nerve palsy. The results of the physical examination and diagnostic studies were most consistent with axillary nerve mononeuropathy, probably caused by traction or pressure due to wearing a pack while hiking or firing a weapon. With sling protection, limitation of physical activity, and gradual return to progressive resistance exercises, the patient had full return of strength and function 2 1/2 months after onset of symptoms. The differential diagnosis for shoulder girdle weakness should be well understood by physical therapists. This knowledge will help the therapist promptly identify the cause of shoulder girdle weakness and initiate appropriate treatment. If the condition requires further evaluation or treatment by another healthcare provider, prompt identification of pathology will allow appropriate timely referral." }, { "id": "wiki20220301en323_9234", "title": "Axillary nerve palsy", "score": 0.012768449824287388, "content": "An injury to the axillary nerve normally occurs from a direct impact of some sort to the outer arm, though it can result from injuring a shoulder via dislocation or compression of the nerve. The axillary nerve comes from the posterior cord of the brachial plexus at the coracoid process and provides the motor function to the deltoid and teres minor muscles. An EMG can be useful in determining if there is an injury to the axillary nerve. The largest numbers of axillary nerve palsies arise due to stretch injuries which are caused by blunt trauma or iatrogenesis. Axillary nerve palsy is characterized by the lack of shoulder abduction greater than 30 degrees with or without the loss of sense in the low two thirds of the shoulder. Normally the patients that have axillary nerve palsy are involved in blunt trauma and have a number of shoulder injuries. Surgery is not always required to solve the problem (information from: Midha, Rajiv, Zager, Eric. Surgery of Peripheral Nerves: A Case-Based" }, { "id": "pubmed23n0069_5441", "title": "[Surgical repair of the axillary nerve. Apropos of 37 cases].", "score": 0.012690763052208835, "content": "The authors have reviewed the results of the operative repair of 37 injuries of the axillary nerve. In 25 patients only the axillary nerve was injured, in 8 the suprascapular nerve was also damaged and in a further 4 the musculocutaneous nerve had also sustained injury. There was an associated anterior dislocation of the shoulder in 10 patients and a fracture was present in 8. Eleven patients out of 25 had a nearly normal range of abduction in spite of paralysis of the deltoid muscle, and this accounted for delay in diagnosis. Operation was undertaken 8 months after injury using a combined anterior and posterior approach. In 34 patients disruption of the nerve had occurred in relation to the quadrilateral space. In 32 cases nerve grafts were employed, in 2 direct suture and 1 underwent neurolysis. The results were good or very good in 23 out of the 25 direct repairs of isolated axillary lesions, and in all 4 patients with associated injury to the musculocutaneous nerve. Only 4 good results were obtained in the 8 patients who also had injuries to the suprascapular nerve. The results suggest that repair should be carried out early at between 3 and 6 months. E.M.G. studies are necessary before operation for proper assessment of nerve recovery." }, { "id": "wiki20220301en014_15404", "title": "Shoulder", "score": 0.01259254763927661, "content": "Fracture Fractures of shoulder bones can include clavicular fractures, scapular fractures, and fractures of the upper humerus. Pain Shoulder problems, including pain, are common and can relate to any of the structures within the shoulder. The primary cause of shoulder pain is a rotator cuff tear. The supraspinatus is most commonly involved in a rotator cuff tear. When this type of cartilage starts to wear out (a process called arthritis), the joint becomes painful and stiff. Arthritis Frozen shoulder Impingement syndrome Shoulder dislocation Nerve entrapment syndrome Imaging Imaging of the shoulder includes ultrasound, X-ray and MRI, and is guided by the suspected diagnosis and presenting symptoms. Conventional x-rays and ultrasonography are the primary tools used to confirm a diagnosis of injuries sustained to the rotator cuff. For extended clinical questions, imaging through Magnetic Resonance with or without intraarticular contrast agent is indicated." }, { "id": "wiki20220301en323_9230", "title": "Axillary nerve palsy", "score": 0.012291845493562232, "content": "Axillary nerve palsy is a neurological condition in which the axillary (also called circumflex) nerve has been damaged by shoulder dislocation. It can cause weak deltoid and sensory loss below the shoulder. Since this is a problem with just one nerve, it is a type of Peripheral neuropathy called mononeuropathy. Of all brachial plexus injuries, axillary nerve palsy represents only .3% to 6% of them. Signs and symptoms Axillary nerve palsy patients present themselves with differing symptoms. For instance, some axillary nerve palsy patients complain that they cannot bend their arm at the elbow, however no other pain or discomfort exists. To further complicate diagnosis, onset of palsy can be delayed and may not be noticed until 12-24 hours after the trauma of shoulder region occurred. Therefore it is important to recognize the symptoms, but also to realize that different people have various combinations of them." }, { "id": "pubmed23n0747_24947", "title": "Shoulder abduction and external rotation restoration with nerve transfer.", "score": 0.012130187947388835, "content": "In upper brachial plexus palsy patients, loss of shoulder function and elbow flexion is obvious as the result of paralysed muscles innervated by the suprascapular, axillary and musculocutaneus nerve. Shoulder stabilisation, restoration of abduction and external rotation are important as more distal functions will be affected by the shoulder situation. Between 2005 and 2011, eleven patients with upper type brachial plexus palsy were operated on with triceps nerve branch transfer to anterior axillary nerve branch and spinal accessory nerve transfer to the suprascapular nerve for shoulder abduction and external rotation restoration. Nine patients met the inclusion criteria for the study. All patients were men with ages ranged from 21 to 35 years (average, 27.4 years). The interval between injury and surgery ranged from 4 to 11 months (average, 7.2 months). Atrophy of the supraspinatus, infraspinatus and deltoid muscle and subluxation at the glenohumeral joint was obvious in all patients preoperatively. During the pre-op examination all patients had at least muscle grading 4 on the triceps muscle. The mean post-operative value of shoulder abduction was 112.2° (range: 60-170°) while preoperatively none of the patients was able for abduction (p&lt;0.001). The mean post-operative value of shoulder external rotation was 66° (range: 35-110°) while preoperatively none of them was able for external rotation (p&lt;0.001). Postoperative values of shoulder abduction were significantly better that those of external rotation (p=0.0004). The postoperative average muscle grading for shoulder abduction according the MRC scale was 3.6±0.5 and for the shoulder external rotation was 3.2±0.4. Combined nerve transfer by using the spinal accessory nerve for suprascapular nerve neurotisation and one of the triceps nerve branches for axillary nerve and teres minor branch neurotisation is an excellent choice for shoulder abduction and external rotation restoration." }, { "id": "pubmed23n0299_9923", "title": "[Arthrodesis of the shoulder for post-traumatic palsy of the brachial plexus. Analysis of a series of 18 cases].", "score": 0.011939025690224923, "content": "In case of severe traction injuries of the supraclavicular brachial plexus in adult, the functional results of direct shoulder nerve repair are less predictable than those of the elbow. Furthermore, the surgical management of the remaining flail shoulder is still controversial. The post-operative results and the indication for shoulder arthrodesis are evaluated in this study. Between October 1978 and January 1994, 18 gleno-humeral arthrodesis were performed on 18 patients for paralytic shoulder following brachial plexus injury. The average age at the time of operation was 25 years. A C5C6 lesion was present in 2 patients, a C5C6C7 lesion in 8 patients and a C5 to T1 lesion in the remaining 8 patients. Seven patients had a suprascapular nerve reinnervation failure. All these 18 patients recovered an active elbow flexion spontaneously or following direct nerve repair, tendon or free muscle transfer. The average delay between nerve repair and arthrodesis was 2 years and 4 months. For fixation, we always used internal fixation by screws, combined to an external fixator device in 10 cases. 16 patients were reviewed with an average follow-up of 6 years and 10 months (min. 6 months, max. 15 years and 8 months). Two types of complications occurred: 2 cases of gleno-humeral non-union requiring revision with bone-grafting, and 3 humeral fractures in the first 6 months after arthrodesis. The study of the arthrodesis position showed an average abduction of 25 degrees, an average flexion of 18 degrees, an average internal rotation of 22 degrees. The average motion values are 60 degrees of abduction and flexion, 14 degrees of extension, 0 degree of external rotation and 48 degrees of internal rotation. The range of motion depends closely on scapulo-thoracic muscles strength, especially the serratus anterior muscle. A flail hand primarily influences the subjective result. 14 of the 16 patients could easily reach their mouth. The average muscle shoulder strength, evaluated with the Isobex device, is 11 kg for flexion and abduction, 9 kg for adduction, 8 kg for internal rotation and 4 kg for external rotation. Gleno-humeral arthrodesis is a reliable method for restoring shoulder function in case of brachial plexus sequellae lesion, giving more strength, but less external rotation than shoulder nerve repair." }, { "id": "wiki20220301en139_54330", "title": "Shoulder surgery", "score": 0.011600378787878788, "content": "Arthritis or osteolysis of the acromioclavicular joint Arthritis or osteolysis of the acromioclavicular joint can be treated with the Mumford procedure (open or arthroscopic). Scapular Winging Scapular winging due to serratus anterior muscle (long thoracic nerve) palsy can be treated with a pectoralis major transfer. Scapular winging due to trapezius muscle (spinal accessory nerve) palsy can be treated with an Eden-Lange procedure. Scapular winging due to facioscapulohumeral muscular dystrophy can be treated with a scapulopexy or scapulothoracic fusion. See also Shoulder problems Separated shoulder Clavicle fracture Arthroscopy Arthritis Articular capsule of the humerus (shoulder joint) Glenoid cavity Glenoid labrum Snapping scapula syndrome References 2. http://www.rothmaninstitute.com/specialties/treatments/biceps-tenodesis 3. http://www.drgartsman.com/biceps-tenodesis/ External links American Academy of Orthopaedic Surgeons - Shoulder Surgery" }, { "id": "wiki20220301en323_9232", "title": "Axillary nerve palsy", "score": 0.010922619047619047, "content": "Usually, an outside force is acting to suppress the nerve, or cause nerve damage. Most commonly, shoulder dislocation or fractions in the shoulder can cause the palsy. Contact sports such as football and hockey can cause the injury Other cases have been caused by repeated crutch pressure or injuries accidentally caused by health professionals (iatrogenesis). Furthermore, following an anterior shoulder operation; damage to the axillary nerve is possible and has been documented by various surgeons, thus causing axillary nerve palsy. Other possible causes include: deep infection, pressure from a cast or splint, fracture of the humerus, or nerve disorders in which the nerves become inflamed." }, { "id": "article-18059_8", "title": "Axillary Nerve Injury -- History and Physical", "score": 0.010817307692307692, "content": "The principle presenting symptoms are a weakness in glenohumeral abduction with or without numbness to the lateral shoulder area. Patients may also present with weakness in glenohumeral external rotation; however, this may not be apparent due to the ability of the infraspinatus. In patients presenting after dislocation or fracture, signs of trauma will be evident on physical exam. During external rotation and abduction, one may note the weakness of the deltoid and teres minor muscles." }, { "id": "wiki20220301en012_18490", "title": "Axillary nerve", "score": 0.010622953375955091, "content": "Variation Traditionally, the axillary nerve is thought to only supply the deltoid and teres minor. However, several studies on cadavers pointed out that the long head of triceps brachii is innervated by a branch of the axillary nerve. Function The axillary nerve supplies three muscles in the arm: deltoid (a muscle of the shoulder), triceps (long head) and teres minor (one of the rotator cuff muscles). The axillary nerve also carries sensory information from the shoulder joint. It also innervates the skin covering the inferior region of the deltoid muscle, known as the regimental badge area. This is innervated by the superior lateral cutaneous nerve branch of the axillary nerve. The posterior cord of the brachial plexus splits inferiorly to the glenohumeral joint giving rise to the axillary nerve which wraps around the surgical neck of the humerus, and the radial nerve which wraps around the humerus anteriorly and descends along its lateral border." }, { "id": "wiki20220301en134_9550", "title": "Dislocated shoulder", "score": 0.010399843390593647, "content": "Damage to the axillary artery and axillary nerve (C5, C6) may result. The axillary nerve is injured in 37% making it the most commonly injured structure with this type of injury. Other common, associated, nerve injuries include injury to the suprascapular nerve (29%) and the radial nerve (22%). Axillary nerve damage results in a weakened or paralyzed deltoid muscle and as the deltoid atrophies unilaterally, the normal rounded contour of the shoulder is lost. A person with injury to the axillary nerve will have difficulty in abducting the arm from approximately 15° away from the body. The supraspinatus muscle initiates abduction from a fully adducted position. Posterior (backward)" }, { "id": "pubmed23n0668_7215", "title": "[Posterior approach to the shoulder].", "score": 0.010322717960997152, "content": "Safe approach to the posterior shoulder and scapula. Posterior shoulder stabilization. Posterior bony reconstruction of the glenoid. Corrective osteotomies of the glenoid. Treatment of scapular neck fractures. Treatment of posterior glenoid rim fractures. Treatment of fractures of the acromion. Arthrodesis of the shoulder. Biopsy. Tumor resection. Relative: shoulder joint replacement with simultaneous posterior glenoid reconstruction. Relative: treatment of posterior dislocated proximal humerus fractures. General contraindications. Landmarks: scapular spine and acromion. Incision depending on goal of surgery: from horizontal to oblique or vertical: - horizontal incision along the scapular spine to the posterior corner of acromion, - oblique incision along the lateral border of scapula. Authors' preference: angle bisector between scapular spine and lateral border of scapula. Detachment of the deltoid with a bony chip from scapular spine beginning laterally (subacromial space). Under the deltoid the infraspinatus is exposed. Approach to glenoid: the internervous plane is between the infraspinatus (suprascapular nerve) and teres minor (axillary nerve). Approach to scapular neck (attention: identify axillary nerve!): more dangerous internervous plane between teres minor (axillary nerve) and teres major (subscapular nerve). If needed, detachment of infraspinatus from tendinous insertion for better visualization of posterior capsule and glenoid. According to the operated pathology. Results are according to the operated pathology. As an example, results from the authors' clinic are presented. Between 1982 to 1995, 24 patients (26 shoulders) with posterior instability underwent open posteroinferior capsular shift. Mean follow-up was 7.6 years. The average relative Constant-Murley Score amounted to 91%. Subjective result was good to excellent for 24 and fair for two shoulders. Recurrence occurred in 23% (all cases with surgery before index procedure or new trauma). No approach-related complications (weakness or insufficiency) were noted." }, { "id": "Neurology_Adams_1684", "title": "Neurology_Adams", "score": 0.010217507503803298, "content": "Pain localized to the shoulder region, worsened by motion, and associated with tenderness and limitation of movement, especially internal and external rotation and abduction, points to a tendonitis, subacromial bursitis, or tear of the rotator cuff, which is made up of the tendons of the muscles surrounding the shoulder joint. The term bursitis is often used loosely to designate these disorders. Shoulder pain, like spine and plexus pain, may radiate vaguely into the arm and rarely into the hand, but sensorimotor and reflex changes—which always indicate disease of nerve roots, plexus, or nerves—are absent. Shoulder pain of this type is very common in middle and late adult life. It may arise spontaneously or after unusual or vigorous use of the arm. Local tenderness over the greater tuberosity of the humerus is characteristic. Plain radiographs of the shoulder may be normal or show a calcium deposit in the supraspinatus tendon or subacromial bursa. MRI is able to demonstrate more subtle" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 301, 354 ] ], "word_ranges": [ [ 51, 61 ] ], "text": "the dentist \"didn't see anything\", so he rules out 1." }, "2": { "exist": true, "char_ranges": [ [ 355, 473 ] ], "word_ranges": [ [ 61, 85 ] ], "text": "It is not an abscess of the base of the tongue either, because in three months it would have killed him: neither is 2." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 559, 665 ] ], "word_ranges": [ [ 97, 119 ] ], "text": "When there is doubt that it could be cancer, we should not fool around and order a new CT scan and biopsy." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Dental cause / reevaluation by the dentist.", "2": "Abscess of the base of the tongue / debridement.", "3": "Ankyloglossia / surgical release of the same.", "4": "Malignant process of oropharynx / repeat CT scan and biopsy.", "5": "Nonspecific inflammation / corticosteroid treatment." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0518_10309", "title": "[Delayed diagnosis of carcinoma of the oral cavity].", "score": 0.013121693121693121, "content": "Approximately 4% of cancers are located in the mouth and pharynx, 95% of which are squamous cell carcinoma (SCC). The case fatality rate of SCC is very high 50%, but early diagnosis significantly lowers the fatality rate. Diagnosis and treatment of oral lesions are shared by numerous specialists including dermatologists, otolaryngeologists, family physicians, general dentists and specialists in oral medicine and in oral surgery. The article describes a patient who was referred to a dermatologist because of a lesion of two months duration on the lateral aspects of the tongue. The dermatologist clinically diagnosed an apthous ulcer and treated it as such. When he returned after two and a half months after no clinical improvement he was diagnosed as suffering from candidiasis and treated accordingly. The unsatisfied patient turned to another dermatologist who referred him to a specialist in oral surgery. He immediately performed a biopsy. SSC was diagnosed, one third of the tongue was resected as well as the submandibular lymph nodes and salivary gland. An Israeli study has demonstrated that dentists performed better than physicians from general medical specialist fields in diagnosing early stage oral cancer. The authors suggest that patients suffering from oral lesions should be referred to specialists in oral medicine or in oral surgery for the diagnosis of oral lesions in order to diagnose oral cancer earlier." }, { "id": "article-36936_12", "title": "Glossitis -- History and Physical -- Physical Exam", "score": 0.012358882947118241, "content": "The examination of the tongue is an essential part of the physical examination and is a component of the overall oral cavity examination. The examiner should note the appearance of the tongue surface (dorsal and ventral), as well as the character of the mucosa (wet, dry, erythematous, leukoplakia, etc.). Any lesions visible on the tongue should be noted, as well as the overall dental health. Chronic friction from jagged teeth can lead to mucosal changes and even ulcerations of the tongue that the examiner must distinguish from primary tongue pathology. The language and floor of mouth should be palpated to assess for tenderness or palpable lesions. A thorough head and neck exam are also necessary to note any lymphadenopathy. Atrophic glossitis [14] : Erythematous tongue Lack of the lingual papillae and a smooth, shiny, dry appearance Atrophic tongue Median rhomboid glossitis:" }, { "id": "article-97302_14", "title": "Tongue Cancer -- History and Physical", "score": 0.012250830564784054, "content": "The examination should include a complete physical exam with an emphasis on the head and neck region. The neck should be thoroughly examined for palpable lymphadenopathy, especially the submental, submandibular, and jugulodigastric regions. An invasive examination of the patient’s oral cavity should be performed. This includes a detailed description of the lesion or mass in question, including but not limited to location, general appearance, color, shape, margins, and the presence or absence of ulceration. Thorough palpation should also be performed with the intention of assessing the regions of the tongue that are involved or spared by the tumor. Palpation of the base of the tongue/vallecula region is also encouraged, as it may reveal asymmetrically indurated or protruding areas. Several specific clinical signs and symptoms may offer insight into the extent of tumor extension." }, { "id": "article-25574_29", "title": "Nasopharyngeal Cancer -- History and Physical", "score": 0.011448948948948948, "content": "An oral cavity and oropharyngeal examination should focus on mucosal lesions, dental health, and palpation of the tongue, base of the tongue, and floor of the mouth. Flexible laryngoscopy is necessary to examine the tongue base, oropharynx, and hypopharynx thoroughly. Any masses or lymphadenopathy, thyroid nodules, and stridor or hoarseness should be carefully noted during the neck examination. A cranial nerve examination is mandatory, particularly in identifying deficits or asymmetries." }, { "id": "InternalMed_Harrison_6651", "title": "InternalMed_Harrison", "score": 0.011370571419394213, "content": "Carcinomas of the oral cavity present as nonhealing ulcers, changes in the fit of dentures, or painful lesions. Tumors of the tongue base or oropharynx can cause decreased tongue mobility and alterations in speech. Cancers of the oropharynx or hypopharynx rarely cause early symptoms, but they may cause sore throat and/or otalgia. HPV-related tumors frequently present with neck lymphadenopathy as the first sign. Hoarseness may be an early symptom of laryngeal cancer, and persistent hoarseness requires referral to a specialist for indirect laryngoscopy and/or radiographic studies. If a head and neck lesion treated initially with antibiotics does not resolve in a short period, further workup is indicated; to simply continue the antibiotic treatment may be to lose the chance of early diagnosis of a malignancy." }, { "id": "pubmed23n0678_7955", "title": "A case study associated with oropharyngeal cancer.", "score": 0.009900990099009901, "content": "Squamous cell carcinoma (SCC) is the most common oral malignancy, commonly located on the anterior floor of the mouth, lateral borders of the tongue, tonsillar pillars and lateral soft palate. A 59 year old male presented to a Midwestern university dental hygiene clinic following referral for pre-radiation and chemotherapy oral prophylaxis and comprehensive examination. He reported he found a firm lump in his neck and brought it to the attention of his general physician. Biopsy confirmed the diagnosis of SCC of the left tonsil. Surgery, radiation and chemotherapy were performed. This case study demonstrates the need to include careful palpation of lymph nodes in every intra- and extra-oral examination. Dental hygienists should document significant findings and notify the dentist of abnormalities and the need for subsequent referral, providing early detection results in improved prognosis for those who encounter experiences with oral, head and neck cancer." }, { "id": "pubmed23n0719_987", "title": "Base of tongue tuberculosis: a case report.", "score": 0.009900990099009901, "content": "We report a rare case of base of tongue tuberculosis following pulmonary tuberculosis. Patient presented to us with chief complaints of sore throat and pain on swallowing for period of 3 months. On examination with 70 degree telescope, we observed an ulcer on right side of base of tongue. The edges of the ulcer appeared to be undermined with whitish slough at the centre of the ulcer. Examination of neck showed a multiple small palpable middle deep cervical lymph nodes on right side of neck. Biopsy of the ulcer was taken, which showed granulomatous inflammation, suggestive of tuberculosis. Laboratory investigations revealed a raise in erythrocyte sedimentation rate, sputum for acid fast bacilli was strongly positive. Chest X ray was performed for patient showed multiple areas of consolidation. Patient was referred to chest clinic for further management of tuberculosis and was started on anti-tuberculous drugs. In conclusion tuberculosis of oral cavity is rare, but should be considered among one of the differential diagnosis of the oral lesions and biopsy is necessary to confirm the diagnosis." }, { "id": "pubmed23n1006_2558", "title": "Tongue ischemia - an unusual presentation of Giant Cell Arteritis.", "score": 0.00980392156862745, "content": "Unusual presentations of Giant Cell Arteritis (GCA) can sometimes delay the diagnosis and its prompt treatment. An 83-year-old male patient was admitted in the emergency department with a few hours evolution of tongue swelling, dysphagia and dysarthria. He also complained of a bitemporal headache with about 4 months of evolution and resistant to all treatment prescribed, including ergotamine, that he had started one week before. Upon examination, the patient presented a bilateral temporal pain and reduced mobility of the tongue which evolved to complete cyanosis. The blood tests revealed normocytic normochromic anaemia, an erythrocyte sedimentation rate of 62 mm/h, and C-reactive protein of 23,6 mg/dl. Cranial CT scan was normal and the cervical CT angiogram showed reduced vascularization of the left submandibular gland and of the base of the tongue. The cervical doppler ultrasound was compatible with arterial inflammation. Given the high suspicion of GCA, the patient was immediately put on a high dose of corticosteroid, resulting in a big improvement of the symptoms, which continued in the following weeks. In conclusion, the clinical suspicion of GCA is fundamental for an early diagnosis. The authors consider that ergotamine might have triggered tongue ischemia in this case." }, { "id": "pubmed23n0242_3456", "title": "[Evolution of the N0 patients with primary carcinoma of the oral tongue treated by interstitial radiumtherapy (author's transl)].", "score": 0.00980392156862745, "content": "In a retrospective and not randomized clinical study we have selected 175 cases of squamous carcinoma of the anterior 2/3 of the tongue treated by interstitial radium therapy on the primary from January 1959 to December 1970. At the end of the treatment 64 patients (36.6%) were operated by radical neck dissection in homolateral lymphatic areas and 111 underwent no operation on the neck. The incidence of false negative is 25% (16/64 cases operated) and 3 patients showed lymph nodal and perilymph nodal metastasis (4.7% of the whole number of operated cases). In the following evolution the homolateral lymph nodal relapse are 2 among the 64 operated patients (3.1%) (both were N+) and 36 among the 101 non operated ones of whom a sufficient follow-up is available (greater than or equal to 3 years) (35.6%); in this last group 9 patients initially were T1, 24 were T2, 3 were T3. The data about the clinical evolution and the analysis of survival curves, in the two groups that underwent or not the neck dissection, permit to draw useful parameters for therapeutic planning." }, { "id": "pubmed23n0990_10251", "title": "Human papillomavirus-related small cell carcinoma of the oropharynx: a case report and literature review.", "score": 0.009708737864077669, "content": "Small cell carcinoma (SCC) is a rare variant of head and neck cancer characterized by a high-grade neuroendocrine cancer with similar features to small cell lung carcinoma (SCLC). Human papillomavirus (HPV) is an increasingly recognized cause of head and neck cancer but usually associated squamous cell carcinoma of the oropharynx. In this report, we present the clinical presentation, diagnosis, and management of a patient with HPV-related SCC of the oropharynx that responded favorably to chemotherapy with cisplatin plus etoposide and concomitant radiation therapy, a regimen typically used in SCLC. We present a rare case of a 56-year-old man who presented with a three-month history of an enlarging left-sided neck mass. Imaging was consistent with a soft tissue density at the left tongue base, left level IIB nodal conglomerate, and multiple bilateral cervical lymph nodes, without evidence of distant metastasis. The patient underwent a core biopsy of the left neck level II node which read as a poorly differentiated neuroendocrine carcinoma consistent with small cell carcinoma. Polymerase chain reaction revealed that the tumor was positive for HPV16. The tumor was staged T1N2cM0 (stage IVA). He went on to receive four cycles of cisplatin and etoposide. On cycle two, he started radiotherapy to the oropharynx and involved neck nodes. He received a dose of 70 Gray (2 Gy/fraction) over a seven week-period. During the concomitant phase of chemo-radiation, the patient experienced grade IV mucositis, grade II nausea, and dehydration for which he received additional outpatient fluid and electrolyte replacement. Three months after completion of therapy, a PET/CT showed complete resolution of the tumor and metastatic lymph nodes along with no evidence of distant metastasis. Patients with HPV-related cancer of the oropharynx require identification of the small cell variant to optimize therapy and improve outcomes." }, { "id": "wiki20220301en466_23961", "title": "Off-the-Neck Historic District", "score": 0.009708737864077669, "content": "Description and history" }, { "id": "pubmed23n0571_10409", "title": "Surgical management of accidentally displaced mandibular third molar into the pterygomandibular space: a case report.", "score": 0.009615384615384616, "content": "Surgical removal of the mandibular third molar is a regular surgical procedure in dental clinics, and like all operations, it may have some complications, such as infection, bleeding, nerve injuries, trismus and so on. An accidentally displaced lower third molar is a relatively rare complication, but may cause severe tissue injury and medicolegal problems. As few papers and cases have been published on this topic, we report this case to remind dentists on ways to prevent and manage this complication. The patient, a 28-year-old male, had his right lower mandibular third molar extraction in January 2006. The dentist resected the crown and attempted to remove the root but found that it had suddenly disappeared from the socket. Assuming that the root had been suctioned out he closed the wound. The patient was not followed up regularly because he studied abroad. About 3 months later, the patient felt a foreign body sensation over his right throat, and visited a local hospital in Australia. He was told after a computed tomography (CT) scan that there was a root-like radio-opaque image in the pterygomandibular space. The patient came to our hospital for further examination and management in June 2006. We rechecked with both Panorex and CT and confirmed the location of the displaced root. Surgery for retrieving the displaced root was performed under general anesthesia by conventional method without difficulty, and the wound healed uneventfully except for a temporary numbness of the right tongue. This case reminds us that the best way to prevent a displaced mandibular third molar is to evaluate the condition of the tooth carefully preoperatively, select adequate instruments and technique, and take good care during extraction. If an accident does occur, dentists should decide whether to retrieve it immediately by themselves or refer the case to an oral and maxillofacial surgeon, and should not try to remove the displaced root without proper assurance. Localization with images and proper surgical methods are the keys to retrieving the displaced fragment successfully. When immediate retrieval is decided on, Panorex and occlusal view are useful in localizing the displaced fragment. When the fragment moves into a deeper space or the retrieval has been delayed for months, three-dimensional CT seems to be a better choice." }, { "id": "pubmed23n0638_18102", "title": "[Tuberculosis of the tongue initially suspected of tongue cancer: a case report--including the search for recent 16 cases in Japan].", "score": 0.009615384615384616, "content": "A 56-year-old man, having no particular past history, was admitted to our hospital, with a 9-month history of painful ulcerated lesion of the tongue and a 6-month history of productive cough. A physical examination revealed swelling of his cervical lymph nodes, and a chest roentgenogram on admission showed cavities in the both upper lung fields and nodular shadows over the both lung fields. He was initially suspected of having both cancer of the tongue and pulmonary tuberculosis, but finally diagnosed as secondary tuberculosis of the tongue due to sputum smear-positive pulmonary tuberculosis by biopsy of the tongue and sputum examination. He was treated with isoniazid, rifampicin, ethambutol and pyrazinamide, and his pain and ulcerated lesion of the tongue rapidly improved. Due to our search for recent 16 cases of tuberculosis of the tongue in Japan, we found that the patients of tuberculosis of the tongue were more likely to have concurrently sputum smear-positive pulmonary tuberculosis. In some cases, the delay in diagnosis was seen. These cases suggest that refractory ulcerated cases of the tongue should be subjected to the biopsy and examination for acid fast bacilli of the tongue with suspicion of tuberculosis of the tongue, and then a chest roentgenogram with suspicion of pulmonary tuberculosis." }, { "id": "pubmed23n0798_17142", "title": "Isolated unilateral idiopathic transient hypoglossal nerve palsy.", "score": 0.009523809523809525, "content": "A 52-year-old Caucasian man presented with sudden onset of difficulty in moving his tongue to the left with preceding left-sided headache with no neck pain. Earlier, he had self-limiting chest infection without rashes or tonsillar enlargement. His medical and surgical history was unremarkable with no recent trauma. Oral examination revealed difficulty in protruding his tongue to the left with muscle bulk loss and fasciculation on the same side, suggesting left hypoglossal nerve palsy. Examination of the rest of the cranial nerves and nervous system was normal. The patient's oropharyngeal and laryngeal examination was unremarkable with no cervical lymphadenopathy. He had normal laboratory investigations and cerebrospinal fluid examination. Extensive imaging of the head, neck and chest failed to reveal any pathology. Further review by an otorhinologist and rheumatologist ruled out any other underlying pathology. He made a good recovery without treatment. English literature search revealed very few cases of idiopathic, transient, unilateral hypoglossal nerve palsy. " }, { "id": "pubmed23n0990_4562", "title": "[Benign tumor of the oral cavity: idiopathic granuloma of the tongue].", "score": 0.009523809523809525, "content": "The diagnosis of granuloma of the oral cavity can favour the detection of several diseases such as sarcoidosis, Crohn's disease, tuberculosis, syphilis and malignant tumors. In Melkerson Rosenthal syndrome it has an idiopathic origin. In this regard, we here report an original case of idiopathic granuloma of the tongue not secondary to Melkerson Rosenthal syndrome and being part of benign tumors of the oral cavity. The study involved a 60-year old female patient, with no particular past medical history, presenting with discomfort during mastication secondary to a swelling on the free edge of the tongue which had occurred one month before her admission. Physical examination showed overgrowth at the level of the right edge of the tongue measuring 15 mm along its longer axis. The tongue was not plicated and there was no cervical adenopathy. The remainder of the physical examination was normal. MRI of the oral cavity showed suspected necrotizing tissue lesion on the right free edge of the mobile tongue measuring 15x12x19 mm without signs of extension to the ipsilateral lingual pedicle or to the floor of the oral cavity and without cervical adenomegalies. Biopsy of tongue lesion showed gigantocellular epithelioid granulomas without caseous necrosis or histological signs of malignancy. Biologically, there was no inflammatory syndrome, leukopenia or lymphopenia. The assessment of an underlying cause was negative: syphilis serology, evaluation of phosphocalcic profile, dosing of the angiotensin-converting enzyme, intradermo tuberculin reaction, chest radiograph, thoracoabdominopelvic CT scan and ophthalmological examination. Finally, the diagnosis of idiopathic granuloma was retained in the absence of arguments in favor of its secondary nature." }, { "id": "wiki20220301en034_52471", "title": "Toothache", "score": 0.009433962264150943, "content": "Examination The clinical examination narrows the source down to a specific tooth, teeth, or a non-dental cause. Clinical examination moves from the outside to the inside, and from the general to the specific. Outside of the mouth, the sinuses, muscles of the face and neck, the temporomandibular joints, and cervical lymph nodes are palpated for pain or swelling. In the mouth, the soft tissues of the gingiva, mucosa, tongue, and pharynx are examined for redness, swelling or deformity. Finally, the teeth are examined. Each tooth that may be painful is percussed (tapped), palpated at the base of the root, and probed with a dental explorer for dental caries and a periodontal probe for periodontitis, then wiggled for mobility." }, { "id": "article-40409_36", "title": "Adenopathy -- History and Physical", "score": 0.009433962264150943, "content": "Jugular lymphadenopathy typically drains the tongue, the tonsils, the pinna, and the parotid gland" }, { "id": "pubmed23n0717_25114", "title": "Granular cell tumor presenting as a tongue nodule: two case reports.", "score": 0.009345794392523364, "content": "Granular cell tumor is an uncommon neoplasm that can occur in any part of the body, including the orofacial region. The tumor is usually benign, but there are reports of cases in which the tumor shows a locally aggressive behavior, malignancy, and distant metastases. The most widely accepted hypothesis is that granular cell tumor arises from the altered metabolism of Schwann cells. The tumor is typically asymptomatic and appears as a nodule that does not exceed 3 cm. In case 1, a 26-year-old Caucasian man was seen at the Oral Medicine out-patient clinic of the São José dos Campos Dental School, Universidade Estadual Paulista, with a 'small blister on the tongue', which he had noted approximately three years ago. The nodule was located on the dorsum of the tongue, measured about 1.5 cm in diameter, and was not tender to palpation. Treatment consisted of an excisional biopsy performed on the basis of the diagnostic hypothesis of granular cell tumor, which was confirmed by microscopic analysis. In case 2, a 31-year-old Caucasian woman attended the out-patient clinic of the São José dos Campos Dental School, Universidade Estadual Paulista, with a five-year history of a 'painful lump on the tongue'. Intra-oral examination revealed the presence of a nodular lesion measuring approximately 0.8 cm in diameter, which was located deep in the submucosa of the right lateral margin of the tongue. Treatment consisted of an excisional biopsy performed on the basis of the differential diagnosis of neurofibroma and granular cell tumor. Microscopic analysis defined the final diagnosis of granular cell tumor. Granular cell tumor is an uncommon tumor that must be carefully diagnosed and treated correctly." }, { "id": "article-20292_9", "title": "Deep Neck Infections -- History and Physical", "score": 0.009345794392523364, "content": "Proximal deep neck infections (peritonsillar, parapharyngeal, parotid, and submandibular) infections and abscesses tend to present with a sore throat and sometimes with trismus. Trismus occurs due to the local inflammation of the muscles of mastication or the direct involvement of these muscles by the infection. A physical exam may reveal neck or lower facial swelling, local erythema, tenderness, and regional lymphadenitis. Medial displacement of the uvula in conjunction with tonsillar asymmetry suggests peritonsillar abscess, whereas medial displacement of the pharyngeal wall is suggestive of parapharyngeal space infection. Local pressure may result in dysphagia or odynophagia and may have associated inflammation in the cricoarytenoid joints. If the vagus nerve is affected, dysphonia and hoarseness can occur, the so-called \"hot potato\" voice. Infections in the submandibular space may occur after spreading from dental abscesses, sublingual or submaxillary salivary glands, or oral infections following trauma. Cellulitis in this space is also known as Ludwig’s angina if it originates from the 3rd molars, which can lead to life-threatening airway obstruction if untreated. Ludwig’s angina presents with drooling, inability to swallow, trismus, and induration and elevation of the floor of the mouth." }, { "id": "pubmed23n0551_9237", "title": "Sister Mary Joseph's nodule as a presenting sign of internal malignancy.", "score": 0.009259259259259259, "content": "CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I." }, { "id": "pubmed23n0988_13577", "title": "A case report of a tongue ulcer presented as the first sign of occult tuberculosis.", "score": 0.009259259259259259, "content": "Tuberculosis (TB) is a serious infectious disease with considerable fatality, typically affecting the pulmonary system and, rarely, other body organs including the oral cavity. Due to the rarity of oral TB, it is frequently overlooked in differential diagnosis of oral lesions. Despite a declining trend in TB incidence in recent years, it is still a major public health problem with high contagiousness, thereby requiring the early diagnosis and prompt treatment. A 57-year-old male patient presented with chief complaint of painful ulcer on tip of his tongue. He reported that the ulcer developed without any remarkable event such as mechanical trauma, vesicle formation or systemic illness. His past medical history revealed the TB over 40 years ago, which had reportedly healed after pharmacological treatments. As the ulceration persisted after topical steroid application and careful education about avoiding possible mechanical stimuli, biopsy was performed and histological finding showed typical findings of oral tuberculosis including intense granulomatous inflammatory features with small red rods of mycobacterial organisms as well as epithelioid cells and Langhans giant cells. After suitable antituberculosis treatments, oral tuberculosis ulcer was almost completely healed. We present a case of oral TB affecting tip of the tongue in a patient with a history of pulmonary TB and emphasize the understanding of intraoral manifestations for early diagnosis and prompt treatment of TB. The present case represented the importance of understanding oral tuberculosis manifestations for dental clinicians who might be frequently the first health care professionals to encounter various oral lesions." }, { "id": "pubmed23n1106_18816", "title": "Tapia's Syndrome (Concurrent Unilateral Recurrent Laryngeal and Hypoglossal Nerve Palsy) Following Left Retrosigmoid Craniotomy for Schwannoma Resection.", "score": 0.009174311926605505, "content": "Tapia's syndrome, a unilateral, extracranial combined lesion to the hypoglossal nerve (cranial nerve [CN] XII) and the recurrent laryngeal branch of the vagal nerve (CN X), has been observed to occur after general anesthesia for a variety of surgical procedures. Surgical intraoperative neck positioning and airway management are hypothesized as causative factors. The condition presents with ipsilateral motor paralysis of the tongue and vocal cords. Postoperatively, patients often present with dysphonia, dysphagia, and difficulty swallowing. We discuss a unique case of Tapia's syndrome occurring after retrosigmoid craniotomy for left vestibular schwannoma resection in a 42-year-old male. General anesthesia was uneventful with an atraumatic, grade 2a intubation and a normal endotracheal tube cuff pressure of 30 cm of water. The patient was positioned laterally, even though the exact head position was not documented. Institutional practice in these cases is for the head to be maintained neutral or with a slight turn. An uneventful subtotal resection of the tumor was performed after retrosigmoid exposure. Postoperatively, the patient complained of left-sided mouth tingling, a hoarse voice, and tongue weakness which impacted his ability to chew and swallow. He had mild left-sided facial weakness and decreased sensation in the V1 and V2 distribution of the trigeminal nerve. Postoperative brain MRI showed postsurgical changes without evidence of neurological or vascular involvement. Fiberoptic endoscopy performed in the otolaryngology clinic showed immobility of the right vocal cord. Consequently, Tapia's syndrome was diagnosed. He later underwent a right vocal fold injection with Prolaryn gel (Merz North America, Inc, Greensboro, NC, USA) via flexible laryngoscopy with a slight improvement in his dysphonia. At his last visit, he declined further interventions based on acceptable voice quality. Tapia's syndrome can occur due to the close anatomical proximity of the hypoglossal and recurrent laryngeal nerves as they pass lateral to the oropharynx and hypopharynx. This predisposes the nerves to anesthetic and surgical insults such as over-stretching of the nerves during head manipulation and trauma to the nerve fibers following laryngoscopy. Our case report highlights this potential rare complication to anesthetic and surgical teams. Awareness of this concurrent paralysis can assist practitioners to rapidly diagnose and treat patients who present in this way postoperatively. It can also enable avoidance of causative factors and remind practitioners of the importance of meticulous perioperative documentation." }, { "id": "pubmed23n0043_12589", "title": "[Ultrasound staging research of progressive pathology of the base of the tongue].", "score": 0.009174311926605505, "content": "Diagnosis of tongue tumours is often retarded mainly because tumours grow prevalently in deep muscular layers. A correct exploration of the region might be difficult solely employing clinical examination. Therefore, it would be useful to confirm the suspect of a neoplastic lesion at the base of the tongue with a promptly available imaging method. These considerations led us to evaluate ultrasonography (US) as a diagnostic tool for neoplastic lesions of this region. Initially 10 normal patients were studied in order to become familiar with US anatomy of the area. In a second phase our study involved 24 patients with diagnosed carcinoma of the tongue base and 26 patients with clinical suspect of neoplasm in the region. US examination was carried out with real-time equipment provided by a 5 Mhz convex transducer. Patients were examined in supine position with the neck hyperextended. Longitudinal, oblique and transverse scan of the submental region were obtained. The study showed that US gives detailed images of the floor of the mouth and the tongue. Neoplastic infiltration of the base of the tongue is clearly recognizable as a hypoechoic area. It was possible to detect masses ranging from 1.4 to 3.8 cm. In cases of larger lesions, US was useful in evaluating deep infiltration, whereas in other cases the method allowed the diagnosis of small lesions with submucosal growth. US did not proved to be highly reliable in the diagnosis of lesions confined to superficial planes (false negative results).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0742_19052", "title": "Bilateral lemierre syndrome secondary to periodontitis: a case report and review of the literature.", "score": 0.00909090909090909, "content": "Lemierre syndrome is the typical presentation of human necrobacillosis. It is characterized by an initial infection, progressing to septic thrombophlebitis, septicemia, and multisystem embolic necrotic abscesses. It is usually caused by Fusobacterium necrophorum, but its pathophysiology remains obscure. A case of bilateral Lemierre syndrome secondary to periodontitis is reported. A previously healthy 24-year-old African American man presented with a 2-week history of fever, chills, dyspnea, abdominal pain and vomiting, nonbloody diarrhea, anorexia, and body aches. He occasionally smoked marijuana but had no pets, and denied sick contact or recent travel. Physical examination was remarkable for tachypnea, tachycardia, pyrexia, icteric sclera, dry oral mucosa, moderate-to-severe gingival inflammation, and dental caries involving the upper and lower molars. The oropharynx was clear. He had tenderness over the sternocleidomastoid muscles bilaterally, and nontender cervical lymphadenopathy. Chest examination revealed reduced breath sounds in both bases with fine crackles at the right base. Examination of the cardiovascular and gastrointestinal systems was significant for tenderness in the right upper quadrant with no rebound. Laboratory findings were significant for leukocytosis with a left shift, anemia, abnormal liver function tests, elevated creatine phosphokinase, and positive blood culture for F. necrophorum. Chest radiographs and computed tomography scans revealed multilobar cavitary nodular densities with pleural effusions. Duplex sonography of the neck demonstrated thrombosed left internal jugular vein with complete occlusion of the lumen, thrombosed left subclavian, and axillary veins with minimal blood flow. There was also a small thrombus in both the right internal jugular and right subclavian veins with partial occlusion of their lumina. He was prescribed penicillin, metronidazole, and anticoagulation therapy and had complete resolution of the lung lesions and marginal improvement of the bilateral neck thrombophlebitis. He was awaiting dental procedures. A case is reported of extensive bilateral septic thrombophlebitis of the deep neck veins secondary to periodontal disease. To the best of my knowledge, this is the first case of bilateral Lemierre syndrome due to periodontal disease reported in the literature. It highlights the typical septic thrombophlebitis of Lemierre syndrome and its protean manifestations, such as hepatitis and rhabdomyolysis. This presentation also underscores the significance of thorough dental examinations in febrile patients. With respect to anticoagulation therapy in Lemierre syndrome, though still not established, there is some evidence of utility with no untoward effects." }, { "id": "pubmed23n0814_343", "title": "Acute tongue swelling, the only initial manifestation of carotid artery dissection: a case report with differentiation of clinical picture.", "score": 0.009009009009009009, "content": "While it is well known that carotid artery dissection can cause hypoglossal palsy, which can cause muscle atrophy and fat tissue replacement in the chronic stage but what is less well known is the acute edematous stage, which can mimic tongue angioedema. We present a case report of a 52-year-old man presented to accident and emergency department with 3 hr history of right-side tongue swelling. He was initially diagnosed with angioedema and treated with corticosteroids and antihistamines. His tongue swelling persisted and subsequently developed unilateral weakness. Magnetic resonance imaging scan of the tongue, head, and neck revealed denervation of the right half of the tongue because of injury to hypoglossal nerve during extracranial internal carotid artery (ICA) dissection. There was no evidence of ischemic complication of right cerebral artery distribution. He was commenced on antiplatelet therapy to prevent cerebral ischemia as a prophylactic measure. Swelling and weakness of the tongue subsided in the following months. We believe that hypoglossal palsy caused by ICA dissection should be considered in the differential diagnosis of patients who present with acute tongue swelling." }, { "id": "article-40409_34", "title": "Adenopathy -- History and Physical", "score": 0.009009009009009009, "content": "Submandibular nodes typically drain the tongue the lips and the mouth and the conjunctiva" }, { "id": "pubmed23n0855_15317", "title": "Tongue abscess induced by embedded remnant fishbone.", "score": 0.008928571428571428, "content": "The authors reported a 56-year-old man with progressive pain over left bottom of oral cavity involving tongue for 3 days. He had a puncture history of tongue by fishbone, which was immediately removed 3 weeks ago. The subsequent contrast-enhanced computed tomography scan of neck disclosed an abscess formation with a faint linear radiopaque material inside, consisting with remnant fishbone retention. The patient was treated conservatively with intravenous antibiotics, followed by an uneventful course during subsequent follow-up for more than 9 months until now. Tongue abscess is a rare but potentially life threatening clinical entity. Foreign body puncture-related tongue abscess should be listed as a differential diagnosis in cases with acute tongue swelling." }, { "id": "pubmed23n0847_22761", "title": "Solitary Neurofibroma at the Base of the Tongue: A Rare Presentation.", "score": 0.008849557522123894, "content": "A 75-year-old man presented with a slowly growing mass at the right side of the base of the tongue for 4 months. The mass was painless initially but had become very painful during preceding 4 weeks. On examination a 3 cm diameter, oval swelling was observed at the right side of the base of the tongue. It was firm in consistency, slightly tender, non-ulcerative, and with irregular surface. A deep incisional biopsy was taken from mass under general anesthesia. Histopathology report identified the mass consistent with neurofibroma. It featured typical pallisading arrangement of fascicles of spindle-shaped cells and there was no evidence of malignancy. An absence of Verocay body and thick hyalinized vessels ruled out Schwannoma. No similar lesions were found in any other part of the patient's body. He exhibited no skin pigmentation, no hearing deficit, and no evidence suggestive of any systemic disorders that might have been attributable to the tongue base neurofibroma. His family history was also negative. Thus, a diagnosis of isolated neurofibroma of the tongue was established. The patient was advised excision of the mass but he refused and lost in follow up. " }, { "id": "wiki20220301en516_3534", "title": "Tongue Untied", "score": 0.008849557522123894, "content": "Plot" }, { "id": "pubmed23n1073_10914", "title": "Repeated loss of consciousness as the first symptom of recurrence of head and neck malignancy: a case report.", "score": 0.008771929824561403, "content": "Head and neck malignancies rarely cause reflex syncope. Three mechanistic patterns of reflex syncope are known in such patients: carotid sinus syndrome, glossopharyngeal neuralgia syndrome, and parapharyngeal space lesions syncope syndrome. There are few reports describing parapharyngeal space lesions syncope syndrome. A 61-year-old man with a history of head and neck cancer underwent left lingual resection and left anterior cervical lymph node dissection followed by chemoradiotherapy. Two months later, he experienced his first syncope and was admitted to our hospital for further investigation. During the first few days in the hospital, he experienced loss of consciousness. Carotid artery massage and cervical rotation-extension examinations revealed no abnormalities, and glossopharyngeal neuralgia was not observed. Cervical computed tomography showed recurrence of tongue cancer infiltrating the para-nasopharyngeal space. Consequently, the patient had sinus pause during the loss of consciousness; hence, we suspected parapharyngeal space lesions syncope syndrome. Pacemaker implantation was considered but could not be performed as the patient passed away because of the original malignancy. Parapharyngeal space tumours are often characterized by the absence of subjective symptoms, although symptoms such as neck swelling and discomfort in the throat have been reported. Parapharyngeal space lesions syncope syndrome is caused by tumour invasion into the parapharyngeal space, and there is no known trigger for syncope. Our case is unique because the patient's first symptom of recurrence of tongue cancer infiltrating the para-nasopharyngeal space was repeated loss of consciousness." }, { "id": "pubmed23n0374_7233", "title": "[Early diagnosis and prevention of malignant tumors in the head and neck region].", "score": 0.008771929824561403, "content": "In the Netherlands more than 2000 new patients with head and neck cancer are diagnosed annually. Most of these cancers are squamous cell carcinomas. The use of tobacco and alcohol are well established aetiologic factors. Head and neck cancers usually affect patients above the age of 40 years and are somewhat more common in men than in women. The type of the initial symptoms of head and neck cancer depends largely on the exact location. Often, these symptoms are rather aspecific. However, laryngeal cancer is an exception. In this site cancer usually presents at an early stage with sudden hoarseness. Hoarseness of more than three weeks' duration requires laryngoscopic examination. Particularly the cancers of the floor of the mouth and the borders on the tongue can be detected early because of the accessibility of these sites, which allows proper inspection and palpation. The most common clinical manifestation of oral cancer is an indurated ulcer. An oral ulcer present for more than three weeks is an indication for biopsy. The prognosis of head and neck cancer in general depends largely on the stage at diagnosis. Small cancers carry a much better prognosis after surgical removal or radiotherapy than larger ones." }, { "id": "pubmed23n1089_8182", "title": "Pleural malignant mesothelioma with metastatic deposition in the tongue.", "score": 0.008695652173913044, "content": "A 70-year-old man with epithelioid malignant pleural mesothelioma was referred to the maxillofacial surgery department with a painful lesion on the lateral border of his tongue which interfered with swallowing. Physical examination demonstrated a 3 cm firm, non-ulcerated mass on the left lateral tongue, histologically shown to be metastatic epithelioid mesothelioma. MRI of the neck and CT scan of the thorax, abdomen and pelvis scans also demonstrated progressive local and metastatic disease. The patient was not felt to be fit for further treatment. More than 90% of oral cavity cancers are squamous cell carcinoma. All reported cases of metastasis of malignant mesothelioma to the tongue have been of the epithelioid subtype with 10 cases reported in the literature to date. Diagnosis is important as tongue lesions can significantly impact on quality of life and synchronous tongue primaries should be ruled out. Tongue lesions may herald metastases to other extrapleural locations." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 128 ] ], "word_ranges": [ [ 0, 18 ] ], "text": "Glomerulonephritis is typically associated with dysmorphic red blood cells and hematic casts in the sediment (option 1 correct)." }, "2": { "exist": true, "char_ranges": [ [ 129, 263 ] ], "word_ranges": [ [ 18, 39 ] ], "text": "Proteinuria can also appear in variable range, although it is not usual in the form of isolated microalbuminuria (incorrect option 2)," }, "3": { "exist": true, "char_ranges": [ [ 268, 345 ] ], "word_ranges": [ [ 40, 51 ] ], "text": "hematuria with pyuria although it is not characteristic (incorrect option 3)." }, "4": { "exist": true, "char_ranges": [ [ 346, 445 ] ], "word_ranges": [ [ 51, 67 ] ], "text": "Clots usually appear in the context of alterations of the lower urinary tract (option 4 incorrect)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Dysmorphic red blood cells and/or hematic casts.", "2": "Proteinuria of 1 g/day, with negative test strip result and with microalbuminuria greater than 300 mg/24 hours.", "3": "Coexistence of hematuria with pyuria without bacteriuria.", "4": "Clots in the urine with the naked eye.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en074_14199", "title": "Microhematuria", "score": 0.01890999910801891, "content": "Microhematuria, also called microscopic hematuria (both usually abbreviated as MH), is a medical condition in which urine contains small amounts of blood; the blood quantity is too low to change the color of the urine (otherwise, it is known as gross hematuria). While not dangerous in itself, it may be a symptom of kidney disease, such as IgA nephropathy or Sickle cell trait, which should be monitored by a doctor. The American Urological Association (AUA) recommends a definition of microscopic hematuria as three or more red blood cells per high-power microscopic field in urinary sediment from two of three properly collected urinalysis specimens. Microhematuria is usually asymptomatic, and there are medical guidelines on how to handle asymptomatic microhematuria (AMH) so as to avoid problems such as overtreatment or misdiagnosis. See also Proteinuria Hematuria Myoglobinuria Hemoglobinuria References External links 2012 AUA Guidelines" }, { "id": "pubmed23n0820_14586", "title": "Renal biopsy findings and clinical indicators of patients with hematuria without overt proteinuria.", "score": 0.016666666666666666, "content": "Whether to perform a renal biopsy for isolated hematuria remains a matter of controversy. We performed renal biopsy in hematuria without overt proteinuria patients and reported the proportion of glomerulonephritis, pathological activities, and statistical analysis of indicators associated with glomerulonephritis. Among 203 patients who underwent renal biopsy in Okubo Hospital, Japan, between January 2008 and October 2013, we identified 56 patients who fulfilled the criteria: (1) urine dipstick examination shows equal to or greater than ± blood on three or more visits, (2) proteinuria &lt;0.3 g/day (g/g Cr), (3) eGFR ≧60 ml/min/1.73 m(2), and (4) no current medication for renal disease. We investigated biopsy findings and compared the clinical indicators in the IgA nephropathy (IgAN) and non-IgAN group. The pathological diagnosis was IgAN in 35 cases (62 %), thin basement membrane disease (TBMD) in 7 (13 %), minor glomerular abnormality (MGA) in 6 (11 %), glomerular basement membrane (GBM) abnormality in 5 (9 %), and others in 3 (5 %). The histological grade of IgAN was I in 90 % and II in 10; 31 % of patients had some crescentic lesions. Comparisons between the IgAN and non-IgAN group revealed significant differences in age of onset (26 ± 13 vs. 34 ± 17 years, p = 0.04), serum IgA (340 ± 114 vs. 220 ± 101 mg/dl, p &lt; 0.01), proteinuria (0.08 [0-0.25] vs. 0 [0-0.23] g/day [g/gCr], p &lt; 0.01), and the presence of poikilocytes (40 vs. 10 %, p = 0.02). The proportion of IgAN in hematuria without overt proteinuria was high and the pathological activities were variable. Patients with hematuria without overt proteinuria should continue their medical follow-up and the best timing of biopsy may be controversial for these patients who have multiple risk factors of IgAN." }, { "id": "wiki20220301en022_16871", "title": "Clinical urine tests", "score": 0.016145371660124096, "content": "Urine test strip A urine test strip can quantify: Leukocytes – with presence in urine known as leukocyturia Nitrite – with presence in urine known as nitrituria Protein – with presence in urine known as proteinuria, albuminuria, or microalbuminuria Erythrocytes – with presence in urine known as hematuria Specific gravity Glucose - with presence in urine known as glucosuria Bilirubin - with presence in urine known as bilirubinuria Ketones - with presence in urine known as ketonuria Microscopic examination" }, { "id": "wiki20220301en022_61054", "title": "Hematuria", "score": 0.016112170223233503, "content": "The first step in evaluation of red or brown colored urine is to confirm true hematuria with urinalysis and urine microscopy, where hematuria is defined by three of more red blood cells per high power field. Although a urine dipstick test may be used, it can give false positive or false negative results. In gathering information, it is important to inquire about recent trauma, urologic procedures, menses, and culture-documented urinary tract infection. If any of these are present, it is appropriate to repeat a urinalysis with urine microscopy in 1 to 2 weeks or after treatment of the infection. If the results of the urinalysis and urine microscopy reveal a glomerular origin of hematuria (indicated by proteinuria or red blood cell casts), consultation of a nephrologist should be made. If the results of the urinalysis indicate a non-glomerular origin, a microbiological culture of the urine should be performed, if it has not been done already. If the culture is positive, treatment of the" }, { "id": "wiki20220301en026_25242", "title": "IgA nephropathy", "score": 0.015326715392167557, "content": "For an adult patient with isolated hematuria, tests such as ultrasound of the kidney and cystoscopy are usually done first to pinpoint the source of the bleeding. These tests would rule out kidney stones and bladder cancer, two other common urological causes of hematuria. In children and younger adults, the history and association with respiratory infection can raise the suspicion of IgA nephropathy. A kidney biopsy is necessary to confirm the diagnosis. The biopsy specimen shows proliferation of the mesangium, with IgA deposits on immunofluorescence and electron microscopy. However, patients with isolated microscopic hematuria (i.e. without associated proteinuria and with normal kidney function) are not usually biopsied since this is associated with an excellent prognosis. A urinalysis will show red blood cells, usually as red cell urinary casts. Proteinuria, usually less than 2 grams per day, also may be present. Other renal causes of isolated hematuria include thin basement" }, { "id": "wiki20220301en057_61744", "title": "Nephritic syndrome", "score": 0.015039606080068508, "content": "Signs and symptoms that are consistent with nephritic syndrome include: Hematuria (red blood cells in the urine) Proteinuria (protein in the urine) ranging from sub-nephrotic (<3.5 g/day) to >10 g/day, although it is rarely above nephrotic range proteinuria levels. Hypertension resting blood pressure is persistently at or above 130/80 or 140/90 mmHg. Blurred vision Azotemia (increased plasma Urea and Creatinine) Oliguria (low urine output <400 ml/day) Red blood cell casts (seen with urine analysis and microscopy) Pyuria (white blood cells or pus in the urine) Causes" }, { "id": "pubmed23n0323_20430", "title": "Refined microscopic urinalysis for red blood cell morphology in the evaluation of asymptomatic microscopic hematuria in a pediatric population.", "score": 0.014697510738498162, "content": "The use of refined microscopic urinalysis for the presence of dysmorphic red blood cells (RBCs) has been evaluated in children and adults with a known source of hematuria. We examined the clinical usefulness of this study in a pediatric population with an unknown source of hematuria. Children 12 years old or younger referred for evaluation of asymptomatic microscopic hematuria exhibiting 4 or more RBCs per high power field were enrolled in this study. Patients provided a first morning urine sample subjected to refined urinalysis for RBC morphology. Standard evaluation of patients was performed until a final diagnosis of the hematuria source was identified. A total of 44 patients completed the study. Refined urinalysis revealed pure dysmorphic RBCs in 22 patients, pure isomorphic RBCs in 8 and mixed isomorphic/dysmorphic RBCs in 14. The presence of dysmorphic RBCs correctly predicted a glomerulotubular source of hematuria in 29 of 36 patients (sensitivity 83%, specificity 81%), while the presence of isomorphic RBCs predicted a uroepithelial source of hematuria in 2 of 8 patients (sensitivity 25%, specificity 22%). Hematuria and 2+ proteinuria (100 mg./dl.) were more sensitive (100%) and specific (83%) than the presence of dysmorphic RBCs in predicting glomerulotubular hematuria. We believe that this is a costly test offering little additional information to the evaluation of microscopic hematuria in children. A thoughtful history and physical examination with microscopic urinalysis and dipstick for proteinuria provide an equal amount of diagnostic information. We do not recommend its routine use in the evaluation of microscopic hematuria in children." }, { "id": "wiki20220301en254_18211", "title": "Urine test strip", "score": 0.014199485454185631, "content": "Blood Blood may be present in the urine either in the form of intact red blood cells (hematuria) or as the product of red blood cell destruction, hemoglobin (hemoglobinuria). Blood present in large quantities can be detected visually. Hematuria produces cloudy red urine, and hemoglobinuria appears as a clear red specimen. Any amount of blood greater than five cells per microliter of urine is considered clinically significant; visual examination cannot be relied upon to detect the presence of blood. Microscopic examination of the urinary sediment shows intact red blood cells, but free hemoglobin produced either by hemolytic disorders or lysis of red blood cells is not detected. Therefore, chemical tests for hemoglobin provide the most accurate mean for determining the presence of blood. Once blood has been detected, the microscopic examination can be used to differentiate between hematuria and hemoglobinuria." }, { "id": "wiki20220301en057_61758", "title": "Nephritic syndrome", "score": 0.013311688311688313, "content": "Blood urea nitrogen (BUN) - Also measured using a BMP or CMP, blood urea nitrogen is an indicator of how much nitrogen is in the blood at the time of the phlebotomy. The kidney is responsible for excreting nitrogenous substances in the urine, so an elevated BUN usually indicates that the kidney is not functioning appropriately. Urine Analysis (Urinalysis) - After the patient provides a urine specimen, it is sent to the lab for analysis using a variety of methods including urine dipstick testing and microscopic examination. Because the kidney is responsible for making urine, analyzing the urine directly can provide crucial data that can help the physician diagnose nephritic syndrome. Some findings on urinalysis that are consistent with nephritic syndrome include red blood cells (hematuria), red blood cell casts, proteinuria, and possibly white blood cells (pyuria)." }, { "id": "wiki20220301en022_61059", "title": "Hematuria", "score": 0.01294463568559954, "content": "a female less than 50 years old or a male less than 40 years old; has 3-10 red blood cells per high power field; has not had microscopic hematuria before; and has no other risk factors for urothelial cancer. To be in the intermediate risk category, one must satisfy any of the following criteria: Has smoked 10-30 pack-years; is a female 50-59 years old or a male aged 40-59 years old; has 11-25 red blood cells per high power field; or was previously a low-risk patient with persistent microscopic hematuria and has 3-25 red blood cells per high power field. To be in the high risk category, one must satisfy any of the following criteria: Has smoked more than 30 pack-years; is older than 60 years of age; or has above 25 red blood cells per high power field on any urinalysis. For the low risk category, the next step is to either repeat a urinalysis with urine microscopy in 6 months or perform a cystoscopy and renal ultrasound. For the intermediate risk category, the next step is to perform a" }, { "id": "article-22710_8", "title": "Hematuria -- Evaluation", "score": 0.012776222526654356, "content": "Urinalysis is the initial and most useful test to perform. Although urine dipstick is widely available and can be performed quickly, it can give false-positive or false-negative results and warrants urinalysis and urine microscopy to establish the diagnosis. Presence of 3 or more RBCs per High Power Field on urine sediments is defined as microscopic hematuria although there is no \"safe\" lower limit of hematuria. [2] Urine appearance, pH, the presence of proteins, WBCs, nitrites, leukocyte esterase, crystals, and casts is helpful. A dirty urine specimen with significant WBCs and positive nitrites and leukocyte esterase suggests urinary tract infection and a likely cause of hematuria. The presence of excessive proteins with hematuria favors glomerulonephritis." }, { "id": "wiki20220301en026_25230", "title": "IgA nephropathy", "score": 0.012713706172124022, "content": "A smaller proportion (20–30%), usually the older population, have microscopic hematuria and proteinuria (less than 2 gram/day). These patients may be asymptomatic and only picked up due to urinalysis. Hence, the disease is more commonly diagnosed in situations where screening of urine is compulsory (e.g., schoolchildren in Japan). Very rarely (5% each), the presenting history is: Nephritic syndrome Acute kidney failure (either as a complication of the frank hematuria, when it usually recovers or due to rapidly progressive glomerulonephritis which often leads to chronic kidney failure) Chronic kidney failure (no previous symptoms, presents with anemia, hypertension and other symptoms of kidney failure, in people who probably had longstanding undetected microscopic hematuria and/or proteinuria)" }, { "id": "pubmed23n0492_1923", "title": "The presence of microscopic hematuria detected by urine dipstick test in the evaluation of patients with renal colic.", "score": 0.012681159420289856, "content": "Urolithiasis is a common diagnosis in patients presenting at our hospital with flank pain. One of the most important steps in the diagnostic algorithm of renal colic is the presence of hematuria, but this fact has been challenged by authors reporting a negative urinalysis for microscopic hematuria in about 9-18% of such patients. Our aim was to investigate whether the same results are obtained when a sample of urine is tested with a urine dipstick test (UDT) at the time of the initial examination. Data from patients with the clinical diagnosis of renal colic examined at the emergency department of our hospital were reviewed, and the sensitivity of hematuria in urine samples tested by UDT was recorded in a group consisting of patients for whom imaging showed evidence of a stone &gt;3 mm in size. In cases in which UDT was negative, or showed only traces of red blood cells (RBCs), a formal urinalysis was performed. A total of 609 patients were finally included in the study, with a mean age of 49.2 years. Average stone size was 5.8 mm, located mainly in the lower part of the ureter. Dipstick analysis was positive for hematuria in 92.9%. A urinalysis, with a cut-off point of less than three red blood cells per high power field, was used as a means to verify the results of the UDT in 17.8% of cases: in 7.1% of UDT negative patients and 10.7% of patients with traces of blood. The urinalysis was negative in 5.1% of patients, adding only 2% to the diagnostic accuracy of UDT. Therefore, our findings suggest that the sensitivity of a UDT for hematuria in cases of suspected renal colic has a high degree of accuracy when performed at the emergency department, and can be used as a first-line, low cost examination. A microscopic analysis may be useful when the UDT is negative or not clear enough, to verify the results." }, { "id": "nurse-article-22710_7", "title": "Hematuria (Nursing) -- Evaluation", "score": 0.012581913499344692, "content": "Urinalysis is the initial and most useful test to perform. Although urine dipstick is widely available and can be performed quickly, it can give false-positive or false-negative results and warrants urinalysis and urine microscopy to establish the diagnosis. Presence of 3 or more RBCs per High Power Field on urine sediments is defined as microscopic hematuria although there is no \"safe\" lower limit of hematuria. [2] Urine appearance, pH, the presence of proteins, WBCs, nitrites, leukocyte esterase, crystals, and casts is helpful. A dirty urine specimen with significant WBCs and positive nitrites and leukocyte esterase suggests urinary tract infection and a likely cause of hematuria. The presence of excessive proteins with hematuria favors glomerulonephritis." }, { "id": "wiki20220301en022_61043", "title": "Hematuria", "score": 0.012369052126719677, "content": "Hematuria or haematuria is defined as the occurrence of blood or red blood cells in the urine. The word hematuria is derived from Greek haima (αἷμα) \"blood\" and ouron (οὖρον) \"urine\". Hematuria can be visible to the naked eye (termed \"gross hematuria\") and may appear red or brown (sometimes referred to as tea-colored), or it can be microscopic (i.e. not visible to the eye but detected with a microscope or laboratory test). The origin of the blood that enters and mixes with the urine can arise from any anatomical site within the urinary system, including the kidney, ureter, urinary bladder, and urethra, and in men, the prostate. Common causes of hematuria include urinary tract infection (UTI), kidney stones, viral illness, trauma, bladder cancer, and exercise. The underlying causes of hematuria can be divided into glomerular and non-glomerular causes, referring to the involvement of the glomerulus of the kidney. Notably, not all red urine is hematuria. Other substances such as certain" }, { "id": "wiki20220301en022_16872", "title": "Clinical urine tests", "score": 0.012264462809917356, "content": "Microscopic examination The numbers and types of cells and/or material such as urinary casts can yield a great detail of information and may suggest a specific diagnosis. Hematuria – associated with kidney stones, infections, tumors and other conditions Pyuria – associated with urinary infections Eosinophiluria – associated with allergic interstitial nephritis, atheroembolic disease Red blood cell casts – associated with glomerulonephritis, vasculitis, or malignant hypertension White blood cell casts – associated with acute interstitial nephritis, exudative glomerulonephritis, or severe pyelonephritis (Heme) granular casts – associated with acute tubular necrosis Crystalluria – associated with acute urate nephropathy (or acute uric acid nephropathy, AUAN) Calcium oxalatin – associated with ethylene glycol, kidney stone disease Waxy casts – associated with chronic renal disease" }, { "id": "article-25173_15", "title": "Minimal Change Disease -- Evaluation -- Basic labs:", "score": 0.011810916971420832, "content": "Urine collection: A spot protein/creatinine ratio greater than 200 mg/mmol in children and protein/creatinine ratio>300-350mg/mmol in adults is consistent with nephrotic syndrome, as is a 24-hour urine collection that reveals a total protein greater than 3 to 3.5 g/24hour in adults. A report of measuring protein output as gms/m2/hr accounts for differences in body mass. A measurement of 40mg/m2/hour or greater (1gm/m2/24hour) is indicative of proteinuria consistent with nephrotic syndrome in children. Microscopic hematuria is present in 10% to 30% of adults. [13]" }, { "id": "wiki20220301en022_61058", "title": "Hematuria", "score": 0.011725955204216074, "content": "After detecting and confirming hematuria with urinalysis and urine microscopy, the first step in evaluation of microscopic hematuria is to rule out benign causes. Benign causes include urinary tract infection, viral illness, kidney stone, recent intense exercise, menses, recent trauma, or recent urological procedure. After benign causes have resolved or been treated, a repeat urinalysis and urine microscopy is warranted to ensure cessation of hematuria. If hematuria persists (even if there is a suspected cause), the next step is to stratify the risk of the person for urothelial cancer into low, intermediate, or high risk to determine next steps. To be in the low risk category, one must satisfy all of the following criteria: Has never smoked tobacco or smoked less than 10 pack-years; is a female less than 50 years old or a male less than 40 years old; has 3-10 red blood cells per high power field; has not had microscopic hematuria before; and has no other risk factors for urothelial" }, { "id": "pubmed23n0254_19270", "title": "False 'hematuria' due to bacteriuria.", "score": 0.011647361647361647, "content": "To determine the effects of bacteriuria on dipstick urinalysis for microhematuria. Selection of urine samples with dipstick readings of at least one plus (+) for blood, followed by microscopic examination and bacterial culture, from patients with signs and symptoms of urinary tract diseases. A large teaching hospital in Melbourne, Australia. Two hundred forty-six inpatients and outpatients being investigated for signs and symptoms of urinary tract diseases. Seventeen (7%) of 246 patients having within-reference erythrocyte counts had polymicrobic cultures. One hundred nine patients had slight hematuria (1 x 10(7) to 6 x 10(7) cells/L). Of these, 21 bacteriuric patients had significantly higher dipstick findings than 88 abacteriuric patients (P &lt; .005, Fisher's Exact Probability Test, two-tailed). Hydroperoxidase was detected in 80% of isolates (in 27 of 27 gram-negative bacilli cultures, in 6 of 6 staphylococci cultures, and in 3 of 12 streptococci cultures) on agar medium and in 69% of isolates in urine. These results show that patients without hematuria but with bacteriuria may give a false-positive dipstick reading for blood." }, { "id": "wiki20220301en057_61743", "title": "Nephritic syndrome", "score": 0.011568016614745586, "content": "Signs and symptoms Historically, nephritic syndrome has been characterized by blood in the urine (hematuria), high blood pressure (hypertension), decreased urine output <400 ml/day (oliguria), red blood cell casts, pyuria, and mild to moderate proteinuria. If the condition is allowed to progress without treatment, it can eventually lead to azotemia and uremic symptoms. This constellation of symptoms contrasts with the classical presentation of nephrotic syndrome (excessive proteinuria >3.5 g/day, low plasma albumin levels (hypoalbuminemia) <3 g/L, generalized edema, and hyperlipidemia)." }, { "id": "InternalMed_Harrison_21835", "title": "InternalMed_Harrison", "score": 0.01153673835125448, "content": "Patients with glomerular disease usually have some hematuria with varying degrees of proteinuria. Hematuria is typically asymptomatic. As few as three to five red blood cells in the spun sediment from first-voided morning urine is suspicious. The diagnosis of glomerular injury can be delayed because patients will not realize they have microscopic hematuria, and only rarely with the exception of IgA nephropathy and sickle cell disease is gross hematuria present. When working up microscopic hematuria, perhaps accompanied by minimal proteinuria (<500 mg/24 h), it is important to exclude anatomic lesions, such as malignancy of the urinary tract, particularly in older men. Microscopic hematuria may also appear with the onset of benign prostatic hypertrophy, interstitial nephritis, papillary necrosis, hypercalciuria, renal stones, cystic kidney diseases, or renal vascular injury. However, when red blood cell casts (see Fig. 62e-34) or dysmorphic red blood cells are found in the sediment," }, { "id": "article-22710_2", "title": "Hematuria -- Introduction", "score": 0.011448275862068966, "content": "Hematuria is the presence of blood in the urine. Hematuria can be gross or microscopic. Gross hematuria is visible blood in the urine. Microscopic hematuria refers to the detection of blood on urinalysis or urine microscopy. Hematuria can be intermittent or persistent. Hematuria is defined as the presence of at least 5 red blood cells/HPF in 3 of 3 consecutive centrifuged specimens obtained at least 7 days apart. Hematuria may be asymptomatic or symptomatic and may be associated with other urinary tract abnormalities. Hematuria is often first encountered by the primary care provider." }, { "id": "wiki20220301en008_72960", "title": "Proteinuria", "score": 0.011208920187793427, "content": "Protein dipstick measurements should not be confused with the amount of protein detected on a test for microalbuminuria which denotes values for protein for urine in mg/day versus urine protein dipstick values which denote values for protein in mg/dL. That is, there is a basal level of proteinuria that can occur below 30 mg/day which is considered non-pathology. Values between 30 and 300 mg/day are termed microalbuminuria which is considered pathologic. Urine protein lab values for microalbumin of >30 mg/day correspond to a detection level within the \"trace\" to \"1+\" range of a urine dipstick protein assay. Therefore, positive indication of any protein detected on a urine dipstick assay obviates any need to perform a urine microalbumin test as the upper limit for microalbuminuria has already been exceeded. Analysis It is possible to analyze urine samples in determining albumin, hemoglobin and myoglobin with an optimized MEKC method." }, { "id": "pubmed23n0302_14717", "title": "Is the red cell morphology really useful to detect the source of hematuria?", "score": 0.011185752226214655, "content": "Morphological analysis of urinary red blood cells by phase-contrast microscopy to identify the source of bleeding was, and still is, widely used also as a starting point for workup. To evaluate the reliability of this approach, we studied 129 outpatients presenting with persistent isolated microhematuria; 31 subjects also had mild proteinuria (1 g/day), while 21 had pathological albumin levels. All patients were followed for a period of 6 years. During this time, 6 patients underwent renal biopsy for the onset of macrohematuria episodes and proteinuria of 2-3 g/day. Glomerular bleeding was identified in only 14.7% of the patients, despite the persistent microhematuria and the presence of proteinuria or microalbuminuria. The renal origin of the urinary erythrocytes correlated with histological findings in only 2 of 6 patients with dysmorphic erythrocytes who developed proteinuria (exceeding 1 g/day), and none with isomorphic erythrocytes showed urological abnormalities. These results challenge the validity and reliability of morphological analysis to identify the source of bleeding along the urinary tract." }, { "id": "wiki20220301en022_61044", "title": "Hematuria", "score": 0.01114422300862979, "content": "can be divided into glomerular and non-glomerular causes, referring to the involvement of the glomerulus of the kidney. Notably, not all red urine is hematuria. Other substances such as certain medications and foods (e.g. blackberries, beets, food dyes) can cause urine to appear red. Menstruation in women may also cause the appearance of hematuria and may result in a positive urine dipstick test for hematuria. Additionally, a urine dipstick test may be falsely positive for hematuria due to other substances in the urine such as myoglobin during rhabdomyolysis. A positive urine dipstick test should be confirmed with microscopy, where hematuria is defined by three of more red blood cells per high power field. When hematuria is detected, a thorough history and physical examination with appropriate further evaluation (e.g. laboratory testing) can help determine the underlying cause." }, { "id": "wiki20220301en022_61046", "title": "Hematuria", "score": 0.011003726129482999, "content": "In terms of the visibility, hematuria can be visible to the naked eye (termed \"gross hematuria\") and may appear red or brown (sometimes referred to as tea-colored), or it can be microscopic (i.e. not visible to the eye but detected with a microscope or laboratory test). Microscopic hematuria is present when there are three of more red blood cells per high power field." }, { "id": "wiki20220301en024_83392", "title": "Hemoglobinuria", "score": 0.010891727964898696, "content": "Causes Acute glomerulonephritis Burns Renal cancer Malaria Paroxysmal nocturnal hemoglobinuria Microangiopathies, e.g. hemolytic-uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP) leading to microangiopathic hemolytic anemia Transfusion reactions IgM autoimmune hemolytic anemia Glucose-6-phosphate dehydrogenase deficiency Pyelonephritis Sickle cell anemia Tuberculosis of the urinary tract March hemoglobinuria secondary to repetitive impacts on the body, usually the feet Athletic nephritis secondary to strenuous exercise Acute lead poisoning Diagnosis The diagnosis is often made based on the medical history, blood samples, and a urine sample. The absence of urine RBCs and RBC casts microscopically despite a positive dipstick test suggests hemoglobinuria or myoglobinuria. The medical term for RBCs in the urine is hematuria. See also Hematuria References External links Abnormal clinical and laboratory findings for urine" }, { "id": "wiki20220301en045_76512", "title": "Hypertensive kidney disease", "score": 0.010478182414698162, "content": "Malignant nephrosclerosis is where hypertensive nephrosclerosis occurs in presence of malignant hypertension (when DBP > 130mmHg). Vessels feature intimal thickening, fibrinoid necrosis, red blood cell fragmentation, extravasation, thrombosis. These changes create an exaggerated layered appearance (onion skinning). Urine test Microalbuminuria (moderate increase in the levels of urinary albumin) is a non-specific finding in patients with vascular disease that is associated with increased risk of cardiovascular events. The majority of patients with benign nephrosclerosis have proteinuria in the range from 0.5 to 1 g/ 24hr. In the case of glomerular damage occurring in HN, hematuria can occur as well." }, { "id": "article-22282_8", "title": "Crescentic Glomerulonephritis -- Evaluation", "score": 0.009993224932249321, "content": "Complete blood count may show leukocytosis and anemia; inflammatory markers such as ESR and C-reactive protein, as are urea and serum creatinine, are usually elevated. Urinalysis shows modest proteinuria (1 to 4 g/d), microscopic hematuria, RBCs, and RBC and WBC casts. Rarely, urine findings may be minimal, and an absence of active urine sediment does not exclude a diagnosis of RPGN. [8] [9] [10] [11]" }, { "id": "wiki20220301en192_32352", "title": "Loin pain hematuria syndrome", "score": 0.009937792500433335, "content": "Diagnosis LPHS is considered a diagnosis of exclusion. The syndrome presents with hematuria (blood in the urine) and flank (a region of the lower back beneath the ribs and above the ilium) pain which can result from a number of causes. Nonglomerular causes of bleeding (e.g., urinary infection, tumor, or nephrolithiasis) must be excluded. Obstruction of the urinary tract should not be present, confirmed by at least two imaging procedures while pain is present. Diagnosis of loin pain-hematuria syndrome (LPHS) occurs when hematuria is present, recurrent or persistent pain is severe, and other causes of bleeding are excluded. Urine testing can be performed to detect microscopic levels of hematuria. Protein is also commonly found in the urine of patients with LPHS. Kidney biopsies are sometimes performed to look for evidence of glomerular hematuria, excess red blood cells in the kidney tubules, and to assess the width of the glomerular basement membrane." }, { "id": "pubmed23n0954_26278", "title": "Atypical Presentation of IgA Nephropathy Mimicking Acute Pyelonephritis.", "score": 0.00980392156862745, "content": "IgA glomerulonephritis may present with hematuria, flank pain, and fever. This clinical presentation may be easily confused with acute pyelonephritis. We present the case of a 25-year-old female with a typical clinical presentation for acute pyelonephritis (high fever, left flank pain, left costovertebral angle tenderness, hematuria, elevated inflammatory markers, and a hypoenhancing region in the left kidney on contrast-enhanced computed tomography). However, urine and blood cultures were both negative, the serum creatinine was elevated, and the urinalysis revealed significant proteinuria and dysmorphic red blood cells. A kidney biopsy confirmed a diagnosis of IgA nephropathy. She was treated with a combination of lisinopril and methylprednisolone, with good response. Gross hematuria, especially in the absence of pyuria or bacteriuria, should raise the suspicion for underlying IgA nephropathy, even if the rest of the clinical presentation is typical for a urinary tract infection. The presence of significant proteinuria, red blood cell casts, and dysmorphic red blood cells are useful clues suggesting glomerular disease." }, { "id": "pubmed23n0213_1876", "title": "[Critical study of microscopic hematuria disclosed by screening tests].", "score": 0.00980392156862745, "content": "Asymptomatic microscopic haematuria detected by dipstick in 0.28 p. 100 of 95,200 men was confirmed in only 0.11 p. 100. These results lead to the study of 272 cases to determine the value of dipsticks as a screening test and the benefits of complementary investigations to exclude symptomless diseases. Microscopic haematuria was confirmed in 65 p. 100 but results of other tests reduce the false positive screening results to 25.3 p. 100. Addis counting of at least 5,000 RBC/min is preferable to RBC count/ml which is dilution dependent. 77 p. 100 of microscopic haematuria are intermittent and can only be diagnosed by repeated Addis counts. In the absence of confirmed haematuria, only investigations to exclude proteinuria and urinary infections are justified." } ] } } }

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{ "1": "Discourage revascularization surgery because of prolonged ischemia time.", "2": "Apply heat and notify the on-call vascular surgeon.", "3": "Urgent surgical treatment by thromboembolectomy.", "4": "Urgent medical treatment with intravenous prostaglandins.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0782_2813", "title": "Acute limb ischemia: surgical thromboembolectomy and the clinical course of arterial revascularization at ankle.", "score": 0.017216117216117217, "content": "Surgical thromboembolectomy for acute limb ischemia using Fogarty catheter is basically a blind procedure. Therefore, the complete removal of thromboemboli in all calf arteries is difficult even if completion angiography or radiological intervention is performed. The purpose of this study is to identify whether limb salvage could be achieved if at least one ankle artery was revascularized by surgical thromboembolectomy. We also observed the effectiveness of below-knee popliteal approach. Over 1 year, surgical thromboembolectomy via below-knee popliteal artery was performed on 18 acutely ischemic limbs in 14 consecutive patients. All patients were diagnosed based on clinical symptoms and computed tomography (CT) angiography. Surgical thromboembolectomy was terminated when a pulse was detected by a handheld vascular Doppler device in at least one ankle artery after closing the arteriotomy. Patients were observed during postoperative anticoagulation therapy. Of the 14 patients, 1 died and 1 underwent amputation due to the already necrotized lesion in the foot. After 1 week of anticoagulation therapy, two or more arterial pulses were detected at the ankles in all 15 limbs from the remaining 12 patients. During the 6 to 18 months of follow-up, all 15 limbs were salvaged successfully. In acute limb ischemia, successful limb salvage could be achieved by the revascularization of at least one ankle artery by surgical thromboembolectomy with concomitant anticoagulation therapy. Below-knee popliteal approach is an effective method and is worth for further study compared with other approaches. " }, { "id": "pubmed23n1133_2315", "title": "Successful Conservative Treatment of an Acute Arterial Occlusion After Total Knee Arthroplasty: Report of 2 Cases and Review of the Literature.", "score": 0.016215861344537813, "content": "BACKGROUND Acute arterial occlusion after total knee arthroplasty (TKA) is a rare but occasionally limb-threatening complication. Successful outcomes of surgical treatment for acute arterial occlusion after TKA have been frequently reported in the literature; however, few reports have described conservative treatment. This case report describes the successful conservative treatment of popliteal artery occlusion after TKA. CASE REPORT We report 2 cases of popliteal artery occlusion after TKA that were managed with conservative treatment. In Case 1, a 68-year-old woman presented with a weak dorsalis pedis pulse in the foot and weakness to dorsiflexion of the toe on the operative side immediately after TKA. The operative lower extremity arterial ultrasonography and computed tomography angiography demonstrated the popliteal artery occlusion. In Case 2, a 79-year-old woman presented a cold right foot and lack of popliteal and dorsalis pedis pulse in the operated extremity immediately after TKA, and Doppler ultrasound did not reveal a flow for the dorsalis pedis artery. In both patients, urgent angiographies showed popliteal artery occlusion, and blood flow was observable in the anterior tibial, peroneal, and foot arteries collateral perfusion. Thus, conservative treatments were chosen, and anticoagulant and vasodilator therapies were undergone in both patients. At 6 months after surgery, they were able to walk without intermittent claudication. CONCLUSIONS Conservative treatment can be a good option for popliteal artery occlusion after TKA in cases of rich collateral circulation." }, { "id": "pubmed23n0491_20682", "title": "Hyperbaric oxygenation combined with streptokinase for treatment of arterial thromboembolism of the lower leg.", "score": 0.016085271317829455, "content": "Thromboembolic occlusion of peripheral arteries is a common problem in patients referred to vascular surgery departments. Standard treatments include catheter aspiration techniques, use of fibrinolytic agents and surgical thrombendarterectomy. Recent reports have described the use of hyperbaric oxygen therapy in patients with limb ischemia, yet their main focus has been on patients with chronic disorders. We present the case of a 74-year-old woman with atrial fibrillation and acute thromboembolic occlusion of the posterior tibial artery. The patient presented with severe pain in the right calf, unresponsive to non-opioid parenteral analgesia and accompanied by coldness, numbness and partial motor palsy of the right foot. After 60 minutes of oxygenation in a hyperbaric chamber with a pressure of 2.2 bar, the pain receded, although without signs of restored blood flow in the occluded artery. After fibrinolytic therapy with streptokinase, patency of the posterior tibial artery was verified by return of palpable pulsations and color Doppler ultrasonography. By combining hyperbaric oxygenation and streptokinase in the treatment of lower-leg arterial thromboembolism we achieved regression of ischemic pain, prolongation of the survival time of tissues compromised by ischemia and resolved the cause of the ischemia. We believe the use of this therapeutic strategy in selected cases of peripheral arterial thromboembolism is justified." }, { "id": "pubmed23n1063_9587", "title": "Acute Limb Ischemia: A Rare Complication of COVID-19.", "score": 0.014543605390287312, "content": "A 60-year-old male with a history of primary hypertension presented to the emergency department of a tertiary care hospital, in Pakistan, with complaints of fever, cough, and shortness of breath. He tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction, with bilateral infiltrates found in chest X-ray. At admission, oxygen saturation was 80% on room air; hence, he was immediately put on non-invasive ventilation. Laboratory investigation revealed elevated D-dimer, international normalized ratio, and total leukocyte count. C-reactive protein was markedly elevated (82.5 mg/L), indicating the state of a cytokine release syndrome (CRS). Treatment started with antibiotics, prophylactic enoxaparin (40-mg subcutaneous once daily), methyl prednisone 60 mg BD and multivitamins. Intravenous tocilizumab (TCZ) 6 mg/kg was started from Day 1 to address the CRS. On Day 3, he complained of pain in the right lower limb with signs of hypothermia, numbness, and slight blackening of the right foot. Peripheral pulses were not palpable, and vascular ultrasound showed no vascular flow in the popliteal, anterior and posterior tibial, and dorsalis pedis artery. The Vascular Surgery department declared the limb unsalvageable and right limb above-knee amputation. On Day 9, the right foot was blackened and atrophied extending up to the knee. Above-knee amputation was done, and he was discharged on rivaroxaban after 48 hours of observation. We conclude that heparin is effective in treating coronavirus disease 2019-associated coagulopathy, while TCZ, simultaneously, decreases the severity of CRS. Our case suggests that the concomitant use of TCZ and anticoagulation therapy can be beneficial in patients presenting with arterial and venous thrombosis." }, { "id": "Surgery_Schwartz_6390", "title": "Surgery_Schwartz", "score": 0.014488146062312654, "content": "manifests with the “five Ps”: pain, pallor, paresthesias, paralysis, and pulselessness, to which some add a sixth “P”—poikilothermia or “perishing cold.” Pain is the usual symptom that causes a patient to present to the emergency room. The most common location for an embolus to lodge in the leg is at the common femoral bifurcation. Typically, a patient will complain of foot and calf pain. Pulses are absent, and there may be diminution of sensation. Inability to move the affected muscle group is a sign of very severe ischemia and necessitates urgent revascularization. During evaluation of the affected extremity, it is important to compare findings with the contralateral limb. Clinical evaluation is extremely important in determining the etiology and location of the obstruction. One of the most important pieces of information to obtain is whether the patient has had prior vascular procedures or if there is a history of lower extremity claudication. Either of these features suggests" }, { "id": "pubmed23n0480_5074", "title": "[Acute limb ischemia from the general surgeon's point of view. How much knowledge of vascular surgery is necessary?].", "score": 0.012981443941992826, "content": "The diagnosis of acute peripheral ischemia can be obtained based on clinical presentation, inspection, and palpation of the affected extremity. Unfractionated heparin as a single shot is immediately given followed by continuous infusion when diagnosis is clinically evident and contraindications are excluded. Thromboembolectomy using a Fogarty catheter is immediately performed in patients with evidence of arterial embolization and signs of advanced ischemia (TASC IIb/III) followed by intraoperative angiography. Patients with evidence of arterial thrombosis require urgent angiography followed by thrombectomy and probably subsequent endovascular or surgical interventions and vascular reconstruction. For patients with moderate ischemia (TASC IIa), initial diagnostic angiography is recommended followed by primary thrombectomy with subsequent intraoperative angiography and immediate endovascular or operative treatment of remaining vascular problems. As an alternative therapeutic option initial catheter-guided local thrombolysis can be performed in selected patients with the intention of subsequent limb revascularization or unmasking relevant vessel alterations leading to specific endovascular or surgically performed vascular reconstruction. Possible development of muscle ischemia because of increased compartment pressure should be considered and fasciotomy performed when indicated. Primary amputation of the severely ischemic limb after initial thrombectomy might be recommended in patients with life-threatening organ failure related to muscle necrosis." }, { "id": "pubmed23n0599_9721", "title": "Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion.", "score": 0.012556679455877223, "content": "A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4 x 1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large 'snake-like' thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion." }, { "id": "Surgery_Schwartz_6381", "title": "Surgery_Schwartz", "score": 0.01190755973364669, "content": "an initiating event. While the instances of acute leg ischemia caused by emboli have decreased due to more effective treatment of rheumatic fever and atrial fibrillation, the incidence of thrombotic acute leg ischemia has increased. Even with the extensive use of newer endovascular techniques including thrombolysis, most published series report a 10% to 30% 30-day amputation rate.115 The short-term mortal-ity of patients presenting with acute ischemia is 15% to 20%. The most common etiologies of ALI include embolism, native vessel thrombosis, reconstruction thrombosis, trauma, and com-plications of peripheral aneurysm. Most cases of lower extrem-ity ALI are the result of thrombosis of a prosthetic conduit. This stems from increased use of prosthetic conduits to address CLI.Presenting symptoms in ALI are pain and loss of sensory or motor function. The abruptness and time of onset of the pain, its location and intensity, and change in severity over time should all be taken into" }, { "id": "wiki20220301en099_30106", "title": "Dick Cheney", "score": 0.011471861471861472, "content": "On September 24, 2005, Cheney underwent a six-hour endo-vascular procedure to repair popliteal artery aneurysms bilaterally, a catheter treatment technique used in the artery behind each knee. The condition was discovered at a regular physical in July, and was not life-threatening. Cheney was hospitalized for tests after experiencing shortness of breath five months later. In late April 2006, an ultrasound revealed that the clot was smaller. On March 5, 2007, Cheney was treated for deep-vein thrombosis in his left leg at George Washington University Hospital after experiencing pain in his left calf. Doctors prescribed blood-thinning medication and allowed him to return to work. CBS News reported that during the morning of November 26, 2007, Cheney was diagnosed with atrial fibrillation and underwent treatment that afternoon." }, { "id": "pubmed23n0944_25291", "title": "Surgical Thrombectomy, Fibrinolysis, Angioplasty and Stenting: A Combined Approach for Treatment of a May-Thurner Syndrome Presenting as Phlegmasia Cerulea Dolens.", "score": 0.011377721277610043, "content": "Phlegmasia cerulea dolens (PCD) is a rare complication of deep venous thrombosis (DVT). Massive ileo-femoral DVT is usually the cause and prompt treatment is mandatory as it represents a medical emergency. Reported amputation rates range from 12% to 25% and mortality ranges from 25% to 40%. Limb ischemia results from obstruction to arterial inflow secondary to extreme levels of venous hypertension. Primary treatment goal is restoration of venous outflow and can be achieved by endovascular or surgical techniques. After thrombus removal an underlying iliac vein stenosis may be present. May-Thurner syndrome, a condition where the left common iliac vein is compressed by the right iliac artery, is the most prevelant iliac stenotic lesion. We report a case of a 57 years-old male, smoker, with no significant medical history, who presented to the emergency department with excruciating sudden left limb pain and swelling, with no trauma history, with a 2-hour onset. On physical examination he showed significant edema, purplish discoloration of the entire leg and absent dorsalis pedis artery pulse. Hipocoagulation with intravenous heparin was immediately initiated and emergent surgical venous thrombectomy was performed associated with direct intravenous fibrinolytic agent injection. Postprocedure phlebography showed a left common iliac vein lesion which was treated with angioplasty and venous stent placement. Pain, edema and coloration improved markedly after procedure without any complications. The patient was discharged home with anticoagulation treatment and compression stocking. Endovascular approaches such as catheter-directed thrombolysis (CDT) or pharmacomecanical thrombolysis (PMT) are becoming the treatment of choice to achieve venous outflow in DVT. In cases of PCD, when rapid restauration of venous outflow is mandatory, CDT has the disadvantage of having a long mean treatment time. This way, surgical thrombectomy still plays an important role in cases of PCD, especially if PMT is not available. In our case, the combined used of surgical thrombectomy with direct intravenous thrombolytic infusion provided effective treatment of PCD and uncovered an underlying left common iliac vein stenosis, which was successfully managed by angioplasty and stenting." }, { "id": "pubmed23n1099_9475", "title": "Acute Thromboembolism from Trauma in a Patient with Abdominal Aortic Aneurysm.", "score": 0.009900990099009901, "content": "A 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator. Acute thrombosis of AAA and subsequent thromboembolic events are a rare but significant complication that can occur in patients with a history of AAA. Thromboembolic events may occur spontaneously or in the setting of blunt abdominal trauma. Common presenting signs and symptoms include distal limb ischemia and absent femoral pulses. Timely management and recognition of this rare complication is vital as this condition can ultimately result in limb loss or death if not treated in a timely manner. Heparinization after confirmation of non-ruptured AAA as well as vascular surgery, and therapeutic and vascular interventional radiology consultations are key steps that should be taken to decrease patient morbidity and mortality." }, { "id": "pubmed23n0608_21794", "title": "[Septic splenic infarction after acute arterial embolism].", "score": 0.00980392156862745, "content": "A 62-year-old woman was admitted because of sudden onset of increasingly severe pain in the left lower leg and foot. She also reported having had diarrhoea for the past few days. Physical examination revealed a cold and pale left leg below the knee joint. Peripheral sensory and motor functions were normal. While femoral and popliteal arterial pulses were normally palpable, foot pulses were not felt. Magnetic resonance angiography of the pelvic and leg arteries showed an embolic occlusion of the left popliteal artery extending to the arteries of the lower leg. Because of the acute embolic occlusion of the deep femoral and popliteal arteries an embolectomy of the deep and superficial femoral arteries was performed. The source of the emboli had been a free-floating thrombus in the descending aorta. Subsequently a persistent fever and leukocytosis occurred which had been cause by a septic splenic infarction. A conventional splenectomy was done. The postoperative was protracted, because of the development of a pancreatic fistula, which responded to treatment. Anticoagulation treatment started. The patient was finally discharged after more than five weeks. After urgent surgical treatment of an acute peripheral arterial occlusion its cause needs to be identified. Transthoracic echocardiography, computed tomography and magnetic resonance angiography are the methods of choice. If there is a floating aortic thrombus further embolizations, including septic splenic emboli may occur." }, { "id": "pubmed23n0706_15508", "title": "Vascular obstruction at the level of the ankle joint as a complication of hip arthroscopy.", "score": 0.00980392156862745, "content": "We report a case of foot vascular obstruction as a complication of hip arthroscopy. A 23-year-old female patient underwent hip arthroscopy for femoroacetabular impingement. The duration of the procedure was 80 minutes, including 20 minutes with traction for arthroscopy of the central compartment and 60 minutes without traction for cam treatment in the peripheral compartment. Three days postoperatively, the patient complained of a cold foot and pain and paresthesia during leg and foot elevation with continuous passive motion therapy. With persisting symptoms, she was seen by the referring physician 4 days postoperatively. Pulselessness at the level of the ankle and reduced capillary perfusion were observed. Doppler sonography and magnetic resonance angiography showed an occlusion of the peroneal, posterior tibial, and anterior tibial arteries at the level of the right ankle. The patient was readmitted to the hospital and underwent intravenous prostaglandin E1 therapy for 9 days, followed by oral clopidogrel treatment for 6 weeks. After 8 weeks, follow-up Doppler sonographic findings were normal. Subjective paresthesia and sensation of coldness resolved completely after 6 months. Possible theories for this complication and strategies on how to avoid it are discussed." }, { "id": "pubmed23n0924_9735", "title": "Central Nervous System and Limb Embolism Concurrence due to Atrial Myxoma: A Case Report‏.", "score": 0.009708737864077669, "content": "Cardiac myxomas are the most common cardiac tumors with diverse nonspecific clinical manifestations. A 78-year-old man presented to the emergency department with complaints of pain and coldness of the left lower extremity. The left femoral artery pulse was detected, while the pulses of the left popliteal, dorsalis pedis, and posterior tibialis arteries were absent. No blood inflow was detected in the superficial and deep femoral, popliteal, and anterior and posterior tibialis arteries. Thrombectomy was performed, and a fatty-like mass from the bifurcation of the common femoral artery and a thrombotic mass from the proximal portion of the superficial and deep femoral arteries were removed. The pulsatile inflow and palpable pulses of the left femoral, popliteal, dorsalis pedis, and posterior tibialis arteries were restored after surgery. The histological findings of the embolus were suggestive of a cardiac myxoma. The patient's consciousness and lower limb blood flow improved gradually. He was discharged from the hospital with full awareness and improved lower extremity muscle function 2 weeks after surgery." }, { "id": "pubmed23n0367_16458", "title": "[Arterial embolisms of the lower extremities].", "score": 0.009708737864077669, "content": "Embolism is one of the most frequent causes of lower limbs acute arterial occlusion [1]. Of the total number of peripheral embolism 56% of cases involve lower limbs arteries [2]. Inadequate and late treatment of the lower limbs embolism is associated with high morbidity and mortality rate. The aim of this paper was to study the aetiology of lower limbs embolism and to detect factors influencing early and late results after the operative treatment. The study included 204 patients with 224 lower limbs embolism, treated surgically at the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade in the period between 1993 and 1997. There were 107 (52.2%) female and 97 (47.8%) male patients. Thirty two (14.3%) patients were younger than 50 years, 64 (28.6%) were between 51 and 65, 101 (45.1%) between 66-75, while 27 patients (12.1%), were older than 75. Twenty (8.9%) patients were admitted less than 6 hours before the operation, 79 (33.3%) between 6 and 24 hours, and 125 (55.8%) more than 24 hours before the operation (Table 1). One hundred (53.6%) patients had motor and 133 (59.4%) sensor paralysis on admission. Table 2 shows arterial localization of the lower limbs embolism. The popliteal artery was involved in most cases. During the operation transfemoral arterial approach was used in 132 (58.9%) cases, while transpopliteal in 92 (41.1%) cases. Fourteen cases required bypass surgery, 43 fasciotomy, 2 intraoperative streptokinase and 4 intraoperative angiography. All patients were controlled using physical and CW Doppler ultrasonographic examinations immediately after the operation, and then one, six and 12 months, as well as every year. In 173 (84.4%) patients cardiac causes of embolism were found, in 8 (3.9%) noncardiac, while in 8 (3.9%) the cause could not be established. Of all cardiac causes absolute arrhythmia was most frequent. Table 3 and Table 4 show the aetiology of the lower limb embolism. The early amputation rate was 23 (10.3%) cases, while limb salvage was recorded in 174 (77.7%) patients. Of all saved limbs complete recovery was noted in 162 (72.4%) cases and peroneal nerve paresis in 12 (5.3%) cases. The early postoperative mortality rate was 27 (12.0%). Table 5 shows early results of embolectomy. The early results (limb salvage, complete recovery, rethrombosis, early reoperations, amputations rate, morbidity and mortality rate) of embolectomy were statistically significant: worse in cases when the embolus was located in the abdominal aorta and popliteal artery; in cases with a long time interval before the operation as well as in patients with sensor-motoric paralysis on admission (Tables 6-8). Of the total number of patients in 87 (56.5%) cases a late control examination was carried out. Forty nine (31.8%) patients died before the late control, while 18 (11.7%) did not come to control examination. Late recidivation of embolism was found in 3 cases. In these patients the cause could not be found, and they were treated by anticoagulant drugs." }, { "id": "Surgery_Schwartz_6391", "title": "Surgery_Schwartz", "score": 0.009638831377961812, "content": "the most important pieces of information to obtain is whether the patient has had prior vascular procedures or if there is a history of lower extremity claudication. Either of these features suggests preexisting vascular disease, renders revasculariza-tion more complicated, and usually mandates angiography to permit surgical planning. On the contrary, in a patient with no history suggestive of prior vascular disease, the etiology is most likely embolic, and simple thrombectomy is more likely to be successful.Absent bilateral femoral pulses in a patient with bilateral lower extremity ischemia is most likely due to saddle embolus to the aortic bifurcation. A palpable femoral pulse and absent popliteal and distal pulses may either be due to distal common femoral embolus (the pulse being palpable above the level of occlusion) or embolus to the superficial femoral or popliteal arteries. Typically, emboli lodge at arterial bifurcations where they are trapped due to sudden reductions in" }, { "id": "pubmed23n0479_1717", "title": "Vascular evaluation and arterial reconstruction of the diabetic foot.", "score": 0.009615384615384616, "content": "Findings of diminished or absent pulses, pallor on elevation, redness of the foot on lowering of the leg, sluggish refilling of the toe capillaries, and thickened nails or absence of toe hair are consistent with impaired arterial perfusion to the foot. When ischemia is recognized as contributing to pedal ulceration and infection in the diabetic foot, quantitation of its severity may be difficult. Standard clinical evaluation of trophic changes is limited in an infected foot with its accompanying swelling, edema, and erythema. A palpable pedal pulse does not preclude the possibility of the presence of limb-threatening ischemia. Additional non-invasive vascular studies should be undertaken for these patients. Management of the diabetic foot is often a complex clinical problem. However, the principles of care are simple, including correction of systemic factors, such as blood glucose control, cardiovascular risk factor management, and smoking, as well as local factor correction, such as debridement, pressure relief, infection control, and revascularization when indicated. When a patient presents with evidence of infection, adequate drainage and antibiotic therapy are mandatory. The next step should be performed to differentiate the more common neuropathic ulcerations from the truly ischemic ulceration. Symptoms of rest pain or claudication are not often helpful because many of these patients are asymptomatic as a result of the presence of their neuropathy and inactivity. If an infected foot requires debridement or open partial forefoot amputation, observing the wound on a daily base is also important. Once infection is eradicated, there should be prompt signs of healing, including the development of wound granulation within several days. If wounds are not showing signs of prompt healing, arteriography is necessary. Early aggressive drainage, debridement, and local foot amputations combined with liberal use of revascularization results in cumulative limb salvage of 74% at 5 years in high-risk groups. Others report that pedal bypass to the ischemic infected foot is effective and safe as long as infection adequately controlled. These studies strongly suggest that early recognition and aggressive surgical drainage of pedal sepsis followed by surgical revascularization is critical to achieving maximal limb salvage in the high-risk population. Patients who have diabetes present a unique challenge in lower extremity revascularization because of the distal origination of many bypasses, distal distribution of the occlusive disease, and the frequently calcified arterial wall. An aggressive multidisciplinary approach to foot disease associated with diabetes involving the primary care provider, medical specialists, interventional radiology, and podiatric, plastic, and vascular surgeons will provide optimal medical and surgical care. Peripheral vascular disease is highly treatable if intervention is instituted in a timely and collegial fashion." }, { "id": "pubmed23n0371_15869", "title": "[Surgical therapy of acute and chronic arterial occlusions below the inguinal ligament].", "score": 0.009615384615384616, "content": "The history and physical examination are extremely important in the management of vascular surgical patients because a correct diagnosis can usually be made on the basis of information obtained from these two modalities. The severity of the chronic occlusive process leads to characteristic symptoms in the extremity: claudication, rest pain, skin ulcerations and gangrene. Chronic progressive lesions permit enlargement of collateral blood supply which, for a time, minimizes the severity of symptoms. Milde degrees of arterial insufficiency (claudication) can be treated conservatively. Unreconstructed chronic critical ischemia predicts a poor outcome in terms of survival and limb salvage. The outlook with arterial reconstructive surgery is by far better. Arteriography ist the most reliable diagnostic test for occlusive lesions. It ist essential for the operative planning. Vein-bypass procedures are, if feasible, very effective in most cases. Acute embolic occlusion: Sudden occlusion of a previously patent artery is usually a dramatic event producing severe ischemia of the distal tissue. The characteristic symptoms and signs are the 5 P's: pallor, pain, paresthesia, paralysis, pulselessness. Emergent restoration of blood flow by operation may be essential to prevent limb loss. Milder forms of ischemia (acute thrombosis--acute or chronic disease) can be treated initially with intravenous heparin if the extremity is not threatened (minimal sensory loss, no muscle weakness). Elective surgery at a later date is highly successful." }, { "id": "pubmed23n0607_9350", "title": "Reversal of ergotamine-induced vasospasm following methylprednisolone.", "score": 0.009523809523809525, "content": "Ergotamine, an ergot alkaloid with partial agonist effects on alpha1 receptors and serotonin receptors, is widely used in the treatment of migraine. Ergotamine may cause severe vasospasm. A 25-year-old man was admitted to the emergency department with complaints of sudden coldness, pallor, and pain in his hands and feet for 2 days. He had been using a drug containing ergotamine for his migraine headaches for 1 week. On examination, the pulses of the radial, ulnar, popliteal, and tibial arteries were bilaterally undetectable. Treatment consisted of sodium nitroprusside and heparin. On the third day of the admission, bilateral brachial and femoral artery pulses were lost and his complaints exacerbated. Angiography revealed diffuse vasospasm of the arteries in the both lower extremities (Fig. 1A and C). Because of the lack of response to the ongoing therapy, a single dose of methylprednisolone sodium succinate (1 mg/kg) was given intravenously; the nitroprusside infusion was terminated because of the development of hypotension. The pulses were palpable 2 h after the methylprednisolone dose. Angiography done 12 h after the methylprednisolone dose showed improvement of the vasospasm in the lower extremities. Recovery was uneventful and follow-up evaluation found no abnormalities. Although vasodilator agents are first-line therapy in the treatment of ergotism, corticosteroids may be considered as an alternative therapy, especially for intractable cases. The mechanism by which corticosteroids dilate arteries is not clear. Ischemia in an extremity secondary to ergotamine-induced vasospasm unresponsive to sodium nitroprusside may be treated successfully with methylprednisolone." }, { "id": "pubmed23n0858_3816", "title": "Transient Monoplegia as a Result of Unilateral Femoral Artery Ischemia Detected by Multimodal Intraoperative Neuromonitoring in Posterior Scoliosis Surgery: A Case Report.", "score": 0.009433962264150943, "content": "This is to report a case of 16-year-old girl with transient right lower limb monoplegia as a result of femoral artery ischemia detected by multimodal intraoperative spinal cord neuromonitoring (MISNM) during posterior correction surgery of adolescent idiopathic scoliosis.A patient with a marfanoid body habitus and LENKE IA type scoliosis with the right thoracic curve of 48° of Cobb angle was admitted for posterior spinal fusion from Th6 to L2. After selective pedicle screws instrumentation and corrective maneuvers motor evoked potentials (MEP) began to decrease with no concomitant changes in somato-sensory evoked potentials recordings.The instrumentation was released first partially than completely with rod removal but the patient demonstrated constantly increasing serious neurological motor deficit of the whole right lower limb. Every technical cause of the MEP changes was eliminated and during the wake-up test the right foot was found to be pale and cold with no popliteal and dorsalis pedis pulses palpable. The patient was repositioned and the pelvic pad was placed more cranially. Instantly, the pulse and color returned to the patient's foot. Following MEP recordings showed gradual return of motor function up to the baseline at the end of the surgery, whereas somato-sensory evoked potentials were within normal range through the whole procedure.This case emphasizes the importance of the proper pelvic pad positioning during the complex spine surgeries performed in prone position of the patient. A few cases of neurological complications have been described which were the result of vascular occlusion after prolonged pressure in the inguinal area during posterior scoliosis surgery when the patient was in prone position. If incorrectly interpreted, they would have a significant impact on the course of scoliosis surgery." }, { "id": "pubmed23n0409_5657", "title": "Approach to the patient with acute limb ischemia: diagnosis and therapeutic modalities.", "score": 0.009433962264150943, "content": "Good patient outcomes depend on the rapidity and completeness with which re-establishment of arterial blood flow to the limbs occurs. Patients with a greater magnitude of ischemic tissue--such as with an acute aortic occlusion--have worse outcomes than patients with a segmental artery occlusion such as a popliteal arterial thrombosis. Limb loss is high in any situation in which a delay in diagnosis occurs. It is unclear whether or not endovascular therapy will supercede traditional surgery because the etiologies of ALI are too broad to make sweeping conclusions at this time. The author and others [14,15], including those who have promulgated the use of thrombolytic therapy, have come to reasonable conclusions regarding how to deal with ALI: The diagnosis of ALI should be established rapidly. Determine its classification based on the patient's history and physical examination, and promptly institute anticoagulant therapy. Determine whether or not the patient should be taken emergently for surgical thromboembolectomy or a revascularization procedure versus arteriogram and possible thrombolysis. Adjunctive therapy such as antiplatelet agents (e.g., GIIb/IIIa antagonists) and other anticoagulant agents must be better investigated before recommendations can be made. Save life over limb. Emergent guillotine amputation is sometimes required to save a patient's life." }, { "id": "pubmed23n0731_9255", "title": "Lift the quilt in case of atrial fibrillation and disc prolapse.", "score": 0.009345794392523364, "content": "Peripheral embolism to the lower extremities may mimic disc prolapse with severe consequences. A 71-year-old male with a history of chronic alcoholism developed low back pain radiating to both lower extremities in a nonradicular distribution and bilateral dysesthesias of the distal lower legs after lifting a heavy weight. Given that magnetic resonance imaging (MRI) of the lumbar spine showed disc herniation in L3/4 and L4/5, he was scheduled for laminectomy but was unable to undergo surgery due to thrombocytopenia. After transfer to another hospital, persistence of symptoms and signs, absent pulses on the distal lower legs, and rhabdomyolysis with temporary renal insufficiency, peripheral embolism with compartment syndrome was suspected. Magnetic resonance angiography revealed occlusion of the right superficial femoral artery and long high-grade stenosis of the left superficial and profound femoral arteries and distal arteries. He successfully underwent embolectomy and fasciotomy. If lumbar pain is not radicular, peripheral pulses are minimally palpable, and distal limbs are cold and show livid decolorization, peripheral embolism is much more likely than disc herniation, particularly if the patient's history is positive for atrial fibrillation. MRI of the lumbar spine must be interpreted in conjunction with clinical presentation." }, { "id": "pubmed23n0059_1332", "title": "[The diagnosis of peripheral arterial embolism].", "score": 0.009345794392523364, "content": "Acute embolic occlusion of a peripheral artery requires rapid and precise diagnosis in order to provide the appropriate treatment without delay. The symptoms and findings of acute arterial occlusion are characterized by \"the six Ps\": pain of sudden onset in the hypoperfused extremity, paleness, pulselessness, paresthesias, paralysis and, in the extreme case, prostration with the symptoms of shock. With embolization in arterial segments with only minimal residual perfusion via collaterals (for example, the femoral bifurcation), a complete ischemic syndrome is usually incurred manifesting the six Ps as delineated. If preformed collateral systems provide some perfusion distal to an arterial occlusion (for example, in the common iliac artery), there is frequently an incomplete ischemic syndrome observed which is characterized by pain, paleness and pulselessness. Peripheral arterial embolism has a predilection for the femoral bifurcation, the superficial femoral artery and the popliteal artery. In principle, however, embolization can occur in every arterial segment. The diagnosis of the acute ischemic syndrome can generally be established on the basis of the history and physical examination. Diagnostic aid can be provided by electronic segmental oscillography to demonstrate diminished or absent oscillations and with the Doppler sonographically-determined systolic arterial pressure at the ankle which, in the case of severe ischemia, is less than 50 mmHg. Arteriography provides the most accurate morphological information. Abrupt occlusion of the vessel and no collateral perfusion especially in the absence of arteriosclerotic changes are strongly indicative of embolism but not conclusive. If the clinical diagnosis is unequivocal, arteriography need not be performed prior to embolectomy with a Fogarty catheter.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en048_43631", "title": "Revascularization", "score": 0.009259259259259259, "content": "In medical and surgical therapy, revascularization is the restoration of perfusion to a body part or organ that has suffered ischemia. It is typically accomplished by surgical means. Vascular bypass and angioplasty are the two primary means of revascularization. The term derives from the prefix re-, in this case meaning \"restoration\" and vasculature, which refers to the circulatory structures of an organ. It is often combined with \"urgent\" to form urgent vascularization. Revascularization involves a thorough analysis and diagnosis and treatment of the existing diseased vasculature of the affected organ, and can be aided by the use of different imaging modalities such as magnetic resonance imaging, PET scan, CT scan, and X ray fluoroscopy." }, { "id": "pubmed23n0037_10400", "title": "[Our experience with peripheral arterial embolectomy].", "score": 0.009259259259259259, "content": "34 cases of acute peripheral ischaemia examined in recent years at the University of Messina General Surgery Clinic are presented. 16 were subjected to embolectomy according to Fogarty. The remaining 18 received protracted medical therapy. Some successes were obtained. In other cases, gangrene necessitated amputation of the affected limb. Satisfactory results were observed in 70% of the operated series. Success was more marked when only a short interval was left between the embolic episode, with progressively poorer results as the penalty for delay. The long-term results of embolectomy are related to the nature of the underlying disease and the treatment given after surgery." }, { "id": "article-17146_13", "title": "Acute Arterial Occlusion -- Treatment / Management", "score": 0.009195402298850575, "content": "Cases of limb-threatening ischemia require emergent vascular surgery consult. The surgical approach is directed at the reperfusion of the affected extremity. This can be accomplished by surgical bypass, endarterectomy, or embolectomy. Results are variable and will ultimately depend on the duration of the ischemia and the extent of occlusion. Catheter-directed thrombolysis (CDT) by an interventional radiologist is becoming more common and is reserved for patients with a salvageable limb (Rutherford class II, IIa, and IIb). Patients presenting with profound paralysis and absent pain with inaudible arterial and venous pulses are considered to have irreversible damage and will require amputation. Surgical treatment options are typically reserved for more severe cases or where nonsurgical management fails. These options include the following: Open bypass surgery Endovascular therapy, such as stenting, balloon angioplasty, or atherectomy" }, { "id": "pubmed23n0706_12498", "title": "Persistent sciatic artery aneurysm: a case report.", "score": 0.009174311926605505, "content": "In early embryologic development the sciatic artery provides the blood supply to the lower limb bud. When the femoral artery develops, the sciatic artery involutes. However, in rare cases, the sciatic artery persists. It can be visualised as a prolongation of the inferior gluteal artery (branch of the internal iliac artery) and it accompanies the sciatic nerve at the posterior side of the hip. We present the case of a 47-year old woman who consulted because of a numb right foot which presented colder and paler than the left foot. She also had a right painful calf, especially after exercise. Upon physical examination and doppler ultrasound there were no popliteal nor pedal artery pulses in the right leg. CT angiography showed bilateral persistent sciatic arteries with aneurysm formation and the presence of an embolus in the popliteal artery at the right side. Treatment involved thrombolysis of the popliteal occlusion, followed by intra-aneurysmatic stent placement and embolectomy of the popliteal artery and its distal branches. Postoperative clinical results were remarkably good and the patients symptoms dissolved. A persistent sciatic artery is a rare vascular anomaly. It is more prone to vasculopathies such as aneurysm formation. In cases of acute ischemia, correct diagnosis and treatment of this anomaly can avoid serious medical consequences." }, { "id": "pubmed23n0604_10784", "title": "Treatment of critical limb ischemia in the elderly.", "score": 0.009174311926605505, "content": "Acute critical limb ischemia (CLI) is a rather frequent clinical event in elderly patients. Atherosclerotic plaques or cardiopathies (atrial enlargement and fibrillation, ventricular thrombosis) are the most frequent clinical situations related to peripheral embolization. Rapid diagnosis followed by suitable treatment allows us to obtain good results even in elderly patients. The decision about the treatment of acute CLI is related to the clinical and functional condition of the patient. Anamnesis must inquire about recent ischemic or hemorrhagic events in the cardiovascular, gastro-intestinal and urinary apparatuses, or the presence of disorders of coagulation and fibrinolysis. An objective clinical examination and a multidimensional assessment must evaluate the degree of functional impairment and provide the basis of a therapeutic strategy (cost/benefit ratio). Diagnostic examination in the frail elderly patient (FP) involves only the ultrasonographic method, to localize the level of thromboembolic occlusion, which is followed by angiography in the non-frail patient (NFP). In the case of proximal occlusion (of the iliac or femoro-popliteal arteries), the elective treatment in both groups of patients is thromboendarterectomy, plus transcutaneous angioplastics or by-pass in NFP, followed by prostacyclin or heparin infusions. Distal occlusion (below the popliteal artery) in FP is treated only with prostacyclin or heparin, whereas in NFP, fibrinolysis is the elective treatment, followed by prostacyclin or heparin. In the cases of distal gangrene, before amputation is performed, a \"limb salvage\" operation must be considered. After the acute phase of medical or surgical treatment, vasoactive or antiplatelet drugs are employed in FP, whereas in NFP the use of coumadin is the preferred treatment to counteract the rethrombosis and prevent new embolizations. Antiplatelet therapy could be selected when coumadin is contra-indicated." }, { "id": "pubmed23n1152_12506", "title": "A successful surgical management and outcome for a young man with infrarenal aortoiliac occlusion: A rare case report of Leriche syndrome.", "score": 0.00909090909090909, "content": "Leriche syndrome, also known as aortoiliac occlusive disease, is characterized by chronic obstruction of the abdominal aorta and iliac arteries. The disease was first described by Robert Graham in 1814. Leriche syndrome was named after a French surgeon, Rene Leriche, who first operated on the condition. We present a 35-year-old male patient who came to our cardiovascular polyclinic in a wheelchair. He had been complaining for a year about severe back pain, leg cramps on both sides, and weakness in both legs. Associated symptoms included fatigue, lower limb tingling, and numbness. Physical examination revealed pulselessness in the popliteal-dorsalis pedis and posterior tibial arteries in both lower extremities, and coldness and ulcers in the dorsum part of the foot. Leriche syndrome often presents with a triad of clinical symptoms: (1) intermittent lower extremity vascular claudication, (2) impotence, and (3) weak/absent femoral pulses. This case report contributes to the current literature when any patient has lower limb weakness, pain, and ulcers. It must be considered in our differential diagnosis list for Leriche syndrome. This makes us more aware of the need for early diagnosis and intervention to decrease late complications of ischemia. Leriche syndrome, also known as aortoiliac occlusive disease, is considered because of its high morbidity and mortality. This was the first case in Somalia to be successfully managed and operated on by using extra-anatomical bypass, especially axillo-bifemoral bypass, by using it as an emergency measure to save ischemic limbs and shorten the length of time in the hospital." }, { "id": "pubmed23n0994_16338", "title": "Does the new vascular management of acute limb ischemia have effective results with lower treatment costs.", "score": 0.00909090909090909, "content": "Aim To compare hospital costs of acute limb ischemia treatment in two periods of time and to show evidence of long-term repercussions on reducing costs during successful treatment. Methods Retrospective analysis of data obtained from 100 patients' medical history in the period 2000-2016 at the Clinic of Vascular Surgery Sarajevo: group A - 60 patients with acute limb ischemia in the period 2005-2016 and group B - 40 patients with acute limb ischemia (ALI) in the period 2000-2005. From 2000 to 2005 conservative treatment method was used, invasive diagnostic and surgical procedures were often delayed for a shorter or longer period of time. During the period from 2005 to 2016, the management model and safe practice included emergency diagnostic procedures, colour-Doppler, arteriography, emergency surgery (embolectomy by Fogharty and if necessary, vascular by-pass). Results Better health service for the patients with acute limb ischemia was offered in the period 2005-2016, which relied on proven medical treatment trends. The largest share of the total costs of each patient included costs of hospital bed with significant difference between the period 2005-2016 and 2000-2005, mean of 1398.71 KM and 2480.45KM, respectively (p&lt;0.0001), indicating rationalization of time that patients spend at the Vascular Clinic. Conclusion This trend of money/fund savings is an example of good practice, effectiveness and efficiency in the treatment of ALI and as such was used in patients with other vascular diseases." }, { "id": "pubmed23n0362_14684", "title": "Acute arterial thrombosis with antithrombin III deficiency in nephrotic syndrome: report of a case.", "score": 0.009009009009009009, "content": "Nephrotic syndrome frequently causes venous thromboembolic complications. Arterial thrombosis has rarely been reported and is mainly observed in children. Only six cases of lower extremity arterial thrombosis in adults have been reported in the literature. The outcome in these cases was unsatisfactory because of the high rates of limb loss and recurrence of thrombosis. We report successful treatment of a 39-year-old man who suffered from right lower extremity arterial thrombosis associated with decreased levels of serum antithrombin III. He was admitted to our hospital with severe pain in his right foot. No pulse was palpable in his right dorsalis pedis or posterior tibial arteries. His right foot was cold and mottled, with a reduced sensation and motor activity. The laboratory data revealed a serum total protein concentration of 3.9g/dl and an albumin concentration of 1.5 g/dl. The coagulation profile showed a fibrinogen level of 879 mg/dl and antithrombin III value of 9.5%. Right lower extremity arteriography showed a complete occlusion of the right deep femoral artery and popliteal artery, and a filling defect in the common femoral artery. An emergency thrombectomy was performed under general anesthesia. The patient was treated successfully, and surgical treatment was followed by anticoagulant therapy with 1,000 units of antithrombin III. A renal biopsy revealed histologic evidence of minimal change of glomerulonephritis. He was discharged 3 months later, and no recurrence of thrombosis has yet been observed." }, { "id": "pubmed23n0875_14525", "title": "Popliteal Artery Occlusion in a Wrestler in the Absence of Known Trauma.", "score": 0.008928571428571428, "content": "In brief: A college wrestler was first seen by an athletic trainer when he complained of a burning pain in his right foot. He recalled no traumatic event that might have caused the pain. He was referred to the athletic department's consulting podiatrist. An examination showed that the patient's right foot was cool and pale and that the pedal pulses were absent. Immediate referral was made to a vascular surgeon. A right femoral arteriogram showed complete occlusion of a 3.5-cm segment of the popliteal artery. A femoral popliteal artery bypass was performed. The patient recovered fully but was discouraged from participating in competitive sports. " } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 257, 379 ] ], "word_ranges": [ [ 40, 63 ] ], "text": "In this case we are being told that the teste is always in the inguinal canal (cryptorchidism) so we can discard option 1." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 380, 620 ] ], "word_ranges": [ [ 63, 100 ] ], "text": "Hormonal treatment with HCG has already fallen into disuse, due to its low efficacy, possibility of reascension and because apoptotic and inflammatory phenomena have been described in the teste associated with its use (we discard option 3)." }, "4": { "exist": true, "char_ranges": [ [ 621, 766 ] ], "word_ranges": [ [ 100, 125 ] ], "text": "Orchidopexy is the treatment of choice when we are faced with cryptorchidism, being desirable to perform it between 6 months and one year of age," }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The most probable diagnosis is retractile testicle.", "2": "Wait until two years of age for its spontaneous decrease.", "3": "Human chorionic gonadotropin is the treatment of first choice.", "4": "The indication for orchidopexy should not be deferred.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0513_9119", "title": "The efficacy of human chorionic gonadotropin in retractile testis.", "score": 0.01709901351845086, "content": "To evaluate the efficacy of hCG therapy on retractile testis in various testicular locations and age groups. This study comprised 123 boys whose diagnosis were retractile testis with scrotal base, high scrotal and superficial inguinal localizations with an average age of 4,2 (1-8) years. 123 boys with retractile testes were given a total dose of 9000 hCG and its effect on scrotal base, high scrotal and superficial inguinal located testes were evaluated after 2 weeks and 6 months of completing hCG course. The patients were evaluated in four age groups such as less than 2 years of age, between 2-4, 4-6 years and more than 6 years of age and the response rates were also noted in these age groups. In unilateral cases, the response in base, high scrotal and superficial inguinal levels were found as 100%, 83,3%, 72,7% respectively where as these rates were found as 100%, 92,6%, 76,3% respectively in bilateral cases after 2 weeks of hCG therapy. The response rates in less than 2 year old group, 2-4, 4-6 and more than 6 years group were found as 0%, 80%, 78,7%, 100% respectively in unilateral cases and 33,3%, 90%, 86,9% and 83,3% respectively in bilateral cases. After 6 months, reascend was observed in 12,4% in unilateral group and 6,7% in bilateral group. 72,7-100% of retractile testes respond to hCG administration with the highest response in the age of more than six year group. High response rates observed in retractile testes after hCG therapy in more than 2 years old age group indicate that hCG must be given as a primary treatment in retractile testes and orchiopexy for the failures. Also patients must be followed up closely for reascend cases." }, { "id": "pubmed23n0594_12978", "title": "[The undescended testis: arguments in favour of early treatment, provided retractile testis and acquired non-scrotal testis have been excluded].", "score": 0.016877937615724255, "content": "--Guidelines for the treatment ofundescended testis (UDT) are sparse. Often an operation in the second year of life is advised. --Recent data indicate that the normal maturation process, which will ultimately lead to a normal quantity and quality of germ cells, is impaired as early as in the first half year of a newborn's life. None of the guidelines take this into account. Spontaneous descent after the fourth month following birth, of testes that have previously not descended, hardly ever occurs. --No differences have been shown in complication numbers between surgery before and after the first birthday. Orchidopexy prior to the 13th birthday reduces the risk of testicular cancer. --Therefore, based on these data, it is advised to perform orchidopexy in the second half of the first year of a newborn's life. In older boys a UDT must be treated before the 13th birthday. --In the Netherlands a lot more orchidopexies are done despite what may be expected based on prevalence numbers of UDT: testes retaining a normal volume that would most probably have descended spontaneously come puberty. --It remains important to carry out a careful physical examination and document the position of the testes soon after birth, and later on if UDT is suspected, to avoid unnecessary operations on retractile testes and acquired UDT." }, { "id": "pubmed23n0539_14754", "title": "[HCG in the treatment of cryptorchidism. The effect of age and position of the testis].", "score": 0.016783216783216783, "content": "In a recent study, the effect of human chorionic gonadotropin (HCG) in the treatment of children with cryptorchidism aged less than four years was questioned. The purpose of the present study was to determine, on the basis of a retrospective examination of patients' records, the effect of HCG treatment, whether outcomes are age-dependent and whether the effects of treatment are related to the position of the testis. Patients diagnosed with undescended testis who had been treated at the Department of Urology at Gentofte Hospital (Copenhagen) in the period from 1 November 1998 to 31 May 2003 were identified. Patients who had been treated with HCG were included in the sample. Boys who at an earlier stage had been operated on in the inguinal or scrotal region, or who had suffered from inguinal hernia, were excluded, and clinical retractile testes were separated from true undescended testes. The criterion of success for efficient treatment was complete descent to the bottom of the scrotum. In the 306 records examined, 121 patients met the inclusion criteria. In total, there were 170 undescended testes. The patients' median age at time of treatment was 3.6 years. The overall success rate was 34.7%. The success rates in the individual age categories were: 1-2 years, 36.7%; 3-4 years, 33.4%; and 5-13 years, 35%. The position of the testis at the beginning of treatment showed that the lower the pretreatment position, the better the success rate. The overall success of HCG treatment of cryptorchidism was 34.7%. No age dependency of HCG effects was found, but the position of the testis before treatment influenced the success rate." }, { "id": "pubmed23n0394_16949", "title": "[Non-scrotal testes; first line of management].", "score": 0.01626123744050767, "content": "For non-scrotal testes a distinction can be made between retractile testes (completely descended and normally developed but sometimes situated subcutaneously in the groin area), retained testes (testes cannot be brought into the scrotum or this can only be achieved using light manual pressure) and ectopic testes (lying outside of the descent trajectory). It is estimated that 0.7-0.8% of all boys have as yet undescended testes. The first few days after the birth are the most suitable for testing and registration, as then the cremaster reflex is absent. Registration should take place in both the youth healthcare file and in the 'growth book' for the parents. Retractile testes do not require treatment. There is no consensus concerning the treatment of (possible) acquired nonscrotal testes. For undescended testes the management depends on previous testes localisations. For ectopic testes and testes that have never been scrotal, a referral for surgical treatment should be made prior to the second birthday. Orchidopexy (a better description is orchidofuniculolysis followed by orchidopexy) is only justified in the case of testes which have never descended. In the case of a clear indication, the general practitioner should make a prompt referral (before the second birthday) and in other cases assurance should be provided and an expectant policy adopted until puberty." }, { "id": "pubmed23n1027_23747", "title": "Comparison of diagnostic and treatment guidelines for undescended testis.", "score": 0.016076962809917356, "content": "Cryptorchidism or undescended testis is the single most common genitourinary disease in male neonates. In most cases, the testes will descend spontaneously by 3 months of age. If the testes do not descend by 6 months of age, the probability of spontaneous descent thereafter is low. About 1%-2% of boys older than 6 months have undescended testes after their early postnatal descent. In some cases, a testis vanishes in the abdomen or reascends after birth which was present in the scrotum at birth. An inguinal undescended testis is sometimes mistaken for an inguinal hernia. A surgical specialist referral is recommended if descent does not occur by 6 months, undescended testis is newly diagnosed after 6 months of age, or testicular torsion is suspected. International guidelines do not recommend ultrasonography or other diagnostic imaging because they cannot add diagnostic accuracy or change treatment. Routine hormonal therapy is not recommended for undescended testis due to a lack of evidence. Orchiopexy is recommended between 6 and 18 months at the latest to protect the fertility potential and decrease the risk of malignant changes. Patients with unilateral undescended testis have an infertility rate of up to 10%. This rate is even higher in patients with bilateral undescended testes, with intra-abdominal undescended testis, or who underwent delayed orchiopexy. Patients with undescended testis have a threefold increased risk of testicular cancer later in life compared to the general population. Self-examination after puberty is recommended to facilitate early cancer detection. A timely referral to a surgical specialist and timely surgical correction are the most important factors for decreasing infertility and testicular cancer rates." }, { "id": "pubmed23n0056_419", "title": "The undescended testicle.", "score": 0.015874015748031496, "content": "Cryptorchidism results from a complex hereditary series of incompletely understood events involving the HPG axis. The incidence is indirectly related to birth weight and dramatically decreases during the first 3 months after birth. Many nonscrotal testes are retractile and require no therapy whatsoever. True cryptorchid testes develop identifiable histologic alterations within 2 years of parturition, and endocrine abnormalities are often detectable during infancy. Hormonal therapy with hCG is effective in causing descent in only a small percent of children with cryptorchidism. GnRH nasal spray is no different from placebo in double-blind studies in which retractile testes have been excluded. The results are best in low-lying testes and in older children, but a recognized late-failure rate requires continued surveillance. HCG therapy appears to be of little use in nonpalpable cryptorchid testes. The risk of testicular cancer is increased in men with a history of cryptorchidism and even includes the contralateral descended testes. This risk may be reduced by early orchidopexy. Fertility is impaired in men with cryptorchidism and is reported to be no better than 75% and 50%, respectively, in men who have undergone successful unilateral or bilateral orchidopexy. There is unconfirmed evidence that orchidopexy carried out before the age of 2 years may improve these fertility rates. It is recommended that all children with cryptorchid testes undergo treatment by the age of 1 or 2 years. The parents of children with a nonpalpable testis should be informed of the high rate of testicular absence. If hormonal therapy is to be used, it must be initiated at 10 months of age. Treatment failures must be identified quickly to allow prompt referral of these children to a pediatric urologist or surgeon for orchidopexy." }, { "id": "pubmed23n0096_18018", "title": "Acquired undescended (ascended) testis: effects of human chorionic gonadotropin.", "score": 0.015440969287123133, "content": "A total of 7 boys 4 to 10 years old was evaluated for undescended testes. All patients had been seen previously by a pediatric urologist and diagnosed as having a retractile testis. In fact 4 boys had undergone surgical correction of a contralateral undescended testis at an earlier date at which time the testis in question could be manipulated into the scrotum. Another boy was examined under anesthesia and the operation was canceled because the testis could be brought into the scrotum. Subsequently, on followup evaluation 2 to 8 years later the ipsilateral testis could not be manipulated into the scrotum. Of the boys 6 then were treated with a short course of human chorionic gonadotropin. Four patients had a positive response but in 3 the testis was undescended again at examination 6 months later. Of the boys 6 ultimately underwent orchiopexy. Boys with highly retractile testes require periodic examination until puberty to ensure that those testes do not ascend secondarily." }, { "id": "pubmed23n0263_8981", "title": "Fertility in cryptorchidism. Does treatment make a difference?", "score": 0.01489136195018548, "content": "The testis which remains nonscrotal beyond puberty will not produce sperm. While much of the data presented imply that therapy of cryptorchidism during childhood will decrease the likelihood of infertility, the available data do not substantiate this. There are also inadequate data to indicate whether treatment at very young ages in childhood decreases the risk of infertility. In fact, it is not clear that fertility rates among males who were unilaterally cryptorchid is different than that of the unaffected male population! Therefore, verification is needed to determine whether or not fertility is decreased in cryptorchidism. Paternity is a better index for verification than sperm counts since it is known that men with subnormal sperm counts may have normal paternity rates. Such verification using paternity may require more than fathering a child, such as the age of the father at the birth of the first child, length of marriage or partnership before birth of the first or subsequent children, or duration of intercourse without contraception to birth. Because of the multiple etiologies of the cryptorchid state, factors such as the relative size of the testis before treatment, and the position of the testis and the histology of the testis need to be considered since the small testis, the abdominal testis and the testis with the most histologic changes would appear to be at the greatest risk for defects in spermatogenesis. Until these data become available, most physicians are likely to recommend treatment of the undescended testis when detected if the child is older than six months. However, it must be remembered that there are no data to indicate benefit of early treatment. Before treatment is initiated, the physician must be careful to rule out a retractile testis. Also, the possibility of ascent of the testis which may occur during midchildhood, the age of physiologically normal hypogonadotropism, must be remembered. The testis which was previously normally descended but resides much of the time during midchildhood years within the inguinal canal may be a variant of normal and not require therapy. The approach to the patient with cryptorchidism must involve a careful history and repeated examinations looking for a cause and for accurate position of the testis. If the testis can be moved from the nonscrotal position into the scrotum, the potential function of the testis should not be harmed.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0318_8095", "title": "Effect of a combined GnRH/hCG therapy in boys with undescended testicles: evaluated in relation to testicular localization within the first week after birth.", "score": 0.01473922902494331, "content": "Among 509 boys referred with undescended testicles, 112 had true undescended testicles unilaterally and 62 bilaterally. Patients with true undescended testicles were offered hormonal treatment unless the condition was associated with hernia or previous operations. Boys less than 5 years old were primarily treated with gonadotrophin releasing hormone (GnRH), while boys more than 5 years old were primarily treated with human chorionic gonadotrophin (hCG). If the effect of the primary treatment was insufficient the other hormone was given. Testicular descent was obtained for 64% (23/36) of the intraabdominally located testicles in boys with bilaterally undescended testicles versus only 14% (3/21) in boys with unilaterally undescended testicles (p &lt; .001). Treating 1 to 4 years old boys with GnRH resulted in descent in 16 of 95 testicles and secondary treatment with hCG yielded an additional 34, whereas secondary treatment of 5 to 13 years old boys with GnRH added only 10 descended testicles to 51 of 101 testicles. Reading the maternity records of 272 of the boys support other studies showing that testicles may reascend. Boys with endocrinological or \"surgical\" causes of incomplete testicular descent were relatively more likely to have had one or two undescended testicles during the first postnatal week compared with boys found to have only retractile testicles (p &lt; .001). Treatment with hormones resulted in descent in 56% of boys whose testicles were both descended within one week after birth. Conversely, only 1 of 20 boys with unilateral testicular undescent postnatally was sufficiently treated with hormones (p &lt; .001). The hormonal effect in boys with bilaterally undescended testicles at delivery did not differ significantly from boys with either one or none undescended testicle postnatally. In 35 of 51 boys (69%) in whom the hormonal effect was insufficient, operation revealed a \"surgical cause\" of the incomplete testicular descent." }, { "id": "Pediatrics_Nelson_3509", "title": "Pediatrics_Nelson", "score": 0.014634846238461906, "content": "The undescended testis is usually histologically normal at birth. Atrophy and dysplasia are found after the first year of life. Some boys have congenital dysplasia in the contralateral descended testis. Surgical correction at an early age results in greater chance of adult fertility. Administration of human chorionic gonadotropin causes testosterone release from functioning testes and may result in descent of retractile testes. Orchidopexy is usually done in the second year of life. Most extra-abdominal testes can be brought into the scrotum with correction of the associated hernia. If the testis is not palpable, ultrasound or magnetic resonance imaging may determine its location. The closer the testis is to the internal inguinal ring, the better the chance of successful orchidopexy." }, { "id": "wiki20220301en017_70969", "title": "Cryptorchidism", "score": 0.014267802326084137, "content": "Diagnosis The most common diagnostic dilemma in otherwise normal boys is distinguishing a retractile testis from a testis that will not descend spontaneously into the scrotum. Retractile testes are more common than truly undescended testes and do not need to be operated on. In normal males, as the cremaster muscle relaxes or contracts, the testis moves lower or higher (\"retracts\") in the scrotum. This cremasteric reflex is much more active in infant boys than older men. A retractile testis high in the scrotum can be difficult to distinguish from a position in the lower inguinal canal. Though various maneuvers are used to do so, such as using a cross-legged position, soaping the examiner's fingers, or examining in a warm bath, the benefit of surgery in these cases can be a matter of clinical judgment." }, { "id": "pubmed23n0289_8759", "title": "Reappraisal of the role of human chorionic gonadotropin in the diagnosis and treatment of the nonpalpable testis: a 10-year experience.", "score": 0.014059514059514059, "content": "We retrospectively evaluated the ability of human chorionic gonadotropin (HCG) to make the nonpalpable cryptorchid testis become palpable and promote testicular descent. Through surgical bookings we identified 94 patients younger than 11 years who received HCG between 1984 and 1994 for the diagnosis or treatment of a nonpalpable undescended testis. The dose of HCG was 1,500 IU/m.2 intramuscularly 2 times weekly for 4 weeks. Testis location was determined by physical examination before and after hormone administration, and confirmed at surgical exploration. Of the 99 nonpalpable testes identified in 94 patients 39 (39%) became palpable following HCG administration and only 2 (2%) completely descended. A total of 60 testes remained nonpalpable with the most common reason being an absent or severely atrophic testis (40, 67%). Of the testes remaining nonpalpable after hormonal stimulation 73% were surgically located at or distal to the internal ring. HCG is preoperatively efficacious in causing the nonpalpable undescended testis to become palpable. For patients failing to respond to hormonal stimulation we recommend preliminary inguinal exploration, since most testes or testicular remnants are located within the inguinal canal or immediately below the internal ring." }, { "id": "pubmed23n0909_21405", "title": "Practical approach to evaluating testicular status in infants and children.", "score": 0.01398635477582846, "content": "To review the differences between normal, retractile, ectopic, ascended, and undescended testes and to describe the optimal way to perform a testicular examination to distinguish one from the other, as well as to demonstrate that ultrasound imaging is not necessary and to clarify when to consider specialist referral. This paper is based on selected findings from a MEDLINE search on undescended testes and orchiopexy referrals, and on our experience at the Urology Clinic at the Children's Hospital of Eastern Ontario in Ottawa, including review of referrals to our clinic for undescended testes and the resultant findings of normal variants versus surgical cases. The MeSH headings used in our MEDLINE search included <iundescended testicle, retractile testicle, ectopic testicle, ascended testicle, referral and consultation,</i and <iorchiopexy</i. An <iundescended testis</i is defined as the true absence of one testis (or both testes) from normal scrotal position. Ectopic and ascended testes will likewise be absent from the scrotum, the latter having been present at one point in development. Differentiating among testicular examination findings is important, as descended and retractile testes are managed conservatively, while prompt surgical intervention should be offered for ascended, ectopic, and undescended testes. Uncertainty surrounding the diagnosis of an undescended testis causes anxiety, might lead to unwarranted imaging, and might increase the wait list for specialty assessment. For this reason, avoidance of ultrasound in the evaluation of undescended testes was included in the recent Choosing Wisely Canada campaign. We seek to clarify the physical examination findings in the evaluation of possible undescended testes, the suggested referral parameters, and the subsequent management. Undescended testes and their variants are common. As decision for referral is based on the primary care physician's physical examination findings, we clarify distinguishing between normal and abnormal findings on testicular examination to aid in appropriate referral for subspecialist evaluation. Consultation, if needed, should be sought at 6 months' corrected gestational age, or at detection if later than 6 months, without delay for ultrasound imaging, as surgical management is recommended for those patients with undescended, ectopic, or ascended testes." }, { "id": "pubmed23n0613_13618", "title": "Further evidence for acquired undescended testicle in the UK and its incompatibility with current recommendations in the Hall Report.", "score": 0.013515870247645622, "content": "The 4th edition of the Hall Report [Hall DMB. Health for all children. Oxford: Oxford University Press; 2003. p. 167] does not expect undiagnosed undescended testicles at the age of 5 years or subsequently to be seen if its advice for diagnosis is carried out. We examine whether that recommendation can be relied upon. A retrospective audit was performed of 228 boys who underwent orchidopexy between January 1992 and December 2003 at the County Hospital Hereford, UK. During that time, 10,048 boys were born at the hospital. Child health records, hospital records and some GP records were used. A total of 103 boys (45%) were treated before their 5th birthday and 125 (55%) were treated after the age of 5; 93 orchidopexies were performed as a result of diagnosis made at birth or 6 weeks, but 83 were undertaken in boys documented as having scrotally placed testes both at birth and 6 weeks. A further 21 had documentation for scrotal testes either at birth (14) or at 6 weeks (7) but not both. The records of the remaining 31 are either missing or did not yield the information required largely because the Parent Held Child Record was introduced after their time. The literature was reviewed, and the results found to concur with those of other papers, in particular with a recent study from The Netherlands, which led to a new classification of undescended testis drawing attention to 'acquired undescended testicle'. The progressive nature of this entity was seen from review of the case notes. The natural history of acquired undescended testis means that recommendations as set out in the Hall Report \"that no further check after six weeks need be made if the testes are 'well down' at that stage\" cannot be successful, and all concerned in childhood surveillance will need to be aware of this and remain vigilant at least until puberty. Perhaps a prospective study following the Netherlands design should be undertaken in this country." }, { "id": "Surgery_Schwartz_11520", "title": "Surgery_Schwartz", "score": 0.01262998676498393, "content": "the incidence of infertility is approx-imately two times higher in men with unilateral orchidopexy compared to men with normal testicular descent.The use of chorionic gonadotropin occasionally may be effective in patients with bilateral undescended testes, suggest-ing that these patients are more apt to have a hormone insuf-ficiency than children with unilateral undescended testicle. The combination of micro-penis and bilateral undescended testes is an indication for hormonal evaluation and testoster-one replacement if indicated. If there is no testicular descent after a month of endocrine therapy, operative correction should be undertaken. A child with unilateral cryptorchidism should have surgical correction of the problem. The operation is typi-cally performed through a combined groin and scrotal incision. The cord vessels are fully mobilized, and the testicle is placed in a dartos pouch within the scrotum. An inguinal hernia often accompanies a cryptorchid testis. This should be" }, { "id": "pubmed23n0263_12527", "title": "Effect of human chorionic gonadotrophin (hCG)/follicle-stimulating hormone treatment versus hCG treatment alone on testicular descent: a double-blind placebo-controlled study.", "score": 0.012475709288767976, "content": "The medical treatment of retentio testis remains controversial because of ineffectiveness and/or adverse events. Follicle-stimulating hormone (FSH) seems to influence the spontaneous descent of the testis; furthermore, it induces luteinizing hormone (LH) receptors. Therefore, we performed a double-blind placebo-controlled study to investigate the effect of FSH with human chorionic gonadotrophin (hCG) versus hCG alone in retentio testis patients. Twenty-two boys with retentio testis were investigated, excluding retractile testis. Group A (N = 14: four with bilateral and 10 with unilateral retentio testis; mean age 3.15 years) was treated with 150 IU of FSH twice a week for 2 weeks followed by 150 IU of FSH and 250 IU of hCG (half the recommended World Health Organization dose) twice a week for another 4 weeks. Group B (N = 8: two with bilateral and six with unilateral retentito testis; mean age 3.3 years) was treated with 250 IU of hCG twice a week for 6 weeks. Testicular position, volume and consistency as well as the appearance of the scrotum and the penile length were determined at the start of the treatment as well as at weeks 2, 4, 6 and 12 by two independent investigators. Blood investigation consisted of measurements of LH, FSH, testosterone and sex hormone-binding globulin. Successful descent was considered when the testis reached a mid- or low scrotal position. In group A, 6/18 testes descended successfully. In group B, 6/10 testes descended. Of the unsuccessfully treated patients, six of group A and three of group B underwent surgery.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1028_17531", "title": "[German guideline on undescended testis-what is relevant in daily routine?]", "score": 0.012207602339181285, "content": "With an incidence of 0.7-3% in male infants, undescended testicles is one of the most common congenital anomalies. In the first 6 months of life, the testicles may spontaneously descend in up to 70% of individuals. If the testicle is not in a scrotal position afterwards, fertility can gradually be reduced and the risk of a testicular tumor increases. Therefore, the current German guideline for undescended testis recommends that therapy should be take place between 6 and 12 months of life. After extensive information on the advantages and disadvantages, hormone therapy with the aim of a descensus or in those with bilateral anomaly with the aim of improving the germ cell pool can be offered. After the first year of life, hormone therapy is obsolete. Otherwise, surgical intervention is the treatment of choice. In the case of gliding or deep inguinal testis via scrotal or inguinal access, in the case of nonpalpable and sonographically undetectable testis, laparoscopy is carried out for diagnosis and simultaneous therapy. In the first postoperative year, adequate follow-up should be done to detect a re-ascensus and/or insufficient growth. Regular self-examinations from the age of 15 serve for the early detection of a testicular tumor that occurs only very rarely (approximately 0.003%)." }, { "id": "pubmed23n0362_16775", "title": "Management of undescended testis.", "score": 0.012003954243750881, "content": "The term cryptorchidism indicates a testis, which has failed to descend to the scrotum and is located at any point along the normal path of descent or at an ectopic site. Hormones play a pivotal role in testicular descent except during the migration to the level of internal inguinal ring. Cryptorchidism is present in about 4.5% of newborns with a higher incidence in preterms. The incidence decreases to 1.2% by the first year. It is classified as palpable and impalpable. The most common site of an ectopic testis is superficial inguinal pouch. Retractile testis is often bilateral and most common in boys between 5 and 6 years of age. Hypospadias and inguinal hernias are the most common associated anomalies seen with undescended testis. A thorough clinical examination helps in arriving at the etiology. A short hCG stimulation test helps to exclude anorchia. Different imaging techniques are of little help in diagnosis and require the help of an experienced radiologist. Laparoscopy has an important role in the diagnosis and management of undescended testis. The common complications include torsion and atrophy of testis. Infertility is seen in about 40% of unilateral and 70% of bilateral cryptorchidism. Undescended testis is 20 to 40 times more likely to undergo malignant transformation than normal testis. Both hCG and GnRH have been used with limited success in these children. All boys with cryptorchidism should be referred to a pediatric surgeon before 2 years of age. These children should be followed up every year after surgery to identify testicular tumors." }, { "id": "wiki20220301en027_64583", "title": "Orchiopexy", "score": 0.011714151165528607, "content": "Orchiopexy (or orchidopexy) is a surgery to move and/or permanently fix a testicle into the scrotum. While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve testicular torsion. Indications Undescended testicle Undescended testicles affect 1% of males and are 10% bilateral. The cause is unknown, with a small percentage associated with developmental abnormalities or chromosomal aberrations. Early orchiopexy reduces the risks for cancer and sterility in males with cryptorchidism, or undescended testes. Cryptorchidism is definitively diagnosed after 1 year of age, as testicular descent may occur after birth. Surgical placement into the scrotum is recommended by 18 months to decrease the likelihood of testicular cancer, testicular atrophy, and sterility." }, { "id": "pubmed23n0950_12835", "title": "The volume of unilaterally undescended testis after hCG therapy compared to orchidopexy and combined methods.", "score": 0.011497584541062802, "content": "The aim of the study was to compare the effects of human chorionic gonadotropin (hCG) therapy with those of surgical or combined therapy on testicular volume (TV) in boys at different ages with unilateral canalicular undescended testis (UDT). In total, 155 boys aged 1 to 12 years were treated: either surgically (ST), or by 50 IU/kg body weight hCG administration every three days for five weeks (HT), or by a combination of the two. The patients underwent ultrasound examination of TV before the treatment, 9-12 (median 10) and 24-39 months (median 32) after therapy. The testicular atrophy index (TAI) of the affected testicle was calculated. The success rate was 94.7% for ST, 39.2% for HT and 98% for HST patients. The atrophy rate was 5.3% for ST, 0% for HT and 2% for HST. Neither treatment type nor patient age significantly influenced gonadal atrophy. No significant differences in TV of the affected testis were observed after treatment between the groups. The TAI values were significantly the lowest in HT group (p = 0.0006). Both TV and TAI changes from the baseline values did not differ between the treatment groups. At the 24- to 39-month follow-up, no significant differences were observed in the change in baseline TV and baseline TAI between age groups. TV of the affected testis increased significantly (p = 0.0000), and TAI decreased significantly over time (p = 0.01), with no significant differences depending on the age group, treatment type or the interaction of the two factors. The hCG therapy did not impair the development of affected and healthy testes, neither as single nor as neoadjuvant therapy, both during early assessment and after 2-3 years. Patients' age at the initiation of treatment seems irrelevant." }, { "id": "pubmed23n0650_18574", "title": "Natural history and long-term testicular growth of acquired undescended testis after spontaneous descent or pubertal orchidopexy.", "score": 0.01144678221846444, "content": "To assess prospectively the natural history and long-term testicular growth of acquired undescended testis (UDT) after spontaneous descent or pubertal orchidopexy in case of nondescent. From 1996 until 2008, 391 boys with 464 acquired UDT were included in the study. In accordance with Dutch consensus on non-scrotal testes, spontaneous descent at puberty was awaited; if this did not take place, orchidopexy was performed at puberty. Acquired UDT was defined as a testis previously residing in the scrotum that can no longer be manipulated into a stable scrotal (high scrotal) or nonscrotal (inguinal, impalpable) position. After referral, testis position, testis volume and puberty stage were monitored annually until adolescence. Testis volume was assessed using an orchidometer and compared with the Dutch standard. All investigations were carried out by the same physician (W.H.). Of these boys, 84 (mean age 12.9 years, range 6.4-21.3) were also clinically assessed by a second physician (J.G.), unaware of the results of the first examination. In addition, these boys were assessed with testicular ultrasonography, carried out by both physicians. Currently the mean (range) follow-up is 4.7 (0.1-12.0) years, and 253 acquired UDT have reached the scrotum. In 196 of these 253 cases (77.5%), there was spontaneous descent at puberty (mean age at descent 12.9 years, range 9.8-16.9); in the other 57 cases (22.5%), pubertal orchidopexy was required due to nondescent; five cases required orchidectomy. Of the 494 testis volume measurements after spontaneous descent, 458 (92.7%) were at ≥10th centile for age, of which 311 (63.0%) were ≥50th centile, and 107 (21.7%) ≥90th centile. After pubertal orchidopexy for nondescent, of the 85 measurements, 79 (92.9%) were at ≥10th centile, 53 (62.4%) ≥50th centile and 12 (14.1%) ≥90th centile. In unilateral cases, after spontaneous descent 174 of the 294 (59.2%) retained testes were found to be smaller than their counterpart and 90 of 294 (30.6%) were equal in size. After pubertal orchidopexy in unilateral cases, 40 of the 51 (78.4%) testes were smaller, and nine (17.6%) were equal in size. There was a strong correlation between both investigators for the measurement of testicular volume by orchidometer, and for the main investigator (W.H.) between his measurements by ultrasonography and the Prader orchidometer. Acquired UDT has a 77.5% tendency of spontaneous descent at puberty. In nearly all cases, after spontaneous descent as well as after pubertal orchidopexy, long-term testicular growth is within the normal range." }, { "id": "wiki20220301en017_70973", "title": "Cryptorchidism", "score": 0.011074800290486565, "content": "When the undescended testis is in the inguinal canal, hormonal therapy is sometimes attempted and very occasionally successful. The most commonly used hormone therapy is human chorionic gonadotropin (hCG). A series of hCG injections (10 injections over five weeks is common) is given and the status of the testis/testes is reassessed at the end. Although many trials have been published, the reported success rates range widely, from roughly 5% to 50%, probably reflecting the varying criteria for distinguishing retractile testes from low inguinal testes. Hormone treatment does have the occasional incidental benefits of allowing confirmation of Leydig cell responsiveness (proven by a rise of the testosterone by the end of the injections) or inducing additional growth of a small penis (via the testosterone rise). Some surgeons have reported facilitation of surgery, perhaps by enhancing the size, vascularity, or healing of the tissue. A newer hormonal intervention used in Europe is the use" }, { "id": "pubmed23n0045_12047", "title": "[Cryptorchidism].", "score": 0.010789077866481546, "content": "Cryptorchidism is a frequent abnormality which affects approximately 1% of children at age 1 year. Many nonscrotal testes are retractile and require no therapy. The pathogenesis remains controversial and involves possible mechanical, dysgenetic or hormonal factors. The latter are consistent with a partial defect in the hypothalamo-pituitary-gonadal axis, which may cause progressive histologic alterations in the testes after the first 6 months of life. Ultrasound is the simplest diagnostic technique (after clinical examination) to identify the testes in the inguinal region, while Magnetic Resonance Imaging can be performed to visualize abdominal testes. Therapy is still a matter of controversy. Hormonal treatments with HCG, LHRH or both should be used as first-intention treatment and their efficacy ranges from 0% to 60% in the various studies. LHRH nasal spray seems less effective if used alone. An early surgical treatment is recommended if the gonad is in the abdomen or close to the internal inguinal ring. The risk of cancer is increased in subjects with a history of cryptorchidism and even includes the contralateral descended testes. Early orchidopexy is not associated with a certain decrease of the risk. Cancer can be prevented by searching for in situ carcinoma with a biopsy performed after puberty. Fertility is impaired mainly in men with a history of bilateral cryptorchidism. There is weak evidence that early orchidopexy may improve fertility rates." }, { "id": "wiki20220301en017_70954", "title": "Cryptorchidism", "score": 0.01037106524911403, "content": "Undescended testes are associated with reduced fertility, increased risk of testicular germ-cell tumors, and psychological problems when fully-grown. Undescended testes are also more susceptible to testicular torsion (and subsequent infarction) and inguinal hernias. Without intervention, an undescended testicle will usually descend during the first year of life, but to reduce these risks, undescended testes can be brought into the scrotum in infancy by a surgical procedure called an orchiopexy. Although cryptorchidism nearly always refers to congenital absence or maldescent, a testis observed in the scrotum in early infancy can occasionally \"reascend\" (move back up) into the inguinal canal. A testis that can readily move or be moved between the scrotum and canal is referred to as retractile. Cryptorchidism, hypospadias, testicular cancer, and poor semen quality make up the syndrome known as testicular dysgenesis syndrome. Signs and symptoms" }, { "id": "pubmed23n0347_9355", "title": "[Cryptorchism. Outcome of treatment and referral patterns in an unselected group of patients in a 3-year period].", "score": 0.009900990099009901, "content": "The age of diagnosis and referral together with the efficacy of HCG treatment were studied retrospectively in 196 unselected cryptorchid patients seen over a period of three years. The median age of diagnosis was 2 years and 7 months, whereas the median age of referral was three years later. During the period of study, guidelines for referral and therapy were published in a nationwide journal and in the local region, and a slight but significant fall in age of referral was seen thereafter. The median age of treatment with HCG, 92 patients, was 6 years and 11 months, and median age of surgery, was 7 years and 7 months. The rate of success with HCG was for bilateral testes 41% and for unilateral testes 21%, giving an overall success rate of 30%. This result is lower than previously reported, which is most likely explained by a higher suprascrotal position of testes before treatment. Guidelines and recommendations for referral and therapy seem to influence the time of referral, which is, however, in this study not in accordance with the consensus of definitive treatment before the age of two years. Early diagnosis is recommended and should be followed by referral to a paediatric department with particular interest and knowledge about cryptorchidism." }, { "id": "pubmed23n0307_8893", "title": "The fate of undescended testes in patients with gastroschisis.", "score": 0.00980392156862745, "content": "Cryptorchidism is frequently associated with gastroschisis, yet little is published on its management in such circumstances. In a review of 10 consecutive boys with gastroschisis since 1980, 4 had undescended testes. Gestational age and birth weight did not differ from the 6 boys with normally descended testes. The first two patients had associated arthrogryposis multiplex congenita. The first underwent bilateral orchidopexy at 9 years of age for inguinal testes. In the second patient, the left testis was intraabdominal at the level of the sigmoid colon at birth; at 3 months of age, when a left inguinal hernia repair was required, left groin exploration revealed the testis at the internal ring and orchidopexy was performed successfully. In the third patient the left spermatic vessels were divided at the time of gastroschisis repair and the testis anchored in the prebubic area. The second-stage orchidopexy was performed at 16 months. In the last patient the intraabdominal testis could be placed in a scrotal pouch without mobilisation or division of the vessels. From our experience and a review of the literature we conclude that: 1) undescended testes are frequently associated with gastroschisis; 2) mechanical factors rather than prematurity are likely responsible for this association; 3) if the testis easily reaches the scrotum, orchidopexy can be done safely at the time of gastroschisis repair; 4) if the testis does not reach easily and appears to have a gubernaculum, it may be preferable to leave it in place since spontaneous descent can occur." }, { "id": "pubmed23n0263_19027", "title": "[Results of treating cryptorchism with HCG in boys previously qualified for surgical treatment].", "score": 0.00980392156862745, "content": "Hundred one boys, aged between 1.5 and 13 years, previously classified for surgery for uni- or bilateral cryptorchidism were examined. In 78 patients (77.2%) cryptorchidism was diagnosed, including 51 cases (50.5%) of unilateral undescended testicle. In the remaining 23 boys (22.9%) migrating testes were found: unilateral in 6 cases (5.9%) and bilateral in 17 cases (16.8%). An improvement was achieved after HCG therapy in 21 cases of migrating testes (91.3%), partial improvement in 1 case (4.35%), and no effect in 1 case (4.35%). The treatment with HCG produced recovery in 20 cases (25.6%) of cryptorchidism, partial improvement in cases (23.2%), and no effect in 40 cases (51.2%). A complete recovery was achieved in 41 out of 101 patients, i.e. in 40.6%, partial improvement in 19 cases (18.6%), and no effect in 41 cases (40.6%). The treatment with HCG enabled an avoidance of unnecessary surgery in 40.6% of all examined boys." }, { "id": "pubmed23n0606_17452", "title": "UNDESCENDED TESTES.", "score": 0.009708737864077669, "content": "Orchiopexy was performed upon 152 patients. Follow-up observation was inadequate, but of known results 14 per cent were poor. As an increasing number of investigators have observed spontaneous descent of undescended testes, this possibility should be considered in weighing indications for operation on boys before the age of puberty. Coexisting clinically demonstrable hernia (59 per cent in this series) is an indication for early operation. Otherwise, orchiopexy may be best delayed, perhaps until the twelfth year. This was done in 25 per cent of the cases in this series. Three methods of operation were used, the Torek, the Cabot-Nesbit, and the Bevan. There were fewer poor results with the Torek than with the Cabot-Nesbit procedure. The greatest number of poor results was in cases in which the Bevan technique was used." }, { "id": "pubmed23n0898_15309", "title": "Discontinued Splenogonadal Fusion and Bilateral Empty Scrotum in an 18-Month-Old Boy.", "score": 0.009615384615384616, "content": "Splenogonadal fusion is a rare benign congenital anomaly defined as the presence of splenic tissue adherent to gonads. It was first described in 1883 by Bostroem, a German pathologist. We present a case of an 18-month-old boy who was referred as a case of bilateral empty scrotum since birth. During routine laparoscopic exploration, right vas deferens and testicular vessels were entering the right internal inguinal ring so right inguinal exploration was done, which revealed blind ending vas deferens and testicular vessels and the left testis was found intra-abdominally near the left internal ring with a mass on its upper pole. Wedge biopsy was taken from the upper pole of the testicle (site of the mass) for tissue diagnosis followed by orchidopexy. Histology showed splenic tissue. Although splenogonadal fusion is a rare condition, surgeons should be aware of this rare disease entity to avoid unnecessary aggressive interventions such as orchiectomy." }, { "id": "pubmed23n0204_6465", "title": "[Surgical indications in testicular ectopias].", "score": 0.009615384615384616, "content": "The ideal age for treatment is still controversial. However, all recent histological studies show that the number of spermatogonia and the diameter of the tubules remain virtually normal until the beginning of the third year of life. Treatment therefore should take place in the second year, after all chances of spontaneous migration have vanished and before lesions due to cryptorchidism develop. Chorionic gonadotropic hormones should be used systematically; they avoid surgery in only one out of five cases, but they make it possible to test the possibilities of testicular descent and testosterone secretion. Surgical treatment should follow precise rules. The spermatic vessels might, if necessary, be severed, but care must be taken to preserve the gubernaculum. The alternative is, microsurgical autotransplantation. Only time will show whether the poor fertility of these patients is bettered by early treatment." }, { "id": "pubmed23n0204_6795", "title": "Undescended testes: treatment with gonadotropin.", "score": 0.009523809523809525, "content": "The therapeutic success of treatment of testicular maldescent must be judged according to 2 parameters, - I. occurrence of descent, II. fertility. Ad I. Indication for hCG-treatment is always given unless an unequivocal indication for operation exists, i.e. ectopias, accompanying hernias, retention after herniotomy and advanced puberty. The optimal time for treatment is the second year of life. The large European statistics which include the prescrotal but not the retractile testes, unanimously show success rates of 50-55%. In the largest American series which does not include prescrotal testicles, descent was observed in 40% of the bilateral and in 30% of the unilateral cases. Analyzing those cases which did not respond to hormones but had to be operated, in the majority of cases ectopic, not dystopic gonads were found. Ad II. Infertility in testicular maldescent can have two reasons, 1. congenital anomalies of the primordium, 2. acquired damages due to the malposition. The few large prospective studies at hand show fertility in the majority of cases with descent after hCG, but in the minority of those coming down only after additional operation. Obviously the latter group represents a negative selection. Unilateral cases had a higher fertility rate than bilateral ones." }, { "id": "pubmed23n0394_16951", "title": "[Previous testicular position in boys who underwent orchidopexy due to undescended testis at the Alkmaar Medical Center, the Netherlands, during the period 1986-1999].", "score": 0.009433962264150943, "content": "To determine the previous testicular position in boys, in whom orchidopexy was performed for undescended testis. Retrospective, descriptive. All boys, aged 0-18 years, who underwent orchidopexy in the Alkmaar Medical Centre, the Netherlands, during the period 1986-1999, were studied. The following information was obtained from the hospital medical records: indication for operation, date of the operation, laterality (unilateral or bilateral), the surgical findings and whether previous testicular position played a role in the decision to perform orchidopexy. For each boy who underwent orchidopexy for undescended testis, previous testicular positions up until the date of the operation were obtained from the appropriate youth health care institutions. Hospital records were available for 851 boys who had undergone orchidopexy. The operation for undescended testis was performed in 717 boys and previous testicular positions were obtained for 565 boys. On a per testicle basis, 707 operations were carried out (142 bilaterally, 205 left-sided, 218 right-sided). From these 707 testes, a previous intrascrotal position was found at least once in 572 (80.9%), at least twice in 493 (69.7%) and at least three times in 419 (59.3%); 135 (19.1%) testes had never been intrascrotal. The majority of previously undescended testes were operated on at 3 years of age; most operations on previously descended testes were performed at 10.5 years of age. For 344 (48.7%) out of 707 testes, previous testis localisation was known in the hospital's medical records, for 96 (13.6%) testes registration was unclear and in 267 (37.8%) testes it was not reported. In 8 (1.4%) boys, testis registration after the birth was used on referral to document previous testicular position. In total 80.9% of all orchidopexy operations were performed on testes that had previously been diagnosed as having descended normally. These probably included retractile testes as well as acquired forms. In 51.3% of the cases, previous testicular position was not known in the hospital's medical records at the time of operation." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 403 ] ], "word_ranges": [ [ 0, 66 ] ], "text": "The Thessaly maneuver consists of the patient, using monopodal support and knee flexion of 5º and then 20º, performing internal and external rotations of the leg. In case this reproduces the pain that the patient refers, the test will be considered as positive. It is a test used for the diagnosis of meniscal pathology (sensitivity greater than 90% and specificity greater than 95%) (Answer 1 correct)." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Meniscal injury.", "2": "Injury by rupture of the anterior cruciate ligament.", "3": "Injury by rupture of the posterior cruciate ligament.", "4": "Degenerative arthropathy injury.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0065_2466", "title": "Injuries to the posterior cruciate ligament of the knee.", "score": 0.01602077001013171, "content": "The posterior cruciate ligament (PCL) is the strongest ligament about the knee and is approximately twice as strong as the anterior cruciate ligament. Its main function is to prevent the posterior dislocation of the tibia in relation to the femur, providing 95% of the strength to resist the tibial posterior displacement. Along with the anterior cruciate ligament (ACL) the PCL controls the passive 'screw home' mechanism of the knee in terminal knee extension. It also provides mechanical support for the collateral ligaments during valgus or varus stress of the knee. PCL ruptures are uncommon apparently due to its strong fibre structure. The most frequent injury mechanism in isolated PCL tears is a direct blow on the anterior tibia with the knee flexed thus driving the tibia posteriorly. Automobile accidents (in which the knee hits the dashboard) and soccer injuries (in which an athlete receives a blow to the anterior surface of the tibia during knee flexion) characteristically produce this type of injury. In other PCL injury mechanisms (hyperextension, hyperflexion or rotational injuries with associated valgum/varum stress), other knee structures are also often damaged. The most characteristic diagnostic finding in a knee with a PCL rupture is the 'posterior sag sign' meaning the apparent disappearance of the tibial tubercle in lateral inspection when the knee is flexed 90 degrees. This is due to gravity-assisted posterior displacement of the tibia in relation to the femur. A positive posterior drawer test performed at 90 degrees of flexion and a knee hyperextension sign are sensitive but nonspecific tests. False negative findings are frequent, especially in acute cases. If necessary, the clinical diagnosis of the PCL tear can be verified by magnetic resonance imaging, examination under anaesthesia, arthroscopy, or a combination of these modalities. If a PCL avulsion fragment has been dislocated, surgical treatment is recommended. In isolated, complete midsubstance tears of the PCL the majority of the recent studies recommend conservative treatment, since abnormal residual posterior laxity1 in most of these knees is consistent with functional stability and minimal symptoms. This has been the case even in athletes. In isolated PCL tears, the outcome seems to depend more on the muscular (quadriceps) status of the knee than on the amount of residual posterior laxity. Therefore, the conservative treatment protocol emphasises intensive quadriceps exercises, and only a short (under 2 weeks) immobilisation period followed by early controlled activities and early weightbearing.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0540_6354", "title": "Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.", "score": 0.015753259295026557, "content": "The purpose of the study was to evaluate the mid-term results of surgical treatment in different groups of patients with multiple knee ligament injuries. Review of our patients' records revealed that 48 acute and chronic patients were surgically treated for combined knee injury. Due to severe capsular damage in these injuries, open techniques were used. In our treatment protocol, avulsed ligaments and tears of the posterolateral and posteromedial corner were repaired if possible, whereas midsubstance tears of cruciate ligaments and chronic cases were reconstructed with autografts. Postoperatively, an accelerated program of rehabilitation was introduced, aiming to progressively mobilize the joint and improve muscle endurance. For the follow-up evaluation we designed a protocol composed of two parts. In the first part, anatomical lesions were recorded and in the second part, clinical evaluation was performed using the Lysholm score, the Tegner rating system, the IKDC evaluation form, and the KT1000. Student's t tests and chi-square tests were used for data analysis. Forty-eight patients (mean age 28.6+/-11.9 years; 41 males) were classified according to the specific anatomical structures involved. Group A included 12 anterior cruciate ligament (ACL) and medial structure injuries, group B included 11 ACL or posterior cruciate ligament (PCL) ruptures combined with posterolateral injuries, and group C consisted of 25 knee dislocations (ACL and PCL ruptures which might be combined with damage of the collateral ligaments). Thirty-eight patients were surgically treated during the acute phase and ten patients were treated chronically. Forty-four patients (91.6%) were followed up at a mean of 51.3+/-29.9 months. Average Lysholm score was 87+/-12.3; average Tegner score was 5.09+/-2.19 before accident and 4.34+/-2.12 in re-examination; IKDC score was A in 10 cases, B in 22, C in 6, and D in 6. The mean range of motion was 129.9 degrees +/-12.5 degrees . The average loss of extension and flexion were 1.6 degrees +/-2.5 degrees and 7.6 degrees +/-7.9 degrees , respectively. The side-to-side difference in corrected anterior and posterior translation in quadriceps neutral angle and in anterior translation in 30 degrees angle was &lt;3 mm for about 65% of our patients. Surgical treatment of multiple knee ligament injuries, using autografts, provided satisfactory stability, range of motion, and subjective functional results. However, despite the improvement of the quality of life, the preinjury patients' activity level was not fully obtained in re-examination. Patients underwent surgical treatment during the acute phase had better scores in several points, but finally there was no statistical significance between acute and chronic patients. Moreover, no statistically significant differences were observed among the groups with specific damaged anatomical structures." }, { "id": "pubmed23n0675_14556", "title": "Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for \"isolated\" anterior cruciate ligament tear.", "score": 0.015503425850656137, "content": "Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries. To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft. Case series; Level of evidence, 4. Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment. Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle &lt;17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age &lt;18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C). Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization." }, { "id": "pubmed23n0107_3961", "title": "[Examination of the knee joint. The value of clinical findings in arthroscopic control].", "score": 0.014245548266166821, "content": "Purely clinical examination of the knee joint can, at best, only be regarded as a \"screening procedure\". Diagnosis with the aid of apparatus (sonography, arthrography, CT, NMR) produces better results. However, arthroscopy performed by an experienced examiner confirms the diagnosis in cases of suspected meniscus injury or isolated lesions of the cruciate ligaments and leads to early and therefore optimal therapy. In a retrospective study 300 arthroscopies performed in 1985 were selected and evaluated. In 1986/87, a further 300 patients were clinically examined prospectively, according to the same criteria, and findings were compared with the arthroscopy performed the following day. Clinically, in 287 patients with multiple diagnoses, internal meniscus lesions were diagnosed in 162 cases (54%), external meniscus lesions in 38 (13%), chondropathia patellae in 54 (18%), and old ruptures of the cruciate ligaments in 46 (15%). In 13 patients no diagnosis could be established. Arthroscopically, pathology of the internal meniscus was found in 98 (33%) of the 300 patients, of the external meniscus in 40 (13%), cartilage damage in 103 (34%), old cruciate ligament ruptures in 51 (17%), and recent anterior cruciate ligament ruptures in 156 (52%); in 40 cases findings were normal. At 78%, the highest positive predictive value (proportion of tentative clinical diagnoses confirmed by arthroscopy) was found in cases of old ruptures of the anterior cruciate ligament, followed by external meniscus lesions (61%) and internal meniscus lesions (55%); i.e., only 55 out of 100 clinically suspected internal meniscus lesions are diagnosed by arthroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en108_37995", "title": "Anterior cruciate ligament injury", "score": 0.014132104454685102, "content": "Most ACL injuries can be diagnosed by examining the knee and comparing it to the other, non-injured knee. When a doctor suspects ACL injury in a person who reports a popping sound in the knee followed by swelling, pain, and instability of the knee joint, they can perform several tests to evaluate the damage to the knee. These tests include the pivot-shift test, anterior drawer test, and Lachman test. The pivot-shift test involves flexing the knee while holding onto the ankle and slightly rotating the tibia inwards. In the anterior drawer test, the examiner flexes the knees to 90 degrees, sits on the person's feet, and gently pulls the tibia towards him or herself. The Lachman test is performed by placing one hand on the person's thigh and the other on the tibia and pulling the tibia forward. These tests are meant to test whether the ACL is intact and therefore able to limit the forward motion of the tibia. The Lachman test is recognized by most authorities as the most reliable and" }, { "id": "pubmed23n0764_20185", "title": "[Surgical treatment of posteromedial corner injury combined with cruciate ligament rupture of knee].", "score": 0.013682909604519775, "content": "To investigate the methods and effectiveness of surgical treatment for posteromedial corner (PMC) injury combined with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) ruptures. Between February 2009 and February 2012, 15 patients (15 knees) with PMC injury combined with ACL and PCL ruptures underwent PMC repair with suture anchor and ACL and PCL reconstruction. There were 7 males and 8 females with an average age of 39 years (range, 15-59 years). The causes of injury were traffic accident injury in 6 cases, sport injury in 7 cases, and sprain injury in 2 cases. The disease duration was 3-15 days with an average of 7 days. All patients presented positive results of anterior drawer test, posterior drawer test and valgus stress test, and dysfunction of knee joint. Of 15 cases, 3 had ACL and PCL ruptures, 5 had ACL rupture, 3 had ACL injury at the attachment point of the condyles crest, and 4 had PCL rupture; 9 had PMC tear at the femur insertion, 5 had PMC tear at the tibia insertion, and 1had PMC tear in the body area. All incisions healed by first intention with no complication of infection or stiffness of knee. All cases were followed up 18.4 months on average (range, 10-36 months). At last follow-up, 14 cases had normal knee flexion and extension ranges, but 1 case had 10 degree limitation of the knee extension. Except 1 case which had weakly positive valgus stress test, the other patients showed negative results of anterior drawer test, posterior drawer test, and valgus stress test. Based on the improved Lysholm classification standard, the results were excellent in 8 cases, good in 5 cases, and fair in 2 cases; the excellent and good rate was 86.7%. Early repair of the PMC and reasonable reconstruction of cruciate ligament can effectively restore the knee stability for patients with PMC injury combined with ACL and PCL ruptures." }, { "id": "pubmed23n0761_359", "title": "[Anatomical reconstruction of posterolateral complex in treatment of multi-ligament injury of knees].", "score": 0.013432165318957773, "content": "To evaluate the short-term effectiveness after static anatomical reconstruction of posterolateral complex (PLC) in the treatment of traumatic multi-ligament injury of the knee. Between June 2007 and July 2011, 23 cases of multi-ligament injury of the knee were treated. There were 15 males and 8 females with an average age of 41 years (range, 19-56 years). The injury was caused by traffic accident in 9 cases, sprain in 7 cases, bruise in 3 cases, and falling from height in 4 cases. The time between injury and operation was 13-78 days (mean, 32 days). The results of posterior drawer test and Lachman test were positive, and all cases complicated by varus and external rotation instability. The Lysholm score of the knee was 43.4 +/- 5.7. According to International Knee Documentation Committee (IKDC) scoring, all were rated as grade D. According to Fanelli typing, all were classified as type C. The X-ray films showed that load-induced posterior motion of the knee was (13.3 +/- 4.2) mm; the lateral joint space was (15.1 +/- 2.4) mm. Anterior cruciate ligament/posterior cruciate ligament and PLC were reconstructed simultaneously with auto-semitendinosus, gracilis tendon, and allogeneic tendon. All incisions healed by first intention, and no complication occurred. All patients were followed up 12-56 months (mean, 28 months). At last follow-up, the results of posterior drawer test and Lachman test were negative; 3 cases had varus instability, and 2 cases had external rotation instability. The Lysholm score of the knee was 85.6 +/- 16.7, showing significant difference when compared with preoperative score (t=-11.469, P=0.000). According to IKDC scoring, 7 cases were rated as grade A, 12 as grade B, and 4 as grade C; significant difference was found when compared with preoperative value (Z=4.285, P=0.000). The load-induced posterior motion of the knee was (5.1 +/- 4.4) mm, the lateral joint space was (3.2 +/- 2.8) mm, showing significant differences when compared with preoperative ones (P &lt; 0.05). In the treatment of traumatic multi-ligament injury of the knee, the anatomical reconstruction of the PLC using auto-semitendinosus, gracilis tendon, or allogeneic tendon can obtain good short-term effectiveness." }, { "id": "pubmed23n0292_9586", "title": "Primary repair plus intra-articular iliotibial band augmentation in the treatment of an acute anterior cruciate ligament rupture. A follow-up study of 70 patients.", "score": 0.012678790760331234, "content": "Between September 1987 and November 1989, we treated 90 consecutive patients with an acute anterior cruciate ligament (ACL) rupture with the multiple suture technique and iliotibial band augmentation. Seventy of these patients were re-examined 2 to 5 years after the operation (mean 3.5 years), the examination consisting of a questionnaire, clinical examination, laxity tests with the KSS machine (Acufex), radiological examination and isokinetic muscle strength testing (Cybex 6000). There were 32 men and 38 women (mean age 34 years). The injury was sustained in sports in 44 (63%) cases, and the sports most frequently involved were downhill skiing (18 cases), soccer (9 cases) and volleyball (5 cases). Of the injuries, 38 were isolated ACL ruptures and 31, ACL ruptures combined with a medial CL rupture. In 9 cases, an additional meniscus injury and in one case an additional posterior CL - lateral CL rupture was found. At the follow-up, 55 patients (79%) were satisfied with the end result, and according to our objective functional criteria 55 (79%) had an excellent or good outcome. According to the Lysholm score, 53 (76%) patients were excellent or good (&gt; or = 82 points). In the Lachman test, 29 knees (41%) were completely stable. The Lachman test was mildy positive in 40 knees (57%) (36 had 1+ laxity and 4, 2+ laxity), and one patient had 3+ laxity with a hard end-point. Similarly, the anterior drawer test was negative in 53 knees (76%), and the other 17 (24%) had mild laxity (16 had 1+ laxity and 1, 2+ laxity). The total anterior-posterior laxity measured with the KSS averaged 9.7 +/- 3.5 mm in the injured knee and 7.3 + 3.0 mm in the uninjured knee (the laxity measured at a knee angle of 20 degrees of flexion). Corresponding values at a knee angle of 90 degrees of flexion were 6.1 +/- 2.4 mm and 4.7 +/- 1.9 mm, respectively. The pivot shift test was negative in 62 patients (89%) and 1+ positive in the remaining 8 patients (11%). Fifty-eight patients (83%) had full knee extension and 40 patients (57%), full knee flexion. Compared with the uninjured knee, the operated knees showed an average 14% strength deficit in isokinetic knee extension and 6% deficit in flexion at the speed of 60 degrees/s. At the speed of 180 degrees/s, the corresponding deficits were 8% and 4%, respectively. Of the 44 patients who were active in sport before the injury, 40 (91%) were able to return to sports. A flexion deficit of 5 degrees or more was associated with thigh muscle atrophy (P &lt; 0.05) and quadriceps weakness, both at the slow speed (P &lt; 0.05) and high speed (P &lt; 0.001) of the isokinetic movement. In conclusion, in an acute rupture of the ACL, primary repair of the ligament with intraarticular iliotibial band augmentation seems to be a good method to restore the functional capacity of the injured knee." }, { "id": "wiki20220301en090_1528", "title": "Knee examination", "score": 0.012672012672012671, "content": "cause medial collateral ligament rupture, meanwhile a varus force can cause lateral collateral ligament rupture. When a person suddenly slows down during running, twisting, or pivoting with valgus force applying on the knee, the anterior cruciate ligament can rupture. Posterior dislocation of the tibia can cause posterior cruciate ligament injury. Twisting and pivoting while bearing weight can cause tearing of the meniscus. Fractures of the knee are less common but should be considered if direct trauma to the knee has occurred such as during a fall. Examples of fractures involving knee joints are: tibial plateau fractures, fractures of the lateral condyle of femur, medial condyle of femur, and patellar fractures." }, { "id": "wiki20220301en022_48996", "title": "Posterior cruciate ligament", "score": 0.01182914182006741, "content": "An additional test of posterior cruciate ligament injury is the posterior sag test, where, in contrast to the drawer test, no active force is applied. Rather, the person lies supine with the leg held by another person so that the hip is flexed to 90 degrees and the knee 90 degrees. The main parameter in this test is step-off, which is the shortest distance from the femur to a hypothetical line that tangents the surface of the tibia from the tibial tuberosity and upwards. Normally, the step-off is approximately 1 cm, but is decreased (Grade I) or even absent (Grade II) or inverse (Grade III) in injuries to the posterior cruciate ligament. The posterior drawer test is one of the tests used by doctors and physiotherapists to detect injury to the PCL. Patients who are suspected to have a posterior cruciate ligament injury should always be evaluated for other knee injuries that often occur in combination with an PCL injuries. These include cartilage/meniscus injuries, bone bruises, ACL" }, { "id": "pubmed23n0369_19744", "title": "[Knee injuries in general practice].", "score": 0.011730681744329629, "content": "Careful technique of examination of the knee joint allows to establish the diagnosis of the most frequent knee joint injuries already through simple clinical and radiological evaluation: Recurrent dislocation of the patella with the Apprehension sign; meniscal injuries with the test of McMurray, pain on the joint line and pain on passive hyperextension; the anterior cruciate ligament tear with Lachman's sign and the Pivot Shift test and posterior cruciate injury with the Sag sign. Further imaging techniques allow to establish a definite diagnosis, which has replaced in many cases the classical, purely diagnostic arthroscopy. Thanks to careful aspiration of the knee joint the patient can be referred with a more precise diagnosis to the traumatologist and orthopaedic surgeon. Meniscal lesions don't have to be treated as emergencies with exception of the locked knee. Equally, in presence of a fresh tear of the anterior cruciate ligament a delay of surgery for eight weeks may be beneficial, be it only to rehab and prepare the knee joint for surgery. Posterior cruciate ligament tears should only be treated by a few centers, since they demand a high degree of experience. The same accounts for the new techniques for the treatment of cartilage lesions like the mosaicplasty or the autologous chondrocyte implantation." }, { "id": "pubmed23n0648_9380", "title": "[Primary clinical results of double-bundle anterior cruciate ligament reconstruction with semitendinosus allografts].", "score": 0.011659831203606412, "content": "To evaluate the primary clinical results of double-bundle anterior cruciate ligament reconstruction (ACLR) with semitendinosus allografts. From March 2006 to October 2006, 33 patients underwent double-bundle ACLR with semitendinosus allografts. The complete followed-up data of 31 patients was analyzed retrospectively. There were 24 males and 7 females aged 18-35 years old (average 25 years old). The injury was caused by sports accidents in 23 cases and traffic accidents in 8 cases, involving the left knee in 18 cases and the right knee in 13 cases. Anterior cruciate ligament rupture were confirmed by MRI and arthroscopy in all the patients, without lateral collateral ligaments injuries and posterior cruciate ligament injuries. The time from injury to operation was 1-43 months (average 11 months). The knee was fixed at 0 degree position after operation for 2 weeks and got knee joint rehabilitation exercises gradually. The incision of 2 patients showed effusion 4 and 7 days after operation, respectively, and healed after symptomatic treatment. The incision of 29 patients healed by first intention. There were no complications such as stiffness of knee joint, neurovascular injuries and joint infections. All the patients were followed up for 24-29 months (average 26 months). MRI displayed the anterior cruciate ligament grafts presented with good connection and signal similar to the normal 2 years after operation. There was significant difference between the preoperational value and the final follow-up value in terms of bilateral knee joint difference of prior laxity, Lachman test, and pivot shift test (P &lt; 0.05 ). The circumference difference between the injured and the normal was (11.6 +/- 7.9) mm before operation and (5.0 +/- 3.1) mm at the final follow-up (P &lt; 0.05). The Tegner score, Lysholm score, and International Knee Documentation Committee score was 3.83 +/- 1.15, 64.38 +/- 6.81, and 41.42 +/- 6.30, respectively, before operation, and 6.29 +/- 0.64, 94.45 +/- 3.03, and 95.72 +/- 3.10, respectively, at the final follow-up. There was a significant difference between before and after operation (P &lt; 0.05). The primary clinical results of double-bundle ACLR with semitendinosus allografts are satisfactory and the allogeneic semitendinosus are good grafts for double-bundle ACLR." }, { "id": "pubmed23n0520_2112", "title": "Gravity-assisted pivot-shift test for anterior cruciate ligament injury: a new procedure to detect anterolateral rotatory instability of the knee joint.", "score": 0.010112017841755791, "content": "The denominated gravity-assisted pivot-shift test was introduced as a new procedure to detect anterolateral rotatory instability of the knee joint. The patient lies in the supine position or slightly rotated onto the affected side. The affected knee flexed approximately 60 degrees and the ipsilateral hip flexed, abducted and externally rotated so that the plane of the knee motion runs parallel to the floor. The examiner instructs the patient to raise the affected leg off the examining table and to extend the affected knee gradually. If the lower leg is internally rotated suddenly, with the knee subluxated at an angle of approximately 20 degrees , followed by the reduction in flexion, this test is regarded as positive. This test was investigated on 51 anterior cruciate ligament (ACL) deficient knees, being positive in 30 knees (Group P) and negative in 21 (Group N) with the positive rate of 59%. There was no significant correlation between the result of this test and the clinical features, but Group N included relatively small number of females and recurrent injuries tended to occur more frequently in Group P. Thirty-six knees received ACL reconstruction subsequently. There was no statistically significant difference between the groups in the side-to-side difference in anterior knee laxity at one year postoperatively. However, three patients with the side-to side difference of more than 3 mm belonged to Group P. Relatively low positive rate in ACL deficient knees suggests that it may not be used as a diagnostic procedure for ACL injury. It is possibly used for the prediction of high risk patients for symptomatic giving-way and/or patients with poor prognosis after ACL reconstruction." }, { "id": "wiki20220301en099_32461", "title": "Cruciate ligament", "score": 0.009900990099009901, "content": "In animals the two cruciate ligaments that cross the inside of the knee joint are referred to as the cranial cruciate (equivalent to anterior in humans) and the caudal cruciate (equivalent to the posterior in humans). The cranial cruciate ligament prevents the tibia from slipping forward out from under the femur. Stifle injuries are one of the most common causes of lameness in rear limbs in dogs, and cruciate ligament injuries are the most common lesion in the stifle joint. A rupture of the cruciate ligament usually involves a rear leg to suddenly become so sore that the dog can barely bear weight on it. How a rupture can occur: There are several ways a dog can tear or rupture the cruciate ligament. Young athletic dogs can be seen with this rupture if they take a bad step while playing too rough and injure their knee. Older dogs, especially if overweight, can have weakened ligaments that can be stretched or torn by simply stepping down off the bed or jumping." }, { "id": "pubmed23n0316_2255", "title": "[Effect of external extra-articular ligament plasty on the results of anterior cruciate ligament reconstruction with patellar tendon, a 4 years follow-up].", "score": 0.009900990099009901, "content": "The purpose of this study was to compare the functional results obtained when an external extra-articular plasty was added to an anterior cruciate ligament (ACL) reconstruction using an autologous bone tendon-bone patellar tendon graft. The authors analyzed two consecutive series of 60 and 50 patients operated by the same surgeon for a chronic rupture of the anterior cruciate ligament, one by reconstruction of the cruciate ligament with a free graft of the patellar tendon supplemented by an external extra-articular plasty made with a quadriceps tendon graft and the second with an isolated free patellar tendon graft. Anterior laxity was measured before and after surgery, by dynamic X-rays and by the Medmetric KT-1000 arthrometer. Functional results were evaluated four years after operation, with the French A.R.P.E.GE score based on sport activity level and intensity. Anterior laxity was not different before operation in both groups and there was no difference between males and females. Medmetric KT-1000 arthrometer showed the same negative differential laxity immediately after surgery in both groups and the same evolution during the first 4 years, without any significant difference on laxity on the middle aspect of the knee. Radiological results were different. After a 4 years follow-up, anterior laxity did not show significant difference on the medial compartment of the knee (5.3 +/- 2.3 mm and 5.5 +/- 1.7 mm), but there was a significant minor laxity in the lateral compartment for the lateral extra-articular plasty group (11.0 +/- 2.3 mm against 14.8 +/- 3.8 mm)(p = 0.002). Functional results and sport activity were similar in both groups. Examination showed 4 positive pivot shift tests (2 \"sliding\" and 2 positive) in the group with extra-articular plasty, even though 8 positive pivot shift tests in the isolated ACL group (5 \"sliding\" and 3 positive) were found. This study, as well as five others studies found in literature, was not randomized. In all these series, the surgical techniques, the rehabilitation programs and the functional score evaluation were too different to allow any pertinent comparison. Extra-articular plasty helps to control the laxity of the lateral compartment of the knee which is incompletely controlled by ACL reconstruction, particularly in chronic cases. This is proved by radiological measurements and pivot shift tests. Jensen in 1983, about 205 patients with a 4 year follow-up and Noyes, which used an allograft patellar tendon, found an advantage to do extra-articular plasty. But Strum (in 1989), as O'Brien (in 1991) and Roth (in 1987), did not found any advantage with extra-articular plasty. It is therefore obvious, after a four-year follow-up, that extra-articular supplementation presents an advantage for reconstruction of the ACL. by a free graft of the patellar tendon in chronic cases. Further randomized study will confirm that isolated ACL reconstruction is possible in some well defined categories of anterior laxity." }, { "id": "wiki20220301en061_67541", "title": "Anterior cruciate ligament reconstruction", "score": 0.00980392156862745, "content": "The Anterior Cruciate Ligament is the ligament that keeps the knee stable. Anterior Cruciate Ligament damage is a very common injury, especially among athletes. Anterior Cruciate Ligament Reconstruction (ACL) surgery is a common intervention. 1 in every 3,000 American suffers from a ruptured ACL and between 100,000 and 300,000 reconstruction surgeries will be performed each year in the United States. Around $500 million health care dollar will come from ACL injuries. ACL injuries can be categorized into groups- contact and non-contact based on the nature of the injury Contact injuries occur when a person or object come into contact with the knee causing the ligament to tear. However, non-contact tears typically occur during the following movements: decelerating, cutting, or landing from a jump. ACL injury is 4-6 times higher in females than in males. ACL injuries account for a quarter of all knee injuries in the high school population.</ref> An increased Q angle and hormonal" }, { "id": "pubmed23n0616_18003", "title": "[The ACL tear from the pre-operative analysis to a 2-year follow-up, influence of the graft choice on the subjective and objective evaluation].", "score": 0.00980392156862745, "content": "This study is a synthesis of three series. The first study was prospective on 418 patients with an anterior cruciate ligament (ACL) tear (group I). Two population of ACL ruptures were identified. One population with a postero-lateral bundle preserved in 16%, the mean medial anterior tibial translation side to side was 4.97 mm, the Lachman test was delayed in 40% with no or glide pivot shift in 73%. The second population with a complete ACL tear had a mean medial anterior tibial translation side to side of 7.93 mm, the Lachman test was soft in 98% with gross pivot shift in 80%. The second study was a retrospective study on 258 patients (group II) at 26 months follow-up, it correlated the impact of the type of graft on the clinical objective and subjective results. Twenty-eight percent had anterior knee pain, 33% for the patellar tendon and 25% for the hamstrings, the subjective IKDC was significantly lower for the painful knees, and 68% of the patellar tendon had a hypoesthesia and only 32% for the hamstrings. The ability to walk on the knee was 68% for the hamstrings and 35% for the patellar tendon. The third study was retrospective on 127 patients, 24 months after ACL reconstruction (group III), all were tested on a isokinetic machine for the extensor, the flexor and the internal rotator. In the total population, a 10% extensor and flexor deficit and a 5% rotator deficit was noted. A significant difference between patellar tendon and hamstrings in terms of muscular recovery was found. It pointed out that a more specific rehabilitation should be done on the hamstring group. The muscular recovery was correlated to the highest subjective score. This study allowed the surgeon to be more specific in the ACL tear definition, to adapt the graft choice to the type of sport activity but also to the type of work the patient does and finally to modify the rehabilitation protocol for the hamstring technique." }, { "id": "wiki20220301en200_11449", "title": "Meniscus tear", "score": 0.009708737864077669, "content": "A meniscus can tear due to an internally or externally rotated knee in a flexed position, with the foot in a flexed position. It is not uncommon for a meniscal tear to occur along with injuries to the anterior cruciate ligament ACL and the medial collateral ligament MCL — these three problems occurring together are known as the \"unhappy triad,\" which is seen in sports such as football when the player is hit on the outside of the knee. Individuals who experience a meniscal tear usually experience pain and swelling as their primary symptoms. Another common complaint is joint locking, or the inability to completely straighten the joint. This is due to a piece of the torn cartilage preventing the normal functioning of the knee joint." }, { "id": "pubmed23n0395_17127", "title": "[Ligamentoplasty of the anterior cruciate ligament after 40 years: a series of 41 patients].", "score": 0.009708737864077669, "content": "Ligamentoplasty for tears of the anterior cruciate ligament (ACL) is generally thought to be unreliable after the age of 40 years. The purpose of this retrospective analysis was to assess the five-year outcome after ACL plasty in patients aged over 40 at the time of surgery. Between 1990 and 1997, 41 patients aged 44.5 +/- 4.5 years (28 men, 25 right side) underwent intra-articular reconstruction of the ACL. Clinical and radiological assessment using the IKDC criteria was obtained at a mean 62 months postoperatively using manual instrumental measurements with KT-1000. The indication for reconstruction was instability in daily life activities for 40 patients and difficulties encountered in sports activities in one; there were three cases of remodeling. Arthroscopy was used in all cases to perform a patellar tendon graft (bone-tendon-bone in 30 cases associated with extra-articular lateral reinforcement in eleven). There were no significant complications. Among 12 patients who initially participated in competition sports, seven were able to resume their activity at their former level. At last follow-up, global IKDC score was A for 12, B for 25, and C for three and D for one. All patients scored C or D had a poor IKDC symptom score, basically because of pain. Motion was not modified. The IKDC radiology score was A for 25, B for 15 and C for one, but the three cases of remodeling did not progress. Prognostic factors for overall IKDC result were: age of the patient at the time of reconstruction (under 45 years), and the delay to surgery for accident victims (less than one year). The following criteria had no effect at last follow-up: gender, sport practiced, type of initial laxity (anterior alone or global anterior), presence of meniscal damage, preservation of the medial and/or lateral meniscus, chondral injury observed peroperatively, and use of a lateral reinforcement. Radiographic remodeling observed in this group of 41 patients was related to delay from accident to surgery (p=0.0007) and preservation of the medial meniscus (p=0.03). Age, gender, type of activity before surgery, degree of initial and residual laxity had no statistically significant effect on remodeling. Age over 40 years is not a contraindication for arthroscopic free patellar tendon graft for the treatment of chronic anterior laxity. Using rigorous preoperative assessment criteria (delay from accident to surgery, absence of joint space narrowing on the AP and lateral view before intervention, symptomatic instability in daily life activities and motivated patient) this type of procedure can be performed safely and provides good functional outcome at five years. The current follow-up is insufficient to judge potential joint degradation. Age is not a contraindication if certain precautions are taken." }, { "id": "wiki20220301en058_57566", "title": "Drawer test", "score": 0.009615384615384616, "content": "The drawer test is used in the initial clinical assessment of suspected rupture of the cruciate ligaments in the knee. The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner positions himself by sitting on the examination table in front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. The tibia is then drawn forward anteriorly. An increased amount of anterior tibial translation compared with the opposite limb or lack of a firm end-point may indicate either a sprain of the anteromedial bundle or complete tear of the ACL. If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly suggests that the anterior cruciate ligament is injured, whereas excessive posterior displacement of the tibia may indicate injury of" }, { "id": "pubmed23n0050_3857", "title": "[Diagnosis of anterior cruciate ligament injury of the knee joint].", "score": 0.009615384615384616, "content": "From January, 1979 to May, 1989, 107 patients with problems related to anterior cruciate ligament (ACL) were treated in our hospital. 100 of the patients had anterior cruciate ligament injury confirmed by arthrotomy or arthroscopy. The remaining 7 patients were found to be normal either by arthroscopy or arthrotomy. 29 patients had fresh ACL injury and 71 old. All the patients had history of trauma of the knee joint. Swelling and pain in the affected knee joint took place in fresh cases and few of them complained of instability or deformity of the knee. On examination, floating patella test was positive in the majority of the fresh cases. It was shown that accurate diagnosis could be made by Lachman test rather than by conventional anterior drawer test in dealing with fresh injury, but with old ones, Lachman test didn't show the advantages. Examination under anesthesia or arthroscopy helped a lot in diagnosing fresh ACL injury. Anterior drawer test (ADT) was significant in determining the existence of ACL injury. When ADT was positive, ACL injury was found in the majority of the cases, however, injured ACL couldn't be ruled out by negative ADT only. Positive valgus stress test on 0 degrees position suggests possibility of ACL injury, even ADT was negative. Despite the negative anterior drawer test positive posterior drawer test on three directions indicated the injury of the posterior cruciate ligament and the anterior cruciate ligament. The positive rate of ADT was higher than that of pivot shift test in dealing with anterior cruciate ligament injury. Positive pivot shift test suggests ACL injury." }, { "id": "pubmed23n0687_17020", "title": "[Repair of old injury of knee medial collateral ligament by a combination of dynamic and static stability].", "score": 0.009523809523809525, "content": "To observe the effectiveness of the combination of dynamic and static stability in the treatment of old knee medial collateral ligament injury. Between March 2004 and June 2008, 26 cases of old knee medial collateral ligament injury were treated, including 19 males and 7 females with a mean age of 38 years (range, 21-48 years). Injury was caused by traffic accident in 6 cases, by sprains in 12 cases, by falling from height in 8 cases. The location was left knee in 15 cases and right knee in 11 cases. Of them, 24 patients showed the positive result of knee valgus test, 2 cases showed slightly relaxed knee tendon. The knee X-ray films of valgus stress position showed that the medial joint space differences between both knees were 3-5 mm in 2 cases and 5-12 mm in 24 cases. The injuries included avulsion of the medial femoral condyle starting point in 19 cases, central laceration in 6 cases, and tibial point laceration concomitant meniscus injury in 1 case. The time from injury to hospitalization was 3-14 months (mean, 6.4 months). Gracilis muscle was used to repair knee medial collateral ligament and the sartorius muscle transfer to reconstruct the medial rotation of knee stability function. All incisions healed by first intention. No joint infection, deep vein thrombosis, or other postoperative complications occurred. Twenty-six cases were followed up 12-58 months with an average of 30 months. The results of knee valgus stress test were negative with no joint tenderness. At 3 months after operation, the knee X-ray films of valgus stress position showed the medial joint space differences between both knees were less than 1 mm. According to the modified Lysholm-Scale score, the results were excellent in 18 cases, good in 7 cases, and fair in 1 case with an excellent and good rate of 96% at last follow-up. A combination of dynamic and static stability in repairing old knee medial collateral ligament injury is easy-to-operate and has the advantages to perform the operation in the same incision, so it can avoid the shortcomings of single repair method and achieve better effectiveness." }, { "id": "pubmed23n0766_16162", "title": "[Intrafix fixation and remnants preservation in single-tunnel double-bundle reconstruction of anterior cruciate ligament with anatomical placement of hamstring tendons].", "score": 0.009433962264150943, "content": "To study the feasibility and short-term effects of Intrafix fixation and remnants preservation in single -tunnel double-bundle reconstruction of anterior cruciate ligament (ACL) with anatomical placement of hamstring tendons. From August 2011 to November 2011, 25 patients with ACL injuries were treated with arthroscopic reconstruction of ACL using hamstring tendon. There were 19 males and 6 females, with a mean age of (26.26 +/- 9.53) years (ranged, 16 to 50 years). Fifteen patients had injuries in left knees, and 10 patients had injuries in right knees. The duration of the disease ranged from 1 to 60 d, with a mean of 9.6 d. All patients with acute injuries had swelling and pain on the knee, and anterior drawer test showed positive results in 14 cases, Lachman test showed positive results in 17 cases. Among patients with old injuries, 5 patients had knee joint pain, 5 patients had unstability of knee joint, 5 patients had positive results of anterior drawer test, and 5 patients had positive results of Lachman test. The diagnosis of ACL injury was determined by the anterior drawer test and Lachman test. There were 20 patients with acute injuries and 5 patients with old injuries. MRI was performed in all patients to confirm the diagnosis of ACL injuries and provide additional information on meniscal and other ligament injuries. Preservation of the remnants was through patellar tendon portal using meniscus suture guide. The femoral tunnel was placed at lateral femoral condyle at 2:00 or 10:00 position through the anteromedial (AM) portal with the knee flexed to 120 degree using an offset guide (DePuy Mitek). The tibia tunnel was placed at the center of the ACL remnant through the AM portal using a tibia guide set 45 degree. The AM and PL bundles were rotated by rotating the positioning tool to achieve the desired positions of the bundles and were fixed by femoral Intrafix and tibia Bio-Intrafix fixation. The anterior drawer test, Lachman test and Lysholm scores were observed to determinate the function of the knee and the activity of the patients. All the patients were followed up, and the duration ranged from 12 to 18 months. The Lysholm scores improved from preoperative 34.08 +/- 7.60 (25 to 49 scores) to 94.52 +/- 2.86 (89 to 98 scores) at the follow-up time (t = 21.29, P &lt; 0.01). No postoperative complications such as synovitis, ligament rupture and movement restriction occurred. Intrafix fixation and remnants preservation in single-tunnel double-bundle reconstruction of ACL with anatomical placement of hamstring tendons is simple, effective, useful, reproducible, and gives a satisfactory short-term results." }, { "id": "pubmed23n0751_15183", "title": "[Evaluation of the clinical results in patients with symptomatic partial tears of the anterior cruciate ligament diagnosed arthroscopically].", "score": 0.009433962264150943, "content": "The study presents a retrospective evaluation of clinical data and arthroscopic findings in a group of our patients with symptomatic knee instability due to a partial tear of the anterior cruciate ligament (ACL). The group included 31 patients diagnosed with symptomatic partial ACL tears, i.e. an isolated tear of the posterolateral (PL) or the anteromedial (AM) bundle. The patients' average age was 26.5 years. A side-to-side difference in ventral knee laxity was assessed using the anterior drawer test and the Lachman test under general anaesthesia before arthroscopy was commenced; rotational knee laxity was evaluated by the pivot shift test. An objective evaluation of side-to-side ventral laxity differences in both knees was performed on the GNRB® arthrometer with an applied pressure of 134 N and 250 N in the conscious patient. During arthroscopic examination, findings on the two ACL bundles were recorded. All 31 patients were diagnosed with symptomatic partial ACL tears, of them 22 had a PL bundle lesion and nine had an AM bundle tear. All patients with PL bundle lesions only reported problems in association with pivot sports, and all patients with AM bundle tears had problems regardless of any sports activities. In all patients with isolated AM bundle tears, the lesion was located close to its femoral attachment. In the patients with PL bundle tears, femoral location was found in 68% and tibial location in 32% of the patients. In the patients with partial PL bundle lesions, + and ++ results in the pivot shift test were recorded in 32% and 68% of the treated patients, respectively. The Lachman test showed + and ++ results in 71% and 9% of the patients, respectively. The anterior drawer test had negative results in 87% and positive + results in 13% of the patients. The side-to-side difference on the GNRB arthrometer ranged from 0.4 to 2.3 mm at a pressure of 134 N and from 1.2 to 4.2 mm at 250 N in the patients with isolated PL bundle lesions. In the patients with AM bundle lesions, the results were as follows: pivot shift test, 89% negative. 11% positive +; Lachman test, 56% negative, 44% positive +; anterior drawer test, 89% +, 11% ++; GNRB test, 2.2 to 4.4 mm at 134 N, and 4.3 to 7.1 at 250 N. The diagnosis of partial ACL lesions, i.e., isolated tears of the AM or the PL bundle, requires accurate knowledge of knee anatomy and its biomechanics. In accordance with other authors our results showed that an arthroscopic examination of both bundles of the ligament as well as knee laxity evaluation under general anaesthesia are most essential for making the definite diagnosis in partial ACL tears. They also confirmed that, in isolated AM bundle lesions, ventral laxity is present more often particularly at a higher degree of knee flexion while, in PL bundle lesions, rotational laxity is more frequent and ranges from 0 to 30 degrees of knee flexion. To make the definite diagnosis of partial ACL tears, patient medical history, clinical knee examination including instability type and degree assessment under general anaesthesia and, most importantly, arthroscopic findings on both ACL bundles are necessary." }, { "id": "pubmed23n0304_14458", "title": "[Meniscus lesions after isolated anterior cruciate ligament rupture].", "score": 0.009345794392523364, "content": "In this retrospective study the meniscal status of 34 patients with untreated complete anterior cruciate ligament (ACL) tears is reported. The anterior cruciate ligament injury was initially documented by examination under anesthesia and arthroscopy. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. The mean follow-up was 7.3 years. Twenty-two (65%) patients showed signs of meniscal pathology at an average of 2.5 years after the ACL injury during the follow-up period. Rearthroscopy was performed and showed a higher incidence of medial meniscus tears (53%) than lesions of the lateral meniscus (41%). The most common tear of the medial meniscus was the bucket-handle type, followed by the flap tear and the single longitudinal split of the posterior horn. Secondary reconstruction of the ACL was necessary in 18 patients (82%) complaining of symptoms indicative of permanent anterior instability of the knee. The remaining 4 patients had rearthroscopy 3.5 years after the ACL injury and a partial meniscectomy and ACL reconstruction was performed. 12 patients (35%) had no symptoms or signs of joint instability or meniscal pathology during the follow-up period, but discontinued their sporting activities. This study indicates the increasing incidence of meniscal tears during ACL insufficiency. We recommend that patients with ruptures of the anterior cruciate ligament should be investigated for meniscal tears and that early ligament reconstruction of the knee and meniscal repair or partial meniscectomy should be considered simultaneously." }, { "id": "pubmed23n0068_3577", "title": "The long-term course after treatment of acute anterior cruciate ligament ruptures. A 9 to 16 year followup.", "score": 0.009345794392523364, "content": "Acute total ACL (N = 60) and concomitant medial collateral ligament (N = 46) ruptures were repaired in 60 patients (mean age, 28 years) without augmentation. Menisci were removed in 23 knees. Fifty-three (88%) of the patients were reexamined 9 to 16 years later with special emphasis on manual and instrumented stability testing (Stryker, Genucom), knee function score (Lysholm), and activity level (Tegner). Standing roentgenograms (30 degrees of knee flexion) were taken in 69% of the patients. At followup, an ACL reconstruction had been performed in seven patients (12%) due to symptomatic instability. Sixty-four percent of the knees had a positive Lachman sign and 40% a positive pivot shift. Sagittal laxity difference was +3 mm or more in 57%. Knee function score was a mean of 86 +/- 12 points. The mean activity level had changed from recreational team sports (Level 7) to recreational individual sports (Level 5). Only patients with good knee stability were able to perform demanding sports and could continue at their desired activity level. Osteoarthritis of slight to moderate degree (Fairbank I/II) was found in 58% of the patients younger than 35 years of age at the time of trauma and in 87% of the older patients. Knees with intact menisci had less osteoarthritis than knees with removed menisci (P less than 0.05)." }, { "id": "pubmed23n0748_8694", "title": "Shelbourne's update of the O'Donoghue knee triad in a 17-year-old male Rugby player.", "score": 0.009259259259259259, "content": "Acute athletic knee injuries are often caused by a combination of valgus impact with external rotation of the tibia leading to a triad of injuries involving medial collateral and anterior cruciate ligament disruption with associated meniscal damage. This injury pattern has been greatly discussed in the literature with conflicts of opinion and evidence as to whether medial or lateral meniscal pathology has a higher incidence. This case report introduces a 17-year-old male athlete with this unhappy triad It will evaluate the clinical assessment which suggested a medial meniscal lesion follow the patient through arthroscopy revealing a lateral meniscal tear in addition to complete anterior cruciate ligament rupture and grade 2 medial collateral ligament tear. It will go on to look at the evidence base for the relative incidence of lateral and medial meniscal injuries and will evaluate the role of MRI in assessing acute athletic knee injuries." }, { "id": "pubmed23n1102_14643", "title": "[Early Operative Treatment of Anterior Cruciate Ligament Lesions: 3-Year Experience].", "score": 0.009259259259259259, "content": "PURPOSE OF THE STUDY The aim of this study is to show new possibilities for the treatment of anterior cruciate ligament injuries. For many years, the long-established rules have been followed. However, throughout history, treatment strategies have been gradually modified. The advent of new modern technologies now makes it possible to perform reconstructive procedures already in the acute phase, and thus shorten the treatment time significantly. MATERIAL AND METHODS 85 patients were followed after an acute knee injury with an isolated anterior cruciate ligament (ACL) lesion. There were 51 men and 34 women with the average age of 32 years. All patients underwent an acute knee arthroscopy with subsequent ACL reconstruction according to the type of lesion. The results were evaluated according to the clinical examination, Lysholm and Tegner activity scores. We compared 2 surgical techniques (Internal Brace, All-Inside ACL reconstruction) and assessed the possible occurrence of complications. RESULTS The injury was most often observed in patients aged 20-40 years, when mainly sports activities put a major strain on the knee joint. After performing ACL reconstruction, all patients reported a subjective improvement in the overall condition. The number of complications was very low - only in connection with a slower warm-up of the knee joint after surgery. DISCUSSION All patients achieved full stabilization of the knee joint, which is objectified by an increase in the Lysholm score. The improvement in patient's subjective feelings is also confirmed by the increase in Tegner activity scores. Only a few patients experienced a slight restriction of movement in the 8th week after surgery, but thanks to intensive rehabilitation the function of the knee joint was completely restored within 3 months of the operation. CONCLUSIONS Our study proves that if the set rules are followed, it is possible to perform the ACL reconstruction already in the acute phase. However, in order to choose this approach, the patient's motivation, gently performed procedure and early intensive rehabilitation are necessary. When meeting these criteria, the patient is able to return to normal life, including sports activities, quite early and there is no increased risk of complications. Key words: Internal Brace, ACL reconstruction, arthroscopy, early, rehabilitation, All-Inside." }, { "id": "wiki20220301en058_57568", "title": "Drawer test", "score": 0.009255696635458083, "content": "See also Anterior cruciate ligament injury Posterior cruciate ligament injury Lachman test References Examination of the knee" }, { "id": "pubmed23n0683_15213", "title": "Arthroscopic prevalence of ramp lesion in 868 patients with anterior cruciate ligament injury.", "score": 0.00909090909090909, "content": "A special type of repairable meniscal lesion involving the peripheral attachment of the posterior horn of the medial meniscus is commonly associated with anterior cruciate ligament deficiency and is termed a \"ramp lesion.\" However, there are no previously published articles reporting the epidemiologic characteristics of ramp lesions. The ramp lesion is a special type of medial meniscal tear with high prevalence associated with anterior cruciate ligament rupture; the prevalence increases with time from anterior cruciate ligament injury. Age and gender are risk factors affecting the prevalence of the ramp lesion. Cross-sectional study; Level of evidence, 3. From April 2002 to October 2007, 868 consecutive knees were diagnosed as having an anterior cruciate ligament injury and received arthroscopic surgery for anterior cruciate ligament reconstruction. All the patients had verified tears of the ramp area under arthroscopy. The prevalence of the ramp lesion was evaluated retrospectively. Then, all cases were divided into different groups depending on the time interval from anterior cruciate ligament injury to anterior cruciate ligament reconstruction and other relevant risk factors such as age and gender. The effects of age, gender, and time from injury on the prevalence of ramp lesions were analyzed. Among 868 knees that underwent surgery for anterior cruciate ligament reconstruction, 144 knees were diagnosed as having a ramp lesion. The mean age was 24.7 years; there were 113 male and 31 female patients. The mean time from injury to anterior cruciate ligament reconstruction was 27.2 months. The prevalence of ramp lesions was 16.6%, which was analyzed as a logarithmic correlation with time from injury. Patients younger than 30 years of age and male patients had a significantly higher prevalence of ramp lesions. The ramp lesion is a common meniscal injury that can occur at the time of anterior cruciate ligament rupture or as a result of knee laxity associated with anterior cruciate ligament insufficiency. The prevalence of ramp lesion in this patient group was 16.6%, which increased with time until 24 months after initial injury. Patients younger than 30 years of age and male patients had a higher prevalence of ramp lesions." }, { "id": "pubmed23n0263_7093", "title": "[Mid-term results of 173 cases of surgery of the anterior cruciate ligament using the Mac Intosh procedure, reinforced by the Kennedy Ligament Augmentation Device].", "score": 0.009009009009009009, "content": "This is a retrospective study of 173 chronic laxities of the knee operated on between May 1985 and December 1988 using the Mac Intosh procedure, reinforced by the Kennedy L.A.D. Follow-up was between 4-8 years and the same surgeon operated on all the knees. 171 patients were operated on (113 men and 58 women) aged between 15-49 years (average age 26.5 years). The vast majority were sportsmen both at competition level (51 cases) and at recreational level (119 cases). The average time-span between accident and intervention was 15 months (1-240 months). In the pre-operative assessment, 80 cases (46.2 per cent) were found to have a grade II Lachman test and 91 cases (52.6 per cent), a grade III Lachman test; a positive pivot shift was found in more than 95 per cent of cases. There were lesions of the medial meniscus in 101 cases (58.4 per cent), of the lateral meniscus in 94 cases (54.4 per cent) and there was no meniscal lesion in only 41 cases (23.8 per cent). Finally there were 22 chondral lesions of the medial femoral condyle (12.7 per cent) and 7 of the lateral condyle (4.1 per cent). These were based on 159 cases (14 lost to follow-up before the third post-operative month), but only 107 (61.8 per cent) were reviewed by one of us (i.e. not the original surgeon). Tolerance of the L.A.D. was excellent. There was no sign of synovitis or joint effusion persisting beyond 1 year. Furthermore, there were no serious complications (no sepsis, only 4 cases (2.3 per cent) of joint stiffness, 2 cases of reflex sympathetic dystrophy and 5 cases of sural phlebitis (2.9 per cent). Moreover, the few minor complications that arose resolved with the appropriate treatment. Anatomical results, evaluated using. Lachmans test (maximum manual Lachman measured with the Bercovy Laximeter) showed 24 cases (22.4 per cent) with zero differential residual laxity, 54 cases (50.5 per cent) with a differential laxity of between 0-2 mm; 20 cases (18.7 per cent) with a laxity of between 2-4 mm and in 9 cases (8.4 per cent) a laxity of greater than 4 mm. Functional results, using the Arpège C.L.A.S. system showed good results in 83 per cent (score &gt; and unsatisfactory results in 17 per cent of cases. The long time-span between intervention and subsequent review with the C.L.A.S. system should be taken into account. However, the proportion of competitive sportsmen to recreational sportsmen was practically identical when comparing pre-traumatic figures (C = 29.5 per cent, R = 68.8 per cent) to figures at the time of follow-up (C = 21 per cent, R = 69.5 per cent). Radiological results (A.P. and Schuss films) showed 63 knees (58.9%) with no signs of either medial or lateral, preliminary or full-blown, femoro-tibial osteo-arthritis. With an average follow-up of &gt; 5 years (4-8 years), it is possible to say that ligamentoplasty of the anterior cruciate ligament using the Mac Intosh procedure reinforced with the Kennedy L.A.D. is not causative of any iatrogenic problems. The anatomical results were totally satisfactory (almost normal) in 72.9 per cent of cases; the radiological results showed \"\"normal'' knees in 58.9 per cent of cases and functional results were identical to results obtained using many other techniques." }, { "id": "pubmed23n0049_19299", "title": "A modified repair for the anterior cruciate ligament deficient knee.", "score": 0.008928571428571428, "content": "A retrospective analysis of 48 sportsmen and women from an original series of 76 consecutive patients who had undergone a modified McIntosh repair was carried out to establish whether or not the procedure could provide a satisfactory recovery and return to previous ability. The type and level of sport before injury was compared with that after operation. Symptoms of pain and giving way, and examination findings of pivot shift, and Lachman's test were compared before and after operation. Of the 48 patients assessed, 28 (58%) returned to full sporting capacity; 17 (35%) patients were participating in different sports or lower levels of their previous sports, and three patients did not participate in any sport. The more severely symptomatic knees did not perform so well after operation. The degree of preoperative anterior draw and Lachman's test did not influence the final result and the pivot shift, present in all before operation, was abolished in all but one case, which remained badly symptomatic. Concurrent meniscal injury or medial or lateral laxity did not influence return to sport once a full postoperative recovery was made. No deterioration was noticed in the level of sporting ability achieved thereafter. In this study it has been shown that the modified McIntosh repair is a swift extra-articular reconstruction for the anterior cruciate ligament deficient knee, which is less elaborate than previously described Ellison and McIntosh procedures, and which has produced a comparable result." } ] } } }

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{ "1": "Neurofibroma of the gastric wall.", "2": "Gastrointestinal stromal tumor.", "3": "Leiomyoma.", "4": "Granulocytic sarcoma.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0379_17432", "title": "[Gastric stromal tumor with myxoid degeneration. Report of a case and review of the literature].", "score": 0.01763791763791764, "content": "Gastrointestinal stromal tumors (GIST's) represent a heterogeneous group of neoplasms that have as their common histologic denominator an immature proliferation of epithelioid or spindle cells. Although originally believed to represent atypical variants of leiomyoma or leiomyosarcoma, recent studies have demonstrated that only a subset of such tumors actually display well developed immunohistochemical, ultrastructural features of smooth muscle differentiation. Most gastrointestinal mesenchymal tumors are of uncertain histogenesis. Current studies have shown a striking morphological and immunophenotypic similarities of these tumors with the interstitial cells of Cajal. And that they may originate from stem cells that differentiate toward a pacemaker cell phenotype. Most GIST's have a co-expression of Kit (CD117) or CD34, which is also express in interstitial cells of Cajal. This review will attempt to summarize the current knowledge and understanding of these lesions based on review of the literature, with an analysis of the criteria for distinguishing between benign and malignant tumors. We report a Gastrointestinal Stromal Tumor of the stomach with prominent cystic degeneration. The patient had diarrhea, abdominal pain and was found to have abdominal mass. X-ray and computed axial tomography examination showed a lesion that seems to be a pancreatic cystic lesion. At laparotomy a large intramural tumor located in the stomach was found. Histologically, the lesion was composed of epithelioid and spindle cells embedded in an abundant myxoid stroma. Tumor cells showed positive staining for vimentin and CD34 positive. We conclude that the diagnosis of gastrointestinal stromal tumor whit prominent cystic degeneration can be made in this case." }, { "id": "pubmed23n0926_9513", "title": "Rupture of gastrointestinal stromal tumor presenting with sudden onset chest and back pain and accompanied by gastric dilatation.", "score": 0.017011197243755383, "content": "A 72-year-old man with hypertension was admitted with acute-onset chest and back pain followed by epigastralgia. He was transported by helicopter due to suspected acute aortic dissection. Systolic blood pressures were equal in both arms. Physical examination showed epigastric tenderness without rebound. Blood tests showed leukocytosis. Electrocardiogram and echocardiogram were normal. Abdominal radiography showed acute gastric dilatation with an air-outlined large mass-like shadow. Abdominal computed tomography revealed a 6-cm exophytic mass and large intramural hematoma in the lesser curvature of the gastric body. The patient underwent urgent laparotomy with total gastrectomy. The resected tumor showed positivity for CD117 and CD34 but negativity for S100, indicating a gastrointestinal stromal tumor. Fourteen days after the surgery, the patient was uneventfully discharged. Intramural bleeding of submucosal tumors including gastrointestinal stromal tumor should be considered in cases of acute gastric dilatation. Abdominal radiography may be a clue regarding the presence of this condition." }, { "id": "pubmed23n1119_9754", "title": "[A Case of Spindle Cell Tumor in the Gastric Mucosa Treated with Laparoscopic Local Gastrectomy].", "score": 0.01607142857142857, "content": "The patient was a 43-year-old man. An upper gastrointestinal endoscopic examination revealed a gastric submucosal tumor(SMT)-like, elevated 8-mm lesion in the greater curvature of the upper body of the stomach. It was diagnosed as spindle cell tumor on the basis of biopsy findings, and a gastrointestinal stromal tumor(GIST)was suspected. Various immunohistochemical staining techniques were used; however, a definitive diagnosis could not be achieved. There was no evidence of distant metastasis even on thoracoabdominal computed tomography imaging; thus, the patient was referred to our department for definitive diagnosis and surgical treatment. Laparoscopic local gastrectomy with concomitant intraoperative gastroscopy was performed. Pathological examination of the resected specimen showed a type Ⅱc-like lesion with a maximum diameter of 6 mm in the mucosal layer along with spindle cell proliferation. Immunostaining was negative for c- kit, DOG1, CD34, S-100, SMA, WT-1, desmin(N), EMA, and keratin(pan)and positive for β-catenin, Bcl-2, and vimentin; furthermore, low Ki-67(MIB-1)expression was detected. Therefore, GIST, solitary fibrous tumor, leiomyoma, leiomyosarcoma, desmoid tumor, spindle cell carcinoma, and synovial sarcoma were excluded, and an unclassifiable spindle cell tumor arising from the gastric mucosa was diagnosed. The patient has remained recurrence-free for 1 year and 8 months post-operatively and is currently under careful outpatient follow-up." }, { "id": "pubmed23n0560_11242", "title": "[Gastrointestinal mesenchymal tumors: a clinical pathologic and immunohistochemical study of 210 cases].", "score": 0.015934065934065933, "content": "To study the clinical pathologic and immunohistochemical features of gastrointestinal mesenchymal tumors (GIMTs), and to investigate the value of molecular markers in GIMTs clinical differentiation diagnosis. The clinical and pathological data of 210 cases of GIMTs, collected from Jan. 1987 to Dec. 2005 in our hospital, were investigated retrospectively. GIMTs were rediagnosed by using standard immunostaining technique in paraffin-embedded tissue. The expression level of CD117, CD34, Desmin, SMA and PS100 were detected by immunohistochemical method. Among 210 cases of GIMTs, 127 cases were Gastrointestinal stromal tumors (GISTs) (60.5%), 33 leiomyomas and leiomyosarcomas (15.7%), 27 neurogenic tumours (12.8%), and 23 miscellaneous tumors (11.0%). The incidences of GIST, leiomyoma and leiomyosarcoma were similar among men and women. Men were more likely to develop neurogenic tumors and miscellaneous tumors than women. Of all the GISTs, 51.2% cases originated from stomach, 19.7% from small intestine, 11.0% from esophagus, 10.2% from colon and rectum. The most common location of leiomyomas and leiomyosarcomas was esophagus (45.5%). The most common location of neurogenic tumors was retroperitoneum (74.1%). Common symptoms of GISTs included digestive tract hemorrhage in 36 cases (28.3%), abdominal pain in 27 cases (21.3%) and abdominal mass in 24 cases (18.9%). Other GIMT cases except GISTs had no first symptom of digestive tract hemorrhage. It was noticed that 79.5% of GISTs had no obvious invasion, and 72.7% of leiomyomas and leiomyosarcomas had no obvious invasion. 33.3% of neurogenic tumors invaded the adjacent organs or tissues. No metastases had been found in other GIMT cases except GISTs. The neoplastic cells of GISTs were composed of various percentage of spindle (72.5%), epithelioid (11.8%) and mixed-type cells (15.7%). The percentage of spindle cells in leiomyomas and leiomyosarcomas was 94. The immunohistochemical results of GISTs showed that the positive rate of CD117 was 93.7%, CD34 was 69.3%, Desmin was 13.4%, SMA was 12.6%, and PS100 was 10.2%. The immunohistochemical results of leiomyomas and leiomyosarcomas showed that the positive rate of Desmin was 78.5%, SMA was 63.6%, while as the expressions of CD117, CD34, and PS100 were negative. Diffuse strong positive staining of PS100 was observed in 88.9% of neurogenic tumor patients. GISTs are the most common tumors among GIMTs. GISTs are different from neurogenic tumors, leiomyomas and leiomyosarcomas in initial symptom, tumor location, biological behavior and immunophenotype. Immunohistochemistry plays an important role in differentiating GISTs from leiomyomas and neurogenic tumors." }, { "id": "pubmed23n0560_11244", "title": "[Analysis of prognostic and clinicopathologic factors in gastrointestinal stromal tumors of the stomach].", "score": 0.014831869779396016, "content": "To identify the clinical pathological characteristics and prognostic factors in patients with gastrointestinal stromal tumors of the stomach. The data of 98 patients of gastric stromal tumors, leiomyomas, leiomyosarcomas, leiomyoblastomas, schwannomas and neurofibromas, collected from Mar. 1983 to Dec. 2001 in our hospital with complete clinical and pathological data, were investigated retrospectively. Gastric stromal tumors were diagnosed by reviewing the tumor slides stained with hematoxylin and eosin (H&amp;E). Two histomorphologically representative areas of each tumor slides were identified and arrayed on a tissue microarray. Immunohistochemistry staining were performed using antibodies to c-kit (CD117), CD34, smooth muscle actin (SMA), Desmin and S-100 proteins. The relations of various clinicopathologic characteristics and outcomes were tested by univariate analysis and multivariate analysis. Ninety-one patients were clearly identified as gastric stromal tumors from the 98 patients, who were diagnosed as gastric stromal tumor, leiomyoma, leiomyosarcoma, leiomyoblastoma schwannoma and neurofibroma (92.9%). The follow-up rate was 91% and the median follow up time was 54 months. The patient survival rates at 1, 5 and 10 years were 88.8%, 79.6% and 63.7% respectively. Univariate analysis showed that tumor size, mitotic count, tumor necrosis, nuclear pleomorphism, cell type, cell density, surgical procedure, mucosal invasion, age and lable index of Ki-67 were associated with prognosis (P&lt;0.05). Multivariate analysis showed that tumor size, mitotic count, mucosal invasion and tumor necrosis were predictors of prognosis (P&lt;0.05). Tumor size of &gt;10 cm, mitotic count of &gt;10 mitoses per 50 high power fields, necrosis and mucosal invasion are often associated with an aggressive clinical course in gastric stromal tumors." }, { "id": "pubmed23n0478_23454", "title": "[Clinicopathological, immunohistochemical and molecular genetic study of intra-abdomen extra-gastrointestinal stromal tumors].", "score": 0.01472213847854487, "content": "To explore the clinicopathological, immunohistochemical and molecular genetic features of intra-abdomen extra-gastrointestinal stromal tumors (EGISTs) and their differential diagnosis. Nine cases of EGISTs from the abdominal cavity or retroperitoneum which were previously diagnosed as leiomyoma, leiomyoblastoma, or leiomyosarcoma etc. by a panel of antibodies such as CD117, CD34, alpha-SMA, MSA, desmin, S-100, and PGP9.5 from which five cases were detected for c-kit gene mutation. The tumors occurred in 5 men and 4 women, the age ranged from 38 to 72 years (mean 61.7 years). Four cases arose from the mesentery, two from omentum, two from retroperitoneum and one located at the hilus of the spleen. The size of tumors ranged from 5 cm to 23 cm (mean 12.9 cm) in diameter and the tumor cell components varied: mainly spindle cells (seven cases), epithelioid cells (one case), mixed cells (one case). Tumors expressed CD117 (8/9), CD34 (5/9), alpha-SMA (3/9), MSA (4/9), desmin (0), S-100 protein (1/9) and PGP9.5 (1/9). Of the five cases examined for heterozygous deletion mutation of 11 exon of the c-kit gene two were found positive. Two borderline cases showed long-term survival of 8 years and 11 years, respectively. In seven malignant cases, two showed adverse outcome, one survived 4 years without recurrence, two were lost in follow up and two new cases were still being in followed. GIST-type stromal tumors can also occur in the abdomen, most cases were borderline or malignant, tumor coagulative necrosis, mitoses &gt;or= 5 per 50 high-power fields and obvious nuclear atypia indicating malignancy. Differential diagnosis of EGIST including benign or malignant smooth muscle tumors, benign or malignant nerve sheath tumors etc." }, { "id": "wiki20220301en532_18597", "title": "Gastroblastoma", "score": 0.01440185830429733, "content": "Histology The tumour is biphasic and contains spindle and epithelial cells. The spindle cells form diffuse sheets. The epithelial cells occur in clusters which may form glandular structures. Immunochemistry The epithelial component is positive for keratin (keratin AE1/AE3, keratin 18, keratin 7) c-KIT and CD56. The mesenchymal component is positive for CD10 and vimentin. Electron microscopy Desmosomes and microvilli are present. Differential diagnosis The histological differential diagnosis includes Carcinosarcoma Biphasic synovial sarcoma Teratoma Mixed tumor Other rare stomach tumours Several other rare tumours that may need to be considered in the differential diagnosis include Multiple minute gastrointestinal stromal tumor Interstitial cell of Cajal hyperplasia Nerve sheath tumors (schwannoma and perineurioma) Granular cell tumor Glomus tumor Plexiform angiomyxoid myofibroblastic tumor Primary clear cell sarcoma History" }, { "id": "wiki20220301en022_26782", "title": "Gastrointestinal stromal tumor", "score": 0.014328808446455506, "content": "Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. GISTs arise in the smooth muscle pacemaker interstitial cell of Cajal, or similar cells. They are defined as tumors whose behavior is driven by mutations in the KIT gene (85%), PDGFRA gene (10%), or BRAF kinase (rare). 95% of GISTs stain positively for KIT (CD117). Most (66%) occur in the stomach and gastric GISTs have a lower malignant potential than tumors found elsewhere in the GI tract." }, { "id": "wiki20220301en191_7339", "title": "Stromal tumor", "score": 0.013932950355826116, "content": "Gastrointestinal stromal tumors (GISTs) form in the soft mesenchymal tissue of the gastrointestinal tract and form from the rapid growth of interstitial cells of Cajal (ICCs). GISTs are the most common type of tumor found in the gastrointestinal tract, usually located in the small intestine or stomach. Approximately 10-20 million individuals are diagnosed with this type of tumor every year (Stamatakos et al., 2009). GISTs are most common in individuals ranging in age from 40 years old to 70 years old and are rare in small children and young adults. Individuals with these tumors may experience swelling in the abdomen, pain, vomiting, nausea, appetite loss, weight loss, low blood cell counts, gastrointestinal bleeding (which can result in bloody or dark stool), weakness, and tiredness. The prognosis for these types of tumors depends heavily on the size of the tumor and the rate of mitosis, however approximately 60% of GISTs are diagnosed as benign. Surgery to remove the tumor is the" }, { "id": "pubmed23n0560_22777", "title": "Rectal GIST presenting as a submucosal calculus.", "score": 0.013624338624338624, "content": "This case report presents an incidental finding of a rectal GIST (gastrointestinal stromal tumor) presenting as a submucosal calculus, not previously reported. A 53-year-old man without a significant medical history presented with abdominal pain in the left lower quadrant, and with constipation. Upon rectal examination, a hard submucosal swelling was palpated 4 cm from the anus, at 3 o'clock, in the left rectum wall. X-ray photos, computerized tomography (CT)-scan and a magnetic resonance imaging (MRI) scan clearly showed a calculus. Excision revealed a turnip-like lesion, 3.1 x 2.3 x 1.8 cm. Analysis showed it was a rectal GIST, a rare mesenchymal tumor of the gastrointestinal tract, which expressed CD117 (or c-kit, a marker of kit-receptor tyrosine kinase) and CD34. Calcification is not a usual clinicopathological feature of GISTs [1-3], and although a number of rectal GISTs have been reported [4-9], we have found no cases so far of rectal GIST presenting as a submucosal calculus. In general, GISTs are rare mesenchymal tumors of the gastrointestinal tract (nerve tissue, smooth muscle). Histology and immunohistochemistry discriminate gastrointestinal stromal tumors from leiomyomas and neurinomas. The most important location is the stomach; the rectal location is rare. Usually, the classic signs of malignancy such as cellular invasion and metastasis are missing. A set of histologic criteria stratifies GIST for risk of malignant behavior such as mitotic activity and tumor size, cellular pleomorphism, developmental stage of the cell and quantity of cytoplasma [7,13]. Tumors with a high mitotic activity and size above 5 cm are considered malignant. Recent pharmacological advances such as tyrosine kinase inhibitors have determined c-kit (i.e., CD117) as the most important marker, amongst others. C-kit positive tumors respond extremely well to chemotherapy with Imatinib (Glivec, Gleevec) [10-12]." }, { "id": "pubmed23n0480_1831", "title": "Clinical manifestations and prognostic factors in patients with gastrointestinal stromal tumors.", "score": 0.013595413595413594, "content": "To investigate the incidence of CD117-positive immunohistochemical staining in previously diagnosed gastrointestinal (GI) tract stromal tumors (GIST) and to analyze the tumors' clinical manifestations and prognostic factors. We retrospectively reviewed 91 cases with a previous diagnosis of GI stromal tumor, leiomyoma, or leiomyosarcoma. Tissue samples were assessed with CD117, CD34, SMA and S100 immunohistochemical staining. Clinical and pathological characteristics were analyzed for prognostic factors. CD117 was positive in 81 (89%) of 91 tissue samples. There were 59 cases (72.8%) positive for CD34, 13 (16%) positive for SMA, and 12 (14.8%) positive for S100. There was no gender difference in patients with CD117-positive GIST. Their mean age was 65 years. There were 44 (54%) tumors located in the stomach and 29 (36%) in the small intestine. The most frequent presenting symptoms were abdominal pain and GI bleeding. The mean tumor size was 7.5 +/- 5.7 cm. There were 35 cases (43.2%) with tumors &gt;5 cm. The tumor size correlated significantly with tumor mitotic count and resectability. Tumor size, mitotic count, and resectability correlated significantly with tumor recurrence and survival. There was recurrent disease in 39% of our patients, and their mean survival after recurrence was 16.6 months. Most recurrences were at the primary site or metastatic to the liver. Twenty-six percent of our patients died of their disease. Traditional histologic criteria are not specific enough to diagnose GIST. This diagnosis must be confirmed with CD117 immunohistochemical staining. Prognosis is dependent on tumor size, mitotic count, and resectability." }, { "id": "pubmed23n0513_4364", "title": "Gastric schwannoma.", "score": 0.013376344086021506, "content": "Gastrointestinal mesenchymal tumors are a group of tumors originated from the mesenchymal stem cells of the gastrointestinal tract, consisting of gastrointestinal stromal tumors (GIST), leiomyomas or leiomyosarcomas or schwannomas. Gastric schwannoma is a very rare gastrointestinal mesenchymal tumor, which represents only 0.2% of all gastric tumors and 4% of all benign gastric neoplasms. We report a 24-year-old girl who suffered from an episode of upper gastrointestinal bleeding. The endoscopic examination showed a round submucosal tumor with a central ulceration and bleeding over the high body of the stomach. Surgical resection of the tumor was performed. The pathological examination revealed a picture of spindle cell tumor that was strongly positive for S-100 protein stain, and non-reactive for CD34, CD117, actin, HHF-35, desmin, melan-A and HMB-45, consistent with gastric schwannoma. The literature is reviewed." }, { "id": "pubmed23n0409_15742", "title": "[Clinical analysis of 31 patients with gastric stromal tumors].", "score": 0.013282315169107623, "content": "To investigate the clinical manifestations, diagnosis and treatment of gastric stromal tumors. 31 patients with gastric stromal tumors treated from 1993, 1 - 2001, 9 were analyzed retrospectively. All cases were diagnosed by pathological and immunohistochemistry examinations. According to Levin's standard combining with Hurliman's and Goldbum's methods, the patients were classified. There are no significant difference between male and female patients. 50 - 60 years old patients have high incidence. The distribution of gastric tromal tumors is fundus &gt; body &gt; antrum. Diagnosis of this condition is sometimes difficult and treatment is often delayed because patients usually present with nonspecific abdominal symptoms. The main manifestations of gastric stromal tumors are upper gastrointestinal hemorrhage 61.3% (19/31), 7 patients with acute hemorrhage and 12 with chronic hemorrhage. Most of them were malignant. Abdominal malaises and/or distention 32.3% (10/31) and abdominal pain 22.6% (7/31). Gastroscopy, ultrasound gastroscopy, computed tomography, B type ultrasound and upper gastrointestinal X-ray series are helpful to diagnosis. But the final diagnosis is decided by pathological and immunohistochemistry examinations. Gastric stromal tumors exhibit consistent immunohistochemical expressions of CD(117) and/or CD(34). The operative treatment is thought of the first choice. Effect of the chemotherapy isn't satisfied. There is no standard chemotherapy for gastric stromal tumors. Gastric stromal tumor is a kind of separated submucosal tumor which is different from leiomyoma, leiomyosarcoma and neurogenic tumors. Pathological and immunohistochemistry inspectations are very important to make clear diagnosis. Early diagnosis and rational treatment are the keys to improve the prognosis." }, { "id": "wiki20220301en305_36310", "title": "Carney's triad", "score": 0.013276434329065907, "content": "In addition to these three classical tumors, there is an increased incidence of pheochromocytoma, esophageal leiomyoma and adrenocortical adenoma. The original description employed the then-prevailing terminology of gastric epithelioid leiomyosarcoma. Subsequent advances in molecular biology have led to the current terminology of gastrointestinal stromal tumors (GISTs). However, there is limited evidence to suggest that the gastrointestinal stromal tumors (GIST) in Carney triad lack CD117 (c-kit) mutations (i.e., they are wild-type), and hence these GISTs may prove unresponsive to Imatinib. Taxonomy Carney triad is distinct from two other multiple neoplasia syndromes, also described by J. Aiden Carney. Carney complex The Carney complex is a distinct entity, characterized by myxomatous neoplasms (cardiac, endocrine, cutaneous and neural), and a host of pigmented lesions of the skin and mucosae, including the rarely occurring epitheloid blue nevus." }, { "id": "pubmed23n0710_23419", "title": "Extragastrointestinal Stromal Tumor (EGIST) in the abdominal wall: Case report and literature review.", "score": 0.013234279218933949, "content": "Gastro Intestinal Stromal Tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract (GI). GIST that arises primarily outside the GI tract is termed Extragastrointestinal Stromal Tumor (EGIST). To the best of our knowledge, few cases of EGIST in the abdominal wall were reported. We present a rare case of EGIST in the abdominal wall of a 57 year-old female patient. The asymptomatic tumor was located in the superior aspect of the left rectus abdominis muscle, measured 5.4 × cm 5.3 × cm 6.9 cm and was well circumscribed. Histological examination showed an epithelioid cell morphology. The mitotic count was 7/50 HPFs. Immunohistochemistry showed diffuse strong CD117 positivity, focal positivity for S100. The tumor was excised and the margins were free of malignancy. The patient was doing well postoperatively and was discharged on STI-571 regimen. Although GIST is the most common mesenchymal tumor of the gastrointestinal tract, a case with EGIST in the abdominal wall is rare. Positive immunohistochemical staining for CD117 is a defining feature of GISTs. A great percentage of EGISTs represent a metastasis from a primary GIST. In our case, the clinical and diagnostic work-up have been proved it to be an EGIST. The existing data on EGIST is insufficient to make a final conclusion regarding the malignant potential and clinicopathological factors of EGISTs that determine patient prognosis. Thus a follow-up for a long period is required. EGISTs should be kept in mind in the differential diagnosis for patients presenting with solid mass of the abdominal wall." }, { "id": "pubmed23n0366_9189", "title": "Immunohistochemical spectrum of GISTs at different sites and their differential diagnosis with a reference to CD117 (KIT).", "score": 0.012924606462303232, "content": "Gastrointestinal (GI) stromal tumor (GIST) is the designation for the major subset of GI mesenchymal tumors and encompasses most tumors previously classified as GI smooth muscle tumors. Although GISTs typically express CD117 (KIT), often express CD34, and sometimes express alpha-smooth muscle actin (SMA), the relative frequency of these markers has not been characterized in large series of GISTs of different sites, and the CD117 expression has not been fully characterized in intra-abdominal tumors. In this study, we immunohistochemically analyzed 292 GISTs throughout the GI tract, including omentum and mesentery, and compared the immunoreactivities with 211 other tumors that may enter in the differential diagnosis. GISTs were defined in this study as CD117-positive primary spindied or epithelioid mesenchymal tumors of the GI tract, omentum, or mesentery. The CD34 positivity of GISTs varied from 47% in small bowel to 96 to 100% in rectum and esophagus, whereas SMA expression showed the opposite patterns and was most frequent in the GISTs of small bowel (47%) and rarest in the GISTs of rectum and esophagus (10-13%). Desmin was seen only occasionally. S100 positivity was rare but was seen most frequently in small intestinal GISTs (15%). True leiomyomas from esophagus, muscularis mucosae of colorectum, and pericolic leiomyomas similar to uterine leiomyomas were negative for CD117 and CD34 and positive for SMA and desmin (46 of 46). Inflammatory fibroid polyps of stomach and small intestine were negative for CD117 but were often positive for CD34 (6 of 8) and variable for SMA (3 of 8). Inflammatory myofibroblastic tumors involving gastric or colonic wall were negative for CD117 but some showed CD117-positive endothelia. GI schwannomas were all negative for CD117 and positive for S100 protein (11 of 11). Extremely focal CD117 positivity was seen in the neoplastic cells of some retroperitoneal leiomyosarcomas and liposarcomas. Among other CD117-positive tumors were intestinal metastatic melanomas (8 of 11) and extraskeletal Ewing's sarcomas (5 of 11), two of which were abdominal. In conclusion, strong CD117 expression defines most primary GI mesenchymal tumors as GISTs, which show different patterns for CD34 and SMA in various parts of the GI tract. Some unrelated CD117-positive tumors (melanomas, Ewing's sarcomas) should not be confused with GISTs." }, { "id": "pubmed23n0347_20134", "title": "Gastrointestinal stromal tumors/smooth muscle tumors (GISTs) primary in the omentum and mesentery: clinicopathologic and immunohistochemical study of 26 cases.", "score": 0.012849140126140949, "content": "Gastrointestinal stromal tumor or smooth muscle tumor (GIST) is the designation for a major subset of gastrointestinal mesenchymal tumors that histologically, immunohistochemically, and genetically differ from typical leiomyomas, leiomyosarcomas, and schwannomas. Because GISTs, like the interstitial cells of Cajal, the gastrointestinal pacemaker cells, express CD117 (c-kit protein), the origin of GISTs from the interstitial cells of Cajal has been recently proposed. Comparison of GISTs primary in the omentum and mesentery to GISTs primary in the tubular gastrointestinal tract is of particular diagnostic and histogenetic interest in view of the possible similarity of these tumors with the GIST group. In this study, we analyzed 14 omental and 12 mesenteric primary mesenchymal tumors representing smooth muscle tumors or GISTs. These tumors were phenotypically compared with gastric and small intestinal GISTs, leiomyomas of the esophagus, and leiomyosarcomas of the retroperitoneum. Most (13 of 14) omental and mesenteric (10 of 12) tumors showed histologic features similar to GISTs with elongated spindle cells or epithelioid cells with high cellularity; most of these tumors showed low mitotic activity. Omental and mesenteric GISTs were typically positive for CD117 and less consistently for CD34. They often showed alpha-smooth muscle actin reactivity but were virtually negative for desmin and S-100 protein. One omental and two mesenteric tumors showed features of leiomyosarcoma with ovoid, less elongated nuclei, cytoplasmic eosinophilia; all these tumors had significant mitotic activity. These tumors were positive for alpha-smooth muscle actin and two of them for desmin, but all were negative for CD34 and CD117, similar to retroperitoneal leiomyosarcomas. Tumor-related mortality occurred in the group of mesenteric GISTs, but not in the group of omental GISTs. In contrast, all three patients with a true leiomyosarcoma of the omentum or mesentery had documented liver metastases or died of tumor. In summary, we show that tumors phenotypically identical with GISTs occur as primary tumors in the omentum and mesentery. The occurrence of CD117-positive tumors outside the gastrointestinal tract militates against an origin of these tumors exclusively from the interstitial cells of Cajal." }, { "id": "pubmed23n0712_11040", "title": "Hemoperitoneum caused by a ruptured GIST located in the posterior gastric wall managed by endoscopic diagnosis and laparoscopic treatment: case report and literature review.", "score": 0.012811359669998414, "content": "A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with &lt;1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall." }, { "id": "pubmed23n0528_16366", "title": "[Gastrointestinal stromal tumours and acute haemorrhage: description of four cases].", "score": 0.012594161958568738, "content": "Gastrointestinal stromal tumours are uncommon neoplasias arising from stromal tissue of the intestinal wall. Discovery of the protooncogene c-kit and the presence of the CD117 protein on the neoplastic cells of the majority of gastrointestinal stromal tumours may suggest their possible origin from Cajal cells. The clinical symptoms of gastrointestinal stromal tumours are related to tumour size and are generally aspecific: acute or chronic bleeding, abdominal pain and palpable mass are some of the most common signs. Digestive endoscopy or US-endoscopy for gastroduodenal tumours, ultrasonography and CT scans are the procedures of choice in the evaluation of the location, size, invasion of adjacent organs and metastases. Surgery is the only curative therapy for gastrointestinal stromal tumours. Chemotherapy or radiotherapy are of no use for metastatic disease, but good results are obtained with ST1571 in advanced disease. In the absence of metastases, it is quite difficult to distinguish between benign and malignant lesions. The most important prognostic factors are number of mitoses and tumour size. We report here on 4 consecutive cases of gastrointestinal tumours, 2 gastric and 2 duodenal, which presented with acute gastrointestinal bleeding." }, { "id": "pubmed23n0825_10377", "title": "Giant gastrointestinal stromal tumor of the stomach.", "score": 0.01258658222837918, "content": "Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal malignancies of the digestive tract. Gastric localization is the most frequent. The aim of this study is to evaluate the importance of immunohistochemical factors (CD117, CD34, α-SMA, vimentin, p53, Ki67) in diagnostic and size tumor and mitotic activity as prognostic factors for these tumors. We present the case of a 66-year-old male patient with a giant gastric GIST. Like in the vast majority, the symptomatology in this patient has long been faint, despite the large tumor size, and when it became manifest, it was nonspecific. Imagery wise, the computer tomography (CT) scan was the most efficient, showing the origin of the tumor from the greater curvature of the stomach, its dimensions, as well as the relations with the other abdominal viscera. Surgery in this patient was en-bloc, according to the principles of GIST. The histological aspect is characterized by a proliferation of spindle cells positive for CD117 and CD34. Despite complete microscopic resection, the size of the tumor (25×20×27 cm) and the mitotic activity (21÷5 mm2) remains important relapse factor. " }, { "id": "wiki20220301en022_26786", "title": "Gastrointestinal stromal tumor", "score": 0.012470225584979684, "content": "Due to the change in definition, clinical pathways of care before the year 2000 are largely uninformative in the current era. Signs and symptoms GISTs may present with trouble swallowing, gastrointestinal bleeding, or metastases (mainly in the liver). Intestinal obstruction is rare, due to the tumor's outward pattern of growth. Often, there is a history of vague abdominal pain or discomfort, and the tumor has become rather large by time the diagnosis is made." }, { "id": "wiki20220301en026_100665", "title": "Meckel's diverticulum", "score": 0.012432635668630154, "content": "Umbilical anomalies Anomalies between the diverticulum and umbilicus may include the presence of fibrous cord, cyst, fistula, or sinus, leading to: Infection or excoriation of periumbilical skin, resulting in a discharging sinus Recurrent infection and healing of sinus Abscess formation in the abdominal wall Fibrous cord increases the risk of volvulus formation and internal herniation Neoplasm Tumors in Meckel's diverticulum may cause bleeding, acute abdominal pain, gastrointestinal obstruction, perforation or intussusception. Benign tumors: Leiomyoma Lipoma Vascular and neuromuscular hamartoma Malignant tumors: Carcinoids: most common, 44% Mesenchymal tumors: Leiomyosarcoma, peripheral nerve sheath and gastrointestinal stromal tumors, 35% Adenocarcinoma, 16% Desmoplastic small round cell tumor" }, { "id": "pubmed23n0785_9239", "title": "Extragastrointestinal stromal tumour of the abdominal wall - a case report.", "score": 0.012339093947798876, "content": "Stromal tumours occurring in areas other than the GastroIntestinal Tract (GIT) are known as Extra GastroIntestinal Stromal Tumours (EGISTs). They usually arise in the mesentery, omentum or retroperitoneum, while EGISTs which occur in the abdominal wall are very rare. Both gastrointestinal stromal tumours (GISTs) and EGISTs are histologically and immunophenotypically similar. We are reporting a case of EGIST, which occurred in the anterior abdominal wall in a twenty five-year-old female patient. The tumour was present in the right loin and imaging studies suggested that it was a desmoid tumour. It was surgically excised by doing an abdominal wall mesh repair. The histological examinations revealed a tumour with spindle cell morphology, with &lt;2 mitoses per 50 High Power Field (HPF) and no necrosis, with tumour free margins. Immunohistochemistry was strongly positive for CD117 and Smooth Muscle Actin (SMA), while it was negative for β-catenin and S100. The patient is well post operatively and is on close follow up. EGISTs should be considered in the differential diagnosis of mesenchymal tumours which occur in the abdominal wall, inspite of their rarity, as the high risk patients may need Imatinib chemotherapy. " }, { "id": "wiki20220301en103_10514", "title": "Uterine sarcoma", "score": 0.012274959083469723, "content": "The uterine sarcomas form a group of malignant tumors that arises from the smooth muscle or connective tissue of the uterus. Signs and symptoms Clinically, uterine sarcomas and leiomyomas (fibroids) both have similar symptoms such as increased uterine size, abdominal pain and vaginal bleeding so it can be difficult to tell them apart.Unusual or postmenopausal bleeding may be a sign of uterine sarcoma and needs to be investigated. Other signs include pelvic pain, pressure, and unusual discharge. A nonpregnant uterus that enlarges quickly is suspicious. However, none of the signs are specific. Specific screening test have not been developed; a Pap smear is a screening test for cervical cancer and not designed to detect uterine sarcoma. Histology Tumoral entities include leiomyosarcomas, endometrial stromal sarcomas, carcinosarcomas and \"other\" sarcomas." }, { "id": "pubmed23n0930_13198", "title": "Hemorrhagic polypoid gastric and colonic metastases nine years after uterine leiomyosarcoma - case report.", "score": 0.01194393261384575, "content": "Uterine leiomyosarcoma (ULMS) is a rare tumor, representing 1-2% of all uterine malignancies. It is highly aggressive, with high metastatic rate, especially in lungs, peritoneal cavity, retroperitoneum, bones and liver, usually during the first years after diagnosis. A 58-year-old woman, with subtotal hysterectomy and bilateral adnexectomy, followed by radiochemotherapy for spindle-type ULMS nine years ago, presented with gastrointestinal bleeding and severe anemia. Three polyps ranging from 2 cm to 5 cm in diameter were found at gastroscopy, the largest being ulcerated, which required a total gastrectomy three months later. Colonoscopy identified two pedunculated polyps on the descending colon, 2 cm and 3.5 cm in diameter. Histologically, both sites revealed proliferations of spindle cells with whorled pattern, moderate to severe nuclear atypia, 5 to 8 mitotic figures (MFs)÷10 high-power fields (HPFs) and additional necrosis in the gastric tumors. Immunohistochemistry was negative for CD117, DOG1, S100 and CD34 and positive for smooth muscle actin (SMA), estrogen receptor (ER) and progesterone receptor (PR). Twenty percent of nuclei stained positive for Ki67. The diagnosis was synchronous hemorrhagic gastric and colonic polypoid metastases of ULMS. Thoracic computed tomography (CT) and abdominal ultrasonography were negative for other metastatic lesions, while abdominal CT revealed abdominal and pelvic lymphadenopathy. This case illustrates a distinct pattern of metastasis that is an extremely rare gastric and colonic location and an expanded disease-free period of nine years since the initial treatment. A long-term clinical and imaging follow-up of this patient is essential." }, { "id": "wiki20220301en013_76268", "title": "Sarcoma", "score": 0.011405679274184045, "content": "Signs and symptoms Symptoms of bone sarcomas typically include bone pain, especially at night, and swelling around the site of the tumor. Symptoms of soft-tissue sarcomas vary, but they often present as firm, painless lumps or nodules. Gastrointestinal stromal tumors (a subtype of soft tissue sarcoma) often are asymptomatic, but can be associated with vague complaints of abdominal pain, a feeling of fullness, or other signs of intestinal obstruction. Cause" }, { "id": "wiki20220301en012_125062", "title": "Krukenberg tumor", "score": 0.011343323108158807, "content": "A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast. Gastric adenocarcinoma, especially at the pylorus, is the most common source. Krukenberg tumors are often (over 80%) found in both ovaries, consistent with its metastatic nature. Signs and symptoms Krukenberg tumors often come to the attention when they cause abdominal or pelvic pain, bloating, ascites, or pain during sexual intercourse. Krukenberg tumors can occasionally provoke a reaction of the ovarian stroma which leads to hormone production, that results in vaginal bleeding, a change in menstrual habits, or hirsutism, or occasionally virilization as a main symptom. In rare cases the disease can manifest with hydronephrosis and hydroureter." }, { "id": "pubmed23n0481_9561", "title": "Exophytic pedunculated gastrointestinal stromal tumor with remarkable cystic change.", "score": 0.011308458982877589, "content": "A 59-year-old man with bloody stools, and previously diagnosed with sigmoid colon carcinoma, visited our hospital. Preoperative abdominal ultrasonography (US) showed another tumor, with an uneven irregular surface, measuring about 9 x 5 cm, below the left hypochondrium. The tumor consisted of several cysts. Abdominal computed tomography (CT) showed a multicystic tumor attached to the stomach, and its septum and marginal region were intensely stained on contrast imaging. On magnetic resonance imaging (MRI), low and markedly high signals were revealed in the tumor on T1-weighted and T2-weighted sequences, respectively. Contrast imaging of the upper digestive tract showed extramural compression of the greater curvature of the antral stomach by the tumor. The tumor was partially imaged by endoscopic ultrasonography (EUS), but continuity to the stomach was not confirmed. On abdominal angiography, the tumor was slightly stained via the gastroepiploic arteries. Surgical treatment was performed to excise both the gastric tumor and the sigmoid colon carcinoma. The gastric tumor was removed with gastric wall tissue where the tumor was attached to a 2-cm pedicle. It was multicystic, contained watery fluid, and had a smooth outer surface. Histologically, the tumor consisted of multiple irregular cysts without epithelial lining, and solid epitheloid cell nests in between. The tumor cells had clear or eosinophilic cytoplasm and round nuclei. No mitotic figures were seen. The tumor cells in the pedicle were connected with the muscularis propriae of the stomach. Immunohistochemistry showed c-kit-positive, CD34-positive smooth muscle actin (SMA)-negative, and S-100-negative staining of tumor cells. The final diagnosis was gastrointestinal stromal tumor (GIST)." }, { "id": "pubmed23n0885_17071", "title": "Gastric Angiomyolipoma, a Very Rare Cause of Upper Gastrointestinal Bleeding: A Case Report and a Brief Review of Literature.", "score": 0.010997067448680353, "content": "Angiomyolipoma (AML) is a tumor composed of variable proportions of adipose tissue, spindle and epithelioid smooth muscle-like cells and abnormal thick-walled blood vessels which are usually benign. AML is relatively common in kidney and liver. Gastric angiomyolipoma (GAML) is extremely rare and only 2 cases were reported in the literature. Diagnosis of AML is difficult owing to its rarity and varied immunohistochemical patterns. Here, we report a case of GAML in a 65-year-old male who presented with an episode of hematemesis and intermittent melena for one week. Endoscopy showed a partially obstructing mass arising from gastric antrum with central ulceration. Mass was removed by wedge resection after laparoscopic anterior gastrectomy. Excised specimen showed a benign 6 × 3 × 3 cm homogenous fatty mass with adipose tissue, smooth muscles and prominent vascularity. Immunohistochemistry stains were positive for desmin, smooth muscle actin (SMA), CD34 and negative for human melanoma black (HMB)-45 antigen and CD117. This case reports the largest and HMB-45 negative GAML so far, which can be a very rare cause of upper gastrointestinal bleeding." }, { "id": "wiki20220301en022_26794", "title": "Gastrointestinal stromal tumor", "score": 0.010995670995670996, "content": "When GIST is suspected—as opposed to other causes for similar tumors—the pathologist can use immunohistochemistry (specific antibodies that stain the molecule CD117 [also known as c-kit] —see below). 95% of all GISTs are CD117-positive (other possible markers include CD34, DOG-1, desmin, and vimentin). Other cells that show CD117 positivity are mast cells. If the CD117 stain is negative and suspicion remains that the tumor is a GIST, the newer antibody DOG-1 (Discovered On GIST-1) can be used. Also sequencing of Kit and PDGFRA can be used to prove the diagnosis." }, { "id": "pubmed23n0585_23418", "title": "Primary gastric angiosarcoma presenting as an asymptomatic gastric submucosal tumor.", "score": 0.01086031872058073, "content": "Primary gastric angiosarcoma is a rare gastric tumor. Previously reported cases are limited and usually symptomatic. Preoperative diagnosis is difficult and should be differentiated from adenocarcinoma or gastrointestinal stromal tumor. We report a 55-year-old man with primary gastric angiosarcoma presenting as an asymptomatic gastric submucosal tumor. Abdominal ultrasonography showed a heteroechogenic tumor with several notably anechoic portions between the stomach and the gallbladder. Computed tomography showed that the tumor originated from the stomach, and upper gastrointestinal endoscopy showed a large gastric submucosal tumor at the lower body. Laparotomy was performed and a purple circumscribed tumor measuring 8.5 x 5.0 x 4.0 cm was found on the serosal aspect of the lower body. The tumor was soft and spongy with areas of hemorrhagic pools on section. Microscopically, the tumor was composed of proliferative neoplastic spindle to epithelioid cells. The neoplastic cells infiltrated and dissected the smooth muscle as vessel-forming architectures. On immunohistochemical study, the tumor cells were positive for CD34. These findings confirmed a diagnosis of primary gastric angiosarcoma. The patient has been well during the 11-month postoperative follow-up." }, { "id": "wiki20220301en063_44836", "title": "International Classification of Diseases for Oncology", "score": 0.010857248267320211, "content": "M8920/3 Alveolar rhabdomyosarcoma M8921/3 Rhabdomyosarcoma with ganglionic differentiation Ectomesenchymoma 893–899 Complex Mixed And Stromal Neoplasms M8930/0 Endometrial stromal nodule M8930/3 Endometrial stromal sarcoma, NOS Endometrial sarcoma, NOS Endometrial stromal sarcoma, high grade M8931/3 Endometrial stromal sarcoma, low grade Endolymphatic stromal myosis Endometrial stromatosis Stromal endometriosis Stromal myosis, NOS M8932/0 Adenomyoma Atypical polypoid adenomyoma M8933/3 Adenosarcoma M8934/3 Carcinofibroma M8935/0 Stromal tumor, benign M9835/1 Stromal tumor, NOS M8935/3 Stromal sarcoma, NOS M8936/0 Gastrointestinal stromal tumor, benign GIST, benign M8936/1 Gastrointestinal stromal tumor, NOS GIST, NOS/uncertain malignant potential Gastrointestinal autonomic nerve tumor (GANT) Gastrointestinal pacemaker cell tumor M8936/3 Gastrointestinal stromal sarcoma GIST, malignant" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 71 ] ], "word_ranges": [ [ 0, 9 ] ], "text": "Thessaly test. Provocation test performed in suspected meniscal injury." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Meniscal injury.", "2": "Injury due to rupture of the anterior cruciate ligament.", "3": "Injury by rupture of the posterior cruciate ligament.", "4": "Degenerative arthropathy injury.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0065_2466", "title": "Injuries to the posterior cruciate ligament of the knee.", "score": 0.017507645259938837, "content": "The posterior cruciate ligament (PCL) is the strongest ligament about the knee and is approximately twice as strong as the anterior cruciate ligament. Its main function is to prevent the posterior dislocation of the tibia in relation to the femur, providing 95% of the strength to resist the tibial posterior displacement. Along with the anterior cruciate ligament (ACL) the PCL controls the passive 'screw home' mechanism of the knee in terminal knee extension. It also provides mechanical support for the collateral ligaments during valgus or varus stress of the knee. PCL ruptures are uncommon apparently due to its strong fibre structure. The most frequent injury mechanism in isolated PCL tears is a direct blow on the anterior tibia with the knee flexed thus driving the tibia posteriorly. Automobile accidents (in which the knee hits the dashboard) and soccer injuries (in which an athlete receives a blow to the anterior surface of the tibia during knee flexion) characteristically produce this type of injury. In other PCL injury mechanisms (hyperextension, hyperflexion or rotational injuries with associated valgum/varum stress), other knee structures are also often damaged. The most characteristic diagnostic finding in a knee with a PCL rupture is the 'posterior sag sign' meaning the apparent disappearance of the tibial tubercle in lateral inspection when the knee is flexed 90 degrees. This is due to gravity-assisted posterior displacement of the tibia in relation to the femur. A positive posterior drawer test performed at 90 degrees of flexion and a knee hyperextension sign are sensitive but nonspecific tests. False negative findings are frequent, especially in acute cases. If necessary, the clinical diagnosis of the PCL tear can be verified by magnetic resonance imaging, examination under anaesthesia, arthroscopy, or a combination of these modalities. If a PCL avulsion fragment has been dislocated, surgical treatment is recommended. In isolated, complete midsubstance tears of the PCL the majority of the recent studies recommend conservative treatment, since abnormal residual posterior laxity1 in most of these knees is consistent with functional stability and minimal symptoms. This has been the case even in athletes. In isolated PCL tears, the outcome seems to depend more on the muscular (quadriceps) status of the knee than on the amount of residual posterior laxity. Therefore, the conservative treatment protocol emphasises intensive quadriceps exercises, and only a short (under 2 weeks) immobilisation period followed by early controlled activities and early weightbearing.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0764_20185", "title": "[Surgical treatment of posteromedial corner injury combined with cruciate ligament rupture of knee].", "score": 0.015378435760601366, "content": "To investigate the methods and effectiveness of surgical treatment for posteromedial corner (PMC) injury combined with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) ruptures. Between February 2009 and February 2012, 15 patients (15 knees) with PMC injury combined with ACL and PCL ruptures underwent PMC repair with suture anchor and ACL and PCL reconstruction. There were 7 males and 8 females with an average age of 39 years (range, 15-59 years). The causes of injury were traffic accident injury in 6 cases, sport injury in 7 cases, and sprain injury in 2 cases. The disease duration was 3-15 days with an average of 7 days. All patients presented positive results of anterior drawer test, posterior drawer test and valgus stress test, and dysfunction of knee joint. Of 15 cases, 3 had ACL and PCL ruptures, 5 had ACL rupture, 3 had ACL injury at the attachment point of the condyles crest, and 4 had PCL rupture; 9 had PMC tear at the femur insertion, 5 had PMC tear at the tibia insertion, and 1had PMC tear in the body area. All incisions healed by first intention with no complication of infection or stiffness of knee. All cases were followed up 18.4 months on average (range, 10-36 months). At last follow-up, 14 cases had normal knee flexion and extension ranges, but 1 case had 10 degree limitation of the knee extension. Except 1 case which had weakly positive valgus stress test, the other patients showed negative results of anterior drawer test, posterior drawer test, and valgus stress test. Based on the improved Lysholm classification standard, the results were excellent in 8 cases, good in 5 cases, and fair in 2 cases; the excellent and good rate was 86.7%. Early repair of the PMC and reasonable reconstruction of cruciate ligament can effectively restore the knee stability for patients with PMC injury combined with ACL and PCL ruptures." }, { "id": "pubmed23n0675_14556", "title": "Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for \"isolated\" anterior cruciate ligament tear.", "score": 0.015362511052166225, "content": "Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries. To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft. Case series; Level of evidence, 4. Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment. Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle &lt;17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age &lt;18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C). Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization." }, { "id": "pubmed23n0761_359", "title": "[Anatomical reconstruction of posterolateral complex in treatment of multi-ligament injury of knees].", "score": 0.015143978334162384, "content": "To evaluate the short-term effectiveness after static anatomical reconstruction of posterolateral complex (PLC) in the treatment of traumatic multi-ligament injury of the knee. Between June 2007 and July 2011, 23 cases of multi-ligament injury of the knee were treated. There were 15 males and 8 females with an average age of 41 years (range, 19-56 years). The injury was caused by traffic accident in 9 cases, sprain in 7 cases, bruise in 3 cases, and falling from height in 4 cases. The time between injury and operation was 13-78 days (mean, 32 days). The results of posterior drawer test and Lachman test were positive, and all cases complicated by varus and external rotation instability. The Lysholm score of the knee was 43.4 +/- 5.7. According to International Knee Documentation Committee (IKDC) scoring, all were rated as grade D. According to Fanelli typing, all were classified as type C. The X-ray films showed that load-induced posterior motion of the knee was (13.3 +/- 4.2) mm; the lateral joint space was (15.1 +/- 2.4) mm. Anterior cruciate ligament/posterior cruciate ligament and PLC were reconstructed simultaneously with auto-semitendinosus, gracilis tendon, and allogeneic tendon. All incisions healed by first intention, and no complication occurred. All patients were followed up 12-56 months (mean, 28 months). At last follow-up, the results of posterior drawer test and Lachman test were negative; 3 cases had varus instability, and 2 cases had external rotation instability. The Lysholm score of the knee was 85.6 +/- 16.7, showing significant difference when compared with preoperative score (t=-11.469, P=0.000). According to IKDC scoring, 7 cases were rated as grade A, 12 as grade B, and 4 as grade C; significant difference was found when compared with preoperative value (Z=4.285, P=0.000). The load-induced posterior motion of the knee was (5.1 +/- 4.4) mm, the lateral joint space was (3.2 +/- 2.8) mm, showing significant differences when compared with preoperative ones (P &lt; 0.05). In the treatment of traumatic multi-ligament injury of the knee, the anatomical reconstruction of the PLC using auto-semitendinosus, gracilis tendon, or allogeneic tendon can obtain good short-term effectiveness." }, { "id": "pubmed23n0540_6354", "title": "Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.", "score": 0.01494711849773365, "content": "The purpose of the study was to evaluate the mid-term results of surgical treatment in different groups of patients with multiple knee ligament injuries. Review of our patients' records revealed that 48 acute and chronic patients were surgically treated for combined knee injury. Due to severe capsular damage in these injuries, open techniques were used. In our treatment protocol, avulsed ligaments and tears of the posterolateral and posteromedial corner were repaired if possible, whereas midsubstance tears of cruciate ligaments and chronic cases were reconstructed with autografts. Postoperatively, an accelerated program of rehabilitation was introduced, aiming to progressively mobilize the joint and improve muscle endurance. For the follow-up evaluation we designed a protocol composed of two parts. In the first part, anatomical lesions were recorded and in the second part, clinical evaluation was performed using the Lysholm score, the Tegner rating system, the IKDC evaluation form, and the KT1000. Student's t tests and chi-square tests were used for data analysis. Forty-eight patients (mean age 28.6+/-11.9 years; 41 males) were classified according to the specific anatomical structures involved. Group A included 12 anterior cruciate ligament (ACL) and medial structure injuries, group B included 11 ACL or posterior cruciate ligament (PCL) ruptures combined with posterolateral injuries, and group C consisted of 25 knee dislocations (ACL and PCL ruptures which might be combined with damage of the collateral ligaments). Thirty-eight patients were surgically treated during the acute phase and ten patients were treated chronically. Forty-four patients (91.6%) were followed up at a mean of 51.3+/-29.9 months. Average Lysholm score was 87+/-12.3; average Tegner score was 5.09+/-2.19 before accident and 4.34+/-2.12 in re-examination; IKDC score was A in 10 cases, B in 22, C in 6, and D in 6. The mean range of motion was 129.9 degrees +/-12.5 degrees . The average loss of extension and flexion were 1.6 degrees +/-2.5 degrees and 7.6 degrees +/-7.9 degrees , respectively. The side-to-side difference in corrected anterior and posterior translation in quadriceps neutral angle and in anterior translation in 30 degrees angle was &lt;3 mm for about 65% of our patients. Surgical treatment of multiple knee ligament injuries, using autografts, provided satisfactory stability, range of motion, and subjective functional results. However, despite the improvement of the quality of life, the preinjury patients' activity level was not fully obtained in re-examination. Patients underwent surgical treatment during the acute phase had better scores in several points, but finally there was no statistical significance between acute and chronic patients. Moreover, no statistically significant differences were observed among the groups with specific damaged anatomical structures." }, { "id": "wiki20220301en108_37995", "title": "Anterior cruciate ligament injury", "score": 0.014759411618050363, "content": "Most ACL injuries can be diagnosed by examining the knee and comparing it to the other, non-injured knee. When a doctor suspects ACL injury in a person who reports a popping sound in the knee followed by swelling, pain, and instability of the knee joint, they can perform several tests to evaluate the damage to the knee. These tests include the pivot-shift test, anterior drawer test, and Lachman test. The pivot-shift test involves flexing the knee while holding onto the ankle and slightly rotating the tibia inwards. In the anterior drawer test, the examiner flexes the knees to 90 degrees, sits on the person's feet, and gently pulls the tibia towards him or herself. The Lachman test is performed by placing one hand on the person's thigh and the other on the tibia and pulling the tibia forward. These tests are meant to test whether the ACL is intact and therefore able to limit the forward motion of the tibia. The Lachman test is recognized by most authorities as the most reliable and" }, { "id": "pubmed23n0565_16158", "title": "[Treatment of posterolateral corner injury of knee joint with anatomical reconstruction].", "score": 0.014753764753764755, "content": "To discuss the diagnosis and treatment of posterolateral corner injury of the knee joint, and to evaluate the clinical results after anatomical reconstruction. Sixteen cases of posterolateral corner injury of the knee were treated, being accompanied with grade II or above existing serious varus or external rotation. At a mean follow-up of 13 months (7 to 18 months), we evaluate the clinical results using Lysholm and IKDC (international knee documentation committee) scoring systems. Among them, there were 14 males and 2 females aging 19-46 years (mean 38 years). It was 4-12 d from injury to operation. On conditions of anesthesia, varus stress test (VST) showed that instability of varus was more than 10 degrees under the 30 degrees and 0 degrees of genuflexion respectively and external rotation test showed that instability of external rotation was more than 10 degrees when compared with normal side. Five cases complicated by rupture of anterior cruciate ligament, 8 cases by rupture of posterior cruciate ligament and 3 cases by rupture of both ligaments. All patients were followed 7 to 18 months and no patients had instability of the knee. The VST showed that no abnormal lateral instability was found at 0 degrees of flexion except 3 cases at 30 degrees with less than 5 degrees. Cooper test showed that no rotational instability at 90 degrees except 1 cases at 30 degrees with less than 5 degrees. The range of motion of the knee was from 75 degrees to 130 degrees of flexion(mean 118 degrees)and from 0 degrees to 5 degrees of extension. Posteroperative scores were from 54 to 96 according to Lysholm scoring systems and from 46 to 94 according to IKDC scoring systems. Although the overall incidence of posterolateral corner injury is less than that of other ligament injuries of the knee, we should pay much attention to posterolateral corner injury because of its important role in resisting posterior tibia translation, external rotation and varus of knee. This injury can result in a significant degree of disability for patients." }, { "id": "pubmed23n1004_724", "title": "[Mid-term effectiveness of arthroscopic anterior cruciate ligament reconstruction combined with meniscus allograft transplantation].", "score": 0.014381914381914381, "content": "To summarize the mid-term effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction combined with meniscus allograft transplantation. A clinical data of 21 patients treated with arthroscopic ACL reconstruction and meniscus allograft transplantation and followed up more than 5 years between February 2007 and December 2014 was retrospectively analyzed. There were 12 males and 9 females, aged from 18 to 45 years, with an average age of 23.5 years. The cause of injury was sport sprain in 15 cases, falling in 4 cases, and traffic accident in 2 cases. The time from injury to operation ranged from 2 to 36 months, with an average of 12 months. Among them, 15 patients underwent previous meniscectomy, with an average interval of 1.6 years (range, 3 months to 6.5 years). All patients were primary ACL reconstruction. Preoperative anterior drawer test, Lachman test, and pivot shift test were positive. Lysholm score was 43.6±10.2. International Knee Documentation Committee (IKDC) score was 60.50±14.06. Of the 21 patients, 10 were gradeⅠ-Ⅱcartilage injuries and 11 were grade Ⅲ cartilage injuries according to MRI. All patients were followed up 5.1-7.8 years, with an average of 5.5 years. There were 2 cases of numbness of lower extremity, 3 cases of slight exudation of incision, 2 cases of articular movement bounce, 5 cases of mild joint swelling and pain after exercise. At last follow-up, Lachman tests were negative in 18 cases and positive in 3 cases; anterior drawer tests were negative in 19 cases and positive in 2 cases; pivot shift tests were negative in all cases. Lysholm score was 84.5±16.5 and IKDC score was 85.25±4.60, which were significantly higher than those before operation ( <iP</i&lt;0.01). The flexion and extension of the affected knee joint were (128±13) and (3±7)°, respectively, which were smaller than those of the healthy knee joint [(133±15), (0±5)°] ( <iP</i&lt;0.01). The results of KT-1000 test showed that when knee flexion was 30 and 90°, tibial anterior displacement of affected side [(2.35±1.20), (1.60±1.15) mm] were not significantly different from those of healthy side [(1.20±1.10), (1.10±1.03) mm] ( <iP</i&gt;0.01). MRI showed that the ACL graft was in normal position and meniscus survived well. Cartilage injuries were gradeⅠ-Ⅱ in 18 cases and grade Ⅲ in 3 cases. For patients with severe meniscus injury and ACL rupture, ACL reconstruction combined with meniscus allograft transplantation can restore the stability of the joint, recover the meniscus function which is conducive to the protection of articular cartilage and obtain satisfactory mid-term effectiveness." }, { "id": "pubmed23n0292_9586", "title": "Primary repair plus intra-articular iliotibial band augmentation in the treatment of an acute anterior cruciate ligament rupture. A follow-up study of 70 patients.", "score": 0.014202256244963738, "content": "Between September 1987 and November 1989, we treated 90 consecutive patients with an acute anterior cruciate ligament (ACL) rupture with the multiple suture technique and iliotibial band augmentation. Seventy of these patients were re-examined 2 to 5 years after the operation (mean 3.5 years), the examination consisting of a questionnaire, clinical examination, laxity tests with the KSS machine (Acufex), radiological examination and isokinetic muscle strength testing (Cybex 6000). There were 32 men and 38 women (mean age 34 years). The injury was sustained in sports in 44 (63%) cases, and the sports most frequently involved were downhill skiing (18 cases), soccer (9 cases) and volleyball (5 cases). Of the injuries, 38 were isolated ACL ruptures and 31, ACL ruptures combined with a medial CL rupture. In 9 cases, an additional meniscus injury and in one case an additional posterior CL - lateral CL rupture was found. At the follow-up, 55 patients (79%) were satisfied with the end result, and according to our objective functional criteria 55 (79%) had an excellent or good outcome. According to the Lysholm score, 53 (76%) patients were excellent or good (&gt; or = 82 points). In the Lachman test, 29 knees (41%) were completely stable. The Lachman test was mildy positive in 40 knees (57%) (36 had 1+ laxity and 4, 2+ laxity), and one patient had 3+ laxity with a hard end-point. Similarly, the anterior drawer test was negative in 53 knees (76%), and the other 17 (24%) had mild laxity (16 had 1+ laxity and 1, 2+ laxity). The total anterior-posterior laxity measured with the KSS averaged 9.7 +/- 3.5 mm in the injured knee and 7.3 + 3.0 mm in the uninjured knee (the laxity measured at a knee angle of 20 degrees of flexion). Corresponding values at a knee angle of 90 degrees of flexion were 6.1 +/- 2.4 mm and 4.7 +/- 1.9 mm, respectively. The pivot shift test was negative in 62 patients (89%) and 1+ positive in the remaining 8 patients (11%). Fifty-eight patients (83%) had full knee extension and 40 patients (57%), full knee flexion. Compared with the uninjured knee, the operated knees showed an average 14% strength deficit in isokinetic knee extension and 6% deficit in flexion at the speed of 60 degrees/s. At the speed of 180 degrees/s, the corresponding deficits were 8% and 4%, respectively. Of the 44 patients who were active in sport before the injury, 40 (91%) were able to return to sports. A flexion deficit of 5 degrees or more was associated with thigh muscle atrophy (P &lt; 0.05) and quadriceps weakness, both at the slow speed (P &lt; 0.05) and high speed (P &lt; 0.001) of the isokinetic movement. In conclusion, in an acute rupture of the ACL, primary repair of the ligament with intraarticular iliotibial band augmentation seems to be a good method to restore the functional capacity of the injured knee." }, { "id": "wiki20220301en061_67541", "title": "Anterior cruciate ligament reconstruction", "score": 0.013747143945163747, "content": "The Anterior Cruciate Ligament is the ligament that keeps the knee stable. Anterior Cruciate Ligament damage is a very common injury, especially among athletes. Anterior Cruciate Ligament Reconstruction (ACL) surgery is a common intervention. 1 in every 3,000 American suffers from a ruptured ACL and between 100,000 and 300,000 reconstruction surgeries will be performed each year in the United States. Around $500 million health care dollar will come from ACL injuries. ACL injuries can be categorized into groups- contact and non-contact based on the nature of the injury Contact injuries occur when a person or object come into contact with the knee causing the ligament to tear. However, non-contact tears typically occur during the following movements: decelerating, cutting, or landing from a jump. ACL injury is 4-6 times higher in females than in males. ACL injuries account for a quarter of all knee injuries in the high school population.</ref> An increased Q angle and hormonal" }, { "id": "pubmed23n0874_15497", "title": "[CLINICAL OBSERVATION OF ONE-STAGE ARTHROSCOPIC RECONSTRUCTION AND STRICT IMMOBILIZATION FOR TREATMENT OF KNEE DISLOCATION].", "score": 0.013435956755794811, "content": "To investigate the effectiveness of one-stage arthroscopic reconstruction and strict immobilization for 6 weeks for treatment of knee dislocation. Between August 2010 and May 2013, 22 cases (22 knees) of knee dislocation were treated with one-stage reconstruction and strict immobilization for 6 weeks. There were 15 males and 7 females, aged 21-54 years (mean, 31.5 years). The left knee and right knee were involved in 8 cases and 14 cases respectively. The disease causes were traffic accident in 12 cases, falling from height in 6 cases, and sports injury in 4 cases. The time between injury and operation was less than 2 weeks in 6 cases, 2-3 weeks in 10 cases, and more than 3 weeks in 6 cases. The results of anterior drawer test, posterior drawer test, and Lachman test were positive in all patients. The posterior displacement of the tibia was more than 10 mm. The results of valgus stress test and varus stress test were positive in 13 cases and 11 cases respectively. The preoperative knee range of motion was (58.2 ± 28.4)°, Lysholm score was 39.7 ± 4.6. All patients had anterior cruciate ligament rupture and posterior cruciate ligament rupture; combined injuries included medial collateral ligament rupture in 11 cases, lateral collateral ligament rupture in 9 cases, both medial and lateral collateral ligament rupture in 2 cases, femoral condylar avulsion fracture in 2 cases, and meniscus injury in 7 cases. No nerve or blood vessel injury was observed. All cases obtained primary healing of incision without infection. All the patients were followed up 12-48 months (mean, 27.8 months). At 12 months after operation, the results of the anterior drawer test, posterior drawer test, Lachman test, valgus stress test, and varus stress test were all negative; the knee range of motion increased was significantly to (121.3 ± 7.9)° (t = 30.061, P = 0.000); Lysholm score was 87.2 ± 6.1, showing significant difference when compared with preoperative score (t = 24.642, P = 0.000). A combination oathogopi osta ge reconstruction and strict immobilization for treatment of knee dislocation is a safe and effective method, good stability and joint function can be achieved." }, { "id": "pubmed23n0520_2112", "title": "Gravity-assisted pivot-shift test for anterior cruciate ligament injury: a new procedure to detect anterolateral rotatory instability of the knee joint.", "score": 0.013272863443455105, "content": "The denominated gravity-assisted pivot-shift test was introduced as a new procedure to detect anterolateral rotatory instability of the knee joint. The patient lies in the supine position or slightly rotated onto the affected side. The affected knee flexed approximately 60 degrees and the ipsilateral hip flexed, abducted and externally rotated so that the plane of the knee motion runs parallel to the floor. The examiner instructs the patient to raise the affected leg off the examining table and to extend the affected knee gradually. If the lower leg is internally rotated suddenly, with the knee subluxated at an angle of approximately 20 degrees , followed by the reduction in flexion, this test is regarded as positive. This test was investigated on 51 anterior cruciate ligament (ACL) deficient knees, being positive in 30 knees (Group P) and negative in 21 (Group N) with the positive rate of 59%. There was no significant correlation between the result of this test and the clinical features, but Group N included relatively small number of females and recurrent injuries tended to occur more frequently in Group P. Thirty-six knees received ACL reconstruction subsequently. There was no statistically significant difference between the groups in the side-to-side difference in anterior knee laxity at one year postoperatively. However, three patients with the side-to side difference of more than 3 mm belonged to Group P. Relatively low positive rate in ACL deficient knees suggests that it may not be used as a diagnostic procedure for ACL injury. It is possibly used for the prediction of high risk patients for symptomatic giving-way and/or patients with poor prognosis after ACL reconstruction." }, { "id": "wiki20220301en058_57568", "title": "Drawer test", "score": 0.01261904761904762, "content": "See also Anterior cruciate ligament injury Posterior cruciate ligament injury Lachman test References Examination of the knee" }, { "id": "wiki20220301en022_48996", "title": "Posterior cruciate ligament", "score": 0.012508960573476703, "content": "An additional test of posterior cruciate ligament injury is the posterior sag test, where, in contrast to the drawer test, no active force is applied. Rather, the person lies supine with the leg held by another person so that the hip is flexed to 90 degrees and the knee 90 degrees. The main parameter in this test is step-off, which is the shortest distance from the femur to a hypothetical line that tangents the surface of the tibia from the tibial tuberosity and upwards. Normally, the step-off is approximately 1 cm, but is decreased (Grade I) or even absent (Grade II) or inverse (Grade III) in injuries to the posterior cruciate ligament. The posterior drawer test is one of the tests used by doctors and physiotherapists to detect injury to the PCL. Patients who are suspected to have a posterior cruciate ligament injury should always be evaluated for other knee injuries that often occur in combination with an PCL injuries. These include cartilage/meniscus injuries, bone bruises, ACL" }, { "id": "pubmed23n0476_8019", "title": "Evaluation of acute knee pain in primary care.", "score": 0.012309368191721133, "content": "The evaluation of acute knee pain often includes radiography of the knee. To synthesize the literature to determine the role of radiologic procedures in evaluating common causes of acute knee pain: fractures, meniscal or ligamentous injuries, osteoarthritis, and pseudogout. MEDLINE search from 1966 to October 2002. We included all published, peer-reviewed studies of decision rules for fractures. We included studies that used arthroscopy as the gold standard for measuring the accuracy of the physical examination and magnetic resonance imaging (MRI) for meniscal and ligamentous knee damage. We included all studies on the use of radiographs in pseudogout. We extracted all data in duplicate and abstracted physical examination and MRI results into 2 x 2 tables. Among the 5 decision rules for deciding when to use plain films in knee fractures, the Ottawa knee rules (injury due to trauma and age &gt;55 years, tenderness at the head of the fibula or the patella, inability to bear weight for 4 steps, or inability to flex the knee to 90 degrees) have the strongest supporting evidence. When the history suggests a potential meniscal or ligamentous injury, the physical examination is moderately sensitive (meniscus, 87%; anterior cruciate ligament, 74%; and posterior cruciate ligament, 81%) and specific (meniscus, 92%; anterior cruciate ligament, 95%; and posterior cruciate ligament, 95%). The Lachman test is more sensitive and specific for ligamentous tears than is the drawer sign. For meniscal tears, joint line tenderness is sensitive (75%) but not specific (27%), while the McMurray test is specific (97%) but not sensitive (52%). Compared with the physical examination, MRI is more sensitive for ligamentous and meniscal damage but less specific. When the differential diagnosis for acute knee pain includes an exacerbation of osteoarthritis, clinical features (age &gt;50 years, morning stiffness &lt;30 minutes, crepitus, or bony enlargement) are 89% sensitive and 88% specific for underlying chronic arthritis. Adding plain films improves sensitivity slightly but not specificity. Plain films for pseudogout are not sensitive or specific, according to limited-quality studies. We recommend the Ottawa knee rules to decide when to obtain plain films for suspected knee fracture. A careful physical examination should be sufficient to decide whether to refer patients with potential meniscal and ligament injuries, and we prefer clinical criteria rather than plain films for evaluating osteoarthritis. We do not recommend using plain films to diagnose pseudogout." }, { "id": "pubmed23n0648_9380", "title": "[Primary clinical results of double-bundle anterior cruciate ligament reconstruction with semitendinosus allografts].", "score": 0.01227409638554217, "content": "To evaluate the primary clinical results of double-bundle anterior cruciate ligament reconstruction (ACLR) with semitendinosus allografts. From March 2006 to October 2006, 33 patients underwent double-bundle ACLR with semitendinosus allografts. The complete followed-up data of 31 patients was analyzed retrospectively. There were 24 males and 7 females aged 18-35 years old (average 25 years old). The injury was caused by sports accidents in 23 cases and traffic accidents in 8 cases, involving the left knee in 18 cases and the right knee in 13 cases. Anterior cruciate ligament rupture were confirmed by MRI and arthroscopy in all the patients, without lateral collateral ligaments injuries and posterior cruciate ligament injuries. The time from injury to operation was 1-43 months (average 11 months). The knee was fixed at 0 degree position after operation for 2 weeks and got knee joint rehabilitation exercises gradually. The incision of 2 patients showed effusion 4 and 7 days after operation, respectively, and healed after symptomatic treatment. The incision of 29 patients healed by first intention. There were no complications such as stiffness of knee joint, neurovascular injuries and joint infections. All the patients were followed up for 24-29 months (average 26 months). MRI displayed the anterior cruciate ligament grafts presented with good connection and signal similar to the normal 2 years after operation. There was significant difference between the preoperational value and the final follow-up value in terms of bilateral knee joint difference of prior laxity, Lachman test, and pivot shift test (P &lt; 0.05 ). The circumference difference between the injured and the normal was (11.6 +/- 7.9) mm before operation and (5.0 +/- 3.1) mm at the final follow-up (P &lt; 0.05). The Tegner score, Lysholm score, and International Knee Documentation Committee score was 3.83 +/- 1.15, 64.38 +/- 6.81, and 41.42 +/- 6.30, respectively, before operation, and 6.29 +/- 0.64, 94.45 +/- 3.03, and 95.72 +/- 3.10, respectively, at the final follow-up. There was a significant difference between before and after operation (P &lt; 0.05). The primary clinical results of double-bundle ACLR with semitendinosus allografts are satisfactory and the allogeneic semitendinosus are good grafts for double-bundle ACLR." }, { "id": "pubmed23n0766_16160", "title": "[Arthroscopic reconstruction of anterior cruciate ligament with preservation of the remnant bundle].", "score": 0.011891712340142833, "content": "To evaluate clinical effects of arthroscopic anterior cruciate ligament (ACL) reconstruction with preservation of the remnant bundle. From January 2002 to December 2009, 57 patients with ACL partial rupture were treated with preservation of the remnant bundle. There were 39 males and 18 females, with an average age of 28.5 years old (ranged, 16 to 49 years old). Thirty-three patients had injuries in the left knees,and 24 patients had injuries in the right knees. Forty patients had injuries caused by sports, 7 patients had injuries caused by traffic accidents and 10 patients had injuries caused by daily sprain. The anterior drawer test showed positive results in 23 patients, weakly positive results in 6 cases; Lachman test showed positive results in 19 patients, and weakly positive in 4 patients. Both anterior drawer test and Lachman test showed positive results in 5 patients; and valgus stress test (medial) showed positive results in 24 patients. The mean value of Rolimeter measurement was 8.7 mm, (ranged, 7.5 to 11.5 mm). The mean International Knee Documentation Committee (IKDC) score was 70.0 +/- 7.5 and the Lysholm score was 68.0 +/- 6.3. The duration from injury to surgery was 1 week to 12 months,with an average of 3.1 months. There were 32 patients treated with anteromedial bundle reconstruction and 25 patients treated with poterolateral bundle reconstruction. Fifty-seven patients were followed up, and the mean follow-up time was 22.5 months (ranged, 13 to 37 months). The anterior drawer test and Lachman test were all negative at 1 month post-operation. At the end of the follow-up, the range of motion of all the knees was 120 to 130 degree. There were 54 patients with negative results of anterior drawer test and Lachman test, 1 with weakly positive result of anterior drawer test and 2 with weakly positive results of Lachman test. The measurements of Rolimeter showed excellent stability of the knee. The mean IKDC score was 92.0 +/- 4.9 and the mean Lysholm score was 91.0 +/- 3.7, which all improved compared to preoperative scores. Arthroscopic reconstruction of anterior cruciate ligament with preservation of the remnant bundle has satisfactory effects on the knee stability, which could increase the angiogenesis and collagen of the ACL and improve the proprioception of the knee." }, { "id": "wiki20220301en090_1528", "title": "Knee examination", "score": 0.011441974884865128, "content": "cause medial collateral ligament rupture, meanwhile a varus force can cause lateral collateral ligament rupture. When a person suddenly slows down during running, twisting, or pivoting with valgus force applying on the knee, the anterior cruciate ligament can rupture. Posterior dislocation of the tibia can cause posterior cruciate ligament injury. Twisting and pivoting while bearing weight can cause tearing of the meniscus. Fractures of the knee are less common but should be considered if direct trauma to the knee has occurred such as during a fall. Examples of fractures involving knee joints are: tibial plateau fractures, fractures of the lateral condyle of femur, medial condyle of femur, and patellar fractures." }, { "id": "pubmed23n0349_118", "title": "Isokinetic assessment of the flexor-extensor balance of the knee in athletes with total rupture of the anterior cruciate ligament.", "score": 0.011319921801097307, "content": "The purpose of this study was to assess the flexor-extensor group of muscles of the knee in young athletes diagnosed with a total rupture of the anterior cruciate ligament (ACL). Eighteen knees of 18 athletes (14 men and 4 women) with an average age of 21.6 years (range 16-32 years) were assessed with a Cybex 6000 model isokinetic apparatus. The average internal between occurrence of the injury and assessment was 10.2 months (range 2-48 months). There was an associated meniscal injury in eight of the knees. Athletes with any other kind of associated injury, limitation, or blockage of the movement of the joint, significant pain during the exam, or interval between injury and exam of less than two months were excluded from the study. The parameters studied were the peak torque-velocity and flexor-extensor relationships at the constant angular velocities of 60 degrees/sec and 240 degrees/sec. Previous warming-up was done by means of an ergometric bicycle and adaptation with 3 submaximal repetitions. The contra-lateral side, which presented no injury, was used as control. Peak torque (PT) at the constant velocity of 60 degrees/sec was greater than that at 240 degrees/sec for knees with and without injuries. However, there was no significant difference between the injured and uninjured sides at 60 degrees/sec or at 240 degrees/sec. The average value for the flexor-extensor relationship at 60 degrees/sec on the injured was 60% ((6), compared to 57% ((10) on the contra-lateral side. At 240 degrees/sec, the average value was 75% ((10) on the injured side, and 65% ((12) on the contra-lateral side. In conclusion, despite the complete rupture of the ACL of one knee, the average values for the flexor-extensor relationship were similar on the injured and uninjured sides at the velocity of 60 degrees/sec. As the velocity increased, an increase in the values for the flexor-extensor relationship of the knee also occurred, indicating a tendency of the performance of the flexor muscle group to approach that of the extensor muscle group, and this tendency was more pronounced on the side of the injury." }, { "id": "wiki20220301en125_33931", "title": "Unhappy triad", "score": 0.011225806451612903, "content": "Component injuries The anterior cruciate ligament The anterior cruciate ligament is one of the four crucial ligaments in the knee. It originates from the lateral condyle of the femur and goes to the intercondyloid eminence of the tibia. Its function is to provide stability in the knee and minimize stress across the knee joint. It also restrains excessive forward movement in the leg and limits rotational movements in the knee. Injury An anterior cruciate ligament injury results from excess tension on the ligament. This can come from a sudden stop or twisting motion of the knee. A few initial symptoms include swelling, knee instability, and pain. A popping sound or sensation may or may not be heard when the ACL first tears. A following symptom usually includes the feeling of the knee \"giving out\". Tearing of the ACL is the most significant injury because it leaves the knee unstable, which also causes the knee to lose its normal function. Epidemiology" }, { "id": "pubmed23n0050_3857", "title": "[Diagnosis of anterior cruciate ligament injury of the knee joint].", "score": 0.009900990099009901, "content": "From January, 1979 to May, 1989, 107 patients with problems related to anterior cruciate ligament (ACL) were treated in our hospital. 100 of the patients had anterior cruciate ligament injury confirmed by arthrotomy or arthroscopy. The remaining 7 patients were found to be normal either by arthroscopy or arthrotomy. 29 patients had fresh ACL injury and 71 old. All the patients had history of trauma of the knee joint. Swelling and pain in the affected knee joint took place in fresh cases and few of them complained of instability or deformity of the knee. On examination, floating patella test was positive in the majority of the fresh cases. It was shown that accurate diagnosis could be made by Lachman test rather than by conventional anterior drawer test in dealing with fresh injury, but with old ones, Lachman test didn't show the advantages. Examination under anesthesia or arthroscopy helped a lot in diagnosing fresh ACL injury. Anterior drawer test (ADT) was significant in determining the existence of ACL injury. When ADT was positive, ACL injury was found in the majority of the cases, however, injured ACL couldn't be ruled out by negative ADT only. Positive valgus stress test on 0 degrees position suggests possibility of ACL injury, even ADT was negative. Despite the negative anterior drawer test positive posterior drawer test on three directions indicated the injury of the posterior cruciate ligament and the anterior cruciate ligament. The positive rate of ADT was higher than that of pivot shift test in dealing with anterior cruciate ligament injury. Positive pivot shift test suggests ACL injury." }, { "id": "wiki20220301en058_57566", "title": "Drawer test", "score": 0.00980392156862745, "content": "The drawer test is used in the initial clinical assessment of suspected rupture of the cruciate ligaments in the knee. The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner positions himself by sitting on the examination table in front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. The tibia is then drawn forward anteriorly. An increased amount of anterior tibial translation compared with the opposite limb or lack of a firm end-point may indicate either a sprain of the anteromedial bundle or complete tear of the ACL. If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly suggests that the anterior cruciate ligament is injured, whereas excessive posterior displacement of the tibia may indicate injury of" }, { "id": "pubmed23n0316_2255", "title": "[Effect of external extra-articular ligament plasty on the results of anterior cruciate ligament reconstruction with patellar tendon, a 4 years follow-up].", "score": 0.00980392156862745, "content": "The purpose of this study was to compare the functional results obtained when an external extra-articular plasty was added to an anterior cruciate ligament (ACL) reconstruction using an autologous bone tendon-bone patellar tendon graft. The authors analyzed two consecutive series of 60 and 50 patients operated by the same surgeon for a chronic rupture of the anterior cruciate ligament, one by reconstruction of the cruciate ligament with a free graft of the patellar tendon supplemented by an external extra-articular plasty made with a quadriceps tendon graft and the second with an isolated free patellar tendon graft. Anterior laxity was measured before and after surgery, by dynamic X-rays and by the Medmetric KT-1000 arthrometer. Functional results were evaluated four years after operation, with the French A.R.P.E.GE score based on sport activity level and intensity. Anterior laxity was not different before operation in both groups and there was no difference between males and females. Medmetric KT-1000 arthrometer showed the same negative differential laxity immediately after surgery in both groups and the same evolution during the first 4 years, without any significant difference on laxity on the middle aspect of the knee. Radiological results were different. After a 4 years follow-up, anterior laxity did not show significant difference on the medial compartment of the knee (5.3 +/- 2.3 mm and 5.5 +/- 1.7 mm), but there was a significant minor laxity in the lateral compartment for the lateral extra-articular plasty group (11.0 +/- 2.3 mm against 14.8 +/- 3.8 mm)(p = 0.002). Functional results and sport activity were similar in both groups. Examination showed 4 positive pivot shift tests (2 \"sliding\" and 2 positive) in the group with extra-articular plasty, even though 8 positive pivot shift tests in the isolated ACL group (5 \"sliding\" and 3 positive) were found. This study, as well as five others studies found in literature, was not randomized. In all these series, the surgical techniques, the rehabilitation programs and the functional score evaluation were too different to allow any pertinent comparison. Extra-articular plasty helps to control the laxity of the lateral compartment of the knee which is incompletely controlled by ACL reconstruction, particularly in chronic cases. This is proved by radiological measurements and pivot shift tests. Jensen in 1983, about 205 patients with a 4 year follow-up and Noyes, which used an allograft patellar tendon, found an advantage to do extra-articular plasty. But Strum (in 1989), as O'Brien (in 1991) and Roth (in 1987), did not found any advantage with extra-articular plasty. It is therefore obvious, after a four-year follow-up, that extra-articular supplementation presents an advantage for reconstruction of the ACL. by a free graft of the patellar tendon in chronic cases. Further randomized study will confirm that isolated ACL reconstruction is possible in some well defined categories of anterior laxity." }, { "id": "InternalMed_Harrison_26015", "title": "InternalMed_Harrison", "score": 0.009767170644341705, "content": "activity, or chronic knee arthritis, and when the patient relates symptoms of “locking” or “giving way” of the knee. With the knee flexed 90° and the patient’s foot on the table, pain elicited during palpation over the joint line or when the knee is stressed laterally or medially may suggest a meniscal tear. A positive McMurray test may also indicate a meniscal tear.Toperformthistest,thekneeisfirstflexedat90°,andthelegisthen extended while the lower extremity is simultaneously torqued medially or laterally. A painful click during inward rotation may indicate a lateral meniscus tear, and pain during outward rotation may indicate a tear in the medial meniscus. Lastly, damage to the cruciate ligaments should be suspected with acute onset of pain, possibly with swelling, a history of trauma, or a synovial fluid aspirate that is grossly bloody. Examination of the cruciate ligaments is best accomplished by eliciting a drawer sign. With the patient recumbent, the knee should be partially" }, { "id": "wiki20220301en200_11449", "title": "Meniscus tear", "score": 0.009708737864077669, "content": "A meniscus can tear due to an internally or externally rotated knee in a flexed position, with the foot in a flexed position. It is not uncommon for a meniscal tear to occur along with injuries to the anterior cruciate ligament ACL and the medial collateral ligament MCL — these three problems occurring together are known as the \"unhappy triad,\" which is seen in sports such as football when the player is hit on the outside of the knee. Individuals who experience a meniscal tear usually experience pain and swelling as their primary symptoms. Another common complaint is joint locking, or the inability to completely straighten the joint. This is due to a piece of the torn cartilage preventing the normal functioning of the knee joint." }, { "id": "pubmed23n0616_18003", "title": "[The ACL tear from the pre-operative analysis to a 2-year follow-up, influence of the graft choice on the subjective and objective evaluation].", "score": 0.009708737864077669, "content": "This study is a synthesis of three series. The first study was prospective on 418 patients with an anterior cruciate ligament (ACL) tear (group I). Two population of ACL ruptures were identified. One population with a postero-lateral bundle preserved in 16%, the mean medial anterior tibial translation side to side was 4.97 mm, the Lachman test was delayed in 40% with no or glide pivot shift in 73%. The second population with a complete ACL tear had a mean medial anterior tibial translation side to side of 7.93 mm, the Lachman test was soft in 98% with gross pivot shift in 80%. The second study was a retrospective study on 258 patients (group II) at 26 months follow-up, it correlated the impact of the type of graft on the clinical objective and subjective results. Twenty-eight percent had anterior knee pain, 33% for the patellar tendon and 25% for the hamstrings, the subjective IKDC was significantly lower for the painful knees, and 68% of the patellar tendon had a hypoesthesia and only 32% for the hamstrings. The ability to walk on the knee was 68% for the hamstrings and 35% for the patellar tendon. The third study was retrospective on 127 patients, 24 months after ACL reconstruction (group III), all were tested on a isokinetic machine for the extensor, the flexor and the internal rotator. In the total population, a 10% extensor and flexor deficit and a 5% rotator deficit was noted. A significant difference between patellar tendon and hamstrings in terms of muscular recovery was found. It pointed out that a more specific rehabilitation should be done on the hamstring group. The muscular recovery was correlated to the highest subjective score. This study allowed the surgeon to be more specific in the ACL tear definition, to adapt the graft choice to the type of sport activity but also to the type of work the patient does and finally to modify the rehabilitation protocol for the hamstring technique." }, { "id": "pubmed23n1057_4446", "title": "[Clinical Assessment of Anterior Cruciate Ligament Rupture].", "score": 0.009615384615384616, "content": "Anterior cruciate ligament (ACL) rupture is one of the most common traumatic injuries of the knee joint. Acute knee injury is often characterized by pain and the typical accompanying rupture sound. The injured person often feels pain in the knee, with swelling, the movement is painful in the full range of motion. The most commonly used test procedures for rupture include Lachman test, pivot shift test, anterior drawer and lever sign test. This review includes a description of individual tests and the diagnostic value of examination after the ACL rupture. The sensitivity and specificity of the lever sign test was 0.92-1.00, the specificity was 0.94-1.00. The anterior drawer testing reported sensitivity values ranged from 0.18 to 0.92 and specificity values ranged from 0.78 to 0.98. The sensitivity and specificity of the pivot shift test ranged from 0.18 to 0.48 and the specificity from 0.90 to 0.99. The sensitivity and specificity of the Lachman test were 0.63-0.93 and the specificity was 0.55-0.99. The lever sign test, the pivot shift test, the anterior drawer test and the Lachman test are valid parts of the anterior cruciate ligament examination with respect to the prediction of anterior cruciate ligament rupture using Magnetic Resonance Imaging and arthroscopy. Key words: rupture ligamentum cruciatum anterius, test maneuvers, lever sign test, pivot shift test, anterior drawer, Lachman test." }, { "id": "pubmed23n0751_15183", "title": "[Evaluation of the clinical results in patients with symptomatic partial tears of the anterior cruciate ligament diagnosed arthroscopically].", "score": 0.009523809523809525, "content": "The study presents a retrospective evaluation of clinical data and arthroscopic findings in a group of our patients with symptomatic knee instability due to a partial tear of the anterior cruciate ligament (ACL). The group included 31 patients diagnosed with symptomatic partial ACL tears, i.e. an isolated tear of the posterolateral (PL) or the anteromedial (AM) bundle. The patients' average age was 26.5 years. A side-to-side difference in ventral knee laxity was assessed using the anterior drawer test and the Lachman test under general anaesthesia before arthroscopy was commenced; rotational knee laxity was evaluated by the pivot shift test. An objective evaluation of side-to-side ventral laxity differences in both knees was performed on the GNRB® arthrometer with an applied pressure of 134 N and 250 N in the conscious patient. During arthroscopic examination, findings on the two ACL bundles were recorded. All 31 patients were diagnosed with symptomatic partial ACL tears, of them 22 had a PL bundle lesion and nine had an AM bundle tear. All patients with PL bundle lesions only reported problems in association with pivot sports, and all patients with AM bundle tears had problems regardless of any sports activities. In all patients with isolated AM bundle tears, the lesion was located close to its femoral attachment. In the patients with PL bundle tears, femoral location was found in 68% and tibial location in 32% of the patients. In the patients with partial PL bundle lesions, + and ++ results in the pivot shift test were recorded in 32% and 68% of the treated patients, respectively. The Lachman test showed + and ++ results in 71% and 9% of the patients, respectively. The anterior drawer test had negative results in 87% and positive + results in 13% of the patients. The side-to-side difference on the GNRB arthrometer ranged from 0.4 to 2.3 mm at a pressure of 134 N and from 1.2 to 4.2 mm at 250 N in the patients with isolated PL bundle lesions. In the patients with AM bundle lesions, the results were as follows: pivot shift test, 89% negative. 11% positive +; Lachman test, 56% negative, 44% positive +; anterior drawer test, 89% +, 11% ++; GNRB test, 2.2 to 4.4 mm at 134 N, and 4.3 to 7.1 at 250 N. The diagnosis of partial ACL lesions, i.e., isolated tears of the AM or the PL bundle, requires accurate knowledge of knee anatomy and its biomechanics. In accordance with other authors our results showed that an arthroscopic examination of both bundles of the ligament as well as knee laxity evaluation under general anaesthesia are most essential for making the definite diagnosis in partial ACL tears. They also confirmed that, in isolated AM bundle lesions, ventral laxity is present more often particularly at a higher degree of knee flexion while, in PL bundle lesions, rotational laxity is more frequent and ranges from 0 to 30 degrees of knee flexion. To make the definite diagnosis of partial ACL tears, patient medical history, clinical knee examination including instability type and degree assessment under general anaesthesia and, most importantly, arthroscopic findings on both ACL bundles are necessary." }, { "id": "pubmed23n0766_16162", "title": "[Intrafix fixation and remnants preservation in single-tunnel double-bundle reconstruction of anterior cruciate ligament with anatomical placement of hamstring tendons].", "score": 0.009433962264150943, "content": "To study the feasibility and short-term effects of Intrafix fixation and remnants preservation in single -tunnel double-bundle reconstruction of anterior cruciate ligament (ACL) with anatomical placement of hamstring tendons. From August 2011 to November 2011, 25 patients with ACL injuries were treated with arthroscopic reconstruction of ACL using hamstring tendon. There were 19 males and 6 females, with a mean age of (26.26 +/- 9.53) years (ranged, 16 to 50 years). Fifteen patients had injuries in left knees, and 10 patients had injuries in right knees. The duration of the disease ranged from 1 to 60 d, with a mean of 9.6 d. All patients with acute injuries had swelling and pain on the knee, and anterior drawer test showed positive results in 14 cases, Lachman test showed positive results in 17 cases. Among patients with old injuries, 5 patients had knee joint pain, 5 patients had unstability of knee joint, 5 patients had positive results of anterior drawer test, and 5 patients had positive results of Lachman test. The diagnosis of ACL injury was determined by the anterior drawer test and Lachman test. There were 20 patients with acute injuries and 5 patients with old injuries. MRI was performed in all patients to confirm the diagnosis of ACL injuries and provide additional information on meniscal and other ligament injuries. Preservation of the remnants was through patellar tendon portal using meniscus suture guide. The femoral tunnel was placed at lateral femoral condyle at 2:00 or 10:00 position through the anteromedial (AM) portal with the knee flexed to 120 degree using an offset guide (DePuy Mitek). The tibia tunnel was placed at the center of the ACL remnant through the AM portal using a tibia guide set 45 degree. The AM and PL bundles were rotated by rotating the positioning tool to achieve the desired positions of the bundles and were fixed by femoral Intrafix and tibia Bio-Intrafix fixation. The anterior drawer test, Lachman test and Lysholm scores were observed to determinate the function of the knee and the activity of the patients. All the patients were followed up, and the duration ranged from 12 to 18 months. The Lysholm scores improved from preoperative 34.08 +/- 7.60 (25 to 49 scores) to 94.52 +/- 2.86 (89 to 98 scores) at the follow-up time (t = 21.29, P &lt; 0.01). No postoperative complications such as synovitis, ligament rupture and movement restriction occurred. Intrafix fixation and remnants preservation in single-tunnel double-bundle reconstruction of ACL with anatomical placement of hamstring tendons is simple, effective, useful, reproducible, and gives a satisfactory short-term results." }, { "id": "pubmed23n0726_24935", "title": "An extra-articular procedure improves the clinical outcome in anterior cruciate ligament reconstruction with hamstrings in female athletes.", "score": 0.009433962264150943, "content": "A positive glide is a common finding after ACL reconstructions, especially in women. The aim of this study was to prospectively evaluate the role of Cocker-Arnold's extra-articular procedure in reducing the incidence of a residual postoperative rotational knee laxity. Sixty patients affected by an ACL injury with a +2 (clunk) or +3 (gross shift) pivot-shift test entered this prospective study; they were randomly assigned to group A (control group, hamstrings) or group B (study group, hamstrings plus Cocker-Arnold). Thirty-two patients entered group A and 28 group B. At follow-up, patients underwent clinical evaluation, KT-1000 arthrometer and Lysholm, Tegner, VAS and subjective and objective IKDC form. At a mean follow-up of 44.6 months, the same expert surgeon reviewed 55 patients (28 group A and 27 group B). The comparison of the results of the evaluation scales used and of the KT-1000 arthrometer did not show statistically significant differences (p&gt;0.05). Lachman test was negative (S/S) in all the patients of both groups (100 %). A residual positive pivot-shift (glide) was found in 16 patients (57.1 %) of group A and in five patients (18.6 %) of group B (p&lt;0.05). The extra-articular MacIntosh procedure modified by Cocker-Arnold in combination with ACL reconstruction significantly reduces the rotational instability of the knee." }, { "id": "pubmed23n0978_5069", "title": "Open knee dislocation with a patellar tendon rupture: Result of staged surgical repair.", "score": 0.009345794392523364, "content": "Knee dislocation with concomitant multiligament injury is a rare and devastating injury. We report the successful repair of a rare case of open knee dislocation with concomitant multiligament injury and patellar tendon rupture of an 18-year-old male due to a motorcycle accident. The patient presented with an open wound running parallel to the knee joint line and patellar tendon rupture with full exposure of the cartilage of the distal femur. Staged surgical management including the application of a ring-type external fixator with a hinged joint, lateral collateral ligament repair, medial collateral ligament reconstruction using autogenous hamstring tendon, and joint release was performed. Range of movement was recovered to 0 degrees of knee extension and 80 degrees of knee flexion, and extension lag was negative. The Lysholm score of the patient was recovered to 92. The patient was able to return to work in the construction field 2 years after sustaining the injury. The patient had no complaint of pain and was able to resume construction work, even though reconstruction of the anterior cruciate ligament and posterior cruciate ligament was not performed. The application of a hinged ring-type external fixation device might play a key role in early range of movement restoration and to maintain the reduced position and acceptable recovery of the posterior cruciate ligament injury without the need for reconstructive surgery. This report is the first to describe the safety and effectiveness of staged surgical management for the repair of open knee dislocation with concomitant multiligament injury and patellar tendon rupture. However, further studies with longer follow-up periods will be needed to observe the development of osteoarthritis or weakness of the knee. Staged surgical management is a safe and effective procedure for repairing an open knee dislocation with concomitant multiligament injury and patellar tendon rupture." }, { "id": "pubmed23n0687_17020", "title": "[Repair of old injury of knee medial collateral ligament by a combination of dynamic and static stability].", "score": 0.009345794392523364, "content": "To observe the effectiveness of the combination of dynamic and static stability in the treatment of old knee medial collateral ligament injury. Between March 2004 and June 2008, 26 cases of old knee medial collateral ligament injury were treated, including 19 males and 7 females with a mean age of 38 years (range, 21-48 years). Injury was caused by traffic accident in 6 cases, by sprains in 12 cases, by falling from height in 8 cases. The location was left knee in 15 cases and right knee in 11 cases. Of them, 24 patients showed the positive result of knee valgus test, 2 cases showed slightly relaxed knee tendon. The knee X-ray films of valgus stress position showed that the medial joint space differences between both knees were 3-5 mm in 2 cases and 5-12 mm in 24 cases. The injuries included avulsion of the medial femoral condyle starting point in 19 cases, central laceration in 6 cases, and tibial point laceration concomitant meniscus injury in 1 case. The time from injury to hospitalization was 3-14 months (mean, 6.4 months). Gracilis muscle was used to repair knee medial collateral ligament and the sartorius muscle transfer to reconstruct the medial rotation of knee stability function. All incisions healed by first intention. No joint infection, deep vein thrombosis, or other postoperative complications occurred. Twenty-six cases were followed up 12-58 months with an average of 30 months. The results of knee valgus stress test were negative with no joint tenderness. At 3 months after operation, the knee X-ray films of valgus stress position showed the medial joint space differences between both knees were less than 1 mm. According to the modified Lysholm-Scale score, the results were excellent in 18 cases, good in 7 cases, and fair in 1 case with an excellent and good rate of 96% at last follow-up. A combination of dynamic and static stability in repairing old knee medial collateral ligament injury is easy-to-operate and has the advantages to perform the operation in the same incision, so it can avoid the shortcomings of single repair method and achieve better effectiveness." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 523, 649 ] ], "word_ranges": [ [ 87, 104 ] ], "text": "All the data are highly suggestive of Dengue, especially the plateletopenia and petechiae (suggestive of capillary fragility)," }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Coronavirus infection.", "2": "Lymphocytic choriomeningitis.", "3": "Dengue.", "4": "Chikungunya virus infection.", "5": "Saint Louis encephalitis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1000_21564", "title": "[Travel Related Fever and Rash: Two Cases of Dengue Fever].", "score": 0.019419306184012067, "content": "The frequency of travel-related infections in the world has increased due to the easily and widespread use of travel facilities in the 21st century. Vector-borne diseases are an important part of infectious diseases. Dengue fever is one of the travel-related infections that has been reported increasingly in recent years through the development of diagnostic methods. The aim of this report was to present two Dengue fever cases originating from travel. There was a story of mosquito bite during a trip to Sri Lanka travel in our first case. The patient was 30 years old and maculopapular rash appeared on the fifth day of contact. Three days after the onset of the rash, she has admitted to our clinic, complaining with fever and chills. Increased leukopenia and muscle enzymes were detected in the laboratory analysis. Real-time reverse transcriptase polimerase chain reaction (RT-PCR) was positive in the serum sample. The patient was followed up with supportive care and discharged by improvement. The second case, a 24-year-old male, had a story of mosquito bite during his trip to Malaysia. After the patient complained of fever, chills, fever, nausea, vomiting and muscle pain, the Dengue virus (DENV) NS1 antigen test performed in this country was found to be positive. In the second case, there was no maculopapular rash and laboratory analysis showed an increase in leukopenia, thrombocytopenia and muscle enzymes. RT-PCR positivity was detected in the serum sample. The patient was followed up with supportive treatment and discharged with cure. DENV infections are caused by DENV which is common in the tropical areas of the world. There are four DENV-1, DENV-2, DENV-3 and DENV-4 serotypes. DENV infections can present different clinical manifestations such as asymptomatic disease, viral syndrome, Dengue haemorrhagic fever, and Dengue shock syndrome. Dengue fever is often accompanied by arthritis, maculopapular rash and high fever. Our cases were defined as Dengue fever according to this definition. In the diagnosis of the disease, it is necessary first to be suspicious of the disease and the travel history must be questioned. In the definitive diagnosis, virus isolation, antigen, nucleic acid detection and serological tests are used. The virus can be isolated from blood, serum, urine and tissues. In the first five days after beginning of the symptoms associated with DENV infections, serum RT-PCR and Dengue NS1 antigen test may be positive." }, { "id": "pubmed23n1111_11167", "title": "COVID-19 Pneumonia and Dengue Fever Coinfection in an Individual From Southeast Asia.", "score": 0.01873249299719888, "content": "COVID-19 infection is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was declared a pandemic in 2020. Dengue fever (DF) is caused by the dengue virus (DENV) from the <iFlaviviridae</i family and is transmitted via the bite of the female <iAedes</i <iaegypti</i mosquito. COVID-19 pneumonia and dengue fever coinfection is a relatively difficult diagnosis to be established considering the similarities in the clinical manifestation of both diseases. I hereby report an unusual case of dual diagnosis involving COVID-19 pneumonia and dengue fever (DF) on the same day of presentation to the hospital. A 62-year-old male presented to the emergency department with a fever of six days duration associated with chills, rigors, arthralgia, myalgia, and a generalized pinpoint rash over the chest and abdomen. He had contact with a worker who recently tested positive for COVID-19. However, his vital signs were stable with peripheral capillary oxygen saturation (SPO2) of 99% under room air. Laboratory investigations showed polycythemia, increased hematocrit levels, and thrombocytopenia. Liver function tests showed evidence of acute hepatitis. Otherwise, the basic metabolic panel and coagulation profile were normal. Viral screens for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) were negative. The posterior-anterior chest radiograph of the patient showed ground glass opacity in both middle and lower zones of the lungs, which is mostly peripheral with preservation of lung markings. The diagnosis was confirmed by a positive SARS-CoV-2 polymerase chain reaction (PCR) test with a cycle threshold (CT) value of 19.97 and positive immunoglobulin M (IgM) and immunoglobulin G (IgG) titers on the dengue serology panel on the same day of testing. Predisposing risk factors were chronic medical illnesses (type 2 diabetes mellitus, hypertension, and ischemic heart disease) and exposure to probable COVID-19-infected individuals. The patient fully recovered after treatment with oral paracetamol 1 g four times a day for five days and an intravenous drip of 0.9% sodium chloride for 24 hours." }, { "id": "pubmed23n0268_9863", "title": "[Dengue. Apropos of 2 cases].", "score": 0.01803107139982291, "content": "BACKGROUND. Dengue is an acute febrile illness caused by several arthropod-born viruses and characterized by biphasic fever, myalgia or arthralgia, rash, leukopenia and lymphadenopathy. Its diagnosis is based on knowledge of the geographic distribution of dengue viruses. CASE REPORTS Case no 1: A 11 year-old boy suffered from sudden onset of fever accompanied by retro-orbital headache, arthralgia and diffuse myalgia. There was no rash. Hemogram showed: hemoglobin: 11.6 g%; leukocytes: 3,400/mm3 (PMN: 76%); platelets: 190,000/mm3. A diagnosis of viral infection was considered, but, as the boy had recently been to the French West-Indies, a serologic study was performed. This was negative 2 days after the onset of disease and positive (specific IgM for the 4 dengue types), 13 days later. Case no 2: A 7 year-old boy suffered from sudden onset of fever. Severe calf muscle pain 4 days later led to his admission. Creatine phosphokinase activity was very high: 83,100 units (N: 30-120). Hemogram showed: hemoglobin: 11.4 g%; leukocytes: 2,500/mm3 (PMN: 60%); platelets: 124,000/mm3. A diagnosis of acute myositis was considered, but as the patient had recently visited Venezuela, a serologic study was performed. This was negative 8 days after the onset of disease and positive (specific IgM for the 4 dengue types) 16 days later. CONCLUSION. The first case is characteristic of the classical form of dengue fever. The second patient presented with very localized myalgia. The diagnosis in both cases was facilitated by the knowledge that the patient had recently stayed in an endemic area." }, { "id": "pubmed23n0904_2108", "title": "First case of imported chikungunya infection in Croatia, 2016.", "score": 0.017042606516290727, "content": "In recent years, several European countries reported cases of imported chikungunya infection. We present the first imported clinically manifested chikungunya fever in Croatia. A 27-year-old woman returned to Croatia on 21 March 2016, after she stayed in Costa Rica for two months where she had noticed a mosquito bite on her left forearm. Five days after the mosquito bite she developed severe arthralgias, fever and erythematous papular rash. In next few days symptoms gradually subsided. After ten days she felt better, but arthralgias re-appeared accompanied with morning stiffness. Two weeks after the onset of the disease she visited the infectious diseases outpatient department. The physical examination revealed rash on the trunk, extremities, palms and soles. Laboratory findings showed slightly elevated liver transaminases. Serological tests performed on day 20 after disease onset showed a high titer of chikungunya virus (CHIKV) IgM and IgG antibodies which indicated CHIKV infection. CHIKV-RNA was not detected. Serology to dengue and Zika virus was negative. The patient was treated with nonsteroid anti-inflammatory drugs and paracetamol. Her symptoms ameliorated, however, three months later she still complaint of arthralgias. The presented case highlights the need for inclusion of CHIKV in the differential diagnosis of arthralgia in all travelers returning from countries with documented CHIKV transmission." }, { "id": "pubmed23n0859_11260", "title": "[Experience of integrated traditional Chinese and Western medicine in first case of imported Zika virus disease in China].", "score": 0.0158125, "content": "Zika virus disease is an acute infectious disease caused by Zika virus transmitted through Aedes mosquitoes. To explore the therapeutic effect of integrated traditional Chinese and Western Medicine for Zika virus disease, the treatment process of the first imported case in China was reviewed. The first imported Zika virus disease in China was admitted to Ganxian People's Hospital in Jiangxi Province on February 6th, 2016, and the patient received isolation treatment for 9 days and cured later. The effect of antiviral treatments including Xiyanping injection was evaluated based on clinical diagnosis and treatment process of the patient. A 34-year old male patient was admitted with chief complaint of fever for 9 days, orbital pain and itching rash for 4 days on February 6th, 2016. (1) Epidemiological characteristics: the patient was bitted by mosquitoes during his business trip in Venezuela since January 1st, where Zika virus disease was spreading. On January 20th he had dizziness without fever, and the symptom disappeared after taking medicines without details. Paroxysmal dizziness, chills and mild fever without myalgia was experienced on January 28th. On February 3rd small red rash appeared in the neck, spreading to anterior part of chest, limbs and trunk, and the fever, fatigue, nausea was continued, and a new symptom of paroxysmal pain in back of ears and orbits appeared, during which he had not go to hospital. The symptoms relieved on February 4th. He returned to Ganxian County on February 5th, he had yellow stool 3 times with normal temperature, without abdominal pain, and red rash still appeared in the neck. He went to Ganxian People's Hospital on February 6th, 2016. (2) Clinical manifestation: the vital signs showed a temperature of 36.8?centigrade, a pulse rate of 80 bpm, a respiratory rate of 20 bpm, and a blood pressure of 110/70 mmHg (1 mmHg = 0.133 kPa). It was showed by physical examination that red rash appeared in the neck, and no superficial enlarged lymph nodes were found. Bilateral conjunctival congestion was obvious, physiological reflex existed and pathological reflex was not found. (3) Auxiliary lab test and examination: no abnormal finding were revealed throughout examination and laboratory tests, including routine blood test, liver function, renal function, serum myocardial enzyme, electrolyte, blood sugar, C-reactive protein (CRP), troponin I (TnI), and procalcitonin (PCT), except slight prolongation in activated partial thromboplastin time (APTT, 38.6 s) on February 6th; and slightly dense shadow in left lung in lung CT scan, considering inflammatory changes and slight emphysema (especially in the left lower lung) as well as bilateral renal calculus on February 8th. No significant abnormalities were found in electrocardiogram and B ultrasound test of liver, spleen, and pancreas. (4) Virus confirmation: Zika virus nucleic acid was positive reported by Jiangxi Province Center for Disease Control and Prevention (CDC) on February 7th and Chinese CDC on February 9th, respectively, though Dengue virus were negative reported by Ganzhou CDC on February 6th. Right after the first diagnosis, anyone who had been in close contact with the patient received medical monitoring. (5)Treatment process: on February 6th, symptomatic treatment was prescribed since admitted into the infectious isolation wards and daily intravenous drip of Xiyanping injection 250 mg was prescribed for antiviral therapy. On February 7th, the patient had no fever, with occasional chills, neck rash was disappeared, orbital pain relieved and bilateral conjunctival hyperemia range was paler and narrowed, and his condition improved. Ibuprofen was administered for defervesce 3 times a day when his temperature reached to 37.5?centigrade at 16:00. On February 8th, the patient had no fever, times of chills was significantly reduced, without myalgia and rash, orbital pain and conjunctival hyperemia further recovered. On February 9th, bilateral eyes slightly tingling, mild conjunctival congestion, no fever chills or other discomfort was found. The chloramphenicol eye drops was prescribed for relieving sting pain with conjunctival congestion twice a day as recombinant human interferon alpha eye drops was out of store. The patient was comfortable from February 11th to February 13th. Blood and urine test for Zika were reported negative by the Chinese CDC and Jiangxi Province CDC. Because all the discharge criteria were satisfied, the patient was discharged on February 14th. At present, there is no specific effective drug to prevent and treat Zika virus disease effectually. After receiving symptomatic treatment and antiviral treatments including Xiyanping injection, the patient's symptoms were relieved. Zika virus nucleic acid in blood and urine was negative. The patient was discharged. Combination of traditional Chinese medicine and Western medicine maybe a good method to prevent and treat Zika virus disease." }, { "id": "pubmed23n0593_2461", "title": "[Chikungunya: fever and joint pains after vacation in a tropical area].", "score": 0.015109323432343235, "content": "A 27-year-old man was admitted to our hospital, two days after returning from a vacation in Mauritius, with fever, chills, headache and myalgia, as well as arthritis of the legs. He had a temperature of 38.6 C and painful swellings of both talocalcanean joints. Laboratory studies revealed leukopenia, lymphopenia and thrombopenia, as well as a slight elevation of transaminases and serum bilirubin. Diagnostic tests for malaria were negative, as were tests for antibodies against Epstein-Barr virus, cytomegalovirus, leptospirosis, dengue, chikungunya and hepatitis viruses, legionella, streptococcus and HIV. But PCR with chikungunya virus RNA was positive, establishing the diagnosis of acute chikungunya. All symptoms disappeared on administration of analgesics and antipyretics. But after two days a maculopapular rash on the trunk and limbs was noted: it responded well to the application of clemastine. The patient was discharged from hospital three days after admission. Chikungunya virus belongs to the family of alphaviruses and is common in Southeast Asia and Africa. It can be transmitted to humans by bites of the Aedes mosquitoes. Symptoms are similar to those of dengue and consist of fever, headache, arthralgia, myalgia and conjunctivitis. After two or three days these symptoms subside and a maculopapular rash appears. The fever may return. Arthralgia can persist over weeks and even months. While the diagnosis is normally established by antibody tests, these may be negative in early stages of the disease. when the diagnosis can be made by PCR. Treatment is symptomatic with analgesics and antipyretics." }, { "id": "Pharmacology_Katzung_5664", "title": "Pharmacology_Katzung", "score": 0.01478494623655914, "content": "Philip J. Rosenthal, MD A 5-year-old American girl presents with a 1-week history of intermittent chills, fever, and sweats. She had returned home 2 weeks earlier after leaving the USA for the first time to spend 3 weeks with her grandparents in Nigeria. She received all standard childhood immunizations, but no additional treat-ment before travel, since her parents have returned to their native Nigeria frequently without medical consequences. Three days ago, the child was seen in an outpatient clinic and diagnosed with a viral syndrome. Examination reveals a lethargic child, with a temperature of 39.8°C (103.6°F) and splenomegaly. She has no skin rash or lymphadenopathy. Ini-tial laboratory studies are remarkable for hematocrit 29.8%, platelets 45,000/mm3, creatinine 2.5 mg/dL (220 μmol/L), and mildly elevated bilirubin and transaminases. A blood smear shows ring forms of Plasmodium falciparum at 1.5% parasit-emia. What treatment should be started?" }, { "id": "pubmed23n1043_7936", "title": "[A Case of Simultaneous Acute Lymphoblastic Leukemia Diagnosis with Crimean-Congo Hemorrhagic Fever].", "score": 0.014615770969362129, "content": "Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease that can be presented with fever, fatigue, generalized joint/body pain, diarrhea and bleeding in various parts of the body. The risk of developing a severe fatal disease in humans, the possibility of being infected with aerosols and the risk of being used as a biological weapon make the disease still an important health problem all over the world as there is no a specific treatment and vaccine that has proven effective againt the virus today. The pathogenesis of the disease is not known, but vascular endothelial damage is prominent. Therefore, it progresses with thrombocytopenia, anemia, leukopenia and this hematological findings can be confused with hematological malignancies. Acute lymphoblastic leukemia (ALL) is a malignancy included in differential diagnoses and occurs as a result of mutations occuring at a stage of differentiation in the lymphoid precursor cells in the bone marrow. In this study, we present a case of ALL who was diagnosed with CCHF simultaneously. A 43-year old female patient who works in the library and does not have a chronic disease other than asthma and thyroid disorder, has admitted to our hospital with the complaints of intermittent fever, weakness, generalized joint and body pain for about 3 weeks. She had fever and the physical examination revealed bilateral cervical and right postauricular lymphadenopathies. Her aspartate aminotransferase: 77 U/L, alanine aminotransferase: 117 U/L, lactate dehydrogenase: 616 U/L, hemoglobin: 8.27 g/dl, leukocyte count: 15.690/mm3 , neutrophil count: 550/mm3 (%3.5), lymphocyte count: 6690/mm3 (%42.6), platelet count: 102.100/mm3 , C-reactive protein: 163.6 mg/L was detected and the patient was hospitalized on 5 August 2019 for further examination and treatment. Considering that the patient may have viral infection in the foreground the requested test results were detected as; anti-CMV IgM negative, anti-CMV IgG positive, anti-toxoplasma IgM negative, anti-toxoplasma IgG positive, anti-rubella IgM negative, anti-rubella IgG positive, HBsAg negative, anti-HBc IgM negative, antiHBs positive, anti-HAV IgM negative, anti-HAV IgG positive, anti-HCV negative, anti-HIV negative, EpsteinBarr virus (EBV) VCA IgM negative, EBV VCA IgG positive, EBV EBNA IgG positive. Brucella Rose Bengal and Coombs tube agglutination was found be negative. As the cytopenia of the patient deepened, the patient was accepted to have neutropenic fever and it was planned to start piperacillin-tazobactam 4 x 4.5 g/day and two units of erythrocyte replacement therapy. When the patient's history was questioned again, it was learned that she had a tick on her neck about three weeks ago and she had removed the tick herself; 4-5 days later she had the complaints of fever and flu like symptoms and also diarrhea complaints lasting for 3-4 days. Considering the current anamnesis and laboratory findings, the patient was thought to have CCHF and the patient was isolated. The serum sample taken from patient with an initial diagnosis of CCHF and sent to Department of Microbiology Reference Laboratory Public Health Agency of Turkey. The patient was referred to the Antalya Training and Research Hospital. The patient's CCHF serum result was positive. Ribavirin treatment was not initiated in the patient who was accepted to be in the convalescence period, piperacillin-tazobactam 4 x 4.5 g/day treatment was continued and supportive treatment was given. In the follow-up, as the patient's neutropenia, thrombocytopenia and lymphocytopenia still continuing, she was transferred to hematology clinic for malignancy examination and bone marrow biopsy performed by hematology and B cell ALL was diagnosed. She was accepted to be convalescent in terms of CCHF and chemotherapy was started for ALL treatment by hematology. The patient is still being followed up by the hematology clinic and allogenic hematopoietic stem cell tranplantation is planned for the patient. As a result, CCHF is a disease that can be confused with many differential diagnosis. With this case, it is aimed to draw attention to the diagnostic difficulties of CCHF and ALL and to be the first case in the literature." }, { "id": "wiki20220301en015_142667", "title": "Chikungunya", "score": 0.013540260908681961, "content": "Diagnosis Chikungunya is diagnosed on the basis of clinical, epidemiological, and laboratory criteria. Clinically, acute onset of high fever and severe joint pain would lead to suspicion of chikungunya. Epidemiological criteria consist of whether the individual has traveled to or spent time in an area in which chikungunya is present within the last twelve days (i.e.) the potential incubation period). Laboratory criteria include a decreased lymphocyte count consistent with viremia. However a definitive laboratory diagnosis can be accomplished through viral isolation, RT-PCR, or serological diagnosis. The differential diagnosis may include other mosquito-borne diseases, such as dengue or malaria, or other infections such as influenza. Chronic recurrent polyarthralgia occurs in at least 20% of chikungunya patients one year after infection, whereas such symptoms are uncommon in dengue." }, { "id": "pubmed23n0779_21223", "title": "Fever in returning travelers: a case-based approach.", "score": 0.013493866424352567, "content": "Overall, 3% to 19% of travelers to the developing world will return to the United States with fever or will develop fever within weeks of their return. When evaluating the returning traveler with fever, it is important to know which pretravel immunizations the patient received; which medications he or she took during travel; the likely pathogen exposures during travel; and the incubation interval between travel and onset of fever. A physical examination that includes a search for focal findings may narrow the list of possible infections. Fever compatible with a common illness that occurs in the United States (e.g., mononucleosis) should always be considered. If the patient has fever without a focus and a tropical infection is suspected, malaria, dengue fever, and typhoid fever are common causes. These infections may appear clinically similar, with symptoms of fever, headache, muscle pain, joint pain, and malaise, and decreased white blood cell and platelet counts. Malaria can usually be diagnosed with a thin blood smear. Dengue fever is a clinical diagnosis. Serologic testing for dengue virus immunoglobulin M and G and virus detection tests can be performed to confirm the diagnosis, but are not immediately available. Typhoid fever can usually be diagnosed with a blood, urine, or stool culture. " }, { "id": "pubmed23n0748_617", "title": "Pearls and oy-sters: tuberculous meningitis: not a diagnosis of exclusion.", "score": 0.012989203778677462, "content": "A 21-year-old man presented to his local emergency department with 5 days of headache, which was dull, occipital, bilateral, nonthrobbing, and progressively worsening. It was associated with mild fever, photophobia, and neck pain and stiffness. He had no history of headache, chronic illness, recent vaccinations, cutaneous rash, cough, diarrhea, arthralgia, or myalgia. He was from Ecuador and had been living in the United States for less than 1 year. He had been incarcerated while in Ecuador. Sublingual temperature on admission was 102.6°F. Other vital signs were within normal limits. On physical examination, he appeared thin but not cachectic. He had meningismus and photophobia, but no papilledema and his mental status was alert and attentive. There were no focal neurologic deficits. CSF contained red blood cells: 24 × 10(3)/μL; white blood cells: 85/μL (lymphocytic predominant); protein: 128 mg/dL; and glucose: 48 mg/dL (CSF/serum glucose ratio = 0.53). CSF Gram stain and cultures, PPD test, and blood and urine cultures were all negative. CT scan of the head on day of admission was entirely normal. MRI without gadolinium contrast showed a single punctate T2 hyperintensity in the left frontal periventricular white matter. Chest radiograph was clear. He received empiric vancomycin, ceftriaxone, and acyclovir. Corticosteroids were not given. The patient did not improve with antibiotics and continued to be intermittently febrile. On day 5, he became abruptly more somnolent, then comatose, opening eyes only to pain, his pupils were 5 mm and reactive, he had intact brainstem reflexes, withdrawing both arms and legs. Emergent head CT showed development of hydrocephalus and a ventriculoperitoneal shunt was emergently placed. The neurologic examination did not improve after shunt placement, and repeat head CT showed increased hydrocephalus with bilateral cerebral infarcts. On day 11, he was transferred to Columbia University Medical Center for intensive care. He was febrile and comatose. He did not open his eyes to pain, pupils were 7 mm minimally reactive, brainstem reflexes were intact, and he exhibited extensor posturing to pain. Mannitol was given, corticosteroid therapy was started, and an extraventricular drain was placed. The next day, his right pupil was 8 mm and nonreactive. MRI showed diffuse contrast enhancement of the arachnoid, extensive infarction of basal ganglia, midbrain, and pons, and small ring-enhancing lesions in the cerebellum (figure 1, A-D). Repeat lumbar puncture showed red blood cells: 550 × 10(3)/μL; white blood cells: 250/μL (14% neutrophils, 80% lymphocytes, 6% monocytes); protein: 65 mg/dL; and glucose: &lt;10 mg/dL (CSF/serum glucose ratio = 0.08). CSF testing for Cryptococcus and toxoplasmosis was negative. CSF acid fast bacilli (AFB) smear was negative ×2, and CSF nucleic acid amplification test was also negative for tuberculosis. Serum HIV test was negative. Not until 14 days after initial presentation and 3 days after transfer to the intensive care unit was antituberculosis therapy finally started, because the pattern of infarcts on the MRI suggested basilar meningitis and he had not improved on broad-spectrum antibiotics. That same day, the first sputum AFB smear was positive, as were all succeeding daily sputum AFB smears. Tuberculosis nucleic acid amplification was positive from the sputum, but persistently negative from the CSF. Daily portable chest radiographs had been normal (read as likely atelectasis), but chest CT showed dense consolidations in the left lung and diffuse micronodular opacities throughout both lungs. Two days later, only 21 days after the onset of his headache, the patient died of cardiopulmonary arrest secondary to transtentorial cerebral herniation. Thirteen days later, the CSF culture became positive for Mycobacterium tuberculosis sensitive to streptomycin, isoniazid, ethambutol, rifampin, and pyrazinamide." }, { "id": "pubmed23n1165_21080", "title": "[A Case of Plasmodium vivax Complicated with Reactive Hemophagocytic Syndrome].", "score": 0.01287341145403532, "content": "Plasmodium vivax is the most common malaria agent in the world, transmitted by vectoring of anopheles mosquitoes. In the clinical course of the disease, non-specific signs of infection (fever, myalgia, joint pain, nausea, vomiting, etc.) can be seen. Hemophagocytic lymphohistiocytosis; also known as hemophagocytic syndrome, is a rapid-onset and life-threatening clinical condition that develops as a result of uncontrolled immune activation and hypercytokinemia. In this case report, a case who developed hemophagocytic syndrome while under treatment for P.vivax infection was presented. A 37-year-old male patient applied to us with the complaints of high fever, chills-shivering and weakness, started on his return from Sudan. Upon admission, the fever was 40°C, the pulse was rhythmic and 115/minute, the respiratory rate was 24/minute, and the blood pressure was 80/49 mmHg, and he was followed up in the intensive care unit due to the signs of systemic inflammatory response syndrome. During the investigation of the etiology of fever, it was learned that he did not receive prophylaxis for malaria during his stay in Sudan. Thin and thick blood smears were examined. P.vivax infection was detected in the patient and the treatment was initiated, a bone marrow aspiration biopsy was performed with the prediagnosis of hemophagocytic syndrome with persistent fever, deepening of thrombocytopenia, findings of hyperferritinemia, hypertriglyceridemia, hepatosplenomegaly, and myeloid serial hemophagocytosis in the 48th hour of the treatment. In addition to antimalarial therapy, clinical and laboratory response was obtained with polyclonal intravenous immunoglobulin (IVIG) therapy." }, { "id": "wiki20220301en044_81115", "title": "Ross River virus", "score": 0.012732365673542145, "content": "The symptoms of Ross River virus are important to recognise for early diagnosis and therefore early treatment. Symptoms have been illustrated in a case report of an infected Thuringian traveller returning from South-East Australia. This case showed flu-like symptoms that include fever, chills, headache and pains in the body. Additionally, joint pain arose in which some joints become swollen and joint stiffness was particularly noticeable. A clinical examination of the infected individual shows a significant decrease of specific antibodies despite the normal blood count levels. A rash is a good indication that is likely to occur but usually disappears after ten days. The symptoms of Ross River virus are important to be aware of so that early treatment can be administered before the virus worsens. The time between catching the disease and experiencing symptoms is anywhere between three days to three weeks, usually it takes about 1–2 weeks. A person can be tested for Ross River virus by" }, { "id": "pubmed23n0558_4133", "title": "Acute renal failure after a holiday in the tropics.", "score": 0.012684092836764593, "content": "A 20-year-old, previously healthy woman, presented with high fever, headache and myalgia 3 days after her return from a holiday in Southeast Asia. Laboratory data on admission demonstrated a pronounced increase in plasma creatinine, marked thrombocytopenia and moderately elevated liver aminotransferases. After having ruled out malaria, dengue fever was primarily suspected and supportive intravenous fluid therapy was initiated. Still, 1 day after admission, platelet counts dropped even further and she became anuric although she did not appear hypovolemic. On day 2 after admission, urine production commenced spontaneously and the patient slowly recovered. All laboratory test results had returned to normal approximately 2 months later. Serological analysis for dengue fever was negative. It turned out that the patient had been trekking in the jungle while in Thailand and we, therefore, analyzed serology for Leptospira spirochetes which was clearly positive. The patient was diagnosed with leptospirosis which is a serious condition associated with a high mortality when complicated by acute renal failure. Differential diagnoses in patients with acute renal failure and tropical infections are reviewed. The importance of early recognition of leptospirosis, and prompt treatment with antibiotics in suspected cases, is emphasized." }, { "id": "pubmed23n1142_1730", "title": "Prolonged fever and exaggerated hypercoagulopathy in malaria vivax relapse and COVID-19 co-infection: a case report.", "score": 0.012490450725744843, "content": "Coronavirus disease 2019 (COVID-19) often causes atypical clinical manifestations similar to other infectious diseases. In malaria-endemic areas, the pandemic situation will very likely result in co-infection of COVID-19 and malaria, although reports to date are still few. Meanwhile, this disease will be challenging to diagnose in areas with low malaria prevalence because the symptoms closely resemble COVID-19. A 23-year-old male patient presented to the hospital with fever, anosmia, headache, and nausea 1 week before. He was diagnosed with COVID-19 and treated for approximately 10 days, then discharged to continue self-quarantine at home. 2 weeks later, he returned to the hospital with a fever raised intermittently every 2 days and marked by a chilling-fever-sweating cycle. A laboratory test for malaria and a nasopharyngeal swab for SARS CoV-2 PCR were conducted, confirming both diagnoses. The laboratory examination showed markedly elevated D-dimer. He was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days and primaquine 2 tablets per day for 14 days according to Indonesian National Anti-malarial Treatment Guidelines. After 6 days of treatment, the patient had no complaints, and the results of laboratory tests had improved. This report describes the key points in considering the differential diagnosis and prompt treatment of malaria infection during the pandemic of COVID-19 in an endemic country to prevent the worse clinical outcomes. COVID-19 and malaria may also cause a hypercoagulable state, so a co-infection of those diseases may impact the prognosis of the disease. This case report shows that considering the possibility of a co-infection in a COVID-19 patient who presents with fever can prevent delayed treatment that can worsen the disease outcome. Paying more attention to a history of travel to malaria-endemic areas, a history of previous malaria infection, and exploring anamnesis regarding the fever patterns in patients are important points in making a differential diagnosis of malaria infection during the COVID-19 pandemic." }, { "id": "pubmed23n0850_7266", "title": "Guillain-Barre syndrome following dengue fever and literature review.", "score": 0.012398902625859552, "content": "Dengue is an arboviral infection that classically presents with fever, joint pain, headaches, skin flush and morbilliform rashes. The incidence of neurological symptoms and complications in dengue varies from 1 to 25% that include encephalopathy, Guillain-Barre syndrome (GBS), acute motor weakness, seizures, neuritis, hypokalaemic paralysis, pyramidal tract signs, and a few more. Dengue fever as an antecedent infection in GBS is uncommon. A 34-years-old Sri Lankan Sinhalese male presented with fever, headache and myalgia of 3 days and developed leucopenia and thrombocytopenia without evidence of haemoconcentration. The diagnosis of dengue fever was confirmed as he had positive dengue NS1 antigen test on the third day of fever. He made full recovery and was discharged after 4 days of hospital stay. Six days later, he presented with history of acute flaccid weakness of both lower limbs and upper limbs which was of progressive ascending nature. The electromyography had evidence of demyelinating neuropathy and cerebrospinal fluid showed albuminocytological dissociation. Subsequently, IgM for dengue virus was positive. Dengue is endemic in Sri Lanka. Post dengue Guillain-Barre syndrome is a potential neurological complications of this infection." }, { "id": "pubmed23n1021_13220", "title": "[Meningococcemia: Different Serotypes in the Same Region].", "score": 0.011958306561005211, "content": "Meningococcal infections are important health problems causing high morbidity and mortality. Neisseria meningitidis have 13 serogroups. A, B, C, Y and W135 are the most common causes of invasive disease among those serogroups. The distribution of the serogroups differs according to the geographical regions and the age groups. In this case report, two cases of meningococcemia infected with serogroup C and Y of N.meningitidis rarely seen in our country were presented. First case was a two and a half year-old female patient who has admitted to our pediatric emergency unit with fever and rash spreading from lower extremities to her body. The patient had diffuse purpuric rash with generalized weakness and tendency to sleep at admission. The patient has been suspected as meningococcemia because of the skin rash, tendency to sleep and hypotension. Antibiotics treatment was started immediately and lumber puncture was performed. In blood tests, leukocyte count: 3600/mm3 (61% neutrophils), hemoglobin: 11.1 g/ dl, platelet count: 127.000/mm3 , C-reactive protein: 10 mg/dl, erythrocyte sedimentation rate: 6 mm/ hour, prothrombin time: 28.8 seconds (normal value= 11-16), prothrombin activity: 36%, international normalized ratio (INR): 2.13 (normal value= 1-1.5), activated partial thromboplastin time: 57.7 seconds (normal value= 25-35 sec), fibrinogen: 246 mg/dl (normal value= 200-400 mg/dl) and in cerebrospinal fluid protein: 21 mg/dl and glucose: 62 mg/dl were found. There were eight cells in the microscopic examination. Skin rashes were increased and the patient became hypotensive. No microorganisms were isolated in blood and cerebrospinal cultures. N.meningitidis serogroup C was isolated from the cerebrospinal fluid of the patient using polymerase chain reaction (PCR). The patient suffered from immune-mediated arthritis in the sixth day of treatment and nonsteroidal anti-inflammatory drugs were given. The patient has recovered with antibiotics, fresh frozen plasma and inotropic treatment. Second case was a 13 year-old male patient who has admitted three days after the first case with a pre-diagnosis of malignancy because of pancytopenia and fever. The patient had generalized weakness and a few petechial purpuric rashes at the facial region at admission. After the admission general status of the patient has worsened rapidly and he has died as a result of cardiovascular arrest. Blood tests in admission showed leukocyte count: 6000/mm3 (79% neutrophils), hemoglobin: 17.3 mg/dl, platelet count: 16.000/mm3 , C-reactive protein: 8.63 mg/dl, prothrombin time: 92.6 seconds, prothrombin activity: 10%, INR: 6.78, activated partial thromboplastin time: 231.5 seconds. Cerebrospinal fluid obtained from postmortem lumbar puncture showed no growth (protein: 95 mg/dl, glucose: 35 mg/dl) and N.meningitidis serogroup Y was detected by PCR. Two meningococcemia cases caused by two different serogroups which are rarely seen in our region in recent years were presented at the same time period in the same hospital. This case report pointed out that surveillance has a great importance in such diseases." }, { "id": "wiki20220301en002_2175", "title": "Dengue fever", "score": 0.011933962264150944, "content": "Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. Symptoms typically begin three to fourteen days after infection. These may include a high fever, headache, vomiting, muscle and joint pains, and a characteristic skin rash. Recovery generally takes two to seven days. In a small proportion of cases, the disease develops into a more severe dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs. Dengue is spread by several species of female mosquitoes of the Aedes genus, principally Aedes aegypti. The virus has five serotypes; infection with one type usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of severe complications. A number of tests are available to confirm the diagnosis including detecting antibodies to the virus or its RNA." }, { "id": "pubmed23n0476_2513", "title": "Acute human immunodeficiency virus syndrome in an adolescent.", "score": 0.011658717541070483, "content": "Acute human immunodeficiency virus (HIV) seroconversion illness is a difficult diagnosis to make because of its nonspecific and protean manifestations. We present such a case in an adolescent. A 15-year-old boy presented with a 5-day history of fever, sore throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient's only risk factor for HIV infection was a history of unprotected intercourse with 5 girls. Physical examination was significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura on both feet. Laboratory studies demonstrated lymphopenia and mild thrombocytopenia. Hemoglobin, serum creatinine, and urinalysis were normal. The following day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and erythematous papules on the thorax; the purpura was unchanged. Serologies for hepatitis B, syphilis, HIV, and Epstein-Barr virus were negative. Bacterial cultures of blood and stool and viral cultures of throat and conjunctiva showed no pathogens. Coagulation profile and liver enzymes were normal. Within 1 week, all symptoms had resolved. The platelet count normalized. Repeat HIV serology was positive, as was HIV DNA polymerase chain reaction. Subsequent HIV viral load was 350 000, and the CD4 lymphocyte count was 351/mm3. HIV is the seventh leading cause of death among people aged 15 to 24 in the United States, and up to half of all new infections occur in adolescents. Our patient presented with many of the typical signs and symptoms of acute HIV infection: fever, fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, emesis, and diarrhea. Other symptoms commonly reported include headache, myalgias, arthralgias, aseptic meningitis, peripheral neuropathy, thrush, weight loss, night sweats, and genital ulcers. Common seroconversion laboratory findings include leukopenia, thrombocytopenia, and elevated transaminases. The suspicion of acute HIV illness should prompt virologic and serologic analysis. Initial serology is usually negative. Diagnosis therefore depends on direct detection of the virus, by assay of viral load (HIV RNA), DNA polymerase chain reaction, or p24 antigen. Both false-positive and false-negative results for these tests have been reported, further complicating early diagnosis. Pediatricians should play an active role in identifying HIV-infected patients. Our case, the first report of acute HIV illness in an adolescent, emphasizes that clinicians should consider acute HIV seroconversion in the appropriate setting. Recognition of acute HIV syndrome is especially important for improving prognosis and limiting transmission. It is imperative that we maintain a high index of suspicion as primary care physicians for adolescents who present with a viral syndrome and appropriate risk factors." }, { "id": "pubmed23n0877_9219", "title": "Domestic dengue infection with hemophagocytic lymphohistiocytosis successfully treated by early steroid therapy.", "score": 0.011333163069850594, "content": "A 34-year-old man, working at a park in Tokyo, Japan, was repeatedly bitten by mosquitoes while cutting grass. He was hospitalized with sudden fever, fatigue, and weakness. He was eventually diagnosed with dengue virus infection, detected using reverse transcription polymerase chain reaction for the genome and by the presence of nonstructural protein 1 in his peripheral blood. Symptomatic treatments such as acetaminophen for the fever were not effective. Moreover, peripheral blood examination showed drastically decreased white blood cells and platelets, as well as marked elevations of ferritin and soluble interleukin 2 receptor. Furthermore, bone marrow examination revealed increased macrophages with hemophagocytosis. Dengue infection with hemophagocytic lymphohistiocytosis (HLH) was ultimately diagnosed. Half-dose steroid pulse therapy for three days dramatically reduced his temperature, thereby ameliorating physical symptoms and restoring normal peripheral blood data. He was discharged 12 days after admission. Dengue infection with HLH is rare and this is the first report, to our knowledge, of domestic dengue infection with HLH in Japan. Early steroid therapy may be effective in such cases." }, { "id": "wiki20220301en003_199943", "title": "Rocky Mountain spotted fever", "score": 0.009892023685127134, "content": "Diagnosis This disease can be diagnosed by a doctor with and without the use of lab testing. Lab tests are not always relied upon because treatment may be necessary before the results are returned. Abnormal laboratory findings seen in patients with Rocky Mountain spotted fever may include a low platelet count, low blood sodium concentration, or elevated liver enzyme levels. Serology testing and skin biopsy are considered to be the best methods of diagnosis. Although immunofluorescent antibody assays are considered some of the best serology tests available, most antibodies that fight against R. rickettsii are undetectable on serology tests during the first seven days after infection. Differential diagnosis includes dengue, leptospirosis, chikungunya, and Zika fever." }, { "id": "pubmed23n0394_21074", "title": "Perinatal dengue infection.", "score": 0.009708737864077669, "content": "We report a case of vertical transmission of dengue infection in an infant. The mother's was a term pregnancy with a history of chronic hypertension. She presented with high fever of 3 days duration 5 days prior to delivery. Her initial complete blood count showed platelet count of 64,000/mm3. Dengue hemorrhagic fever was diagnosed 2 days later and symptomatic treatment was given. During labor her platelets dropped to 11,000/mm3 and platelet concentrate was given. Cesarean section was performed due to prolonged second stage of labor. Her infant was normal at birth except for petechiae on the left thigh. The child's platelet count was 34,000/mm3 and low grade fever was detected on the first day. Clinical sepsis was suspected and antibiotic treatment was started and continued for 4 days until all the cultures came back as negative. Both mother and her baby made an uneventful recovery and were discharged 6 days after delivery with normal platelet counts. Maternal blood was positive for IgM antibody to dengue virus. Both cord blood and the baby's blood were positive for dengue virus serotype 2 by PCR." }, { "id": "pubmed23n0534_9047", "title": "Severe, persisting, steroid-responsive Dengue myositis.", "score": 0.009708737864077669, "content": "Short-term, general muscle affection is frequent in Dengue infection, but severe, persisting, myositis has not been reported. Case report. The patient is a 38 years old, HIV-negative male who developed sudden-onset fever up to 40.0 degrees C, headache, and sore eyes upon looking into light when on holidays in Thailand. One day after onset severe myalgias occurred in the shoulder girdle and hip girdle muscles. Clinical examination was normal, but blood work revealed elevated creatine-phosphokinase, glutamate-oxalate transaminase, and glutamate pyruvate transaminase, leucopenia and thrombocytopenia. Antibodies against Dengue viruses type 2 and 4 were positive and classical Dengue fever was diagnosed. The infection resolved upon symptomatic therapy, but myalgias, responsive only to opiates, resolved persistently not before the administration of corticosteroids, 2 months after onset. The case shows that Dengue fever may also cause persisting, severe, myositis for weeks, which do not respond to non-steroidal analgesics, but promptly to corticosteroids." }, { "id": "InternalMed_Harrison_15719", "title": "InternalMed_Harrison", "score": 0.009669756784595657, "content": "2 or 3 of the disease. The rash is most intense on the trunk and limbs and may desquamate. Young children develop less prominent signs and are therefore less frequently hospitalized. Children also often develop a bullous rather than a maculopapular/ petechial rash. Maternal–fetal transmission has been reported and in some cases has led to fetal death. Recovery may require weeks, and some elderly patients may continue to experience joint pain, recurrent effusions, or stiffness for several years. This persistence of signs and symptoms may be especially common in HLA-B27-positive patients. In addition to arthritis, petechiae are occasionally seen and epistaxis is not uncommon, but chikungunya virus should not be considered a VHF agent. A few patients develop leukopenia. Elevated concentrations of aspartate aminotransferase (AST) and C-reactive protein have been described, as have mildly decreased platelet counts. Treatment of chikungunya virus disease relies on nonsteroidal" }, { "id": "wiki20220301en166_23465", "title": "Zika fever", "score": 0.009615384615384616, "content": "Zika fever, also known as Zika virus disease or simply Zika, is an infectious disease caused by the Zika virus. Most cases have no symptoms, but when present they are usually mild and can resemble dengue fever. Symptoms may include fever, red eyes, joint pain, headache, and a maculopapular rash. Symptoms generally last less than seven days. It has not caused any reported deaths during the initial infection. Mother-to-child transmission during pregnancy can cause microcephaly and other brain malformations in some babies. Infections in adults have been linked to Guillain–Barré syndrome (GBS). Zika fever is mainly spread via the bite of mosquitoes of the Aedes type. It can also be sexually transmitted and potentially spread by blood transfusions. Infections in pregnant women can spread to the baby. Diagnosis is by testing the blood, urine, or saliva for the presence of the virus's RNA when the person is sick, or the blood for antibodies after symptoms are present more than a week." }, { "id": "pubmed23n0893_13566", "title": "[First case of chikungunya fever in Hermosillo, Sonora, Mexico].", "score": 0.009591335673802805, "content": "The Chikungunya is an arbovirus first described during a 1952 outbreak of febrile exantematic disease in southern Tanganyika (now Tanzania). It is a virus within the alphavirus genus of the Togaviridae family, it is usually transmitted to humans by Aedes mosquitoes. Typically, the disease manifests as acute onset of fever and joint pains. This study describes the clinical characteristics the first imported case infected with chikungunya fever (CHIK) in Hermosillo, Sonora, Mexico. We report the case of a 30 years old man seen in our emergency department due to fever, polyarthralgia, rash and headache. This patient has been in Tapachula, Chiapas, a jungle area in southern México, and he returned from a 45 days trip before the onset his symptoms. The chikungunya viral infection (CHIK) was diagnosed by RT-PCR procedure. Paracetamol therapy was administered and his clinical course was self-limited. We concluded that with the increase of mosquito´s habitat by global warming and frequent traveling, CHIK reemerged and showed global distribution recently. This disease must be suspected in patients with compatible clinical symptoms returning from epidemic/endemic areas. CHIK must be diagnosed on the basis of clinical, epidemiological and laboratory criteria." }, { "id": "pubmed23n0800_4179", "title": "[Hemorrhagic dengue and vertical transmission to the newborn: a case report and literature review].", "score": 0.009523809523809525, "content": "To describe the case of a patient with term pregnancy and infection with hemorrhagic dengue and vertical transmission to the newborn. Thirty-two year old patient with pregnancy at 38 weeks was admitted with fever 2 days earlier (38 degrees C). During her stay she continued with fever of 39 degrees C and platelets of 85,000/mm3. Serology for dengue NS1 antigen was reported positive. Labor was induced getting a new-born, male, 3,220 g, who breathed and cried at birth. During the postpartum period continued with fever, malaise, retro-ocular pain, generalized rash in upper and lower limbs, bleeding gums and petechial on the soft palate and thrombocytopenia of 5,000/mm3, later. At 8 days of stay, platelet concentration increased to 42,000/mm3 without requiring platelet concentrates and she was discharged after ten days in hospital with platelets of 94,000/mm3. The 4th day of extra-uterine live (EUL), neonate shows generalized rash over the trunk; The 5th day starts with 38 degrees C fever and thrombocytopenia (78,000/mm3). Dengue serological tests reported positive for Ag NS1 and negative for Abs IgM and IgG. Neonate was admitted to NICU, he continued with a decrease in platelet of 14,000/mm3- and ecchymotic areas by pressure and veno-punction sites. Four platelet concentrates were transfused. At 10th day of EUL platelet count was reported with 387,000/mm3. In an endemic area, such as Sinaloa state, in a pregnant woman with fever and thrombocytopenia, we should be alert to possibility of a DV infection and its complications. Although rare, such as this case, infection can be transmitted to fetus (vertical transmission) and produce a primary congenital dengue, even in its severe hemorrhagic types." }, { "id": "pubmed23n0863_4006", "title": "A case of acalculous cholecystitis in the course of dengue fever in a traveller returned from Brazil.", "score": 0.009433962264150943, "content": "Dengue is the second cause of fever after malaria in travellers returning from the tropics. The infection may be asymptomatic or it may manifest itself with fever only, some patients, however, may develop haemorrhagic symptoms and shock. A 58-year-old woman came to the University Centre of Tropical Medicine in Gdynia after returning from a tourist journey to Brazil because of fever up to 39°C and malaise. She had lived in South America many years and then moved to Europe 3 years before hospitalisation. On admission physical examination revealed fever, dry mucosa, moderate hypotension and tachycardia. In the laboratory test results, leukopoenia, thrombocytopoenia and elevated transaminases were observed. On the second day of the hospitalisation, the patient reported epigastric pain, clinical examination revealed tenderness of the abdomen and macular rash on the skin of the trunk and thighs. The ultrasonography revealed an enlarged gallbladder with thickened walls, with hypoechogenic area surrounding it, a dilated common biliary duct of heterogenic echo, and some free fluid in the peritoneal cavity. An exploratory laparotomy was performed after 24 h because of the persisting strong abdominal pain and high fever. Intraoperatively, enlarged mesenteric lymph nodes were found, with no symptoms of gallbladder pathology. The postoperative course was uncomplicated and the positive result of immunochromatographic assay for dengue was obtained. The acalculous cholecystitis has been described in the course of various diseases and conditions. The typical symptoms include pain in the right hypochondriac region, fever, positive Murphy's sign, and abnormal liver function tests, which were observed in the presented case. Cholecystectomy is not usually indicated in the course of dengue (typically a self-limiting disease) due to a high risk of bleeding. The case provides a rationale for the inclusion of acalculous cholecystitis in the differential diagnosis in patients with abdominal pain returning from dengue endemic areas." }, { "id": "wiki20220301en287_31902", "title": "Zika virus", "score": 0.009345794392523364, "content": "Zika fever Zika fever (also known as Zika virus disease) is an illness caused by Zika virus. Most cases have no symptoms, but when present they are usually mild and can resemble dengue fever. Symptoms may include fever, red eyes, joint pain, headache, and a maculopapular rash. Symptoms generally last less than seven days. It has not caused any reported deaths during the initial infection. Infection during pregnancy causes microcephaly and other brain malformations in some babies. Infection in adults has been linked to Guillain–Barré syndrome (GBS) and Zika virus has been shown to infect human Schwann cells. Diagnosis is by testing the blood, urine, or saliva for the presence of Zika virus RNA when the person is sick. In 2019, an improved diagnostic test, based on research from Washington University in St. Louis, that detects Zika infection in serum was granted market authorization by the FDA." }, { "id": "pubmed23n1133_15236", "title": "[The Importance of Differential Diagnosis During Pandemic: A Case Report with Coexistence of COVID-19, Brucellosis and Crimean-Congo Hemorrhagic Fever].", "score": 0.009345794392523364, "content": "The coronavirus disease-2019 (COVID-19) pandemic, which affects millions of people around the world, has been affecting our country since March 2020. The fact that the symptoms such as fever, myalgia, headache, joint pain which are common in COVID-19 patients are quite similar to the symptoms of diseases such as Crimean-Congo hemorrhagic fever (CCHF) and Brucellosis. This may cause a diagnostic confusion in regions where these diseases are seen as endemic. In this report, a patient hospitalized with a pre-diagnosis of COVID-19 and diagnosed with acute Brucellosis, CCHF and COVID-19 during followup was presented. A 31-year-old female patient living in a rural area admitted to the emergency service with complaints of fever, weakness, headache, and body/joint pain. Physical examination revealed a temperature of 38.3°C, a pulse rate of 102/minute, and a peripheral capillary oxygen saturation of 97% in room air. The system examination was normal. In the laboratory findings, an increase in liver enzymes and acute phase reactants was observed and the platelet count was at the lower limit of the normal range. In terms of COVID-19, no involvement compatible with COVID-19 was detected in the thorax computed tomography (CT) of the patient whose nasopharyngeal and oropharyngeal mixed swab samples were taken.The patient was transferred to our infectious diseases service with a pre-diagnosis of COVID-19 and CCHF. Serum samples were sent to the Public Health Agency Microbiology Reference Laboratory Department (PHA-MRLD) for CCHF diagnostic tests and supportive treatment was started. Brucella Rose Bengal and Coombs' immuncapture (1/1280 titer) tests were found as positive in the patient, who was examined for brucellosis because of living in a rural area and having a history of consuming fresh dairy products. In the tests performed at PHA-MRLD, CCHF-specific IgM positivity and the presence of viral RNA were detected. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) reverse-transcriptase polymerase chain reaction (RT-PCR) test was negative. For Brucellosis, doxycycline and rifampicin were added to the treatment of the patient whom was given supportive therapy for CCHF. In the followup, the patient's fever was persisting and loss of taste and smell complaint developed. In this context, COVID-19 test was repeated and resulted as positive. Upon this, hydroxychloroquine sulfate treatment was started due to the recommendation of the current Ministry of Health Scientific Committee Guide. No new infiltration was detected in the chest radiography of the patient. The patient's fever subsided during follow-up and laboratory findings improved. The treatment of brucellosis was completed to eight weeks at the outpatient clinic. No problems were detected in the follow-up. This report was prepared because of a case with simultaneous brucellosis, CCHF and COVID-19 infections which could not be encountered in the literature review. As a result; in regions such as our country where both brucellosis and CCHF are seen as endemic, it is very important to keep these diseases in mind in the differential diagnosis of COVID-19 infection." }, { "id": "pubmed23n0867_19398", "title": "[Plasmodium falciparum malaria: evaluation of three imported cases].", "score": 0.009259259259259259, "content": "Among Plasmodium species the causative agent of malaria in Turkey is P.vivax, however the incidence of imported falciparum malaria cases is steadily increasing. P.falciparum may cause severe malaria with the involvement of central nervous system, acute renal failure, severe anemia or acute respiratory distress syndrome. Furhermore most of the casualties due to malaria are related with P.falciparum. There is recently, a considerable increase in malaria infections especially in tropical areas. In this report, three cases, who have admitted to our hospital with three different clinical presentations of falciparum malaria, and all shared common history of travelling to Africa were presented. First case was a 27 years old, male patient who returned from Malawi seven days ago where he stayed for two weeks. He admitted to our hospital with the complaints of sensation of cold, shivering and fever. In physical examination his body temperature was 37.9°C, C-reactive protein level was high, and the other systemic results were normal. The second case was a 25 years old, male patient who returned from Gambia two weeks ago. He was suffering from fever, headache, shivering and unable to maintain his balance. The patient's body temperature was 38°C. Laboratory tests revealed hyperbilirubinemia and thrombocytopenia. Parasitological examination of the Giemsa-stained peripheral blood smear of these two patients demonstrated ring forms compatible with P.falciparum. Treatment was commenced with arthemeter plus lumefantrine, resulting with complete cure. Third case was a 46 years old, male patient who had been working in Uganda, and returned to Turkey two weeks ago. He had sudden onset of fever, headache, nausea and vomiting and impaired consciousness. His peripheral blood smear revealed ring-formed trophozoites and banana-shaped gametocytes of P.falciparum. Arthemeter plus lumefantrine therapy was started, however, he developed severe thrombocytopenia and jaundice under treatment. His general condition was detoriated and the patient lost his consciousness. As the patient's clinical signs were compatible with sepsis ceftriaxone plus clindamycin were added to the antiparasitic treatment emprically. Due to the development of acute tubular necrosis, the patient have undergone hemodialysis. On the 9th day of therapy the complaints and laboratory findings of the patient have improved, so he was discharged. However, visual defects due to retinopathy and severe neurocognitive impairment that were thought to be the complications of malaria continued in his follow-ups. As a result, it should be keep in mind that both the African students who have come to our country for education from endemic regions and as well as the returned citizens of our country who have gone to work in endemic areas, are under risk of malaria and it is very important to consider malaria in the distinctive diagnosis of patients with the complaints of fever, headache, nausea, vomiting and muscle pain. " }, { "id": "pubmed23n0971_23079", "title": "Clinical and Laboratory Characteristics of an Acute Chikungunya Outbreak in Bangladesh in 2017.", "score": 0.009259259259259259, "content": "From April to September 2017, Bangladesh experienced a huge outbreak of acute Chikungunya virus infection in Dhaka. This series describes the clinical and laboratory features of a large number of cases (690; 399 confirmed and 291 probable) suffered during that period. This observational study was carried out at Dhaka Medical College Hospital, Bangladesh. The median age of the patients at presentation was 38 years (IQR 30-50) with a male (57.3%) predominance. Hypertension and diabetes were the most common comorbidities. The mean (±SD) duration of fever was 3.7 (±1.4) days. Other common manifestations were arthralgia (99.2%), maculopapular rash (50.2%), morning stiffness (49.7%), joint swelling (48.5%), and headache (37.6%). Cases were confirmed by anti-chikungunya IgG (173; 43.3%), IgM (165; 42.3%), and reverse transcription polymerase chain reaction (44; 11.0%). Important laboratory findings include high erythrocyte sedimentation rate (156; 22.6%), raised serum glutamic pyruvic transaminase (73; 10.5%), random blood sugar (54; 7.8%), leukopenia (72; 10.4%), thrombocytopenia (41; 5.9%), and others. The oligo-articular (453; 66.1%) variety of joint involvement was significantly more common compared with the poly-articular (237; 34.5%) variety. Commonly involved joints were the wrist (371; 54.1%), small joints of the hand (321; 46.8%), ankle (251; 36.6%), knee (240; 35.0%), and elbow (228; 33.2%). Eleven cases were found to be complicated with neurological involvement and two of them died. Another patient died due to myocarditis. Public health experts, clinicians, and policymakers could use the results of this study to construct the future strategy tackling chikungunya in Bangladesh and other epidemic countries." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 408, 501 ] ], "word_ranges": [ [ 62, 74 ] ], "text": "Verapamil (and calcium antagonists in general) are contraindicated in systolic heart failure:" }, "4": { "exist": true, "char_ranges": [ [ 182, 407 ] ], "word_ranges": [ [ 25, 62 ] ], "text": "fibrillation; she has criteria for anticoagulation, and between the two options that include acenocoumarol we are inclined to choose option 4, since it includes carvedilol, a drug that has been shown to increase survival in heart failure." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Digoxin and acetylsalicylic acid.", "2": "Atenolol and acetylsalicylic acid.", "3": "Verapamil and acenocoumarol.", "4": "Carvedilol and acenocoumarol.", "5": "Carvedilol and clopidogrel." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0754_15408", "title": "ECG of the month. Irregular rhythm in a 25-year-old man with three prior cardiac operations. Coarse atrial fibrillation with a rapid ventricular response, left anterior fascicular block, left ventricular hypertrophy with repolarization abnormality.", "score": 0.01711402033204125, "content": "The patient underwent closure of an atrial septal defect at age 3, had a leaking \"mitral\" valve repaired at age 9, and at age 13 had a \"mitral\" valve replacement. He began taking warfarin sodium at that time and remained symptom-free until 10 days before his initial visit here when he presented to another hospital with dyspnea and palpitations. Treatment there consisted of lisinopril 10 mg qd, carvedilol 6.25 mg bid, aldactone 25 mg qd, furosemide 40 mg qd, digoxin 0.25 mg qd, and a continuation of warfarin sodium 7.5 mg qd. An echocardiogram showed a left ventricular ejection fraction of 20%. After diuresis, he was referred to our cardiology clinic. On his initial visit here, his heart rate was an irregular 120 beats/min, his blood pressure was 106/77 mmHg, and closing and opening snaps of a normally functioning mechanical mitral valvular prosthesis were heard. He was obese (height, 5' 9\"; weight, 272 lbs). An electrocardiogram was recorded (Figure 1)." }, { "id": "pubmed23n0812_18983", "title": "A One-Two Punch: Hydralazine-Induced Liver Injury in a Recovering Ischemic Hepatitis.", "score": 0.015899949723479134, "content": "A 77-year-old woman presented to the emergency department with a 2-day history of nausea and vomiting. Her medical history included diabetes mellitus, hypertension, atrial fibrillation, dilated cardiomyopathy, and coronary artery disease. Her home medications included aspirin, clopidogrel, warfarin, digoxin, metoprolol, losartan, simvastatin, isosorbide dinitrate, furosemide, and spironolactone. Initial physical examination showed blood pressure of 170/80 mm Hg with a heart rate of 69 beats per minute, otherwise unremarkable. Initial laboratory workup was significant for INR of 3.6, with slightly elevated troponin I and creatinine of 0.06 ng/mL and 1.4 mg/dL, respectively. The patient was admitted to the medicine floor. However, a few hours later, her atrial fibrillation went into rapid ventricular response, associated with hypotension. Cardiac enzymes began to trend up along with worsening of her renal function tests and hepatic enzymes. Her INR remained supratherapeutic despite holding coumadin and giving vitamin K. The patient was transferred to the medical intensive care unit for closer monitoring. During day 1 of the medical intensive care unit stay, losartan, simvastatin, and diuretics were held, whereas aspirin, clopidogrel, and isosorbide dinitrate were continued. In the following 2 days, there was worsening of tissue perfusion, and laboratory workup showed AST 514 IU/L, ALT 391 IU/L, INR &gt;9, creatinine 3.8 mg/dL, and troponin I 0.19 ng/mL; therefore, digoxin was also held. Once the patient achieved hemodynamic stability, she was started on hydralazine. On day 4, renal function, cardiac, and hepatic enzymes improved significantly. However, 24 hours later, transaminases began to trend up again reaching a maximum of AST and ALT of 359 and 525 IU/L, respectively. Other possible causes were ruled out because her viral hepatitis markers, antihistone antibody, antinuclear antibody, and anti-double-stranded DNA were all negative. After thorough review of all medications, hydralazine was held with subsequent improvement in transaminases. The patient was seen a month later after her discharge, and all her laboratory workup improved to baseline. " }, { "id": "pubmed23n0737_16050", "title": "Tachycardia-induced cardiomyopathy.", "score": 0.014520902700702921, "content": "Tachycardia-induced cardiomyopathy (TIC) is an important cause of heart failure as it is potentially reversible after ventricular rate control. A 66-year-old hypertensive woman presented with a 15-day history of tachycardia, dyspnoea and oedema. ECG revealed atrial fibrillation with ventricular frequency of 130 beats per minute (bpm). Echocardiogram showed dilated left ventricle (LV) with 0.39 ejection fraction. Angiography revealed non-obstructed coronary arteries. Heart rate and cardiac failure were controlled with amiodarone, digoxine, captopril, metoprolol and furosemide. During follow-up, despite drug dose optimisation, the patient kept complaining of tachycardia and dyspnoea with a ventricular rate between 108 and 120&amp;emsp14;bpm. Medical staff suspected she was not taking her medicines properly. Two months later, the patient was asymptomatic and had converted to sinus rhythm (heart rate of 76&amp;emsp14;bpm). Echocardiogram showed normal LV size and function. Patient's diagnosis was TIC. Although rare, TIC should be considered in all cases of systolic dysfunction associated with tachyarrhythmia." }, { "id": "wiki20220301en166_44933", "title": "WHO Model List of Essential Medicines", "score": 0.014193042796813094, "content": "Antianginal medicines Bisoprolol Glyceryl trinitrate Isosorbide dinitrate Verapamil Antiarrhythmic medicines Bisoprolol Digoxin Epinephrine (adrenaline) Lidocaine Verapamil Amiodaroneα Antihypertensive medicines Amlodipine Bisoprolol Enalapril Hydralazine Hydrochlorothiazide Lisinopril/amlodipine (lisinopril + amlodipine) Lisinopril/hydrochlorothiazide (lisinopril + hydrochlorothiazide) Losartan Methyldopa Telmisartan/amlodipine (telmisartan + amlodipine) Telmisartan/hydrochlorothiazide (telmisartan + hydrochlorothiazide) Sodium nitroprussideα Medicines used in heart failure Bisoprolol Digoxin Enalapril Furosemide Hydrochlorothiazide Losartan Spironolactone Dopamineα Antithrombotic medicines Anti-platelet medicines Acetylsalicylic acid (aspirin) Clopidogrel Thrombolytic medicines Alteplaseα Streptokinaseα Lipid-lowering agents Simvastatin Dermatological medicines (topical)" }, { "id": "pubmed23n0417_6924", "title": "Pharmacologic therapy for patients with chronic heart failure and reduced systolic function: review of trials and practical considerations.", "score": 0.014130434782608696, "content": "Heart failure (HF) is a complex clinical syndrome resulting from any structural or functional cardiac disorder impairing the ability of the ventricles to fill with or eject blood. The approach to pharmacologic treatment has become a combined preventive and symptomatic management strategy. Ideally, treatment should be initiated in patients at risk, preventing disease progression. In patients who have progressed to symptomatic left ventricular dysfunction, certain therapies have been demonstrated to improve survival, decrease hospitalizations, and reduce symptoms. The mainstay therapies are angiotensin-converting enzyme (ACE) inhibitors and beta-blockers (bisoprolol, carvedilol, and metoprolol XL/CR), with diuretics to control fluid balance. In patients who cannot tolerate ACE inhibitors because of angioedema or severe cough, valsartan can be substituted. Valsartan should not be added in patients already taking an ACE inhibitor and a beta-blocker. Spironolactone is recommended in patients who have New York Heart Association (NYHA) class III to IV symptoms despite maximal therapies with ACE inhibitors, beta-blockers, diuretics, and digoxin. Low-dose digoxin, yielding a serum concentration &lt;1 ng/mL can be added to improve symptoms and, possibly, mortality. The combination of hydralazine and isosorbide dinitrate might be useful in patients (especially in African Americans) who cannot tolerate ACE inhibitors or valsartan because of hypotension or renal dysfunction. Calcium antagonists, with the exception of amlodipine, oral or intravenous inotropes, and vasodilators, should be avoided in HF with reduced systolic function. Amiodarone should be used only if patients have a history of sudden death, or a history of ventricular fibrillation or sustained ventricular tachycardia, and should be used in conjunction with an implantable defibrillator [corrected]. Finally, anticoagulation is recommended only in patients who have concomitant atrial fibrillation or a previous history of cerebral or systemic emboli." }, { "id": "Pharmacology_Katzung_1335", "title": "Pharmacology_Katzung", "score": 0.013579622132253711, "content": "A 69-year-old retired teacher presents with a 1-month history of palpitations, intermittent shortness of breath, and fatigue. She has a history of hypertension. An electrocardiogram (ECG) shows atrial fibrillation with a ventricular response of 122 beats/min (bpm) and signs of left ventricular hypertrophy. She is anticoagulated with warfarin and started on sustained-release metoprolol, 50 mg/d. After 7 days, her rhythm reverts to normal sinus rhythm spontaneously. However, over the ensuing month, she continues to have intermittent palpita-tions and fatigue. Continuous ECG recording over a 48-hour period documents paroxysms of atrial fibrillation with heart rates of 88–114 bpm. An echocardiogram shows a left ven-tricular ejection fraction of 38% (normal ≥ 60%) with no localized wall motion abnormality. At this stage, would you initiate treatment with an antiarrhythmic drug to maintain normal sinus rhythm, and if so, what drug would you choose?" }, { "id": "article-26694_21", "title": "Paroxysmal Atrial Fibrillation -- Treatment / Management -- Rate Control", "score": 0.012718697702723263, "content": "Rate control is the preferred strategy for all asymptomatic AF patients. Guidelines on target heart rate in patients selected for rate control are lacking. A previously conducted randomized trial (RACE II) to assess heart rate goal in patients with AF showed no outcome difference between lenient and strict heart rate control; however, sufficient evidence to assess the impact on all-cause mortality was lacking. Physicians usually attempt to control heart rate control with agents such as beta-blockers (metoprolol, esmolol, propranolol), nondihydropyridine calcium-channel blockers (verapamil, diltiazem), or digoxin. All 3 classes of drugs are given intravenously (IV) for acute rate control and can be switched to oral therapy for chronic management. In patients with chronic heart failure with reduced ejection fraction, carvedilol therapy has shown significant improvement in left ventricular ejection fraction. Due to the negative inotropic properties of calcium channel blockers, physicians do not use these not preferred in such patients. Digoxin is usually reserved for patients who do not achieve rate control with beta-blockers or calcium channel blockers alone. Amiodarone can be used as second-line therapy when treatment with other agents has failed. [23] In patients refractory to medical therapy, AV node ablation with a permanent pacemaker placement can effectively control and regularize ventricular heart rate. Low doses of magnesium have shown synergistic effects on rate control. [24]" }, { "id": "pubmed23n1135_9610", "title": "New-Onset Atrial Fibrillation in COVID-19 Infection: A Case Report and Review of Literature.", "score": 0.012260765550239234, "content": "Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many cases of arrhythmias have been reported in patients with COVID-19 infection. We present the case of a 66-year-old female with no known cardiovascular history who presented with worsening shortness of breath and productive cough and tested positive for COVID-19 infection in the ED. The patient had a recent hospitalization for COVID-19 infection during which she was treated with dexamethasone and remdesivir therapy and her course remained uncomplicated at that time. Following this, she developed worsening shortness of breath at home for which she presented to the ED. During this hospitalization, she was treated with dexamethasone, remdesivir, and supplemental oxygen. On day six of hospitalization, the patient became tachycardic and had palpitations. Cardiac monitor and EKG showed evidence of new-onset atrial fibrillation (NOAF). Initially patient received metoprolol and diltiazem, both of which failed to achieve adequate rate control. Following this, the patient was started on carvedilol 30 mg every six hours, which attained good rate control. Her CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category) score was 4 for which she was started on apixaban 5mg twice daily. The patient was discharged on the same medications. Despite increasing reported incidences of NOAF in COVID-19 infection, only little is known about the optimal management strategies and possible etiopathology. The aim of our review is to highlight the possible mechanisms triggering atrial fibrillation in COVID-19 infection and go over the management strategies while reviewing the available literature." }, { "id": "wiki20220301en024_15479", "title": "Third-degree atrioventricular block", "score": 0.012186703483432454, "content": "The 2005 Joint European Resuscitation and Resuscitation Council (UK) guidelines state that atropine is the first-line treatment especially if there were any adverse signs, namely: 1) heart rate < 40 bpm, 2) systolic blood pressure < 100 mm Hg, 3) signs of heart failure, and 4) ventricular arrhythmias requiring suppression. If these fail to respond to atropine or there is a potential risk of asystole, transvenous pacing is indicated. The risk factors for asystole include 1) previous asystole, 2) complete heart block with wide complexes, and 3) ventricular pause for > 3 seconds. Mobitz Type 2 AV block is another indication for pacing. As with other forms of heart block, secondary prevention may also include medicines to control blood pressure and atrial fibrillation, as well as lifestyle and dietary changes to reduce risk factors associated with heart attack and stroke." }, { "id": "wiki20220301en482_21170", "title": "Rahul Potluri", "score": 0.011781988247991365, "content": "Weekend effect on hospital care Potluri presented research from the ACALM Study Unit at the European Society of Cardiology Conference in London, August 2015, which showed that heart attack patients admitted at the weekend died earlier compared to those admitted during the working week. Subsequent research looking at patients discharged from UK hospitals at the weekend had significantly worsened mortality and survival compared to those discharged during the working week. This was the first study of its kind from the UK. The significance and implications of these findings for UK are being widely debated. Further studies performed in 2016 and presented at the British Cardiovascular Society Conference showed that patients admitted with a diagnosis of atrial fibrillation during the weekend had worse mortality and patients with heart failure discharged at the weekend also had a higher risk of death." }, { "id": "pubmed23n0479_20908", "title": "Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?", "score": 0.01055475103041105, "content": "This study examined the relative merits of digoxin, carvedilol, and their combination for the management of patients with atrial fibrillation (AF) and heart failure (HF). In patients with AF and HF, both digoxin and beta-blockers reduce the ventricular rate, and both may improve symptoms, but only beta-blockers have been shown to improve prognosis. If combined therapy is not superior to beta-blockers alone, treatment of patients with HF and AF could be simplified by stopping digoxin. We enrolled 47 patients (29 males; mean age 68 years) with persistent AF and HF (mean left ventricular ejection fraction [LVEF] 24%) in a randomized, double-blinded, placebo-controlled study. In the first phase of the study, digoxin was compared with the combination of digoxin and carvedilol (four months). In the second phase, digoxin was withdrawn in a double-blinded manner in the carvedilol-treated arm, thus allowing a comparison between digoxin and carvedilol (six months). Investigations were undertaken at baseline and at the end of each phase. Compared with digoxin alone, combination therapy lowered the ventricular rate on 24-h ambulatory electrocardiographic monitoring (p &lt; 0.0001) and during submaximal exercise (p &lt; 0.05), whereas LVEF (p &lt; 0.05) and symptom score (p &lt; 0.05) improved. In phase 2, there was no significant difference between digoxin alone and carvedilol alone in any variable. The mean ventricular rate rose and LVEF fell when patients switched from combination therapy to carvedilol alone. Six-minute walk distance was not significantly influenced by any therapy. The combination of carvedilol and digoxin appears generally superior to either carvedilol or digoxin alone in the management of AF in patients with HF." }, { "id": "pubmed23n0386_16798", "title": "[Treatment of heart failure at a hospital in the north-east of Italy].", "score": 0.009956409748365366, "content": "Because the number of patients who require hospitalization for heart failure is increasing, their treatment is often entrusted to physicians operating in Departments of General Medicine. Published data on the in-hospital treatment of heart failure in Italy have not been available up to now, as they are limited only to patients admitted to Department of Cardiology. This study concerns the patients who were discharged from our Hospital after a diagnosis of heart failure (International Classification of Disease--9th Edition, code 428) from January 1 to February 28, 1998. Information collected from patient hospital records included: age, sex, department to which the patient was referred (General Medicine or Cardiology), cause of heart failure, New York Heart Association (NYHA) functional class, symptoms and signs of heart failure, therapy, length of hospitalization and in-hospital mortality. Of the 178 patients identified (82 males--46.1%, 96 females--53.9%, mean age 78 +/- 11 years) 163 (91.6%) were referred to Departments of General Medicine. The cause of heart failure was coronary artery disease in 88 (49.4%) patients, arterial hypertension in 40 (22.4%), primary cardiomyopathy in 28 (15.7%), valvular heart disease in 22 (12.3%). NYHA functional class was reported or deducible from the severity of dyspnea in 57 (32%) patients. In 8 (4.6%) patients symptoms or signs of heart failure were not reported. Chest X-ray was performed in 77.6% of cases, echocardiography in 41%, ambulatory electrocardiography in 10% and coronary arteriography in 5%. Left ventricular ejection fraction was known in 90 (51.6%) patients, in 44 (48.9%) of these it was &gt; or = 45%. ACE-inhibitors were used in 99 (55.6%) patients, but this percentage rose to 63% when considering only patients with left ventricular ejection fraction &lt; 45%. Eighty-five patients were treated with captopril or enalapril; in 52 patients (61.4%) the daily dose of captopril was &lt; 75 mg and that of enalapril was &lt; 20 mg. Diuretics were utilized in 155 (87%) patients, digoxin in 123 (69%), beta-blocker agents in 5 (2.8%) and other vasodilators in 95 (53%). The mean length of hospitalization was 13 +/- 9 days and the overall in-hospital mortality was 18%. In conclusion, the results of this study demonstrate that the patients who are discharged from our hospital with a diagnosis of heart failure are, on the average, very old. The vast majority of these patients are admitted to the Departments of General Medicine. The advanced age of our patients can explain the limited use of ACE-inhibitors and, especially, of beta-blockers." }, { "id": "pubmed23n1093_21018", "title": "Ropinirole-Associated Orthostatic Hypotension as Cause of a Prescribing Cascade in an Elderly Man.", "score": 0.009900990099009901, "content": "Ropinirole is an overall well-tolerated antiparkinsonian medication that is also used to treat restless leg syndrome (RLS). The incidence of side effects is low, with orthostatic hypotension (OH) only anecdotally reported. Additionally, it is known that the elderly population is very susceptible to adverse drug effects and the prevalence of prescribing cascades that these can trigger is unknown. A 71-year-old male with history of atrial fibrillation, well-controlled diabetes on oral agents, hyperlipidemia, hypertension, ischemic heart failure status post (s/p) implantable cardioverter-defibrillator (ICD) placement with improved ejection fraction (EF), transient ischemic attack (TIA), rheumatoid arthritis, RLS, aortic stenosis s/p mechanical aortic valve replacement on anticoagulation, deep venous thrombosis (DVT), and right knee replacement, presented to the ED with generalized weakness, with difficulty standing from seated position, followed by a fall without head trauma. Over the eight months prior to this presentation, the patient had had similar symptoms that resulted in four falls, two hospital admissions, and new prescriptions of midodrine and compression stockings. On admission, vital signs were remarkable for positive orthostatics with blood pressure (BP) 110/74 mmHg, heart rate (HR) of 86 bpm in supine position and BP 87/51 mmHg, HR of 70 bpm while in standing position. Physical exam was unremarkable except for a known ejection murmur and dry oral mucous membranes. Labs included a creatinine 3.6 mg/dl, blood urea nitrogen (BUN) 66 mg/dl, international normalized ration (INR) of 4.1, B-natriuretic peptide (BNP) of 313 pg/mL, troponin &lt;0.03 ng/mL. A kidney ultrasound was normal, and a transthoracic echocardiogram showed left ventricle ejection fraction (LVEF) of 55-65%, improved compared to a prior study. Furosemide, carvedilol and canagliflozin were discontinued and IV fluids were administered. In the subsequent days, his creatinine improved, and so did the patient's volume status, but he continued to be orthostatic despite midodrine and stockings. On further interview, the patient disclosed starting ropinirole 0.25 mg three times daily approximately 10 months prior to this admission, due to asymptomatic RLS that was reported in a sleep study. Decision was made to discontinue this medication, which resulted in improvement of symptoms. We were able to discontinue IV fluids, midodrine and stockings, and reintroduce carvedilol, furosemide and canagliflozin in a stepwise manner. In a follow-up visit one month after discharge, the patient was symptom-free. This case illustrates two major points. First, this prescribing cascade potentially induced by ropinirole, as well as the increase in health care costs associated to iatrogenic admissions, is major preventable problem faced mostly by the geriatric population. Second, although OH associated with ropinirole has only been reported in patients treated for Parkinson's disease, this side effect should be considered when prescribing ropinirole for other indications, with cautious assessment of risks and benefits. Further studies need to be conducted to establish the frequency of OH related to ropinirole." }, { "id": "pubmed23n0620_23588", "title": "Management of atrial fibrillation in the elderly.", "score": 0.009900990099009901, "content": "Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to slow immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in older patients, ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiar-rhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily." }, { "id": "pubmed23n0397_8310", "title": "Management of the older person with atrial fibrillation.", "score": 0.00980392156862745, "content": "Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, verapamil, or diltiazem may be given to slow immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and with symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds that are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and should be continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in older persons, ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Digoxin should not be used to treat patients with paroxysmal AF. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should receive 325 mg of aspirin daily." }, { "id": "wiki20220301en563_1337", "title": "List of cardiology mnemonics", "score": 0.009774938012588212, "content": "Iatrogenic Rheumatic heart: mitral regurgitation Atherosclerotic: MI, CAD Thyroid: hyperthyroid Endocarditis Sick sinus syndrome Atrial fibrillation management ABCD:p. 30 Anti-coagulate Beta-block to control rate Cardiovert Digoxin Beck's triad (cardiac tamponade) 3 D's:p. 30 Diminished heart sounds Distended jugular veins Decreased arterial pressure Betablockers: cardioselective betablockers Betablockers Acting Exclusively At Myocardium:p. 30 Betaxolol Acebutelol Esmolol Atenolol Metoprolol CHF Treatment LMNOP Lasix Morphine Nitrites Oxygen VassoPressors CHF: causes of exacerbation FAILUREp. 30 Forgot medication Arrhythmia/ Anaemia Ischemia/ Infarction/ Infection Lifestyle: taken too much salt Upregulation of CO: pregnancy, hyperthyroidism Renal failure Embolism: pulmonary Complications of Myocardial Infarction Darth Vader Death Arrythmia Rupture(free ventricular wall/ ventricular septum/ papillary muscles) Tamponade" }, { "id": "pubmed23n0328_12245", "title": "[Drugs prescribed for chronic heart failure. Current data on their effectiveness].", "score": 0.009708737864077669, "content": "VARIABLE EFFICACY: Prognosis in patients with chronic heart failure remains poor. Certain drugs can lower mortality and improve quality of life. DRUGS WITH PROVEN EFFICACY: Converting enzyme inhibitors (CEI) have proven efficacy and should be used in all stages of heart failure outside contraindications. High-dose regimens are recommended when tolerated. Certain beta-blockers have also been added to the list of effective drugs for heart failure. Positive data have been reported for metroprolol, bisoprolol and carvedilol. Improved function has been demonstrated only with carvedilol allowing a clear reduction in mortality; it is currently indicated in combination with CEI and diuretics for patients with symptomatic heart failure. DRUGS WITH INSUFFICIENTLY PROVEN EFFICACY: Certain drugs which have been used for many years can improve heart function but data clearly proving lower mortality are lacking. These include diuretics and nitrate derivatives for symptomatic patients and digitalics which are useful not only for patients with complete arrhythmia due to atrial fibrillation but also for symptomatic patients with sinus rhythm. According to preliminary studies, aldosterone antagonists appear to have a positive effect on mortality due to heart failure. DRUGS WITH LIMITED INDICATIONS: Other drugs have been found to have no effect on mortality. Amiodarone, amlodipine and felodipine can thus be used for patients with associated diseases. Finally anticoagulant therapy should be reserved for patients with atrial fibrillation or a history of thromboembolism." }, { "id": "pubmed23n1019_2148", "title": "Ranolazine Induced Bradycardia, Renal Failure, and Hyperkalemia: A BRASH Syndrome Variant.", "score": 0.009615384615384616, "content": "Ranolazine is a well-known antianginal drug, that was first licensed for use in the United States in 2006. It was objectively shown to improve exercise capacity and to lengthen the time to symptom onset in patients with coronary artery disease. The most commonly reported side effects of ranolazine include dizziness, headache, constipation, and nausea. Here, we describe a case of bradycardia, hyperkalemia, and acute renal injury in the setting of ranolazine use. Our patient is an 88-year-old female who presented with abdominal pain, nausea, and vomiting. Her medical comorbidities included hypertension, diabetes, CAD, heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, hypothyroidism, and a history of cerebrovascular accident without any residual deficits. Her prescription regimen included amlodipine, furosemide, isosorbide mononitrate, levothyroxine, metformin, omeprazole, and ranolazine. Physical examination was remarkable for bradycardia and decreased breath sounds in the left lower lung field. Laboratory studies were significant for a serum potassium level of 6.8 mEq/L and a serum creatinine level of 1.6 mg/dL. She was given insulin with dextrose, sodium polystyrene, and calcium gluconate in addition to fluids. Her bradycardia and renal function worsened over the next 24 hours. Ranolazine was discontinued. Metabolic derangements were treated appropriately. After 48 hours from presentation, potassium and renal function returned to baseline and her heart rate improved to a range of 60-100 bpm. She was discharged with an outpatient cardiology follow-up. Ranolazine treatment was not continued upon discharge. In summary, our case illustrates an association between ranolazine and renal failure induced hyperkalemia, leading to conduction delays in the myocardium. Though further studies are warranted, we suspect that this is a variant of the recently described BRASH syndrome. We propose that in cases such as ours, along with treatment of the hyperkalemia, medication review and removal of any offending agent should be considered." }, { "id": "pubmed23n0273_6468", "title": "Optimal management of older patients with atrial fibrillation.", "score": 0.009615384615384616, "content": "Long term oral warfarin should be administered to elderly patients with atrial fibrillation who are at high risk for developing thromboembolic stroke and who have no contraindications to anticoagulant therapy. Oral aspirin (acetylsalicylic acid) 325mg daily may be given to elderly patients with chronic atrial fibrillation who have contraindications to anticoagulant therapy or who are not at high risk for developing thromboembolic stroke. Management of atrial fibrillation includes treatment of the underlying disease and precipitating factors. If patients have paroxysmal atrial fibrillation with a very rapid ventricular rate associated with hypotension, severe left ventricular failure or chest pain due to myocardial ischaemia, immediate direct-current cardioversion should be performed. Intravenous verapamil, diltiazem or a beta-blocker should be used for immediate slowing of a very rapid ventricular rate associated with atrial fibrillation. If a rapid ventricular rate associated with atrial fibrillation persists at rest or during exercise despite digoxin, then oral verapamil, diltiazem or a beta-blocker should be added. Low dosages of oral amiodarone (200 to 400 mg/day) may be used in selected patients with symptomatic life-threatening atrial fibrillation refractory to other therapy. No medication which depresses atrioventricular conduction should be given to patients with atrial fibrillation and a slow ventricular rate. Cardioversion should not be performed in asymptomatic elderly patients with chronic atrial fibrillation. This author would use a beta-blocker for control of ventricular arrhythmias and following conversion of atrial fibrillation to sinus rhythm. Should atrial fibrillation recur, beta-blockers have the additional advantage of slowing the ventricular rate." }, { "id": "pubmed23n0610_5372", "title": "Decrease in blood pressure after intravenous administration of urapidil during recombinant tissue plasminogen activator thrombolysis for acute ischemic stroke.", "score": 0.009523809523809525, "content": "In patients who are candidates for IV recombinant tissue plasminogen activator (rtPA) thrombolysis for the treatment of acute ischemic stroke, blood pressure (BP)-lowering therapy is sometimes needed for systolic BP &gt;185 mm Hg or diastolic BP &gt;110 mm Hg. However, there is vast uncertainty regarding the appropriate choice of an antihypertensive agent. A 68-year-old Algerian woman (height, 161 cm; weight, 68 kg; body mass index, 26 kg/m2) was admitted to the Cardiology Unit of Amiens University Hospital, Amiens, France, for the assessment of nonvalvular atrial fibrillation. She was prescribed furosemide 40 mg/d to treat a slight left cardiac insufficiency. On day 10 of admission, the patient developed left-sided weakness. Neurologic examination revealed left hemiparesis. A computed tomography scan of the head showed no abnormality. Approximately 90 minutes after onset of the neurologic deficit, the patient had a BP of 180/100 mm Hg in both arms, an irregular pulse &gt;75 bpm, and normal heart sounds. The patient was transferred to the Neurovascular Unit. There were no cervical or femoral bruits in this patient. During neurologic examination, the patient was alert and showed no signs of major cognitive deficit. The neurologic examination did reveal, however, minor hemisphere syndrome with left spatial neglect. There was a left lower-facial paresis. Motor examination revealed normal bulk with diminished tone in the patient's left arm and leg. Although there were no physical signs of dehydration, laboratory results revealed moderate signs of dehydration (total protein, 91 g/L [indicating proteinemia]; sodium, 147 mmol [indicating hypernatremia]; and elevated hematocrit, 42.0%). Considering the diagnosis of ischemic stroke and the duration of the symptoms (&lt;3 hours), IV rtPA was administered. Approximately 10 minutes after intravenous rtPA administration, the patient's BP was 210/110 mm Hg, and an IV bolus of urapidil (20 mg) was administered. Approximately 2 minutes following urapidil administration, the patient developed neurologic worsening indicated by left-sided hemiplegia. Her BP was 105/60 mm Hg. The IV rtPA was immediately discontinued and volume replacement was started for 20 minutes. IV rtPA was restarted after the patient remained hemodynamically stable (15 minutes after rtPA was restarted). Following intensive physiotherapy, the patient was discharged on anticoagulation with a favorable outcome. At her 6-month follow-up, the patient had fully recovered. We report a probable case of hypotension associated with IV bolus of urapidil administration during rtPA thrombolysis for acute ischemic stroke in an elderly patient also treated with diuretics." }, { "id": "pubmed23n0773_21706", "title": "Effect of carvedilol on reduction in heart rate in patients with chronic atrial fibrillation.", "score": 0.009433962264150943, "content": "Currently, β-blockers are used most frequently for the purpose of heart rate (HR) control in patients with atrial fibrillation (AF) in worldwide. Carvedilol is one of common β-blockers and known to be effective for hypertension and heart failure. However, little can be found the information about the HR-lowering effect of carvedilol in patients with AF without heart failure. Therefore, we conducted this study to investigate the effect of carvedilol on HR in 3-minute electrocardiogram (ECG) and total heart beats (THBs) in 24-hour Holter ECG monitoring in patients with persistent or permanent AF. A total of 13 hypertensive patients (73 ± 12 years, 7 males) with AF and HR 90 bpm or more were enrolled. All patients received carvedilol from 5 mg/day. The dose of drug was titrated every 4 weeks and raised to 10 or 20 mg/day if HR was 80 bpm or more. Mean HR was decreased from 101.9 ± 13.9 to 85.2 ± 15.2 bpm (P &lt; 0.05) after treatment with carvedilol. THBs were also significantly decreased from 128 to 115 × 1,000/day (P &lt; 0.001). Percent reduction in HR and THBs were 13.9% and 10.7%, respectively. The scores of Atrial Fibrillation Quality of Life Questionnaire (AFQLQ) did not change. Only one patient was required to discontinue carvedilol due to congestive heart failure. We observed that carvedilol certainly reduced HR in patients with chronic AF. We believe that the effect of carvedilol on the reduction in HR can contribute to the management of AF patients treated with rate-control strategy." }, { "id": "pubmed23n0404_3624", "title": "Cardioversion of atrial fibrillation with ibutilide: when is it most effective?", "score": 0.009433962264150943, "content": "Atrial fibrillation (AF) is found in 1% of persons above the age of 60 years. More than 5% of the population older than 69 years and about 14% of octogenarians are at risk for this arrhythmia. It is estimated that 1.5 to 3 million persons in the United States alone suffer from AF. The public health implications and attendant morbidity are a significant drain on our health care system. The purpose of this study was to determine the clinical and echocardiographic predictors of success in converting AF of &gt; or = 24 h duration. Demographic and clinical and echocardiographic parameters of 101 patients with recent onset AF (&gt; 24 h) who received ibutilide were studied. Of 101 patients, 56 (55%) converted to sinus rhythm. Age, gender, hypertension, diabetes mellitus, left ventricular ejection fraction (&lt; or = 35%), congestive heart failure, and previous medication for rate control had no significant effect on the conversion rate. Conversion rate was only 30% (9/30 patients) in the presence of an enlarged left atrium (LA &gt; or = 5 cm) and 37.7% (23/61 patients) in the presence of mitral valve disease (MVD), whereas the conversion rate was 82.5% (33/40 patients) in the absence of MVD and 85% (29/34 patients) in the absence of both enlarged LA and MVD (p = &lt;0.001). Patients with coronary artery disease (CAD) also exhibited a significantly greater response to ibutilide than patients without CAD (77 vs. 46%, p-value 0.005). As a therapy for cardioversion of AF, ibutilide is most effective in a selected subgroup patients, such as in patients with CAD and in patients without MVD and/or markedly enlarged left atrium." }, { "id": "pubmed23n0480_9206", "title": "Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography.", "score": 0.009345794392523364, "content": "This review summarizes the available evidence regarding the efficacy of medications used for ventricular rate control, stroke prevention, acute conversion, and maintenance of sinus rhythm, as well as the efficacy of electrical cardioversion and the use of echocardiography in patients with atrial fibrillation. The Cochrane Collaboration's database of controlled clinical trials and MEDLINE. Primarily randomized, controlled trials of medications. Paired reviewers obtained data on efficacy and safety. Strength of evidence was assessed. Recent clinical trial results showed that most patients with atrial fibrillation have similar outcomes with strategies for controlling ventricular rate compared with strategies for restoring sinus rhythm. For efficacy of primary stroke prevention, compared with placebo, evidence was strong for warfarin and suggestive for aspirin. The evidence for an increased risk for major bleeding was suggestive for warfarin and inconclusive for aspirin. For ventricular rate control, verapamil, diltiazem, atenolol, and metoprolol were qualitatively superior to digoxin and placebo, particularly during exercise. For efficacy of acute conversion, compared with placebo, evidence was strong for ibutilide, flecainide, dofetilide, propafenone, amiodarone, and quinidine. For efficacy of maintenance of sinus rhythm after conversion from atrial fibrillation, evidence was strong for amiodarone, propafenone, disopyramide, and sotalol. Echocardiography was found to be useful in estimating risk for thromboembolism and potentially useful in estimating likelihood of successful cardioversion and maintenance. For several key questions in the pharmacologic management of atrial fibrillation, strong evidence exists to support 1 or more treatment options." }, { "id": "pubmed23n0906_18140", "title": "Late Presentation of Aortic Aneurysm and Dissection Following Cardiac Catheterization.", "score": 0.009259259259259259, "content": "We report a 63-year-old female with hypertension, hyperlipidemia, and prior pacemaker insertion for atrial fibrillation with symptomatic bradycardia, who was admitted with substernal chest pressure and diaphoresis. Her electrocardiogram revealed atrial fibrillation with demand ventricular pacing and her cardiac biomarkers were negative for acute coronary syndrome. Echocardiogram revealed normal left ventricular systolic function and normal aortic root diameter. Coronary angiography revealed 60-70% obtuse marginal lesion, otherwise mild disease. She was treated medically and discharged in stable condition. She was readmitted 1 month later with recurring chest pain, and shortness of breath which started shortly after her most recent discharge. Blood pressure was 152/93 mm Hg, and heart rate was 105 bpm. BNP was elevated at 1,400 pg/mL, and other cardiac biomarkers were negative. She was treated with diuretics, which resulted in decrease of her blood pressure to 81/51 mm Hg. Repeat echocardiogram revealed severely dilated aortic root, measuring 6.7 cm, with aortic dissection flap and moderate to severe aortic regurgitation. CT angiogram revealed aortic dissection extending proximally to the aortic root above the coronary ostia and distally to the left subclavian artery takeoff. She underwent surgery; she, however, could not be weaned off from cardiopulmonary bypass and died in the operating room. This case illustrates the importance of having a high index of suspicion for iatrogenic aortic dissection following cardiac catheterization as a cause of recurrence of cardiac symptoms, as early detection may help avert a catastrophic outcome, as we report in our patient." }, { "id": "pubmed23n0395_18245", "title": "Atrial fibrillation.", "score": 0.009259259259259259, "content": "The prevalence and incidence of atrial fibrillation increase with age. Atrial fibrillation is associated with a higher incidence of coronary events, stroke, and mortality than sinus rhythm. A fast ventricular rate associated with atrial fibrillation may cause tachycardia-related cardiomyopathy. Management of atrial fibrillation includes treatment of underlying causes and precipitating factors. Immediate direct-current cardioversion should be performed in persons with atrial fibrillation associated with acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta-blockers, verapamil, or diltiazem may be used to immediately slow a fast ventricular rate associated with atrial fibrillation. An oral beta-blocker, verapamil, or diltiazem should be given to persons with atrial fibrillation if a rapid ventricular rate occurs a rest or during exercise despite digoxin. Amiodarone may be used in selected persons with symptomatic life-threatening atrial fibrillation refractory to other drug therapy. Nondrug therapies should be performed in persons with symptomatic atrial fibrillation in whom a rapid ventricular rate cannot be slowed by drug therapy. Paroxysmal atrial fibrillation associated with the tachycardia-bradycardia syndrome should be managed with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in persons with atrial fibrillation in whom symptoms such as dizziness or syncope associated with non-drug-induced ventricular pauses longer than 3 seconds develop. Elective direct-current cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than medical cardioversion in converting atrial fibrillation to sinus rhythm. Unless transesophageal echocardiography shows no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective direct-current or drug cardioversion of atrial fibrillation and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer the treatment strategy of ventricular rate control plus warfarin rather than to maintain sinus rhythm with antiarrhythmic drugs, especially in older patients. Digoxin should not be used in persons with paroxysmal atrial fibrillation. Patients with chronic or paroxysmal atrial fibrillation who are at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio (INR) of 2.0 to 3.0. Persons with atrial fibrillation who are at low risk for stroke or who have contraindications to warfarin should receive 325 mg aspirin daily." }, { "id": "pubmed23n1084_2592", "title": "Acute Tachycardia-Induced Cardiomyopathy: A Case Report.", "score": 0.009174311926605505, "content": "BACKGROUND Tachycardia from atrial fibrillation or flutter can lead to left ventricular systolic dysfunction. Some patients deteriorate quickly, and there is an acute drop in their left ventricular systolic function; however, they tend to normalize rapidly after treatment of the underlying arrhythmia. The aim of publishing the present case is to maintain awareness that tachycardia is one of the etiologies of acute systolic heart failure, which is potentially reversible by treatment when recognized. CASE REPORT An 88-year-old woman with a history of hypertension and diabetes presented to the emergency department with shortness of breath and new-onset atrial fibrillation. The physical examination revealed jugular vein distention, an irregular heart rate of approximately 140 beats/min, bilateral basal lung crackles, and no murmurs. One week before this presentation, she underwent electrocardiography, which showed she was in sinus rhythm, and transthoracic echocardiography, which indicated an ejection fraction of 65%. After hospital admission, she was started on beta-blockers for heart rate control and diuretics for heart failure management. As her symptoms persisted, she underwent a transesophageal echocardiography-guided cardioversion, where her ejection fraction was 30%. A repeat transthoracic echocardiography 3 days after the cardioversion indicated the ejection fraction had normalized to 60%. She was followed up every month in the Outpatient Cardiology Clinic and has remained asymptomatic for 1 year to date. CONCLUSIONS Although most literature describes tachycardia-induced cardiomyopathy as a chronic process, it can be acute. Patients benefit from rhythm control, and with early diagnosis and appropriate management, the prognosis is good." }, { "id": "pubmed23n0688_11356", "title": "[A ten-year follow-up of a 109-year-old woman with myocardial infarction].", "score": 0.009174311926605505, "content": "A 109-year-old woman was hospitalized with myocardial infarction in the geriatric long-term care ward of our hospital. Her medical history was unknown, and she was receiving only peroral 20 mg/day furosemide. Her medical records at another hospital revealed that she had been given a previous diagnosis of myocardial infarction of the anteroseptal wall of the left ventricle by a cardiovascular specialist approximately 10 years previously. Although treatment with cardiovascular drugs such as an angiotensin II receptor blocker, aspirin, and spironolactone had been started, it was discontinued because of her hospital transfer and change in her attending physician. Because of aggravation of the symptoms of cardiac failure caused by infection, treatment with the angiotensin-converting enzyme inhibitor temocapril (1 mg/day), spironolactone (12.5 mg/day), aspirin (100 mg/day), and a beta-adrenoceptor blocker carvedilol (2 mg/day) was tentatively initiated. Consequently, her B-type natriuretic peptide (BNP) level improved and her condition stabilized. She finally died of old age. Both inappropriate sharing of patient information among medical facilities and restrictions on medical care in Japanese health care system for the elderly may lead to improper and/or inadequate medical treatment for elderly patients. Although little evidence is available to support medical care for centenarians, treatment which is based on a thorough understanding of their physiological characteristics enables us to improve their quality of life." }, { "id": "pubmed23n0500_15061", "title": "Pre-discharge initiation of beta-blocker therapy in elderly patients hospitalized for acute decompensation of chronic heart failure: an effective strategy for the implementation of beta-blockade in heart failure.", "score": 0.00909090909090909, "content": "Current guidelines recommend beta-blockers in patients with heart failure and left ventricular systolic dysfunction. These agents, however, are largely underused in elderly patients because of the perception of up-titration complexity and the fear of side effects. We prospectively assessed the feasibility, safety, tolerability, and 1-year outcome of the in-hospital initiation of carvedilol in elderly patients admitted for worsening heart failure. Among 164 eligible subjects (age &gt; 70 years, left ventricular ejection fraction &lt; 40% and no sign of congestion), 120 (73%) received carvedilol, on average 4.5 days after admission. The drug was permanently withdrawn in 10 out of 116 survivors (9%) at 60 days: 5 did not tolerate the starting dose because of worsening heart failure (n = 1), bradycardia (n = 1), and bronchospasm (n = 3). Two discontinued carvedilol during the in-hospital dose titration phase because of increasing premature ventricular beats and transient second degree atrioventricular block. The remaining 3 dropouts (fatigue in 2 and symptomatic bradycardia in 1 case) occurred after discharge. During the period between 60 days and 12 months, carvedilol was discontinued in 2 patients because of a depressive syndrome and symptomatic bradycardia. In no case these adverse events lead to death or were life-threatening, required hospitalization or resulted in any disability. The 1-year tolerability was 89%, the mortality was 17.5%, the frequency of hospitalization for worsening heart failure was 21%. Thus, our results show that the in-hospital initiation of carvedilol is feasible and well-tolerated in elderly patients with recent worsening heart failure, and allows rapid identification of the most intolerant patients. The proportion of subjects taking carvedilol after 1 year from discharge was very high. This unconventional approach could significantly modify the use of beta-blockers in clinical practice." }, { "id": "pubmed23n0906_1992", "title": "Atrial Fibrillation: The New Epidemic of the Ageing World.", "score": 0.00909090909090909, "content": "The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases. AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily." }, { "id": "wiki20220301en000_119255", "title": "Digitalis", "score": 0.009009009009009009, "content": "under current regulations by the Food and Drug Administration on the basis of prospective, randomized study and clinical trials. It was also approved for the control of ventricular response rate for patients with atrial fibrillation. American College of Cardiology/American Heart Association guidelines recommend digoxin for symptomatic chronic heart failure for patients with reduced systolic function, preservation of systolic function, and/or rate control for atrial fibrillation with a rapid ventricular response. Heart Failure Society of America guidelines for heart failure provide similar recommendations. Despite its relatively recent approval by the Food and Drug Administration and the guideline recommendations, the therapeutic use of digoxin is declining in patients with heart failure—likely the result of several factors. The main factor is the more recent introduction of several drugs shown in randomised controlled studies to improve outcomes in heart failure. Safety concerns" }, { "id": "pubmed23n0371_468", "title": "The management of heart failure--an overview.", "score": 0.009009009009009009, "content": "National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given \"risk reduction\", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies." }, { "id": "pubmed23n1012_4429", "title": "Serial changes of L wave according to heart rates in a heart failure patient with persistent atrial fibrillation.", "score": 0.008928571428571428, "content": "Mid-diastolic forward flow velocity of transmitral flow (L wave) is known as a marker of diastolic dysfunction and is occasionally observed in patients with fluid retention, low heart rate, and atrial fibrillation (AF). However, how hemodynamic condition affects L wave is still unknown. An 81-year-old woman who underwent implantation of a DDD pacemaker due to complete atrioventricular block 38 years previously suffered from congestive heart failure and was admitted to our hospital. At the time of admission, electrocardiogram showed new-onset AF resulting in mode switch to VVI, and echocardiography showed a giant L wave. At the mid-term of the treatment, AF was converted to sinus rhythm resulting in mode switch to DDD, and pacemaker check-up was performed at pre- and post-cardioversion. During the pacemaker check-ups, L wave was assessed in various pacing rates. As pacing rate was increased, L wave altered according to heart rates and disappeared at 85 bpm in VVI with AF, whereas at 75 bpm in DDD. Through the treatment, L wave got smaller as fluid retention was improved and finally disappeared at the time of discharge. This case suggests that L wave is highly variable and affected by fluid volume, heart rate, and heart rhythm. &lt;<bLearning objective:</b Although L wave is known as a marker of diastolic dysfunction and occasionally observed in patients with high left ventricular filling pressure, low heart rate, and atrial fibrillation, how hemodynamics affects L wave is still unknown. In this case, it was observed that L wave is highly variable in the therapeutic process of heart failure and affected by fluid volume, heart rate, and heart rhythm. L wave potentially can be a useful indicator to evaluate treatment efficacy for heart failure.&gt;." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 108 ] ], "word_ranges": [ [ 0, 15 ] ], "text": "Clinical case of giant cell arteritis. Corticosteroid therapy remains the first choice (answer 1 incorrect)," }, "2": { "exist": true, "char_ranges": [ [ 352, 419 ] ], "word_ranges": [ [ 52, 63 ] ], "text": "which has also been shown to reduce recurrences (answer 2 correct)." }, "3": { "exist": true, "char_ranges": [ [ 109, 255 ] ], "word_ranges": [ [ 15, 39 ] ], "text": "to be administered as pulses (doses differ according to the literature, but at least 125 mg/d) in case of ocular involvement (answer 3 incorrect)." }, "4": { "exist": true, "char_ranges": [ [ 256, 351 ] ], "word_ranges": [ [ 39, 52 ] ], "text": "The current treatment of choice for corticosteroid sparing is Tocilizumab (answer 4 incorrect)," }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Rituximab should be administered, since glucocorticoids have been relegated to second-line treatment due to their side effects.", "2": "Tocilizumab has been shown to be effective in reducing recurrences and cumulative prednisone dose in more than 50% of patients.", "3": "In the presence of ischemic symptoms, and in order not to worsen the vascular risk of the patient, the use of glucocorticoids at doses higher than 30 mg/day should be avoided.", "4": "In conjunction with glucocorticoid boluses of 1 g/day, infliximab should be used as a first-line drug for remission induction.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0753_18189", "title": "[Ocular complications of giant cell arteritis].", "score": 0.01896117900790798, "content": "Permanent visual loss (PVL) is the most dreaded complication of giant cell arteritis (GCA). It results from anterior ischemic optic neuropathy or, less commonly, retinal artery occlusion. This complication still occurs in 14 to 20% of patients and is typically devastating and permanent, although it is highly preventable by an early diagnosis of giant cell arteritis and appropriate glucocorticoid treatment. Transient ischemic symptoms such as amaurosis fugax, episodes of blurred vision or diplopia may occur, either heralding visual loss or remaining isolated. In studies, the main predictors of PVL are jaw claudication, amaurosis fugax, lack of systemic \"B\" symptoms, a modestly increased ESR and a higher haemoglobin level. The evaluation of a GCA patient with PVL includes emergency fundoscopy completed by fluorescein angiography, immediate erythrocyte sedimentation rate, C-reactive protein, and complete blood count. Treatment is extremely urgent mainly because, if left untreated, GCA is associated with visual loss in the fellow eye within days in up to 50% of individuals. Treatment may begin with high-dose intravenous methylprednisolone, followed by oral prednisone administered at 1 mg/kg per day. Daily adjunctive aspirin orally may be added since it has been shown, in retrospective studies, to protect against stroke and visual loss. Although treatment duration of complicated GCA is not codified, an initial PVL deserves close monitoring of patient's systemic symptoms, ESR and CRP to avoid relapses due to a significant risk of late recurrence of visual loss during steroid tapering." }, { "id": "pubmed23n0390_21271", "title": "[Non-complicated Horton's disease: initial treatment with methylprednisolone 500 mg/day bolus for three days followed by 20 mg/day prednisone-equivalent. Evaluation of 15 patients].", "score": 0.014114266396213658, "content": "To assess the efficacy and tolerance of three methylprednisolone boluses (500 mg/d) followed by a standard dose of prednisolone, 20 mg/d, as the initial treatment of non-complicated giant-cell arteritis. A retrospective study of 15 cases. Six men and nine women with a mean age of 70.9 years were treated and followed for 41.5 months. Initial mean ESR was 83 mm; mean C-reactive protein level was 94.6 mg/L. The boluses were well tolerated, excepted in one patient who developed acute psychosis. After initiating the oral treatment, two patients presented signs of clinical relapse during the first month, and were given higher doses of corticosteroids. At 1 month, 12 patients were asymptomatic, nine of whom had normalized ESR and CRP. Mean ESR was 23; mean CRP was 13 mg/L. At 3 months, the mean prednisone dose delivered was 18.2 mg/d. Mean ESR was 12 mm. The cumulative prednisone dose given during the first year was 5,349 (+/- 2,512) mg. In the 13 patients who necessitated no more than 20 mg/d prednisone, no sequelae of giant-cell arteritis, no fractures nor major treatment intolerance occurred-during the first 2 years of treatment. Treatment was stopped in eight patients after a mean duration of 48.6 months. Treatment with pulse methylprednisolone 500 mg/d for 3 days followed by 20 mg/d oral prednisone could be a valuable corticosteroid-sparing strategy in many patients with uncomplicated temporal arteritis." }, { "id": "wiki20220301en046_42765", "title": "Polymyalgia rheumatica", "score": 0.012736472888275546, "content": "Another test that checks the level of C-reactive protein (CRP) in the blood may also be conducted. CRP is produced by the liver in response to an injury or infection, and people with polymyalgia rheumatica usually have high levels. However, like the ESR, this test is also not very specific. Polymyalgia rheumatica is sometimes associated with temporal arteritis, a condition requiring more aggressive therapy. To test for this additional disorder, a biopsy sample may be taken from the temporal artery. Treatment Prednisone is the drug of choice for PMR, and treatment duration is frequently greater than one year. If the patient does not experience dramatic improvement after three days of 10–20 mg oral prednisone per day, the diagnosis should be reconsidered. Sometimes relief of symptoms occurs in only several hours." }, { "id": "wiki20220301en351_7664", "title": "IgG4-related disease", "score": 0.012615714608263716, "content": "Although not validated yet in clinical trials, the common induction regime is prednisolone 30–40 mg per day for 2–4 weeks, then gradually tapered over 3 to 6 months. Recurrences during or after tapering of glucocorticoids are frequent, however. Steroid-sparing immunosuppressive agents might be considered, depending on local availability of these drugs, for use in combination with glucocorticoids from the start of treatment in order to reduce the side-effects of prolonged glucocorticoid usage. Steroid-sparing agents that have been used include rituximab, azathioprine, methotrexate, and cyclophosphamide, although trials are needed to ascertain the effectiveness of each drug in IgG4-RD." }, { "id": "article-26239_19", "title": "Optic Ischemia -- Treatment / Management", "score": 0.012535857716580608, "content": "AAION: In cases of high suspicion treatment with high dose corticosteroids should be started immediately after drawing samples for CBC, ESR, CRP without waiting for results of investigations. Immediate treatment prevents vision loss in another eye as there are high chances of involvement of the second eye within days to weeks. Temporal artery biopsy can be delayed for 7 to 10 days if immediate facilities are not available. Pathological changes in the temporal artery will not be affected as they take weeks to months to change. High-dose intravenous methylprednisolone (1 g/day) for 3 to 5 days is preferred. Some studies suggest different duration for intravenous steroid use, a three-day course of high-dose IV steroids, suggesting benefit on visual recovery in the same eye and prevention of disease in the second eye is favored. [11] [12] The consensus approach after intravenous therapy is to start a moderate to a high dose of oral prednisone (1 mg/kg/day). Steroids are slowly tapered over 3 to 12 months, depending on the response. ESR and CRP are followed closely throughout the course." }, { "id": "wiki20220301en111_27511", "title": "Pemphigoid", "score": 0.012226571494358738, "content": "Glucocorticoid sparing drugs For patients who require high dose of corticosteroids for clearing or maintenance, glucocorticoid sparing agents such as immunosuppressive drugs and anti-inflammatory drugs can be used as an adjunct therapy to reduce the systemic side effects of corticosteroids. Patients who have comorbidities and contraindications for corticosteroids may also consider these glucocorticoid sparing agents. Immunosuppressant drug Immunosuppressant drugs include azathioprine (1–3 mg/kg/day in two equally divided doses), mycophenolate mofetil (1000–3000 mg/day or 40 mg/kg/day in two divided doses), and methotrexate (10–15 mg/week)." }, { "id": "InternalMed_Harrison_25670", "title": "InternalMed_Harrison", "score": 0.011799410029498525, "content": "The goals of treatment in giant cell arteritis are to reduce symptoms and, most importantly, to prevent visual loss. The treatment approach for cranial and large-vessel disease in giant cell arteritis is currently the same. Giant cell arteritis and its associated symptoms are exquisitely sensitive to glucocorticoid therapy. Treatment should begin with prednisone, 40–60 mg/d for ∼1 month, followed by a gradual tapering. When ocular signs and symptoms occur, consideration should be given for the use of methylprednisolone 1000 mg daily for 3 days to protect remaining vision. Although the optimal duration of glucocorticoid therapy has not been established, most series have found that patients require treatment for ≥2 years. Symptom recurrence during prednisone tapering develops in 60–85% of patients with giant cell arteritis, requiring a dosage increase. The ESR can serve as a useful indicator of inflammatory disease activity in monitoring and tapering therapy and can be used to judge the" }, { "id": "wiki20220301en021_14564", "title": "Glucocorticoid", "score": 0.011716261716261715, "content": "If high doses were used for 11–30 days, cut immediately to twice replacement, and then by 25% every four days. Stop entirely when dose is less than half of replacement. Full adrenal recovery should occur within one to three months of completion of withdrawal. If high doses were used more than 30 days, cut dose immediately to twice replacement, and reduce by 25% each week until replacement is reached. Then change to oral hydrocortisone or cortisone as a single morning dose, and gradually decrease by 2.5 mg each week. When the morning dose is less than replacement, the return of normal basal adrenal function may be documented by checking 0800 cortisol levels prior to the morning dose; stop drugs when 0800 cortisol is 10 μg/dl. Predicting the time to full adrenal recovery after prolonged suppressive exogenous steroids is difficult; some people may take nearly a year. Flare-up of the underlying condition for which steroids are given may require a more gradual taper than outlined above." }, { "id": "wiki20220301en029_36333", "title": "Opsoclonus myoclonus syndrome", "score": 0.011632737847943497, "content": "Some of medication used to treat the symptoms are: ACTH has shown improvements in symptoms but can result in an incomplete recovery with residual deficits. Corticosteroids (such as prednisone or methylprednisolone) used at high dosages (500 mg - 2 g per day intravenously for a course of 3 to 5 days) can accelerate regression of symptoms. Subsequent very gradual tapering with pills generally follows. Most patients require high doses for months to years before tapering. Intravenous Immunoglobulins (IVIg) are often used with varying results. Several other immunosuppressive drugs, such as cyclophosphamide and azathioprine, may be helpful in some cases. Chemotherapy for neuroblastoma may be effective, although data is contradictory and unconvincing at this point in time. Rituximab has been used with encouraging results. Other medications are used to treat symptoms without influencing the nature of the disease (symptomatic treatment):" }, { "id": "InternalMed_Harrison_25671", "title": "InternalMed_Harrison", "score": 0.011192415122546127, "content": "with giant cell arteritis, requiring a dosage increase. The ESR can serve as a useful indicator of inflammatory disease activity in monitoring and tapering therapy and can be used to judge the pace of the tapering schedule. However, minor increases in the ESR can occur as glucocorticoids are being tapered and do not necessarily reflect an exacerbation of arteritis, particularly if the patient remains symptom-free. Under these circumstances, the tapering should continue with caution. Glucocorticoid toxicity occurs in 35–65% of patients and represents an important cause of patient morbidity. Aspirin 81 mg daily has been found to reduce the occurrence of cranial ischemic complications in giant cell arteritis and should be given in addition to glucocorticoids in patients who do not have contraindications. The use of weekly methotrexate as a glucocorticoid-sparing agent has been examined in two randomized placebo-controlled trials that reached conflicting conclusions. Infliximab, a" }, { "id": "wiki20220301en001_181772", "title": "Giant cell arteritis", "score": 0.01088405757666458, "content": "GCA is considered a medical emergency due to the potential of irreversible vision loss. Corticosteroids, typically high-dose prednisone (1 mg/kg/day), should be started as soon as the diagnosis is suspected (even before the diagnosis is confirmed by biopsy) to prevent irreversible blindness secondary to ophthalmic artery occlusion. Steroids do not prevent the diagnosis from later being confirmed by biopsy, although certain changes in the histology may be observed towards the end of the first week of treatment and are more difficult to identify after a couple of months. The dose of corticosteroids is generally slowly tapered over 12–18 months. Oral steroids are at least as effective as intravenous steroids, except in the treatment of acute visual loss where intravenous steroids appear to offer significant benefit over oral steroids. Short-term side effects of prednisone are uncommon but can include mood changes, avascular necrosis, and an increased risk of infection. Some of the side" }, { "id": "InternalMed_Harrison_25673", "title": "InternalMed_Harrison", "score": 0.010637480798771122, "content": "Patients with isolated polymyalgia rheumatica respond promptly to prednisone, which can be started at a lower dose of 10–20 mg/d. Similar to giant cell arteritis, the ESR can serve as a useful indicator in monitoring and prednisone reduction. Recurrent polymyalgia symptoms develop in the majority of patients during prednisone tapering. One study of weekly methotrexate found that the use of this drug reduced the prednisone dose on average by only 1 mg and did not decrease prednisone-related side effects. A randomized trial in polymyalgia rheumatica did not find infliximab to lessen relapse or glucocorticoid requirements. Takayasu arteritis is an inflammatory and stenotic disease of medium-and large-sized arteries characterized by a strong predilection for the aortic arch and its branches." }, { "id": "pubmed23n0821_9621", "title": "Tocilizumab in giant cell arteritis: Multicenter open-label study of 22 patients.", "score": 0.010063890089830427, "content": "To assess the efficacy of tocilizumab (TCZ) in giant cell arteritis (GCA) patients with refractory disease and/or with unacceptable side effects due to corticosteroids. A retrospective multicenter open-label study on 22 GCA patients treated with TCZ at standard dose of 8mg/kg/month. The main outcomes were achievement of disease remission and reduction of corticosteroid dose. The mean age ± standard deviation of patients was 69 ± 8 years. The main clinical features at TCZ onset were polymyalgia rheumatica (n = 16), asthenia (n = 7), headache (n =5), constitutional symptoms (n = 4), jaw claudication (n = 2), and visual loss (n = 2). Besides corticosteroids and before TCZ onset, 19 of 22 patients had also received several conventional immunosuppressive and/or biologic drugs. Of 22 patients, 19 achieved rapid and maintained clinical improvement following TCZ therapy. Also, after a median follow-up of 9 (interquartile range: 6-19) months, the C-reactive protein level had fallen from 1.9 (1.2-5.4) to 0.2 (0.1-0.9)mg/dL (p &lt; 0.0001) and the erythrocyte sedimentation rate decreased from 44 (20-81) to 12 (2-20)mm/1st hour (p = 0.001). The median dose of prednisone was also tapered from 18.75 (10-45) to 5 (2.5-10)mg/day (p &lt; 0.0001). However, TCZ had to be discontinued in 3 patients due to severe neutropenia, recurrent pneumonia, and cytomegalovirus infection. Moreover, 1 patient died after the second infusion of TCZ due to a stroke in the setting of an infectious endocarditis. TCZ therapy leads to rapid and maintained improvement in patients with refractory GCA and/or with unacceptable side effects related to corticosteroids. However, the risk of infection should be kept in mind when using this drug in patients with GCA." }, { "id": "article-18191_37", "title": "Behcet Disease -- Treatment / Management -- Posterior uveitis:", "score": 0.009927721088435374, "content": "Initial therapy: Combination of oral prednisone and azathioprine Starting dose of prednisone 1 mg/kg per day for one month and tapering as tolerated Methylprednisolone as pulse therapy at a dose of 1 g/day for three days may be used empirically to save the sight. The initial dose of azathioprine is 50 mg daily. As tolerated, increase the daily dose by 50 mg every four weeks. The target dose is 2.5 mg/kg/day. Complete blood count (CBC) is monitored every two weeks initially till the maximum required dose is achieved and then every 6 to 12 weeks. Severe or refractory disease: Infliximab and adalimumab have been used successfully. [45] The initial dose of infliximab is 5 mg/kg at 0, 4, 8, 16, and 24 weeks or 0, 2, 6, and every eight weeks. Adalimumab is given at a loading dose of 80 mg, followed by 40 mg one week later and 40 mg every two weeks thereafter. [46]" }, { "id": "pubmed23n0419_5874", "title": "Management of giant cell arteritis. Our 27-year clinical study: new light on old controversies.", "score": 0.009900990099009901, "content": "Giant cell arteritis (GCA) is the prime medical emergency in ophthalmology because of its dreaded complication of visual loss in one or both eyes, which is preventable if these patients are diagnosed early and treated immediately and aggressively with systemic corticosteroids. However, there is much controversy on diagnostic criteria and various aspects of steroid therapy to prevent visual loss. We discuss in detail the reasons for the controversy, clinical criteria to establish a definite early diagnosis of GCA, and its management. To provide new information on corticosteroid therapy in GCA, we also present our 27-year planned study on steroid therapy in GCA in 145 temporal artery biopsy-confirmed GCA patients (96 with and 49 without visual loss) seen and followed for 6 weeks or more in our clinic. The median follow-up time was 2.43 years, with interquartile range of 1-6 years (range 6 weeks to 20.2 years). Intravenous megadose steroid therapy was initially given to 33% followed by oral steroids, while the rest had only the oral therapy. The median starting oral prednisone dose was 80 mg/day, with 40% on &gt;/=100 mg/day. We found that the most reliable and sensitive parameters to regulate and taper down steroid therapy were the levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and NOT systemic symptoms. All patients were maintained at the high-dose prednisone till both the ESR and CRP had stabilized at low levels (that usually took 2-3 weeks), after which very gradual tapering of prednisone was started, guided by the ESR and CRP levels only. The median time to reach the lowest maintenance dose of prednisone at which the ESR and CRP stayed low and stable was 48.7 months (95% CI: 34.6, 71.4 months), and the median lowest prednisone dose achieved was 7 mg/day (interquartile range of 1-16 mg/day). A comparison of patients with and without visual loss showed no significant difference in the time to attain the lowest dose (p = 0.359). Our study showed that no generalization is possible for tapering down of prednisone and there is no set formula because of the infinite variation between individuals. Only 10 (7 without visual loss, 3 with visual loss) of 145 patients were able to stop the therapy and maintain stable ESR and CRP levels. We found that only 4% of GCA patients with visual loss showed any visual improvement with high-dose steroid therapy, and 4% developed further visual loss during the first 5 days of high-dose steroid therapy but none after that. Our studies found no evidence that intravenous megadose steroid therapy was more effective than oral therapy in improving vision or preventing visual deterioration due to GCA." }, { "id": "Neurology_Adams_1450", "title": "Neurology_Adams", "score": 0.009821771593699367, "content": "The administration of prednisone, 45 to 60 mg/d in single or divided doses over a period of several weeks, is indicated in all cases, with gradual reduction to 10 to 20 mg/d and maintenance at this dosage for several months or years, if necessary, to prevent relapse. The headache can be expected to improve within a day or two of beginning treatment; failure to do so brings the diagnosis into question. When the sedimentation rate or CRP is elevated, its return to normal, usually over months, is a reliable index of therapeutic response. Whether symptoms or the blood tests are a better guide to reducing the steroid dose is unclear, one should probably be cautious in lowering the medication if the erythrocyte sedimentation rate (ESR) and CRP remain high. Headaches of Pseudotumor Cerebri (Benign or Idiopathic Intracranial Hypertension, See Chap. 29)" }, { "id": "InternalMed_Harrison_4204", "title": "InternalMed_Harrison", "score": 0.009719312945119397, "content": "mg/kg per day. If new lesions continue to appear after 1–2 weeks of treatment, the dose may need to be increased and/or prednisone may need to be combined with other immunosuppressive agents such as azathioprine (2–2.5 mg/kg per day), mycophenolate mofetil (20–35 mg/kg per day), or cyclophosphamide (1–2 mg/kg per day). Patients with severe, treatment-resistant disease may derive benefit from plasmapheresis (six high-volume exchanges [i.e., 2–3 L per exchange] over ~2 weeks), IV immunoglobulin (IVIg) (2 g/kg over 3–5 days every 6–8 weeks), or rituximab (375 mg/m2 per week × 4, or 1000 mg on days 1 and 15). It is important to bring severe or progressive disease under control quickly in order to lessen the severity and/or duration of this disorder. Accordingly, some have suggested that rituximab and daily glucocorticoids should be used early in PV patients to avert the development of treatment-resistant disease." }, { "id": "pubmed23n0403_19754", "title": "[Induction of remission with infliximab in therapy-refractory Wegener's granulomatosis - Follow-up of six patients].", "score": 0.009708737864077669, "content": "BACKGROUND AND QUESTION: The prognosis of patients with Wegener's granulomatosis (WG) refractory to standard treatment for the induction of remission (cyclophosphamide and steroids) has been poor so far. We report on the results of the follow-up of six patients refractory to the standard regimen (Fauci's scheme) with progressive, imminent visual loss, pulmonary and renal involvement, respectively. How long can remissions be successfully maintained with anti-TNF-alpha-antibody infliximab? What side effects occur? Patients received infliximab (3 mg/kg) in addition to standard therapy with cyclophosphamide and steroids. Intervals between the first two infliximab infusions were 2 weeks, thereafter 4 weeks. Based on the impression of higher efficacy patients received 5 mg/kg infliximab for subsequent infusions. Remission was induced after 4-6 infliximab infusions in five patients. Remission has been maintained in four patients for 16-26 months. After 12 months a pulmonary relapse occurred in one patient, who received azathioprine for the maintenance of remission. Infliximab was stopped in another patient because of a suspected infection. In the light of high cumulative cyclophosphamide doses (100 g/275 g) and cyclophosphamide induced hemorrhagic cystitis, infliximab was added to azathioprine in the two patients with a pulmonary relapse and protrusion of the eye with imminent visual loss, respectively. Remission was induced in both patients. A carcinoid of the bronchus was diagnosed in one patient after 12 months in remission. Infliximab means a new therapeutic option and offers better perspectives for a patient group with previously bad prognosis." }, { "id": "pubmed23n0329_5348", "title": "[Principles of acute treatment of Horton's disease. Role of high-dose corticosteroid therapy].", "score": 0.009615384615384616, "content": "Corticosteroid therapy, the elective treatment for temporal arteritis, can produce adverse effects on bone in this elderly population which usually occur late after acute high-dose administration. Such adverse effects are exceptional and generally have little impact as long as certain cortisone-sparing principles are followed: duration of acute treatments should be as short as possible; dosage can be tapered off rapidly, cutting the acute dose in half in 4 weeks; to titrate dosage, inflammatory proteins should be monitored (especially CRP because of its rapid kinetics and sometimes another protein with slower kinetics); this appears to be more useful for cortisone-sparing than the classical method based on clinical analysis and sedimentation rate; acute regimens should be accompanied by anticoagulation until figrinogen has returned to normal levels; clinical relapses during treatment are usually benign and can generally be controlled by raising the dose slightly; in case of failure due to an acute flare-up far from corticosteroid administration, it would be interesting to study the cortisone sparing effect of giving a 240 mg i.v. bolus of methylprednisolone followed by low-dose corticosteroids; if the relapse is only expressed in laboratory tests, holding the dose at same plateau for two weeks generally leads to spontaneous normalization. Intravenous bolus methlyprednisolone is well tolerated in this population of elderly patients. There is no recognized indication in the uncomplicated forms of temporal arteritis. The cortisone-sparing effect of this technique may result from the fact that the acute oral dose can be reduced. Complicated forms, particularly with ocular involvement, are recognized indications for bolus administration although the administration modalities have not yet been validated. In patients with overt ocular involvement, repeating emergency high-dose i.v. boluses every 6 to 8 hours warrants evaluation with the objective of recovering visual function." }, { "id": "wiki20220301en093_40520", "title": "Acute pericarditis", "score": 0.009523809523809525, "content": "NSAIDs in viral or idiopathic pericarditis. In patients with underlying causes other than viral, the specific etiology should be treated. With idiopathic or viral pericarditis, NSAID is the mainstay treatment. Goal of therapy is to reduce pain and inflammation. The course of the disease may not be affected. The preferred NSAID is ibuprofen because of rare side effects, better effect on coronary flow, and larger dose range. Depending on severity, dosing is between 300–800 mg every 6–8 hours for days or weeks as needed. An alternative protocol is aspirin 800 mg every 6–8 hours. Dose tapering of NSAIDs may be needed. In pericarditis following acute myocardial infarction, NSAIDs other than aspirin should be avoided since they can impair scar formation. As with all NSAID use, GI protection should be engaged. Failure to respond to NSAIDs within one week (indicated by persistence of fever, worsening of condition, new pericardial effusion, or continuing chest pain) likely indicates that a" }, { "id": "pubmed23n0526_10260", "title": "[Polymyalgia rheumatica and temporal arteritis].", "score": 0.009433962264150943, "content": "Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are closely related and frequently occurring inflammatory diseases with an incidence of 50 and 18 per 100,000 per year, respectively, in people aged 50 years or over. The most frequent symptom of PMR is aching and morning stiffness lasting more than 1 month and exacerbated by movement, occurring in the shoulder and pelvic girdles and in the neck region. GCA is vasculitis of the large and medium-sized arteries that originate from the aortic arch, causing new and marked headache localised over the temporal or occipital areas, jaw claudication, visual impairment or claudication of the arms. GCA is characterised by histopathological panarteritis with a predominantly lymphohistiocytic cell infiltrate. Activation of macrophages is central to the arteritis. Standard treatment for PMR and GCA is glucocorticoids, which may consist of prednisone 10-20 mg/day or its equivalent for PMR patients and prednisone 30-40 mg to 1 mg/kg body weight for GCA patients. For GCA patients with recently impaired vision, treatment should start with high doses of intravenously administered glucocorticoids, such as methylprednisolone 1 g/day for 3 consecutive days. A treatment duration of 1-2 years is often required for patients with PMR or GCA; because of the side effects associated with long-term use of glucocorticoids, osteoporosis prophylaxis with oral calcium supplementation, vitamin D and bisphosphonates is appropriate." }, { "id": "pubmed23n0061_8604", "title": "[Relapse of Wegener's granulomatosis. Retrospective study of 18 cases].", "score": 0.009433962264150943, "content": "During a mean therapeutic follow-up of 4 years, 25 out of 61 patients with Wegener's granulomatosis had one or several relapses. As in 7 of them the initial diagnosis had proved erroneous, this study concerns the remaining 18 patients who together totalled 31 relapses after the correct diagnosis was made. Twenty relapses occurred early on, within 4 months of a change in treatment, and they corresponded to recurrent activity of the disease. Ten relapses occurred later on, after treatment had been discontinued or kept at maintenance dose level. The relapses appeared as early as the first year in 41 percent of the cases. The ENT region was affected in 61 percent of the patients. Nine relapses occurred in the absence of treatment, including 6 which took place 1 to 8 years after treatment. Three relapses occurred less than 3 months after a prednisone and oral cyclophosphamide therapy was initiated. Compared with the group of patients without relapse, those in the relapse group were younger, more often treated with azathioprine and cyclophosphamide administered intravenously, and followed up for a longer period; their probability of survival was also higher. In case of early relapse after withdrawal of treatment the mean duration of that treatment had been shorter than in the absence of relapse. None of the patients whose treatment had been stopped more than 20 months after its onset had an early relapse. These data prompted us to make the following proposals: initially, cyclophosphamide should be administered as bolus injections (the time required to obtain results is then shorter than with the oral route), and maintenance therapy should last at least 20 months. Azathioprine should be used only when cyclophosphamide is contra-indicated. The relative indications for intravenous and oral cyclophosphamide remain to be determined. Discontinuing all treatments is a difficult decision to make, but even then the patients should be under close supervision in view of the possibility of late relapses." }, { "id": "wiki20220301en115_376", "title": "Management of ulcerative colitis", "score": 0.009345794392523364, "content": "Oral anti-inflammatory drugs require four to six weeks to work. Once remission is induced, maintenance levels can be used: sulfasalazine 2 g/day, mesalamine 1.2-2.4 g/day, or olsalazine 1 g/day. Patients on high dose sulfasalazine require folic supplementation (1 mg/day) because it inhibits folate absorption. If oral Mesalazine is still not working, prednisone is often given, starting at 40–60 mg/day. Prednisone often takes effect within 10–14 days. The dose should then be tapered by about 5 mg/week until it can be stopped altogether." }, { "id": "wiki20220301en021_13989", "title": "Prednisone", "score": 0.009335572227442886, "content": "Withdrawal The magnitude and speed of dose reduction in corticosteroid withdrawal should be determined on a case-by-case basis, taking into consideration the underlying condition being treated, and individual patient factors such as the likelihood of relapse and the duration of corticosteroid treatment. Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have: received more than 40 mg prednisone (or equivalent) daily for more than 1 week been given repeat doses in the evening received more than 3 weeks of treatment recently received repeated courses (particularly if taken for longer than 3 weeks) taken a short course within 1 year of stopping long-term therapy other possible causes of adrenal suppression" }, { "id": "InternalMed_Harrison_2311", "title": "InternalMed_Harrison", "score": 0.009270516717325228, "content": "Virtually all patients experience a gradual recovery of vision after a single episode of optic neuritis, even without treatment. This rule is so reliable that failure of vision to improve after a first attack of optic neuritis casts doubt on the original diagnosis. Treatment with high-dose IV methylprednisolone (250 mg every 6 h for 3 days) followed by oral prednisone (1 mg/kg per day for 11 days) makes no difference in ultimate acuity 6 months after the attack, but the recovery of visual function occurs more rapidly. Therefore, when visual loss is severe (worse than 20/100), IV followed by PO glucocorticoids are often recommended." }, { "id": "article-29921_30", "title": "Giant Cell Arteritis (Temporal Arteritis) -- Treatment / Management -- Dosing", "score": 0.009259259259259259, "content": "Early treatment with a daily divided dose of prednisone 1mg/kg/day or 40 to 60 mg/day (or equivalent) in divided doses is adequate in most cases. This dose shall continue until all the symptoms resolve and acute phase reactants normalize, usually taking 2 to 4 weeks. [24] Subsequently, the dose can be decreased by 10% of the total dose every 2 weeks until the daily dose of 10 mg is reached. Thereafter, tapering shall be by 1mg every month. Alternate-day dosing of corticosteroids is not recommended. Faster tapering of steroids is usually associated with more relapses. Even with the slow tapering, relapses are common and seen in up to 50% of cases and can be associated with recurrence of symptoms and elevation in CRP. The dose of prednisone can be increased by 10mg from the dose during relapse, and once relapse resolves, tapering can resume with careful monitoring." }, { "id": "Neurology_Adams_11270", "title": "Neurology_Adams", "score": 0.009245319436402239, "content": "Most clinicians agree that glucocorticoids (e.g., prednisone, 1 mg/kg, as a single daily dose orally, or intravenously) are a reasonable first therapy for both PM and DM. The response to treatment is monitored by testing of strength and measurement of CK (not by following the erythrocyte sedimentation rate [ESR]). In patients who respond clinically, the serum CK decreases before the weakness subsides; with relapse, the serum CK rises before weakness returns. Once the CK level normalizes and strength improves, typically several weeks or longer, one approach is to reduce the dosage gradually—by no more than 5 mg every 2 weeks—toward 20 mg daily. It is then appropriate to attempt to control the disease with an alternate-day schedule with double this amount (i.e., prednisone, 40 mg every other day) so as to reduce the side effects of the drug. After cautious reduction of prednisone over a period of 6 months to 1 year or longer, the patient can usually be maintained on doses of 7.5 to 20" }, { "id": "wiki20220301en113_39649", "title": "Macrophage activation syndrome", "score": 0.009174311926605505, "content": "Hemoglobin <90g/L (in infants <4 weeks: <100g/L) Platelets <100 x 109/L Neutrophils <1.0 x 109/L Fasting triglycerides ≥3.0 mmol/L (i.e., ≥ 265 mg/dl) Fibrinogen ≤1.5 g/L In addition, other specific markers of macrophage activation (e.g. soluble CD163), and lymphocyte activation (e.g. soluble IL-2 receptor) can be helpful. NK cell function analysis may show depressed NK function, or, flow cytometry may show a depressed NK cell population. Treatment The best treatment for MAS has not been firmly established. Most commonly used treatments include high-dose glucocorticoids, and cyclosporine. In refractory cases treatment regimens are used similar to that in HLH. Anakinra may also be effective. See also Cytokine release syndrome References External links Macrophage Activation Syndrome, MedScape Rheumatology Syndromes" }, { "id": "pubmed23n0051_4978", "title": "[Bolus of methylprednisolone and Horton's disease/rhizomelic pseudo-polyarthritis. Preliminary results of a pilot study of treating the bolus with low doses of corticoids].", "score": 0.009174311926605505, "content": "The aim of this study was to reduce the side effects of corticosteroid therapy responsible for high morbidity in giant cell arteritis. Nine patients were admitted consecutively for temporal arteritis (7 cases) or polymyalgia rheumatica (2 cases) without ocular involvement (mean age: 69.3 years; positive temporal biopsy: 6 cases). The following protocol was used: methylprednisolone, 500 mg/d, i.v., for 3 consecutive days, then low doses (an average of 22.5 mg/d) of prednisone or an equivalent drug. The mean length of follow-up was 15.1 months (range: 6-22 months). The mean lapse of time until the erythrocyte sedimentation rate returned to normal was 10.6 days (range: 3-30 days). The mean dose of prednisone or an equivalent drug at 6 months was 13 mg/d (range: 5-22.5 mg/d). One patient was cured after 17 months of treatment. Another suffered a biological relapse after 13 months of treatment. All the other patients were asymptomatic with no biological signs of an inflammatory syndrome. The complications included: electrocardiogram modifications without necrosis during pulse therapy in 1 woman; unstable angina developed 2 months after the onset of treatment in 1 man; recurrent urinary infections in 1 predisposed male patient. No bone or metabolic side effects have been noted to date. We think that 3 days of intensive intravenous corticotherapy followed by low doses of corticoïds per os constitute an effective and well-tolerated regimen. Additional studies including comparison with conventional treatments should be carried out to confirm these results and, even better, to evaluate the long-term benefits of this protocol in terms of side effects." }, { "id": "wiki20220301en013_70918", "title": "Maprotiline", "score": 0.00909090909090909, "content": "The use of maprotiline in the treatment of enuresis in pediatric patients has so far not been systematically explored and its use is not recommended. Safety and effectiveness in the pediatric population in general have not been established. Anyone considering the use of maprotiline in a child or adolescent must balance the potential risks with the clinical need. In general, lower dosages are recommended for patients over 60 years of age. Dosages of 50 mg to 75 mg daily are usually satisfactory as maintenance therapy for elderly patients who do not tolerate higher amounts. Available forms Coated Tablets, 10 mg, 25 mg, 50 mg, and 75 mg Injectable concentrate, 25 mg Contraindications Maprotiline may worsen psychotic conditions like schizophrenia and should be given with caution. The antipsychotic treatment should be continued. Patients with bipolar affective disorder should not receive antidepressants whilst in a manic phase, as antidepressants can worsen mania." }, { "id": "pubmed23n0547_1296", "title": "[A case in which the subject was affected by Listeia meningoencephalitis during administration of infliximab for steroid-dependent adult onset Still's disease].", "score": 0.00909090909090909, "content": "The subject was a 22-year-old woman who developed high fever and arthralgias and eruptions in the extremities around June 2005. She sought medical advice at a nearby dermatology clinic, where hepatic dysfunction was noted on blood testing. The patient was thus hospitalized the next day. Although CRP levels were significantly high, no sign of infection was observed and bone marrow cell differentiation was normal. Adult onset Still's disease was diagnosed based on the observation of persistent high fever &gt;39 degrees C, eruptions, increased leukocytes, pharyngeal pain, splenomegaly, hepatic dysfunction, negative autoantibody results from blood testing, and high serum ferritin levels. Administration of prednisolone 30 mg/day was initiated, but proved ineffective. Steroid pulse therapy was conducted, and the subject was transferred to our medical facility for continued treatment. Attempts were made to control the disease using combined steroid and cyclosporine administration; but exacerbation of high serum ferritin levels and hepatic dysfunctions were observed, so a second course of steroid pulse therapy was conducted. Symptoms improved temporarily, but steroid levels were difficult to reduce. Cyclosporine was therefore replaced by methotrexate, and administration of infliximab was initiated. In the course of treatment, administration of a sulfamethoxazole/trimethoprim combination was initiated, but was discontinued due to suspicion of drug-induced hepatic injury. A second administration of infliximab was conducted in late August, and rapid improvements in clinical symptoms and abnormal test values was observed. However, high fever and headache developed suddenly in early September. Based on the results of spinal fluid testing, blood and spinal fluid cultures and MRI of the head, Listeria meningoencephalitis was diagnosed. Diplopia and impaired consciousness occurred during the disease course, and formation of a brain abscess was observed on imaging. However, symptoms were controlled by long-term combination administration of ampicillin and gentamicin. Administration of infliximab was discontinued for treatment of adult onset Still's disease, and steroid levels were reduced following double-membrane filtration plasma exchange. On follow-up, no relapse of symptoms or abnormalities in blood test values were observed, so the subject was discharged from our medical facility in December 2005. In treatment for rheumatic diseases, a dramatic improvement in treatment results for pathologies displaying tolerance against conventional treatments has been acquired with the development of biological drugs. However, opportunistic infections represent a serious problem, and appropriate preventative measures are required. The present report describes a case in which the subject was affected by Listeria meningoencephalitis during administration of infliximab for steroid-dependent adult Still's disease. Since listeriosis is one of the complications, along with tuberculosis, that warrants precautionary measures, this case is reported and discussed." }, { "id": "pubmed23n1153_3793", "title": "AGA Clinical Practice Update on the Evaluation and Management of Acute Kidney Injury in Patients With Cirrhosis: Expert Review.", "score": 0.009009009009009009, "content": "The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with suspected acute kidney injury in patients with cirrhosis. This article provides practical advice for the management of patients with cirrhosis and acute kidney injury based on the best available published evidence. This best practice document is not based on a formal systematic review. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Clinical Gastroenterology &amp; Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Acute kidney injury (AKI) should be diagnosed when the serum creatinine increases by ≥0.3 mg/dL within 48 hours or is ≥50% from baseline or when the urine output is reduced below 0.5 mL/kg/h for &gt;6 hours. BEST PRACTICE ADVICE 2: Preventive measures against the development of AKI in cirrhosis include (1) avoidance of potentially nephrotoxic medications like nonsteroidal anti-inflammatory drugs (NSAIDs), (2) avoidance of excessive or unmonitored diuretics or nonselective beta-blockade, (3) avoidance of large-volume paracentesis without albumin replacement, and (4) counseling patients to avoid alcohol use. BEST PRACTICE ADVICE 3: (A) Investigation is directed to determining the cause of AKI, which can be due to hypovolemic causes (volume responsive, and the most common cause of AKI in patients with cirrhosis); acute tubular necrosis; hepatorenal syndrome with AKI (HRS-AKI) (a functional renal failure that persists despite volume repletion); HRS with acute kidney disease, a type of functional renal failure of &lt;3 months- duration in which criteria for HRS-AKI are not met; or postrenal, which occurs only rarely. (B) The specific type of AKI should be identified through a careful history, physical examination, blood biochemistry, urine microscopic examination, urine chemistry (Na+ and urea) and selected urinary biomarkers, and renal ultrasound. BEST PRACTICE ADVICE 4: A rigorous search for infection is required in all patients with AKI. A diagnostic paracentesis should be carried out to evaluate for spontaneous bacterial peritonitis; blood and urine cultures and chest radiograph are also required. There is no role for routine prophylactic antibiotics in patients with AKI, but broad-spectrum antibiotics should be started whenever infection is strongly suspected. BEST PRACTICE ADVICE 5: When AKI is diagnosed, diuretics and nonselective beta-blockers should be held, NSAIDs discontinued, the precipitating cause of AKI treated, and fluid losses replaced, administering albumin 1 g/kg/d for 2 days if the serum creatinine shows doubling from baseline. Urine output, vital signs, and when indicated, echocardiography or CVP (if there is a pre-existing central line) should be used to monitor fluid status. BEST PRACTICE ADVICE 6: When the serum creatinine remains higher than twice the baseline value despite these measures, treatment of HRS-AKI should be initiated with albumin at a dose of 1 g/kg intravenously on day 1 followed by 20-40 g daily along with vasoactive agents (terlipressin; if terlipressin is not available, either a combination of octreotide and midodrine; or norepinephrine, depending on institutional preferences) and continued either until 24 hours following the return of the serum creatinine level to within ≤0.3 mg/dL of baseline for 2 consecutive days or for a total of 14 days of therapy. BEST PRACTICE ADVICE 7: Terlipressin should be initiated as a bolus dose of 1 mg every 4-6 hours (total 4-6 mg/d). The dose should be increased to a maximum of 2 mg every 4-6 hours (total 8-12 mg/d) if there is no reduction in serum creatinine at day 3 of therapy by at least 25% compared to the baseline value. Alternatively, clinicians can administer terlipressin by continuous intravenous infusion at a lower starting dose of 2 mg/d, which may reduce ischemic side effects and increase the dose gradually every 24-48 hours up to a maximum dose of 12 mg/d, or reversal of HRS. As per Food and Drug Administration restrictions, terlipressin should not be used in patients with a serum creatinine ≥5 mg/dL, or oxygen saturation of &lt;90%. BEST PRACTICE ADVICE 8: Oral midodrine when used should be initiated at doses of 7.5 mg and titrated upward to 12.5 mg 3 times daily with octreotide (starting with 100 μg and titrating upward to 200 μg subcutaneously 3 times daily). BEST PRACTICE ADVICE 9: Norepinephrine should be used as a continuous intravenous infusion at a starting dose of 0.5 mg/h and the dose increased every 4 hours by 0.5 mg/h to a maximum of 3 mg/h with the goal of increasing the mean arterial pressure by ≥10 mm Hg and/or the urine output to &gt;50 mL/h for at least 4 hours. BEST PRACTICE ADVICE 10: The risks of ischemic side effects of terlipressin and norepinephrine include angina and ischemia of fingers, skin, and intestine. These side effects may be lowered by starting at the lowest dose and gradually titrating upward. BEST PRACTICE ADVICE 11: Fluid status should be closely monitored because of the risk of pulmonary edema with excessive use of albumin. BEST PRACTICE ADVICE 12: Renal replacement therapy (RRT) may be used in the management of (A) AKI secondary to acute tubular necrosis; (B) HRS-AKI in potential candidates for liver transplantation (that is, RRT should not be used in patients with HRS-AKI who are not candidates for liver transplantation); and (C) AKI of uncertain etiology in which the need for RRT may be considered on an individual basis. BEST PRACTICE ADVICE 13: Transjugular intrahepatic portosystemic shunts should not be used as a specific treatment of HRS-AKI. BEST PRACTICE ADVICE 14: Liver transplantation is the most effective treatment for HRS-AKI. Pharmacotherapy for HRS-AKI before proceeding with liver transplantation may be associated with better post-liver transplantation outcomes. Selected patients with HRS-AKI may require simultaneous liver kidney transplantation based on updated Organ Procurement and Transplantation Network listing criteria." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 97, 211 ] ], "word_ranges": [ [ 14, 32 ] ], "text": "1 is false, there would be fever, hemolysis data, neurological symptoms, in the smear there would be schistocytes." }, "2": { "exist": true, "char_ranges": [ [ 212, 286 ] ], "word_ranges": [ [ 32, 47 ] ], "text": "In 2 the coagulation must be altered and in this case it is not mentioned." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Thrombotic thrombocytopenic purpura.", "2": "Disseminated intravascular coagulation.", "3": "Thrombocytopenia induced by infection.", "4": "Primary immune thrombocytopenia.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en016_42764", "title": "Immune thrombocytopenic purpura", "score": 0.016405517610820944, "content": "Despite the destruction of platelets by splenic macrophages, the spleen is normally not enlarged. In fact, an enlarged spleen should lead to a search for other possible causes for the thrombocytopenia. Bleeding time is usually prolonged in ITP patients. However, the use of bleeding time in diagnosis is discouraged by the American Society of Hematology practice guidelines and a normal bleeding time does not exclude a platelet disorder. Bone marrow examination may be performed on patients over the age of 60 and those who do not respond to treatment, or when the diagnosis is in doubt. On examination of the marrow, an increase in the production of megakaryocytes may be observed and may help in establishing a diagnosis of ITP. An analysis for anti-platelet antibodies is a matter of clinician's preference, as there is disagreement on whether the 80 percent specificity of this test is sufficient to be clinically useful." }, { "id": "pubmed23n0724_12865", "title": "Thrombocytopenia.", "score": 0.015243206211463804, "content": "Thrombocytopenia is defined as a platelet count of less than 150 × 10(3) per µL. It is often discovered incidentally when obtaining a complete blood count during an office visit. The etiology usually is not obvious, and additional investigation is required. Patients with platelet counts greater than 50 × 10(3) per µL rarely have symptoms. A platelet count from 30 to 50 × 10(3) per µL rarely manifests as purpura. A count from 10 to 30 × 10(3) per µL may cause bleeding with minimal trauma. A platelet count less than 5 × 10(3) per µL may cause spontaneous bleeding and constitutes a hematologic emergency. Patients who present with thrombocytopenia as part of a multisystem disorder usually are ill and require urgent evaluation and treatment. These patients most likely have an acute infection, heparin-induced thrombocytopenia, liver disease, thrombotic thrombocytopenic purpura/hemolytic uremic syndrome, disseminated intravascular coagulation, or a hematologic disorder. During pregnancy, preeclampsia and the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome are associated with thrombocytopenia. Patients with isolated thrombocytopenia commonly have drug-induced thrombocytopenia, immune thrombocytopenic purpura, pseudothrombocytopenia, or if pregnant, gestational thrombocytopenia. A history, physical examination, and laboratory studies can differentiate patients who require immediate intervention from those who can be treated in the outpatient setting. Treatment is based on the etiology and, in some cases, treating the secondary cause results in normalization of platelet counts. Consultation with a hematologist should be considered if patients require hospitalization, if there is evidence of systemic disease, or if thrombocytopenia worsens despite initial treatment." }, { "id": "pubmed23n1009_24869", "title": "Teetering on a liver's edge: a case report highlighting clinical decision-making in thrombocytopenia.", "score": 0.015107212475633527, "content": "This report illustrates the importance of a detailed history and physical exam and careful analysis of hematologic parameters when diagnosing ITP. This case demonstrates that even with subtle deviations from typical ITP findings one must promptly reevaluate the diagnosis. This case also highlights the importance of peripheral smear review by an expert in pediatric hematopathology. A previously healthy 10 year-old Asian boy presented with 2 months of easy bruising. Review of systems was negative for any constitutional symptoms. On examination, he appeared well but had numerous large ecchymoses. He had no appreciable lymphadenopathy or splenomegaly. The liver was palpable 1.5 cm below the costal margin. A complete blood count (CBC) showed: platelets = 17 × 109/L, hemoglobin = 128 g/L, white blood cell count = 5.43 × 109/L, and neutrophils = 1.63 × 109/L. A blood smear was reported as normal. Urate was 370 umol/L and lactate dehydrogenase (LDH) was 803 U/L. The child was admitted with a presumptive diagnosis of immune thrombocytopenic purpura (ITP) and treated with intravenous immunoglobulin. The following day, the blood smear was reviewed by a hematopathologist who identified blasts. A bone marrow aspiration (BMA) confirmed the diagnosis of precursor B-cell acute lymphoblastic leukemia. In children presenting with suspected ITP, leukemia should always be considered. A BMA was historically performed on all patients with presumed ITP to rule out leukemia. In 2011, the American Society of Hematology (ASH) stopped recommending routine BMA in patients suspected of having ITP. ASH advises in cases with unusual findings on history, physical examination or CBC, it is reasonable to perform a BMA. Our patient had mild hepatomegaly, which may have qualified him for a BMA. He also had an elevated LDH and urate, which are not listed as criteria for BMA by ASH but were considered atypical for ITP by the clinical team. A literature search did not reveal any primary data assessing these markers. While corticosteroids are a first line treatment in ITP, they must be reserved for when clinicians are confident that the patient does not have leukemia. Steroid administration prior to diagnosing leukemia results in delayed diagnosis and may increase the risk of complications and decrease survival." }, { "id": "wiki20220301en020_74480", "title": "Thrombocytopenia", "score": 0.01314722328936697, "content": "Thrombocytopenia is a condition characterized by abnormally low levels of platelets, also known as thrombocytes, in the blood. It is the most common coagulation disorder among intensive care patients and is seen in 20% of medical patients and a third of surgical patients. A normal human platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. Values outside this range do not necessarily indicate disease. One common definition of thrombocytopenia requiring emergency treatment is a platelet count below 50,000 per microliter. Thrombocytopenia can be contrasted with the conditions associated with an abnormally high level of platelets in the blood: thrombocythemia (when the cause is unknown), and thrombocytosis (when the cause is known). Signs and symptoms" }, { "id": "wiki20220301en299_31048", "title": "Gestational thrombocytopenia", "score": 0.012203897187922747, "content": "Diagnosis Gestational thrombocytopenia will become evident during the mid-second trimester through the third trimester of pregnancy and it is diagnosed based on exclusion. For example, women with a history of immune thrombocytopenia or thrombocytopenia, prior to pregnancy, will not be diagnosed with gestational thrombocytopenia. Patients with low platelet counts, lower than 70,000 / μL, will be difficult to diagnose. The reason is because low platelet counts maybe due to gestational thrombocytopenia or immune thrombocytopenia. In such cases, a treatment of immune thrombocytopenia therapy (corticosteroids, or intravenous immunoglobulin) will be instructed. If there is an improvement in the platelet levels, the patient will be diagnosed with immune thrombocytopenia, and if not the patient will be diagnosed with severe gestational thrombocytopenia In order for the physician to determine the underlying cause of the gestational thrombocytopenia, the following tests are conducted -" }, { "id": "wiki20220301en020_74481", "title": "Thrombocytopenia", "score": 0.011982968369829684, "content": "Signs and symptoms Thrombocytopenia usually has no symptoms and is picked up on a routine complete blood count. Some individuals with thrombocytopenia may experience external bleeding such as nosebleeds, or bleeding gums. Some women may have heavier or longer periods or breakthrough bleeding. Bruising, particularly purpura in the forearms and petechiae in the feet, legs, and mucous membranes, may be caused by spontaneous bleeding under the skin. Eliciting a full medical history is vital to ensure the low platelet count is not secondary to another disorder. Ensuring that the other blood cell types, such as red blood cells and white blood cells are not also suppressed, is also important. Painless, round, and pinpoint (1 to 3 mm in diameter) petechiae usually appear and fade, and sometimes group to form ecchymoses. Larger than petechiae, ecchymoses are purple, blue, or yellow-green areas of skin that vary in size and shape. They can occur anywhere on the body." }, { "id": "wiki20220301en003_74321", "title": "Blood cell", "score": 0.011854103343465046, "content": "The normal range (99% of population analyzed) for platelets is 150,000 to 450,000 per cubic millimeter. If the number of platelets is too low, excessive bleeding can occur. However, if the number of platelets is too high, blood clots can form thrombosis, which may obstruct blood vessels and result in such events as a stroke, myocardial infarction, pulmonary embolism, or blockage of blood vessels to other parts of the body, such as the extremities of the arms or legs. An abnormality or disease of the platelets is called a thrombocytopathy, which can be either a low number of platelets (thrombocytopenia), a decrease in function of platelets (thrombasthenia), or an increase in the number of platelets (thrombocytosis). There are disorders that reduce the number of platelets, such as heparin-induced thrombocytopenia (HIT) or thrombotic thrombocytopenic purpura (TTP), that typically cause thromboses, or clots, instead of bleeding." }, { "id": "InternalMed_Harrison_9124", "title": "InternalMed_Harrison", "score": 0.01107130417475245, "content": "The history and physical examination, results of the CBC, and review of the peripheral blood smear are all critical components in the initial evaluation of thrombocytopenic patients (Fig. 140-2). The overall health of the patient and whether he or she is receiving drug treatment will influence the differential diagnosis. A healthy young adult with thrombocytopenia will have a much more limited differential diagnosis than an ill hospitalized patient who is receiving multiple medications. Except in unusual inherited disorders, decreased platelet production usually results from bone marrow disorders that also affect red blood cell (RBC) and/or white blood cell (WBC) production. Because myelodysplasia can present with isolated thrombocytopenia, the bone marrow should be examined in patients presenting with isolated thrombocytopenia who are older than 60 years of age. While inherited thrombocytopenia is rare, any prior platelet counts should be retrieved and a family history regarding" }, { "id": "wiki20220301en020_74489", "title": "Thrombocytopenia", "score": 0.01088274044795784, "content": "Immune thrombocytopenic purpura Many cases of immune thrombocytopenic purpura (ITP) also known as idiopathic thrombocytopenic purpura, can be left untreated, and spontaneous remission (especially in children) is not uncommon. However, counts under 50,000 are usually monitored with regular blood tests, and those with counts under 10,000 are usually treated, as the risk of serious spontaneous bleeding is high with such low platelet counts. Any patient experiencing severe bleeding symptoms is also usually treated. The threshold for treating ITP has decreased since the 1990s; hematologists recognize that patients rarely spontaneously bleed with platelet counts greater than 10,000, although exceptions to this observation have been documented." }, { "id": "pubmed23n0753_19757", "title": "Idiopathic thrombocytopenic purpura associated with splenic tuberculosis: case report.", "score": 0.010810023310023311, "content": "Tuberculosis is still one of the most prevalent and fatal infectious diseases in spite of considerable improvements in medical science. Splenic tuberculosis is a rare form of extrapulmonary tuberculosis. There are limited numbers of cases in which immune thrombocytopenia is associated with splenic tuberculosis. We report a case of immune thrombocytopenic purpura due to splenic tuberculosis. Our case was a 58-year-old female with headache, gum bleeding, redness in legs, and ecchymoses on the arms for 10 days. On admission to hospital, laboratory tests were as follows: platelet count 6.000/mmc (150 000-450 000), haemoglobin: 12 g/dl, WBC: 8000/mm3, erythrocyte sedimentation rate: 58 mm/h and C-reactive protein was in normal ranges. After standard laboratory tests, the patient was diagnosed with idiopathic thrombocytopenic purpura. The patient presented abdominal lymphadenopathies and spleen in normal size in radiological examinations. Diagnostic laparotomy and splenectomy and lymph node excision was performed and splenic tuberculosis was detected in pathologic and microbiologic examination. The patient was successfully treated with apheresis platelets suspension, intravenous immunoglobulin and antituberculous therapy. In conclusion, splenic tuberculosis should be suspected in patients who have fever, abdominal lymphadenopathies and immune thrombocytopenic purpura. Histopathological examination is still an ideal method to confirm the diagnosis, suitably aided by microbiological examination." }, { "id": "wiki20220301en046_51369", "title": "Schistocyte", "score": 0.010736902705814623, "content": "Schistocyte count A normal schistocyte count for a healthy individual is <0.5% although usual values are found to be <0.2%. A schistocyte count of >1% is most often found in thrombotic thrombocytopenic purpura, although they are more often seen within the range of 3–10% for this condition. A schistocyte count of <1% but greater than the normal value is suggestive of disseminated intravascular coagulation, but is not an absolute diagnosis. The standard for a schistocyte count is a microscopic examination of a peripheral blood smear." }, { "id": "InternalMed_Harrison_9237", "title": "InternalMed_Harrison", "score": 0.010545905707196029, "content": "The mortality ranges from 30 to >80% depending on the underlying disease, the severity of the DIC, and the age of the patient. The diagnosis of clinically significant DIC is based on the presence of clinical and/or laboratory abnormalities of coagulation or thrombocytopenia. The laboratory diagnosis of DIC should prompt a search for the underlying disease if it is not already apparent. There is no single test that establishes the diagnosis of DIC. The laboratory investigation should include coagulation tests (aPTT, PT, thrombin time [TT]) and markers of fibrin degradation products (FDPs), in addition to platelet and red cell count and analysis of the blood smear. These tests should be repeated over a period of 6–8 h because an initially mild abnormality can change dramatically in patients with severe DIC." }, { "id": "article-30096_27", "title": "Thrombocytopenia in Pregnancy -- History and Physical", "score": 0.010462390794800767, "content": "A physical exam provides clues towards determining the etiology of thrombocytopenia. Patients with gestational thrombocytopenia are often healthy, asymptomatic women who are found to have low platelets on lab investigations. [6] [5] [4] On the contrary, a pregnant woman with TMA is usually a gravely-ill patient often presenting to the emergency room or admitted to high-risk obstetric units. Patients with low platelet count usually present with mucocutaneous bleeding. However, joint bleed or severe bleeding should prompt a workup towards severe coagulopathies like DIC. Physical exam should also evaluate for hepatomegaly and/or splenomegaly (cirrhosis, lymphoproliferative disorders, etc.), skeletal deformities (like absent radius, humeral abnormality and sometimes phocomelia seen in thrombocytopenia absent radii syndrome) and skin exam (like petechiae or purpura seen commonly with ITP, or, eczema seen in Wiskott-Aldrich Syndrome). [7] [29]" }, { "id": "wiki20220301en299_31042", "title": "Gestational thrombocytopenia", "score": 0.010168650793650792, "content": "Gestational (incidental) thrombocytopenia is a condition that commonly affects pregnant women. Thrombocytopenia is defined as the drop in platelet count from the normal range of 150,000 –400,000 / μL to a count lower than 150,000 / μL. There is still ongoing research to determine the reason for the lowering of platelet count in women with a normal pregnancy. Some researchers speculate the cause to be dependent on dilution, decreased production of platelets, or an increased turnover event. Although women with normal pregnancy experience a low platelet count, women experiencing a continuous drop in platelet will be diagnosed with thrombocytopenia and women with levels greater than 70,000 / μL will be diagnosed with gestational thrombocytopenia. Thrombocytopenia affects approximately 7-10% of pregnant women and of the 7-10%, within that population; approximately 70-80% have gestational thrombocytopenia" }, { "id": "wiki20220301en083_19322", "title": "Thrombocytopenic purpura", "score": 0.009984520123839009, "content": "Thrombocytopenic purpura are purpura associated with a reduction in circulating blood platelets which can result from a variety of causes, such as kaposi sarcoma. Types By tradition, the term idiopathic thrombocytopenic purpura is used when the cause is idiopathic. However, most cases are now considered to be immune-mediated. Another form is thrombotic thrombocytopenic purpura. Diagnosis Diagnosis is done by the help of symptoms and only blood count abnormality is thrombocytopenia. Treatment See also Aspirin Hematopoietic ulcer Thrombocyte References External links Vascular-related cutaneous conditions Coagulopathies" }, { "id": "pubmed23n0294_2100", "title": "Screening and diagnosis of coagulation disorders.", "score": 0.009953404405845186, "content": "After clinical assessment, pertinent history, and family history, the clinician often has a good idea concerning the cause of a patient's bleeding. The most appropriate laboratory tests can then be ordered. Routine screening tests include a complete blood cell count, platelet count, and evaluation of a peripheral blood sample, a prothrombin time, and an activated partial thromboplastin time. Thrombocytopenia may result from idiopathic thrombocytopenic purpura, disseminated intravascular coagulation, or, less commonly, acute leukemia, aplastic anemia, thrombotic thrombocytopenic purpura, or a particular drug that a patient is taking. Again, the patient's history, physical findings, and evaluation of a well-prepared peripheral blood smear will be helpful in determining the cause of the patient's thrombocytopenia. An isolated prolongation of the activated partial thromboplastin time may result from low levels of factors VIII, IX, or XI. A slightly prolonged activated partial thromboplastin time and a moderate decrease in factor VIII may reflect von Willebrand disease or the \"carrier\" state for hemophilia A. In women a greatly prolonged activated partial thromboplastin time and very low levels of factor VIII (&lt; 3%) most often result from an acquired factor VIII inhibitor (autoantibody against factor VIII) or from severe (type III) von Willebrand disease. If von Willebrand disease is suspected (because of menorrhagia with or without other mucous membrane bleeding, a positive family history, and a prolonged activated partial thromboplastin time), more specific laboratory tests for this disease should be done. These include assays of factor VIII, von Willebrand factor antigen, von Willebrand factor activity (measured by the ristocetin cofactor assay), and template bleeding time. In von Willebrand disease the defect is in von Willebrand factor. The affected individual may have subnormal levels of structurally and functionally normal von Willebrand factor (this is called \"classic\" or type I von Willebrand disease) or may produce von Willebrand factor that is structurally and functionally abnormal (von Willebrand disease type 2). Individuals who inherit a gene for von Willebrand disease from both parents have severe (type 3) von Willebrand disease and will have extremely low levels (&lt; 3%) of von Willebrand factor and factor VIII and will have a very prolonged bleeding time. In most populations type I disease is the most common form, whereas type 3 is the least commonly encountered form. It should be noted that levels of von Willebrand factor can be influenced by the patient's blood type (persons who have blood type AB have 60% to 70% higher levels than do persons who have blood type O) and can be elevated during pregnancy, stress, and hyperthyroidism. The two major functions of von Willebrand factor are to serve as a \"bridge\" between platelets and injury sites in blood vessel walls and to protect circulating factor VIII from rapid proteolytic degradation. Thus, if a patient has either too little or functionally abnormal von Willebrand factor, the bleeding time will be prolonged and factor VIII will be decreased (because it is not being protected by von Willebrand factor). It should be determined which type of von Willebrand disease a particular patient has because treatment depends on type. Multimeric analysis of von Willebrand factor can be done with use of sodium dodecyl sulfate gels, radiolabeled antibody to von Willebrand's factor, and autoradiography. This will allow visualization of the multimeric structure of von Willebrand factor. In type I disease all bands are present, whereas in the type 2 variants 2A and 2B no high-molecular-weight multimers are seen. Desmopressin acetate (which is available in parenteral form for intravenous use and in a highly concentrated intranasal spray formulation) is the treatment of choice for classic type I disease. The drug effects a rapid release of von Willebrand factor from endothelial cell stor" }, { "id": "wiki20220301en020_74485", "title": "Thrombocytopenia", "score": 0.009900990099009901, "content": "Increased destruction Abnormally high rates of platelet destruction may be due to immune or nonimmune conditions, including: Immune thrombocytopenic purpura Thrombotic thrombocytopenic purpura Hemolytic–uremic syndrome Disseminated intravascular coagulation Paroxysmal nocturnal hemoglobinuria Antiphospholipid syndrome Systemic lupus erythematosus Post-transfusion purpura Neonatal alloimmune thrombocytopenia Hypersplenism Dengue fever Gaucher's disease Zika virus Medication-induced These medications can induce thrombocytopenia through direct myelosuppression: Valproic acid Methotrexate Carboplatin Interferon Isotretinoin Panobinostat H2 blockers and proton-pump inhibitors Other causes Lab error, possibly due to the anticoagulant EDTA in CBC specimen tubes; a citrated platelet count is a useful follow-up study Snakebite Niacin toxicity Lyme disease Thrombocytapheresis (also called plateletpheresis) Niemann–Pick disease Diagnosis" }, { "id": "pubmed23n0286_11225", "title": "Efficient diagnosis of thrombocytopenia.", "score": 0.009900990099009901, "content": "Thrombocytopenia may be a benign, incidental finding in an asymptomatic patient or the sign of a potentially life-threatening disorder. The history, physical examination and peripheral blood smear can assist the physician in determining the diagnosis and treatment. After the initial blood count is repeated to help eliminate the possibility of laboratory error, a thorough history, complete physical examination, complete blood cell count and appropriate laboratory tests are required. The history may reveal related illnesses, risk factors such as infection or drug use, or a family history suggestive of congenital thrombocytopenia. The physical examination should concentrate on the lymphatic and hepatosplenic systems, with the physician looking for jaundice, fever or petechiae. With the review of a complete blood cell count and a peripheral smear examination, the initial work-up is completed and may prevent additional, unnecessary testing. Etiology-specific tests follow if needed. Serious spontaneous bleeding is usually a risk only in patients with platelet levels under 20,000 per mm3." }, { "id": "wiki20220301en011_19172", "title": "Coagulation", "score": 0.00980392156862745, "content": "Decreased platelet numbers (thrombocytopenia) is due to insufficient production (e.g., myelodysplastic syndrome or other bone marrow disorders), destruction by the immune system (immune thrombocytopenic purpura/ITP), or consumption (e.g., thrombotic thrombocytopenic purpura/TTP, hemolytic-uremic syndrome/HUS, paroxysmal nocturnal hemoglobinuria/PNH, disseminated intravascular coagulation/DIC, heparin-induced thrombocytopenia/HIT). Most consumptive conditions lead to platelet activation, and some are associated with thrombosis. Coagulation factor disorders The best-known coagulation factor disorders are the hemophilias. The three main forms are hemophilia A (factor VIII deficiency), hemophilia B (factor IX deficiency or \"Christmas disease\") and hemophilia C (factor XI deficiency, mild bleeding tendency)." }, { "id": "article-30093_24", "title": "Thrombocytopenia -- History and Physical", "score": 0.00980392156862745, "content": "History. Obtaining a thorough history helps to identify the etiology of thrombocytopenia. Patients with platelets greater than 50000/mL, rarely have symptoms. Patients with platelets under 20000/mL most likely have spontaneous bleeding." }, { "id": "wiki20220301en004_59256", "title": "Lemierre's syndrome", "score": 0.009756730036790328, "content": "Production of bacterial toxins such as lipopolysaccharide leads to secretion of cytokines by white blood cells which then both lead to symptoms of sepsis. F. necrophorum produces hemagglutinin which causes platelet aggregation that can lead to diffuse intravascular coagulation and thrombocytopenia. Diagnosis Diagnosis and the imaging (and laboratory) studies to be ordered largely depend on the patient history, signs and symptoms. If a persistent sore throat with signs of sepsis are found, physicians are cautioned to screen for Lemierre's syndrome. Laboratory investigations reveal signs of a bacterial infection with elevated C-reactive protein, erythrocyte sedimentation rate and white blood cells (notably neutrophils). Platelet count can be low or high. Liver and kidney function tests are often abnormal." }, { "id": "wiki20220301en010_97374", "title": "Platelet", "score": 0.009708737864077669, "content": "Disorders Adapted from: The three broad categories of platelet disorders are \"not enough\"; \"dysfunctional\"; and \"too many\". Thrombocytopenia Immune thrombocytopenias (ITP) – formerly known as immune thrombocytopenic purpura and idiopathic thrombocytopenic purpura Splenomegaly Gaucher's disease Familial thrombocytopenia Chemotherapy Babesiosis Dengue fever Onyalai Thrombotic thrombocytopenic purpura HELLP syndrome Hemolytic–uremic syndrome Drug-induced thrombocytopenic purpura (five known drugs – most problematic is heparin-induced thrombocytopenia (HIT) Pregnancy-associated Neonatal alloimmune associated Aplastic anemia Transfusion-associated Pseudothrombocytopenia idiopathic thrombocytopenic purpura Vaccine induced immune thrombocytopenia Gilbert's syndrome" }, { "id": "article-30093_32", "title": "Thrombocytopenia -- History and Physical", "score": 0.009708737864077669, "content": "Check for a family history of thrombocytopenia or bleeding disorders." }, { "id": "wiki20220301en141_24158", "title": "Neonatal alloimmune thrombocytopenia", "score": 0.009615384615384616, "content": "Related conditions Immune thrombocytopenic purpura (), sometimes called idiopathic thrombocytopenic purpura is a condition in which autoantibodies are directed against a patient's own platelets, causing platelet destruction and thrombocytopenia. Anti-platelet autoantibodies in a pregnant woman with immune thrombocytopenic purpura will attack the patient's own platelets and will also cross the placenta and react against fetal platelets. Therefore, is a significant cause of fetal and neonatal immune thrombocytopenia. Approximately 10% of newborns affected by will have platelet counts <50,000 μL−1 and 1% to 2% will have a risk of intracerebral hemorrhage comparable to infants with ." }, { "id": "pubmed23n0068_5112", "title": "[The analysis of national examination for the license of medical practice in Japan (reference to the hematological clinical laboratory data)].", "score": 0.009615384615384616, "content": "It seems to us an important task to analyze the problems appeared in the national examinations of the license of medical practice in respect of clinical laboratory data. The national examination of medical license in Japan begun from 1946, about 45 years ago. In those days, clinical examination is not so developed, a pastoral era, so clinical pathology was not clearly distinguished from internal medicine. Recently it is widely emphasized that national examination for the practical medical practice should be focused on the primary care medicine, so on, which has evidently influenced the appearance rate and number of miscellaneous kinds of clinical laboratory data in the examination problems. On the other hand, We have studied the tendency and mode of appearance of clinical laboratory data in the question of above mentioned examination for several years, in general, and especially in the areas of hematology. The cardinal questions of hematological field were blood cell count (RBC, hematocrit, hemoglobin, WBC, white cell differential, PLATELET), blood sedimentation rate, coagulation and fibrinolysis factor, bone marrow findings in miscellaneous diseases, classification and staging of malignant lymphomas, so on. In conclusion, the rate of appearance and significance of clinical laboratory data in the examination mentioned is more and more increased. However, comprehensive education of clinical pathology now is improved but not accomplished, which reflects tendency and styles of the problems of the examination. So more efforts will be needed to those who continuously study clinical pathology and educate them to the medical students." }, { "id": "wiki20220301en043_23414", "title": "Plateletpheresis", "score": 0.009523809523809525, "content": "Platelet transfusion Platelet transfusions are traditionally given to those undergoing chemotherapy for leukemia, multiple myeloma, those with aplastic anemia, AIDS, hypersplenism, idiopathic thrombocytopenic purpura (ITP), sepsis, bone marrow transplant, radiation treatment, organ transplant or surgeries such as cardiopulmonary bypass. Platelet transfusions should be avoided in those with thrombotic thrombocytopenic purpura (TTP) because it can worsen neurologic symptoms and acute renal failure, presumably due to creation of new thrombi as the platelets are consumed. It should also be avoided in those with heparin-induced thrombocytopenia (HIT) or disseminated intravascular coagulation (DIC). In adults, platelets are recommended in those who have levels less than 10,000/µL, or less than 20,000/µL if a central venous catheter is being placed, or less than 50,000/µL if a lumbar puncture or major surgery is required. Whole blood platelets" }, { "id": "article-20610_7", "title": "Disseminated Intravascular Coagulation -- Evaluation", "score": 0.009523809523809525, "content": "No single history, physical exam, or laboratory component can lead to a diagnosis of or rule out DIC; therefore, a combination of both subjective, objective, and laboratory findings should be utilized to make a diagnosis of DIC. Laboratory findings suggestive of DIC include both an increased prothrombin time (PT) and an increased partial thromboplastin time (PTT), as well as a decreased fibrinogen level as widespread activation and consumption of the clotting cascade occurs. The overall platelet count and hematocrit level may be reduced as well. Schistocytes or fragmented erythrocytes are also commonly seen on a peripheral blood smear. The presence of fibrin split products additionally has a high sensitivity but low specificity for the presence of DIC. A specific scoring system to assess for the presence of DIC was established in 2007. This score includes platelet count, fibrin markers such as D-dimer, prolonged PT, and fibrinogen level, with a score over five indicating a high likelihood for overt DIC. [18] [19] [20] [21]" }, { "id": "wiki20220301en141_24159", "title": "Neonatal alloimmune thrombocytopenia", "score": 0.009433962264150943, "content": "Mothers with thrombocytopenia or a previous diagnosis of should be tested for serum anti-platelet antibodies. A woman with symptomatic thrombocytopenia and an identifiable anti-platelet antibody should be started on therapy for their which may include steroids or . Fetal blood analysis to determine the platelet count is not generally performed as -induced thrombocytopenia in the fetus is generally less severe than . Platelet transfusions may be performed in newborns, depending on the degree of thrombocytopenia. Other conditions causing a low platelet count Other conditions that can cause a low platelet count in the neonate include bacterial and viral infection, disseminated intravascular coagulation and other rare congenital conditions associated with a low platelet count." }, { "id": "pubmed23n0416_22915", "title": "[The diagnosis of ITP].", "score": 0.009433962264150943, "content": "Idiopathic thrombocytopenic purpura(ITP) is a hematologic disorder which causes thrombocytopenia. The diagnosis of ITP is based on the history, physical examination and, complete blood count, and examination of the peripheral smear. The diagnostic criteria of ITP established by the Ministry of Health, Welfare, and Labor in Japan requires the bone marrow examination and the measurement of platelet associated IgG, but those tests are not always necessary according to the guidelines developed by the American Society of Hematology. The appropriate strategies for the diagnosis of ITP need to be established. In this paper, some new examinations which may help the diagnosis of ITP are also demonstrated." }, { "id": "wiki20220301en299_31052", "title": "Gestational thrombocytopenia", "score": 0.009345794392523364, "content": "Women who have platelet levels lower than 70,000 / μL, during pregnancy, maybe experiencing severe gestational thrombocytopenia or immune thrombocytopenia. In such cases, if the treatment of immune thrombocytopenia therapy (corticosteroids, or intravenous immunoglobulin) does not improve the platelet count, the patient will be diagnosed with severe gestational thrombocytopenia. Severe gestational thrombocytopenia may pose a risk for complications with the use of epidural or general anesthesia during delivery. Prognosis Those who have no previous history of thrombocytopenia, besides the occurrence in previous pregnancies (gestational thrombocytopenia), the platelet levels will go back to a normal range 1–2 months after the delivery. Post delivery, approximately 1–3 months later, women with gestational thrombocytopenia should have a complete blood test conducted. Lastly, gestational thrombocytopenia is a disorder that may reoccur in future pregnancies" }, { "id": "pubmed23n0325_8875", "title": "Essential thrombocythemia at diagnosis: causes of diagnostic evaluation and presence of positive diagnostic findings.", "score": 0.009345794392523364, "content": "The reasons for diagnostic evaluation and the clinical and laboratory data at diagnosis of 170 patients with essential thrombocythemia (ET) were studied retrospectively. The age distribution was 19-88 years (median 52 years), and 52 patients were under the age of 45 years. In 111 patients (65%) thrombocytosis was a chance finding, but the past history of 37 of these patients revealed symptoms known to be related to ET. The diagnosis was based on a chance finding in a significantly higher proportion of female (74%) than male (53%) patients. The diagnosis of ET is based mostly on negative findings, i.e., on the exclusion of other causes of thrombocytosis, and positive diagnostic tests would be useful. We evaluated the presence of positive diagnostic findings of myeloproliferative disorders in ET. Splenomegaly was seen in 26% and an abnormal karyotype in 5% of the patients. Abnormal megakaryocyte morphology was seen in 80%, abnormal in vitro growth of hematopoietic progenitors in 74%, and abnormal platelet function in 83% of the patients. Both in vitro cultures of hematopoietic progenitors and platelet functions were studied in 36 patients, and in only two of these were both tests normal. We conclude that in most patients with ET the diagnosis can be strongly supported by positive findings, especially by in vitro cultures of hematopoietic progenitors and studies of platelet function." }, { "id": "pubmed23n0319_6679", "title": "[Idiopathic thrombocytopenic purpura in children].", "score": 0.009287925696594427, "content": "Idiopathic (immune) thrombocytopenic purpura (ITP) is the most frequent hemorrhagic disease in children. It represents the acquired megakaryocytic thrombocytopenia with the shortened life of platelets because of immunologic damage (antibodies absorbed by platelets). In the case of this acquired hemorrhagic disorder, in spite of compensatory increased function of the bone marrow, there is a reduced number of platelets because of their increased destruction by the reticuloendothelial system (destructive thrombocytopenia). There are three forms of ITP: acute, chronic and intermittent. The acute form occurs in 80-90% of cases with bleeding episodes lasting a few days or weeks, but no longer than 6 months. The chronic form occurs in 10-15% of children, while the rarest-intermittent form is characterized by periods of normalization in regard to the number of platelets but also with relapse in intervals of 1-3 months. The disease is caused by an immunological disorder in the sense of an imbalanced immune response. Immunologic damages of platelets cause shortening of the opsonized platelets life span. The most frequent platelet opsonins are the immumoglobulin G (IgG) antibodies directed at the platelet membrane in the form of autoantibodies, alloantibodies or possibly absorbed antigen caused by microorganism infection or drug intake. It is typical for the phenomenon of bleeding that it starts suddenly and without any other sign of illness. The most frequent acute form appears between the second and fourth year, and is characterized by seasonal occurrence usually after acute viral infections. Children older than 10 years of age, like adults, often have the chronic form associated with other immunologic disorders. The disease affects girls more often than boys (about three times more often) with moderate and constant increase of antiplatelet antibodies. Hemorrhagic manifestations include: petechiae, purpura, epistaxis, gastrointestinal and genitourinary bleeding. They depend on the grade of thrombocytopenia, although there is no strict correlation between the number of platelets and volume of bleeding. Low mortality of the acute ITP is almost exclusively due to intracranial hemorrhage. LABORATORY STUDIES: Thrombocytopenia represents a decrease in the number of blood platelets being a basic abnormality of the blood count. The half-life of platelets in ITP is shortened. Detection of antiplatelet antibodies is connected with technical difficulties, so they are established in about 30% of cases. Bleeding time is prolonged and so is the coagulum retraction which may be completely missed. The Rumpel-Leede test is positive. Clinical differentiation of drug-induced thrombocytopenia is not possible. However, other differential diagnostic possibilities are thrombotic-thrombocytopenic purpura and hemolytic-uremic syndrome. A child with aplastic anemia or acute leukemia, beside thrombocytopenia, has a characteristic finding of white and red blood cell count. Thrombocytopenia with absent radii syndrome is associated with skeletal system abnormalities. New knowledge about the role of the immune system in ITP determines the modern therapeutic modalities. In cases of acute ITP in children, there are two therapeutic options or therapies of choice: corticosteroids and high doses of intravenous immunoglobulin. Immunosupressive therapy means anti Rh(D) immunoglobulin, cyclosporine, cytostatics, danazol, loaded platelets. In cases of distinctive hemorrhagic syndrome there are also indications for platelet transfusion. Nowadays splenectomy is more restricted, because one third of cases is unsuccessful, whereas plasmapheresis is rarely used in children because of possible complications. ITP is the most frequent hemorrhagic disease in children. The disease is basically caused by an immunologic disorder with platelet destruction due to increased immunoglobulin on their membrane. (ABSTRACT TRUNCATED)" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 384 ] ], "word_ranges": [ [ 0, 56 ] ], "text": "In this clinical case, we are presented with a woman who rapidly presents dyspnea with hypoxemia, a picture compatible with pulmonary thromboembolism. The prothrombin time of 90% and the aPTT with a ratio of 2, is translating a coagulation problem; and antiphospholipid antibodies can be detected through the prolongation of phospholipid-dependent coagulation tests, correct answer 1." }, "2": { "exist": true, "char_ranges": [ [ 385, 528 ] ], "word_ranges": [ [ 56, 81 ] ], "text": "On the other hand, although factor V Leiden has been identified as a common cause of familial thrombosis, it would not alter the clotting time." }, "3": { "exist": true, "char_ranges": [ [ 529, 651 ] ], "word_ranges": [ [ 81, 103 ] ], "text": "In the case of hemophilia there would be a problem in blood coagulation but it is not a frequent cause of thromboembolism." }, "4": { "exist": true, "char_ranges": [ [ 652, 816 ] ], "word_ranges": [ [ 103, 127 ] ], "text": "Finally, although acute pericarditis could manifest itself in 4 days and with tachycardia, the rest of the symptoms or analytical parameters are not characteristic." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Antiphospholipid syndrome.", "2": "Factor V of Leiden.", "3": "Hemophilia.", "4": "Acute pericarditis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1102_22675", "title": "Case 294: Catastrophic Antiphospholipid Syndrome.", "score": 0.01605392156862745, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, [150-400] × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L), and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L]). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/ day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0479_1411", "title": "[Catastrophic antiphospholipid syndrome and acute heart failure. Report of a case].", "score": 0.015516224188790562, "content": "A 33 years old woman was admitted to the hospital after four days with cough, dyspnea, orthopnea and hemoptysis. Blood pressure was 170/90 mmHg, pulse was 112 and temperature was normal. She had cyanosis and a left ventricular gallop, without heart murmurs. A chest radiograph revealed pulmonary edema and echocardiogram showed a global left ventricular systolic disfunction. Oxygen and furosemide were started, but cardiopulmonary collapse ensued. The patient was supported with mechanical ventilation and treated with inotropic drugs. A right sided cardiac catheterization showed pulmonary wedge pressure of 18 mmHg and a cardiac index of 3 l/min/m2. The levels of creatinine and urea nitrogen were elevated and a urine protein was 97 mg/dl. Coagulation tests were normal except by a positive lupic anticoagulant. Markers of connective tissue diseases or vasculitis were negatives. The clinical evolution suggested that a catastrophic antiphospholipid syndrome was ongoing. Intravenous corticoids, gammaglobulin and cyclophosphamide were administered with transient improvement. On her fourth day of treatment, the patient presented sudden pulmonary bleeding and embolism. A plasmapheresis was performed with improvement of renal, cardiac and pulmonary function. After this episode, the patient has been treated with prednisone and oral anticoagulants treatment for the last two years, without further clinical events." }, { "id": "pubmed23n0962_14441", "title": "[Pulmonary embolism in a girl with nephrotic syndrome and factor V Leiden - case report].", "score": 0.015083679778275237, "content": "Thromboembolic complications are found in 2-3% of children with nephrotic syndrome (NS); this increased risk is caused by hypovolemia, hemoconcentration, increased number and activity of platelets, hyperfibrinogenemia and loss of coagulation inhibitors. Risk is even higher in case of additional factors e.g. congenital thrombophilia. Girl with NS aged 17 11/12 years was admitted to hospital due to respiratory tract infection with cough and back pain. NS started 9 months earlier and she had two bouts of disease, and was treated only with prednisone (current dose - 60 mg/48h). On admission she was without any abnormalities on auscultation, with BP 111/65 mmHg, HR 80 bpm, satO2 99%. Lab results showed the increase of WBC 18.3×103/μL, D-dimers 23038 μg/L and proteinuria 900 mg/dL. Other values of examined parameters were in normal limits. Chest X-ray and ECG were also normal. Presumptive diagnosis of pulmonary embolism was made and the patient was given 1000IU of antithrombin III and nadroparine (2x90IU/kg/24h s.c.). In ECHO the occlusion of left pulmonary artery and preserved blood flow in right were revealed. In angioCT clot nearly filling lumen of left pulmonary artery, clot in intermediate part of right pulmonary artery, and focus of pulmonary infarction in 10th segment of left lung were found. Doppler USG of lower limb veins did not reveal thrombi or perforator vein incompetence. Treatment with nadroparine was continued, and rapid improvement of clinical condition and disappearance of pain and cough were observed. Mycophenolate mofetil was added, which resulted in subsidence of proteinuria. Rivaroxaban was used in prophylaxis of recurrences of thromboembolism. Tests for thrombophilia revealed factor V Leiden in patient." }, { "id": "pubmed23n0771_8195", "title": "Pulmonary hypertension secondary to hyperviscosity in a patient with rheumatoid arthritis and acquired von Willebrand disease: a case report.", "score": 0.014886979366208745, "content": "Acquired von Willebrand disease is initiated by autoantibodies and hyperviscosity syndrome caused by a massive polyclonal hypergammaglobulinemia. Acquired von Willebrand disease associated with autoimmune disease in addition to pulmonary hypertension during emergency room presentation is a rare condition. To the best of our knowledge, this is the second case reported in the literature treated with success; the first one was reported in 1987. A 28-year-old mestizo man with a 3-year history of inflammatory arthritis was admitted to our hospital. An overlap of rheumatoid arthritis with systemic lupus erythematosus was suspected; therefore methotrexate was initiated, and later changed to leflunomide because of liver toxicity. Prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), von Willebrand factor activity was observed with low ristocetin cofactor at 33.6UI/dL, high von Willebrand factor antigen &gt;200UI/dL, and a low von Willebrand factor: ristocetin cofactor to von Willebrand factor antigen ratio. He was admitted to the emergency room with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104 beats/min, 60/40 mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed. He was then transferred to the intensive care unit. The placement of a pulmonary artery catheter was made. The initial patterns showed a precapillary pulmonary hypertension; acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, pulmonary artery hypertension associated with connective tissue disease was considered. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient's plasma. Hypergammaglobulinemia was the cause of hyperviscosity syndrome associated with autoantibodies. Three sessions of plasma exchange therapy were made, and clinical improvement was observed. He was then discharged from the intensive care unit and hospital, respectively. He is now attended by an external consult and has no respiratory symptomatology. Hyperviscosity syndrome with pulmonary arterial hypertension presentation in a patient with acquired von Willebrand disease in an autoimmune context is a rare condition that can be treated successfully with plasmapheresis and critical care support." }, { "id": "pubmed23n0903_20488", "title": "A 2-year-old boy with circulatory failure owing to streptococcal toxic shock syndrome: case report.", "score": 0.013752913752913754, "content": "A 2-year-old boy presented with severe hypotension and acute kidney injury after a prodrome of non-bloody diarrhoea and fever in the preceding 3 days. He had a mild Ebstein cardiac anomaly but otherwise a normal past history and growth. On examination, he looked ill, his temperature was 37.5 °C, circulation was poor, and there were several purpuric lesions on the face, hands and scrotum. Haemoglobin was 7.8 g/dL (11-14), total white cell count 27 × 10<sup9</sup/L, platelets 62 × 10<sup9</sup/L, blood urea nitrogen 20.7 mmol/L (4.2-17.1), serum creatinine 95.4 μmol/L (21.2-36.2), CRP 154 mg/L (&lt;5), AST 296 U/L (11-50), ALT 909 U/L (7-40) and C<sub3</sub component of complement 0.8 g/L (0.9-1.8). Activated partial thromboplastin time (APTT) and prothrombin time (PT) were prolonged and fibrinogen level was 1.0 g/L (2-4). He received immediate fluid resuscitation (IV 0.9% saline solution, 2 × 10 ml/kg boluses, followed by glucose 5/0.45% sodium chloride solution, 2 × 10 ml/kg) and antibiotics (ciprofloxacin and amikacin) but circulation continued to deteriorate with development of decreased consciousness. He was placed on mechanical ventilation and vasopressor agents were added. Despite improved circulation over the next 2 days, he developed oliguria, progressive fluid overload, generalised oedema and a right-sided pleural effusion. Dialysis was commenced on day 3 of admission. Differential diagnosis included sepsis, atypical haemolytic uraemic syndrome and lupus nephritis. Blood and urine cultures remained negative but an anti-streptolysin O titre of 1318 (&lt;200) IU/mL led to the diagnosis of streptococcal toxic shock syndrome which is rare in early childhood and associated with high mortality. Haemodialysis was commenced and continued for 10 days with successful treatment of fluid overload and subsequent extubation. Renal function was completely restored over the following 6 weeks and he was discharged in good clinical condition about 2 months after intial admission. The clinical course and outcome are discussed, and the importance of timely initiation of dialysis when there is fluid overload is emphasised." }, { "id": "wiki20220301en114_9174", "title": "Brodifacoum", "score": 0.012854368932038835, "content": "In another case reported in 2013, a 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain, and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio (INR) was reported as above 12.0. Urinalysis revealed hematuria (blood in the urine). Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and a fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX, and X. PT and PTT" }, { "id": "pubmed23n0681_21394", "title": "[Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure, mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case].", "score": 0.012663268556865243, "content": "Disseminated intravascular coagulopathy (DIC) is characterized as activation of the clotting system resulting in fibrin thrombi, gradually diminishing levels of clotting factors with increased risk of bleeding. Basically two types of DIC are distinguished: (1) chronic (compensated) - with alteration of laboratory values and (2) acute (non-compensated) - with severe clinical manifestations: bleeding, shock, acute renal failure (ARF), transient focal neurologic deficit, delirium or coma. Chronic DIC related to metastatic neoplasia is caused by pancreatic, gastric or prostatic carcinoma in most of the cases. Incidence rate of DIC is 13-30% in prostate cancer, among those only 0.4-1.65% of patients had clinical signs and symptoms of DIC. In other words, chronic DIC is developed in one of eight patients with prostate cancer. DIC is considered as a poor prognostic factor in prostatic carcinoma. The similar clinical and laboratory findings of TTP-HUS (thrombotic thrombocytopenic purpura - hemolytic uremic syndrome) and DIC makes it difficult to differentiate between them. A 71 years old male patient with known chronic obstructive pulmonary disease, benign prostatic hyperplasia, significant carotid artery stenosis, gastric ulcer and alcoholic liver disease was admitted to another hospital with melena. Gastroscopy revealed intact gastric mucosa and actually non-bleeding duodenal ulcer covered by clots. Laboratory results showed hyperkalemia, elevated kidney function tests, indirect hyperbilirubinemia, increased liver function tests, leukocytosis, anemia, thrombocytopenia and elevated international normalized ratio (INR). He was treated with saline infusions, four units of red blood cells and one unit of fresh frozen plasma transfusions. Four days later he was transported to our Institution with ARF. Physical examination revealed dyspnoe, petechiae, hemoptoe, oliguria, chest-wall pain and aggressive behavior. Thrombocytopenia, signs of MAHA (fragmentocytes and helmet cells in the peripheral blood), normal INR, elevated lactate dehydrogenase (LDH) and ARF suggested TTP-HUS. Hemodialysis and six plasmaferesis (PF) were carried out. After the fifth PF, skin manifestations of thrombotic microangiopathy occurred on the feet. Clotting analysis revealed elevated D-dimer (&gt;5 μg/mL), normal fibrinogen (3.2 g/L), a slightly raised INR (1.36) and activated partial prothrombin time (APTT) (45.8 sec), normal reticulocyte (57 G/L) and a slightly low platelet count (123 G/L), which proved to be chronic DIC. Therapeutic dose of low-molecular-weight heparin (LMWH) was started. Elevated prostate-specific antigen (PSA) (109.6 ng/mL) suggested prostatic carcinoma. Prostate biopsy revealed adenocarcinoma (Gleason: 4+4 for left lobe and 3+3 for right lobe). Elevated alkaline phosphatase suggested metastases in the bone, which were confirmed by bone scintigraphy. Combined androgen blockade (CAB) was started. After three months follow-up our patient's status is satisfactory. PSA is in the normal range (4.6 ng/mL). Thrombocytopenia of uncertain origin with normal or raised INR, APTT, elevated D-dimer, normal fibrinogen and reticulocyte count prove the diagnosis of chronic DIC. This process warrants searching for metastatic neoplasia. Due to the relatively low serum levels of circulating procoagulant factors (e.g. tissue factor), therapeutic dose of LMWH can be used with good efficiency in chronic DIC with low risk of bleeding. Severe DIC as a complication of metastatic prostate cancer can be treated by androgen deprivation therapy (ADT) or CAB in combination with ketokonazole and concomitant use of supportive treatment. Deme D, Ragán M, Kovács L, Kalmár K, Varga E, Varga T, Rakonczai E. Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case." }, { "id": "wiki20220301en041_54510", "title": "Thrombophilia", "score": 0.012284750576957215, "content": "Diagnosis Tests for thrombophilia include complete blood count (with examination of the blood film), prothrombin time, partial thromboplastin time, thrombodynamics test, thrombin time and reptilase time, lupus anticoagulant, anti-cardiolipin antibody, anti-β2 glycoprotein 1 antibody, activated protein C resistance, fibrinogen tests, factor V Leiden and prothrombin mutation, and basal homocysteine levels. Testing may be more or less extensive depending on clinical judgement and abnormalities detected on initial evaluation. For hereditary cases, the patient must have at least two abnormal tests plus family history." }, { "id": "wiki20220301en014_34439", "title": "Von Willebrand disease", "score": 0.009900990099009901, "content": "Diagnosis Basic tests performed in any patient with bleeding problems are a complete blood count-CBC (especially platelet counts), activated partial thromboplastin time-APTT, prothrombin time with International Normalized Ratio-PTINR, thrombin time-TT, and fibrinogen level. Patients with abnormal tests typically undergo further testing for hemophilias. Other coagulation factor assays may be performed depending on the results of a coagulation screen. Patients with von Willebrand disease typically display a normal prothrombin time and a variable prolongation of partial thromboplastin time." }, { "id": "pubmed23n0540_7041", "title": "An unusual cause of acute abdominal pain - a case presentation.", "score": 0.009900990099009901, "content": "In 1983, Graham Hughes described a condition of Antiphospholipid Syndrome in which there was a danger of thrombosis. The condition is readily detectable by blood tests and, once diagnosed; the risk of further thrombosis can be significantly reduced by anticoagulation treatments. Affected groups of patients can be distinguished by a specific blood test - the detection of antiphospholipid antibody (Ref-1). Patients with Hughes syndrome have hypercoaguable state with a markedly increased risk of both arterial and venous thrombosis and there is temporal persistence of antibody positivity. A 44-year-old woman was admitted under the acute surgical \"take\" with left sided abdominal pain radiating to her back. She had a history of borderline thyrotoxicosis in the early 1990s. She was on etonogestrel-releasing implants for contraception and there was no history of previous deep venous thrombosis. She was very tender, locally, over the left side of the abdomen. Investigations showed haemoglobin of 13.2 g/dl, white cell count of 19.9 10*9/L, and platelets 214 10*9/L with neutrophilia. Amylase and renal function tests were found to be normal. Liver function tests were deranged with Gamma GT 244 u/l (twice normal). An abdominal Ultrasound Scan suggested a possible splenic infarction, which was confirmed by a CT scan of her abdomen. Tests were carried out to investigate the possibility of a post thrombotic state. Coagulation risk factors for thrombosis were within the normal limits; Protein S 67 %(60-140), Protein C 103 % (72-146), Antithrombin 3 110 %(80-120) and Activated P C Resistance was 1.9(2.0-4.3). The Hams test was negative but the Anticardiolipin antibody test was positive. IgM level was 52 (normal is up to 10) and IgG was 18.8 (normal is up to 10). She also had border line APC Sensitivity 1.9 (2 to 4.3). Kaolin time 49 sec (70-120) Ktmix 64 sec (70-120), thyroid function test revealed TSH 0.32 micro/L, fT4 20.2 pmol/L (10-25). Subsequent determination of Anticardiolipin antibody was negative. Her symptoms were settled with the use of simple analgesia and she was discharged home with long-term anticoagulation medication. The INR target for long-term anticoagulation was aimed at &gt;3. This case presented to us as an acute abdominal pain. Subsequent investigations revealed the presence of splenic infarction. Coagulation risk factors for thrombosis proved negative. Haematological investigations revealed the presence of anticardiolipin antibodies at the first instance but subsequent determinations were negative. Hence, it mimicked Hughes syndrome initially but the criteria for temporal persistence of anticardiolipin antibody was not fulfilled. Unusual surgical presentation of a thrombotic abnormality as abdominal pain due to splenic infarction." }, { "id": "wiki20220301en589_2750", "title": "Acquired haemophilia", "score": 0.00980392156862745, "content": "Diagnosis Any acute or recent onset of bleeding symptoms in a patient with no previous history of bleeding, especially in elderly or post-partum patients, and an unexplained isolated prolonged activated partial thromboplastin time (aPTT) suggest the diagnosis of AHA, and need further investigation. The differential diagnosis in prolonged aPPT with a normal prothrombin time (PT) includes factor deficiencies, lupus anticoagulant or heparin therapy. The first step to distinguish between factor deficiency and the presence of an inhibitory substance is to perform a mixing test, in which patient plasma and normal plasma are mixed and aPTT measured; correction of prolonged aPTT suggests a factor deficiency while persistent prolongation indicates the presence of an inhibitor. Prolongation of the aPTT in a mixture of patient and normal plasma after a 1-2 h incubation compared to an immediate mix is typical of FVIII autoantibodies, as FVIII inhibitors are time and temperature-dependent." }, { "id": "wiki20220301en011_19168", "title": "Coagulation", "score": 0.009708737864077669, "content": "Assessment Numerous tests are used to assess the function of the coagulation system: Common: aPTT, PT (also used to determine INR), fibrinogen testing (often by the Clauss method), platelet count, platelet function testing (often by PFA-100), thrombodynamics test. Other: TCT, bleeding time, mixing test (whether an abnormality corrects if the patient's plasma is mixed with normal plasma), coagulation factor assays, antiphospholipid antibodies, D-dimer, genetic tests (e.g. factor V Leiden, prothrombin mutation G20210A), dilute Russell's viper venom time (dRVVT), miscellaneous platelet function tests, thromboelastography (TEG or Sonoclot), euglobulin lysis time (ELT). The contact activation (intrinsic) pathway is initiated by activation of the \"contact factors\" of plasma, and can be measured by the activated partial thromboplastin time (aPTT) test." }, { "id": "pubmed23n1085_24991", "title": "Case 294.", "score": 0.009708737864077669, "content": "History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10<sup9</sup/L (normal range, 150-400 × 10<sup9</sup/L), a C-reactive protein level of 158 mg/L (normal range, &lt;5 mg/L) and a d-dimer level of 2000 mg/L (normal range, &lt;500 mg/L). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, &lt;0.3 g/day), and a high serum troponin level of 1066 ng/L (normal range, &lt;14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4)." }, { "id": "pubmed23n0308_14555", "title": "Activated protein C resistance phenotype in patients with antiphospholipid antibodies.", "score": 0.009615384615384616, "content": "The effect of antiphospholipid antibodies (aPL) on the action of activated protein C (APC) was examined in 32 patients: 19 with lupus anticoagulant (LA), 6 with anticardiolipin antibodies (aCL), and 7 with LA and aCL. Eighteen patients had a ratio of activated partial thromboplastin time (APTT) with APC to APTT without APC (APTT ratio) &lt;2.06 (cut-off level) and no factor V Leiden mutation; these patients showed APC-resistance (APC-R) phenotype. The mean prolongation of APTT after addition of APC in a control group was 45.3 seconds, with a lower limit of 31.4 seconds. Only 3 of the 18 patients with low APTT ratio had a prolongation of &lt;31.4 seconds; they were classified as true APC-R phenotype, whereas the other 15 patients were classified as spurious APC-R. Of the 3 patients with true APC-R, 2 had deep venous thrombosis, 1 with pulmonary embolism, and the third had recurrent abortion. Of the other 15 patients, 2 had had ischemic stroke, 1 had recurrent abortion, and 12 were asymptomatic. Circulating APC level was measured in 14 of the 18 aPL patients with a low APTT ratio; it was lower than the normal lower limit in 4 patients and within the lower limit in 2. Three of the 4 patients with reduced APC levels had a history of thrombosis. We conclude that patients with aPL who show APC-R phenotype due to a low APTT ratio without the factor V Leiden mutation can be classified into two groups: true and spurious APC-R phenotype. Since those with true APC-R phenotype could have greater thrombotic risk, adequate classification of these patients is important. Moreover, aPL can sometimes interfere with the activation of protein C, thus reducing the circulating levels of APC, and this could constitute another thrombotic risk factor." }, { "id": "pubmed23n0055_296", "title": "Treatment of massive pulmonary thromboembolism with low intrapulmonary dosages of urokinase. Short-term angiographic and hemodynamic evolution.", "score": 0.009615384615384616, "content": "Sixteen patients who had massive pulmonary thromboembolism and shock had no history of cardiopulmonary disease. We present an evaluation of the short-term effects of fibrinolytic treatment consisting of intrapulmonary administration of a bolus of 500,000 IU of urokinase followed by infusion of 1 x 10(6) IU into the right auricle over 12 h and subsequent intravenous infusion of heparin. For each patient, the effectiveness of treatment was evaluated by comparing pretreatment angiographic and hemodynamic parameters with those measured 48 h after the start of treatment. The Miller index fell from 22.9 +/- 5.9 to 9.8 +/- 3.3 (p less than 0.001), with a mean improvement of 57.2 percent. All the hemodynamic parameters studied (cardiac output and index, total pulmonary vascular resistance, and systolic, diastolic, and mean pulmonary vascular pressure) also exhibited statistically significant differences between pretreatment and posttreatment values (p less than 0.001 for each parameter), with a mean improvement of over 30 percent in each case. All the patients survived, and in no case did treatment fail; only one patient (6.2 percent) suffered severe hemorrhage. We conclude that this form of administration of urokinase is useful for patients with critical massive pulmonary thromboembolism." }, { "id": "wiki20220301en022_80570", "title": "Prothrombin time", "score": 0.009523809523809525, "content": "The prothrombin time (PT) – along with its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) – is an assay for evaluating the extrinsic pathway and common pathway of coagulation. This blood test is also called protime INR and PT/INR. They are used to determine the clotting tendency of blood, in such things as the measure of warfarin dosage, liver damage, and vitamin K status. PT measures the following coagulation factors: I (fibrinogen), II (prothrombin), V (proaccelerin), VII (proconvertin), and X (Stuart–Prower factor). PT is often used in conjunction with the activated partial thromboplastin time (aPTT) which measures the intrinsic pathway and common pathway of coagulation. Laboratory measurement" }, { "id": "pubmed23n0405_10934", "title": "[Relative value of different antiphospholipid antibodies detected in a department of internal medicine: retrospective study of 124 patients].", "score": 0.009523809523809525, "content": "The value of antiphospholipid antibodies (aPL) detected in the sera of the patients of an Internal Medicine department is not univocal and is still much debated. To test the contribution of such new markers, we reviewed the records of patients having antiphospholipid antibodies detected between 1996 and 1997. One hundred and twenty four patients, having at least one of these two aPL: lupus anticoagulant (LA), anticardiolipin antibodies (aCL), or one of these two anti-proteins: anti-beta 2glycoprotéin I antibodies (anti-beta 2GPI) or anti-prothrombin antibodies (aPT), were studied. LA was detected by a PTT-LA technique and aCL, anti-beta 2GPI and aPT by ELISA-sandwich techniques. For each patient we recorded sex, age, personal and familial history of thrombosis, fetal losses and systemic disease, the reason of aPL detection, the final diagnosis, activated partial thromboplastin time (aPTT), platelets count and type of aPL. The population was composed of 77 women (62%) and 47 men (38%) with a mean age of 54 years [12-92 years]. A thrombocytopenia was strongly correlated to aCL presence (OR = 6.15 et p = 0.03). The reason of aPL detection was venous thrombosis, recurrent fetal losses, systemic disease, infectious disease or fortuitous discovery of a prolonged aPTT. The final diagnosis was a systemic disease in 57% of cases, an infectious disease in 14.5%, a thrombosis in 4.5% and a neoplasia in 3%. LA was detected in 54% of patients, aCL in 39.5%, anti-beta 2GPI in 23% and aPT in 31%. No relationship between the aPTT value and the type of aPL could be established. Our study shows that familial histories of venous thrombosis or systemic disease are useful to enhance antiphospholipid antibodies detection; that LA is mostly associated to systemic and infectious diseases; that aCL and anti-beta 2GPI are predominant in case of venous thrombosis and that thrombocytopenia has to enhance aCL detection and the discussion about a possible APS." }, { "id": "pubmed23n1108_4052", "title": "Acquired hemophilia: clinical case of hemorrhage caused by inhibitors against factor VIII.", "score": 0.009433962264150943, "content": "Acquired hemophilia is caused by antibodies against coagulation factors, especially against factor VIII. As it is a low prevalence disease, our objective is to present an idiopathic case of acquired hemophilia to facilitate decision-making in clinical practice for others, exposing the therapeutic modality used. 65 years old woman, started with non-trauma hematomas, with asthenia, adynamia and dyspnea. Laboratory studies showed anemia (hemoglobin 7.1 g/dl, hematocrit 21%, mean corpuscular volume 91 fl, mean corpuscular hemoglobin 29.6 pg) and long clotting times (activated partial thromboplastin time 100 seconds) and with prothrombin time and International Normalized Index (17 seconds and 1.2 seconds respectively). So, plasma dilution tests were performed with plasma, without aPTT correction (1:2, 76.6 seconds; 1: 4, 60 seconds; 1: 8, 45 seconds) evidencing the presence of the inhibitor. The diagnosis was confirmed by the decrease in factor VIII (1%) and the presence of the factor VIII inhibitor (256 UB). The treatment started with prednisone and cyclophosphamide. Due to the presence of severe bleeding, treatment with activated prothrombin complex concentrate (CCpa) was required. Subsequently, Rituximab was prescribed, with clinical improvement and increased levels of hgb and reduced aPTT from the first week of treatment. The approach of acquired hemophilia should include control of the bleeding, the search for the etiology ruling out of the main causes of malignant neoplasms according to age and gender, and the immediate initiation of immunosuppression to decrease inhibitor levels." }, { "id": "pubmed23n0983_5225", "title": "Preserve encephalus in surgery of trauma: online survey. (P.E.S.T.O).", "score": 0.009345794392523364, "content": "Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients. A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS). The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10-30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [<in</i = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90-100 mmHg [<in</i = 35 (29%)] and 100-110 mmHg [<in</i = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were &gt; 70 mmHg [<in</i = 44 (36%)] and &gt; 80 mmHg [<in</i = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count &gt; 50,000/mm<sup3</sup [<in</i = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT) &lt; 1.5 times the normal control [<in</i = 73 (60%)] to be the safest parameters. For craniotomy, the majority of respondents considered PLT count &gt; 100,000/mm<sup3</sup [<in</i = 67 (55%)] and a PT/aPTT &lt; 1.5 times the normal control [<in</i = 76 (62%)] to be the safest parameters. Almost half of the respondents [<in</i = 53 (43%)], reported that they transfused red blood cells (RBCs)/plasma (P)/PLTs at a ratio of 1/1/1 in TBI polytrauma patients. SMS was performed in 5-19% of patients, requiring both an emergency neurosurgical operation and EES, by almost half of the respondents [<in</i = 49 (40%)]. A great variability in practices during the acute phase management of polytrauma patients with severe TBI was identified. These findings may be helpful for future investigations and educational purposes." }, { "id": "pubmed23n0014_4347", "title": "[Long-term anticoagulant therapy in subjects over 75 years of age. 100 cases].", "score": 0.009345794392523364, "content": "100 patients (median age 79 years) were given anticoagulant therapy (ACT) for a period of time averaging 5 years 3 months (522 follow-up years).--Out of 3 522 Quick tests, converted into prothrombin times and all carried out in the same laboratory, the prothrombin time was at or less than 32% in 60.5%, and 34% in 69.6% of the tests.--The mean therapeutic doses were less than 27% of those for adults, and were decreased by 3 mg of phenindione per year over the age of 75, only the actively treated cases being retained.--The risks are the same as those for the middle-aged adult. They depend more on the quality of the investigations than upon age. In the group which has been studied, slight or frank haemorrhagic complications (0.05/year/patient) were the result of a demonstrable overdosage in only one case in four. They were not responsable for any deaths in this series.--because of the referral patterns, the patients studied consisted of 79 with ischaemic heart disease, 27 with peripheral vascular disease, 9 cerebrovascular accidents, and 6 with thrombo-emoblic problems, not counting the 23 complications during the course of the study. In those patients with ischaemic heart disease, well-regulated anticoagulant treatment was associated with a favourable clinical course, and the correlation was significant.--there is not argument against the administering of a full and prolonged course of ACT to a patient of more than 75 years of age." }, { "id": "pubmed23n1076_13320", "title": "Diagnostic analysis of lupus anticoagulant using clot waveform analysis in activated partial thromboplastin time prolonged cases: A retrospective analysis.", "score": 0.009259259259259259, "content": "Hemophilia was diagnosed in precedence research of clot waveform analysis (CWA) using the activated partial thromboplastin time (APTT). In patients with antiphospholipid syndrome (APS), lupus anticoagulant (LA) causes an increase in APTT, suggesting that the waveform would probably be distorted. Therefore, we evaluated using clinical samples. CWA may be useful low cost for clinical detection of LA. We assessed the clinical value of CWA for detection of LA and coagulation using clinical blood samples collected from patients with a prolonged APTT. We used patient samples inspected between April 2011 and March 2013 in Yamagata University Hospital. CWA was performed using the ACL TOP coagulation analyzer, and the associated software program was used to calculate APTT clotting endpoints. An atypical peak was defined as a derivative plot that did not conform to the normal S-shaped clot reaction curve. In total, 162 patients, including 66 men and 96 women, with an average age of 46 years (range: 24-89 years) were included. We also collected control samples from unmatched healthy donors. All 162 patients were divided according to medication history or condition into the following five groups: heparin (n = 20), warfarin (n = 23), hepatic dysfunction (n = 13), normal (n = 20), and LA-positive antiphospholipid syndrome (APS; n = 86). Twenty healthy individuals were included as controls.Eighty patients had an atypical peak. Among all, 78 patients (90.6%) were LA-positive, and 2 patients (2.5%) were treated with warfarin. The remaining two patients had prothrombin time international normalized ratios (PT-INR) &gt;4.0 while taking warfarin. Those who were APS LA positive with thrombosis and without thrombosis had split the reaction of clotting time, deceleration/acceleration time (D/A) ratio of 2.36 (1.99,3.24) vs 2.34 (2.04,2.86), respectively. The significant atypical peak and D/A ratio extension may be explained by the clotting waveforms observed specifically in patients with LA-positive APS." }, { "id": "pubmed23n0651_21523", "title": "[Catastrophic antiphospholipid syndrome and rituximab: a new report].", "score": 0.009259259259259259, "content": "Catastrophic antiphospholipid syndrome is a distinctly rare dramatic condition characterized by widespread thrombosis of small vessels. Early diagnosis and aggressive therapies are essential in this condition because of its extremely high mortality rate. Therapeutic management include heparine, high dose steroids, cyclophosphamide, plasma exchange, intravenous immunoglobuline, however a number of patients are refractory to treatment. We review and discuss alternative and emerging treatment options by rituximab for patients who fail or cannot tolerate conventional therapy. A 36-year-old female with a two mounths history of dyspnea, palpitation and chest pain was admitted. Physical examination upon admission revealed a fever, ischemic digital necrosis, scleroderma of the hands and beaking of the nose. Laboratory tests showed normal level of liver enzymes, elevation of creatinine level, lymphopenia, haemolytic anaemia with negative Coombs tests, low platelet count, prolonged partial thromboplastin time. The D-Dimer value was 158 ng/ml. Urinalysis revealed a proteinuria. Antinuclear antibody tests and lupus anticoagulant were strongly positive. Echocardiography revealed severe pulmonary hypertension and pericarditis. There was no pulmonary embolism on thoracic angio tomodensitometry. The diagnosis of catastrophic antiphospholipid antibody syndrome associated with systemic lupus and scleroderma was established. She was treated with anticoagulants, corticotherapy, one pulse of intravenous cyclophosphamide, 2 doses of intravenous immunoglobuline and 5 sessions of plasmapheresis. Because of lack of response 2 doses of 375 mg weekly rituximab i.v. were added but she developed pulmonary embolism, alveolar haemorrhage and she died. Effectiveness of Rituximab for the CSAPL should be demonstrated by further studies." }, { "id": "pubmed23n0287_7260", "title": "[Splenic infarction caused by paradoxical emboli in severe pulmonary hypertension].", "score": 0.009174311926605505, "content": "A 55-year-old woman developed increasing shortness of breath and breath-independent pain in the left lower chest. 20 years previously she had had an episode of pulmonary embolism and 10 years previously a central venous thrombosis in the left eye. No cause of the increased thrombogenesis had been found. On admission she had resting dyspnoea but a stable circulation. On auscultation the breath sounds were diminished over the left base and there was a diastolic murmur over the pulmonary area with an accentuated second sound. There was also marked tenderness below the left costal margin. Recurrent pulmonary embolism or left-sided pleuropneumonia was suspected. Arterial blood gases (without additional oxygen) showed severe hypoxaemia (pO2 42.3 mm Hg, pCO2 27.8 mm Hg, pH 7.455, oxygen saturation 80.5%). Transthoracic and transoesophageal echocardiography showed normal left ventricular dimensions, right atrial and ventricular dilatation, and an atrial septal aneurysm with a right to left interatrial shunt. Right heart catheterisation demonstrated severe pulmonary hypertension. Sonography, computed tomography and scintigraphy revealed multiple splenic infarcts. Heparinisation was instituted (partial thromboplastin time 70-90 s) and overlapping oral anticoagulation to a Quick value of 20%. Subsequently the calcium antagonist felodipine (15 mg daily) was given. The mean pulmonary artery pressure was 61 mm Hg before and 57 mm Hg after treatment. Splenic infarction resulting from paradoxical embolisation is rare, but should be routinely considered in the presence of thromboembolic phenomena." }, { "id": "pubmed23n1068_13411", "title": "Case 290.", "score": 0.009174311926605505, "content": "History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism (PE). He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a D-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range, &lt;0.46 mg/L) and an international normalized ratio of 2.45 (therapeutic range, 2.0-3.0 for a patient taking warfarin), except the prothrombin time was 28.2 seconds (reference range, 9.6-12.8 seconds) and the activated partial thromboplastin time was 52.2 seconds (reference range, 24.8-33.8 seconds). Echocardiography, chest radiography, chest CT, and contrast-enhanced CT revealed no abnormalities. The patient underwent right lower extremity vascular conventional US (Philips IU22; Philips) with an L9-3 probe (3-9 MHz, venous condition) and contrast-enhanced US (1.5-2.0 mL, SonoVue; Bracco) with an intravenous bolus injection at the initial evaluation. Two days later, noncontrast and contrast-enhanced CT images of the lower abdomen (1.5 mL per kilogram of body weight, 300 mg/mL iomeprol, Iomeron; Bracco) were acquired for further evaluation (Figs 1-3)." }, { "id": "pubmed23n0990_21068", "title": "First Case of Acquired Hemophilia B in a Patient with HIV Infection: Case Report and Literature Review.", "score": 0.00909090909090909, "content": "Acquired hemophilia B is a rare bleeding disorder in which circulating specific antibodies inhibit the coagulation factors. Usually, it is associated with autoimmune diseases, malignancy and some infections such as hepatitis B (HBV) and C (HCV) viruses. The association with the human immunodeficiency virus (HIV) is rare. We present the first case of hemophilia B acquired in a patient with HIV. A 36-year-old woman with a history of HIV infection stage 3 acquired immunodeficiency syndrome (AIDS) (CDC 2014) and glomerulopathy secondary to HIV. She consulted for subacute non-dysenteric diarrhea. During her hospitalization, bacteremia by methicillin-sensitive Staphylococcus aureus (S.aureus) was documented, requiring hemodialysis catheter replacement with profuse bleeding during the procedure. The coagulation tests showed prolonged activated partial thromboplastin time (aPTT), normal prothrombin time (PT), mixing test with Rosner index: 8.8%, negative lupus anticoagulant, and specific tests for normal factor VIII and XI. The activity of factor IX was &lt;50% and the inhibitor was increased, which confirms the diagnosis of hemophilia B. Acquired hemophilia B in a patient with HIV infection is not a frequent association; it should be suspected in the context of bleeding with prolonged aPTT." }, { "id": "pubmed23n1162_136", "title": "A 52-Year-Old Man With Chest Pain and Dyspnea.", "score": 0.00909090909090909, "content": "A 52-year-old man came to the cardiac surgery clinic for pulmonary thromboendarterectomy (PTE) evaluation. He had initially appeared at an outside hospital 1 year earlier, with chest pain and shortness of breath. He had no known chronic conditions. A CT pulmonary angiogram (CTPA) at that time showed a filling defect at the bifurcation of the main pulmonary artery. A transthoracic echocardiogram revealed mild mitral valve regurgitation, but otherwise the results were normal. As he was hemodynamically stable and not hypoxemic, he was treated solely by anticoagulation. Despite adhering to prescribed apixaban, he developed progressive dyspnea and reduced exercise tolerance over the subsequent year. A repeat CTPA performed 12 months after the initial presentation showed a persistent filling defect at the level of the pulmonary artery bifurcation, with a new extension now completely occluding the right main pulmonary artery. A pulmonary angiogram confirmed this complete occlusion, and right heart catheterization revealed precapillary pulmonary hypertension, with a mean pulmonary artery pressure of 50 mm Hg. His anticoagulation was transitioned to enoxaparin for presumed apixaban treatment failure, and an investigation for hypercoagulable conditions was initiated. His lupus anticoagulant test result was positive, but he did not meet the criteria for antiphospholipid syndrome because he was negative for anticardiolipin and β<sub2</sub-glycoprotein antibodies. Assays for antithrombin III, protein C, prothrombin gene, and factor V Leiden mutations produced normal results." }, { "id": "wiki20220301en198_22391", "title": "PCO2", "score": 0.009009009009009009, "content": "Medicine In medicine, the partial pressure of carbon dioxide in arterial blood is called or PaCO2. Measurement of in the systemic circulation indicates the effectiveness of ventilation at the lungs' alveoli, given the diffusing capacity of the gas. It is a good indicator of respiratory function and the closely related factor of acid–base homeostasis, reflecting the amount of acid in the blood (without lactic acid). Normal values for humans are in the range 35–45 mmHg. Values less than this may indicate hyperventilation and (if blood pH is greater than 7.45) respiratory alkalosis. Values greater than 45 mmHg may indicate hypoventilation, and (if blood pH is less than 7.35) respiratory acidosis. Aquatic Sciences" }, { "id": "pubmed23n0406_14754", "title": "The clinical spectrum of acute renal infarction.", "score": 0.009009009009009009, "content": "Acute renal infarction is an oft-missed diagnosis. As a result, its true incidence, although presumed to be low, is actually unknown. Surprisingly, the medical literature on the subject, other than anecdotal case reports, is scarce. To increase physician awareness of the diagnosis and to identify predictive clinical and laboratory features of the entity. Between 1 November 1997 and 31 October 2000, 11 cases of acute renal infarction in 10 patients were diagnosed in our center by contrast-enhanced computerized tomography. The medical charts of these patients were reviewed regarding risk factors, clinical presentation, possible predictive laboratory examinations, and outcome. During the 36 month observation period, the incidence of acute renal infarction was 0.007%. The mean age of the patients (5 men and 5 women) was 67.4 +/- 21.1 (range 30-87 years). In four cases the right and in five the left kidney was involved; in the other two cases bilateral involvement was seen. In 7/10 patients, an increased risk for thromboembolic events was found. Six had chronic atrial fibrillation and one had a combined activated protein C resistance and protein S deficiency. Three patients had suffered a previous thromboembolic event. Two cases were receiving anticoagulant therapy with an INR of 1.6 and 1.8, respectively. On admission, flank pain was recorded in 10/11, fever in 5 and nausea/vomiting in 4 cases. Hematuria was detected in urine reagent strips in all cases. Serum lactate dehydrogenase and white blood cell count were elevated in all cases (1,570 +/- 703 IU/L and 12,988 +/- 3,841/microliter, respectively). In no case was the diagnosis of acute renal infarction initially entertained. The working diagnoses were renal colic in 2, pyelonephritis in 3, renal carcinoma, digitalis intoxication, and suspected endocarditis in one patient each, and an acute abdomen in 3. Time from admission to definitive CT diagnosis ranged from 24 hours to 6 days. Three patients were treated with intravenous heparin and another with a combination of i.v. heparin and renal intra-arterial urokinase infusion with, in the latter case, no recovery of function of the affected kidney. With the exception of this one patient (with a contralateral contracted kidney) who required maintenance dialysis, in all other cases serum creatinine levels remained unchanged or reverted to the baseline mean of 1.1 mg/dl (0.9-1.2). Acute renal infarction is not as rare as previously assumed. The entity is often misdiagnosed. Unilateral flank pain in a patient with an increased risk for thromboembolism should raise the suspicion of renal infarction. In such a setting, hematuria, leucocytosis and an elevated LDH level are strongly supportive of the diagnosis." }, { "id": "pubmed23n0975_25910", "title": "Acquired hemophilia A presenting as progressive intra-abdominal hemorrhage, muscle hemorrhage and hemothorax postpartum: A case report and literature review.", "score": 0.008928571428571428, "content": "Acquired hemophilia A (AHA) is a rare antibody-mediated condition in which autoantibodies form against a coagulation factor, most commonly factor VIII (FVIII), causing severe coagulopathy. Here the present report presents a case of AHA in a 35-year-old postpartum woman with continuous polyserous bloody effusions who was admitted to the First Affiliated Hospital of Zhejiang Chinese Medical University (Hangzhou, China) in October 2017 without a history of trauma, anticoagulation treatment or coagulopathy. At presentation, the patient's hemoglobin level was low (70 g/l; normal range: 115-150 g/l) g/l, blood pressure was 89/58 mmHg (normal range, 90-140/60-90 mmHg), and activated partial thromboplastin time was 68.4 sec (normal range: 25.0-36.0 sec), with a normal international normalized ratio (0.94; normal range, 0.8-1.2). The reaction time in thrombography was prolonged (35.8 min; normal range: 5-10 min), coagulation FVIII had markedly decreased activity (12.6%; normal range, 60-150%), and FVIII inhibitor had a high titer [7.4 Bethesda units (BU)/ml; normal range, 0-0.6 BU/ml]. Notably, the patient's autoantibody level was markedly higher than normal (1:320; normal range: &lt;1:100). The patient was successfully treated with bleeding control, eradication of FVIII inhibitor, and treatment of the underlying disease. To the best of our knowledge, this is the first case of AHA with polyserous bloody effusions in a patient with an autoimmune disorder during the postpartum period. Reports of such rare cases will aid the characterization of disease pathogenesis, which may in turn lead to the recognition and timely treatment of this rare disorder." }, { "id": "pubmed23n0564_22244", "title": "[Chance finding of a bilateral central pulmonary embolism while using cardiac computed tomography for the clarification of a coronary anomaly].", "score": 0.008928571428571428, "content": "A 42 year-old man reported transient breathlessness and chest pain on the first day after a four-hour flight. During the following five months the symptoms recurred four times. After another episode he went to an outpatient department for further assessment. Blood tests demonstrated slightly elevated LDH (343 U/l) and also a minor increase of the D-dimers (710 microg/l). Hypercholesterolemia was also found (LDL-cholesterol 180 mg/dl). The rest of the blood tests, including the cardiac enzymes, were within normal limits. The electrocardiogram (ECG) showed sinus rhythm, heart rate 85 bpm and pre-terminal T-negativity in the precordial leads V1 to V3. Resting echocardiography and chest X-ray showed no significant abnormalities. The exercise ECG demonstrated no further ECG changes. However, because of the symptoms and a cardiovascular risk profile (family history, hypercholesterolemia and smoking) a coronary angiography was performed, which excluded coronary artery disease but revealed a so-called \"right-sided single coronary artery\", the left and right coronary arteries originating with a common stem from the right sinus of valsalva. To define the exact course of the left main coronary artery (whether in front of the pulmonary artery, between the two great arteries, retroaortic or septal) a contrast-enhanced cardiac computed tomography (CT) was performed, which demonstrated an anomalous position of the left main coronary artery in front of the pulmonary artery. Bilateral pulmonary embolism was an additional and unexpected finding. Oral anticoagulation was initiated after a coagulopathy had been excluded. The ultrasonography of the leg did not demonstrate any thrombosis. There was no evidence of malignant disease. Mild symptoms and absence of right heart congestion do not exclude pulmonary embolism. Depending on the symptoms and history, pulmonary thrombembolism has to be considered, especially if cardiac or extra-cardiac causes have been eliminated. The diagnostic method of choice for the detection or exclusion of pulmonary embolism is contrast-enhanced multi-slice spiral CT." }, { "id": "pubmed23n0203_11595", "title": "[Five cases of disseminated intravascular coagulation after peritoneojugular shunt by Le Veen valve].", "score": 0.008849557522123894, "content": "The authors report the cases of five cirrhotic patients who underwent peritoneo-venous bypass via a Le Veen valve. Coagulation studies revealed on the one hand a worsening in certain pre-existent abnormalities (thrombocytopaenia, decrease in plasma coagulation factor levels), and secondly a frank increase in F.B.P and positivation of the transfer test. Clinically, two haemmorrhagic syndromes were seen, one of which was fatal. At no time was euglobulin lysis time less than 30 minutes. The administration of small doses of heparin corrected these laboratory abnormalities in all patients and stopped haemorrhage in one. These findings as a whole indicate that in these five cases the bypassing of ascites fluid led to a state of disseminated intravascular coagulation." }, { "id": "wiki20220301en040_55093", "title": "Protein S deficiency", "score": 0.008771929824561403, "content": "Mutations in this condition change amino acids, which in turn disrupts blood clotting. Functional protein S is lacking, which normally turns off clotting proteins, this increases risk of blood clots. Diagnosis The diagnosis for deficiency of protein S can be done via reviewing family history of condition and genetic testing, as well as the following: Protein S antigen test Coagulation test (prothrombin time test) Thrombotic disease investigation Factor V Leiden test Differential diagnosis Among the possibilities for differential diagnosis of protein S deficiency are- Antiphospholipid syndrome, disseminated intravascular coagulation and antithrombin deficiency (though this list is not exhaustive)" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 134 ] ], "word_ranges": [ [ 0, 22 ] ], "text": "Dendritic corneal ulcer is typical of herpes simplex keratitis. It presents with pain, not too striking, and scarce or absent red eye." }, "2": { "exist": true, "char_ranges": [ [ 610, 674 ] ], "word_ranges": [ [ 101, 115 ] ], "text": "if it is a dendrite, the first thing we have to think is herpes." }, "3": { "exist": true, "char_ranges": [ [ 675, 731 ] ], "word_ranges": [ [ 115, 122 ] ], "text": "Fungal and bacterial keratitis have corneal infiltrates." }, "4": { "exist": true, "char_ranges": [ [ 675, 731 ] ], "word_ranges": [ [ 115, 122 ] ], "text": "Fungal and bacterial keratitis have corneal infiltrates." }, "5": { "exist": true, "char_ranges": [ [ 736, 885 ] ], "word_ranges": [ [ 123, 142 ] ], "text": "glaucomatocyclitic crisis (Posner Schlossman syndrome) is a type of idiopathic hypertensive anterior uveitis, which does not present with ulceration." } }

{ "1": "Herpetic keratitis.", "2": "Corneal abrasion.", "3": "Fungal keratitis.", "4": "Bacterial keratitis.", "5": "Glaucomatocyclic crisis." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0392_7957", "title": "Keratitis caused by Verticillium species.", "score": 0.017879948914431672, "content": "To report a case of fungal keratitis caused by Verticillium species. A 50-year-old man developed pain, redness, and an infiltrate in his left eye and had no history of trauma. The cornea showed superficial, white, stromal infiltrates and epithelial ulceration with a dendritic margin. The clinical features suggested herpetic keratitis, and the patient was treated with topical antiviral medication. Two weeks later, his condition deteriorated. Examination of the left eye showed stromal infiltrates with a feathery margin and epithelial ulceration with its covering white exudates. Corneal scrapings were taken for direct microscopic examination and culture. Corneal scraping showed the presence of fungal filaments. The fungus was identified as Verticillium species. Topical amphotericin B and systemic fluconazole were started after discontinuing the antiviral treatment. Clinically, the inflammation subsided during the 3 weeks after treatment. This is a rare case of infectious keratitis caused by Verticillium species. Rare species of fungal infection should be considered in the differential diagnosis of stromal keratitis refractive to conventional medical treatment." }, { "id": "wiki20220301en517_2013", "title": "Christmas eye", "score": 0.016645064465516064, "content": "Diagnosis Before confirming the diagnosis, it's important to keep in mind that there are similar conditions that demonstrate similar signs and symptoms, such as herpes keratitis, corneal abrasion and infectious corneal ulcer. In order to diagnosis Christmas Eye, it’s essential to take a look at the history, meaning what the patient was doing prior to attending the emergency room or a day before. Also, particular attention should be placed on the timeline of the pain and discomfort. Biomicroscopy will show the extent of corneal damage and amount of remaining epithelium present, which will assist in providing a confirmation of the diagnosis." }, { "id": "pubmed23n0618_3398", "title": "New-onset herpes simplex virus keratitis after cataract surgery.", "score": 0.01624468557649597, "content": "We report the case of a 34-year-old man who had uncomplicated cataract surgery in his left eye. Medical history was significant for atopic dermatitis, requiring oral immunosuppressive medications. Two days after the surgery, the patient presented with pain, photophobia, decreased vision, and a small corneal abrasion. On postoperative day 5, the patient returned with left upper lid vesicular lesions and 2 corneal dendrites. Corrected vision was 20/100 OS, with intraocular pressure of 18 mm Hg and 1+ pigmented cells in the anterior chamber. Cultures of the lid lesions revealed herpes simplex virus (HSV) type 1. The patient was placed on oral acyclovir 800 mg 5 times a day. By day 8, the dendrites had resolved, and by day 15, the lid lesions healed over. HSV keratitis is an uncommon complication after cataract surgery. Ophthalmologists should be aware of the possibility of developing HSV keratitis even after the most routine cataract extraction." }, { "id": "pubmed23n0383_3717", "title": "[Painless acanthamoeba keratitis].", "score": 0.016167318919612497, "content": "Acanthamoeba keratitis is a severe, painful corneal infection found in contact lens wearers. The entity can easily be confused with herpetic or fungal keratitis, especially if no ocular pain is reported. A 32-year old myopic female presented a unilateral keratitis of unknown etiology since 3 weeks. Administration of topical antiviral substances and corticosteroids led only to temporary improvement of the condition. The patient complained of photophobia but not of ocular pain. The affected eye showed corneal edema, central stromal thickening, descemet's striae as well as fibrin deposits on the corneal endothelium and in the anterior chamber. An aqueous specimen was negative for a viral infection. A culture for bacteria was negative. Staphylococci were cultured from corneal scrapings and Enterococci from the contact lens solution. Another corneal scraping revealed Acanthamoeba class II (6 weeks after the onset of symptoms). Under treatment with propamidine, polymyxin b, neomycin, gramicidin and polyhexidine (topical) as well as fluconazole/ketoconazole (systemic) the diameter of the annular infiltrate, which had developed decreased, but the infiltrate persisted. In the further course, the infiltrate persisted while the amount of fibrin in the anterior chamber increased. Penetrating keratoplasty was performed. Histologic examination of the host corneal tissue revealed massive infiltration with Acanthamoeba. Severe pain and history of wearing contact lenses are features suggestive of Acanthamoeba keratitis. The patient presented here had a history of contact lens wear, but no ocular pain was reported. The characteristic annular infiltrate had a late onset. Bacterial superinfection could not be ruled out. Therapeutic penetrating keratoplasty had to be performed as the condition deteriorated inspite of intensive chemotherapy. With penetrating keratoplasty a good visual acuity could be regained." }, { "id": "pubmed23n0744_12205", "title": "[Delayed course of Acanthamoeba keratitis].", "score": 0.014229994428014231, "content": "A 35-year-old male presented with corneal ulceration on the left eye with a history of treatment over several months. At the first visit in our department we saw an elliptically shaped ulcerative stromal keratitis with circular peripheral neovascularization. There was organized hypopyon with hyphemia. The best corrected visual acuity (BCVA) was light perception. The patient had used contact lenses for many years. Under the suspicion of herpetic keratitis due to a positive \"dendrite\" the patient had undergone antiviral therapy for 6 months in a different department. Our diagnosis was Acanthamoeba keratitis. We performed penetrating excimer laser keratoplasty-à-chaud (8.0 × 7.0 mm/8.1 × 7.1 mm) with simultaneous cryotherapy of the mid-peripheral cornea. The topical therapy was polyhexamethylene biguanide, propamidine isoethionate, neomycin and steroids in intervals. A repeat penetrating excimer laser keratoplasty (8.5 × 7.5 mm/8.6 × 7.6 mm) with simultaneous amniotic membrane patch and lateral tarsorrhaphy was performed 2 months later due to melting of the graft with positive Seidel test. After successful surgery of the mature cataract the BCVA was 20/25. In a patient with a positive contact lens history acanthamoeba keratitis should always be considered as a differential diagnosis to herpes simplex keratitis in the early course of the disease." }, { "id": "wiki20220301en463_16798", "title": "Herpes zoster ophthalmicus", "score": 0.013371741527081333, "content": "Epithelial: punctate epithelial erosions and pseudodendrites: often have anterior stromal infiltrates. Onset 2 to 3 days after the onset of the rash, resolving within 2–3 weeks. Common. Stromal: Nummular keratitis: have anterior stromal granular deposits. Occurs within 10 days of onset of rash. Uncommon Necrotising interstitial keratitis: Characterised by stromal infiltrates, corneal thinning and possibly perforation. Occurs between 3 months and several years after the onset of rash. Rare. Disciform Keratitis (Disciform Endotheliitis): a disc of corneal oedema, folds in Descemet's membrane, mild inflammation evident within the anterior chamber and fine keratic precipitates. Chronic. Occurs between 3 months and several years after the onset of the rash. Uncommon. Neurotrophic: corneal nerve damage causes a persistent epithelial defect, thinning and even perforation. The cornea becomes susceptible to bacterial and fungal keratitis. Chronic. Late onset. Uncommon." }, { "id": "wiki20220301en386_27947", "title": "Herpes simplex keratitis", "score": 0.013065547061035217, "content": "Recurrent eye infection Recurrent herpes of the eye is caused by reactivation of the virus in a latently infected sensory ganglion, transport of the virus down the nerve axon to sensory nerve endings, and subsequent infection of ocular surface. The following classification of herpes simplex keratitis is important for understanding this disease: Dendritic ulcer (Epithelial keratitis) This classic herpetic lesion consists of a linear branching corneal ulcer (dendritic ulcer). During eye exam the defect is examined after staining with fluorescein dye. The underlying cornea has minimal inflammation. Patients with epithelial keratitis complain of foreign-body sensation, light sensitivity, redness and blurred vision. Focal or diffuse reduction in corneal sensation develops following recurrent epithelial keratitis. In immune deficient patients or with the use of corticosteroids the ulcer may become large and in these cases it is called geographic ulcer." }, { "id": "pubmed23n1152_4723", "title": "A Case of Herpetic Keratitis in an Orthokeratology Contact Lens Wearer.", "score": 0.012726556343577621, "content": "We report a case of herpetic keratitis in an orthokeratology lens wearer. A 17-year-old man who wore an overnight orthokeratology lens for correction of myopia presented to our hospital with pain, lacrimation, and blurred vision affecting the left eye. His corrected visual acuity decreased to 18/20, and he showed dendrites and decreased corneal sensitivity in the left eye. The herpes simplex virus (HSV) immunochromatographic assay kit for the diagnosis of herpes epithelial keratitis was positive. As these findings were suggestive of HSV keratitis, topical acyclovir ointment was administered five times daily. All findings disappeared and visual acuity recovered to 20/20 at 14 days after the first visit. Herpetic keratitis rarely develops in orthokeratology lens wearers as well as contact lens (CL) wearers, although <iAcanthamoeba</i keratitis is sometimes erroneously diagnosed as herpetic keratitis in CL wearers with dendrites." }, { "id": "wiki20220301en100_51067", "title": "Acanthamoeba keratitis", "score": 0.01264367816091954, "content": "Diagnosis Due to the relative rarity of Acanthamoeba keratitis (AK) compared to other causes of keratitis (bacterial, viral, etc.), it is often misdiagnosed, especially in the early stages of the disease. AK should be considered in all patients who use contact lenses, and following corneal abrasions or trauma. A thorough history should be obtained, especially relating to contact lens use and any recent changes contact in lens solution, exposure of the eyes to water or foreign objects, and symptoms that the patient is experiencing. The symptoms classically attributed to AK include decreased or blurred vision, sensitivity to light (photophobia), redness of the eye (conjunctival hyperemia), and pain out of proportion to physical exam findings. Another clinical feature that can distinguish Acanthamoeba from bacterial causes of keratitis is a lack of discharge from the eye." }, { "id": "wiki20220301en103_19793", "title": "Fungal keratitis", "score": 0.012558962264150944, "content": "Pathophysiology The precipitating event for fungal keratitis is trauma with a vegetable / organic matter. A thorn injury, or in agriculture workers, trauma with a wheat plant while cutting the harvest is typical. This implants the fungus directly in the cornea. The fungus grows slowly in the cornea and proliferates to involve the anterior and posterior stromal layers. The fungus can break through the descemet's membrane and pass into the anterior chamber. The patient presents a few days or weeks later with fungal keratitis. Diagnosis The diagnosis is made by an ophthalmologist/optometrist correlating typical history, symptoms and signs. Many times it may be missed and misdiagnosed as bacterial ulcer. A definitive diagnosis is established only after a positive culture report (lactophenol cotton blue, calcoflour medium), typically taking a week, from the corneal scraping. Recent advances have been made in PCR ref 3./immunologic tests which can give a much quicker result." }, { "id": "wiki20220301en150_20958", "title": "Corneal ulcer", "score": 0.012482389405466329, "content": "Many micro-organisms cause infective corneal ulcer. Among them are bacteria, fungi, viruses, protozoa, and chlamydia: Bacterial keratitis is caused by Staphylococcus aureus, Streptococcus viridans, Escherichia coli, Enterococci, Pseudomonas, Nocardia, N. Gonorrhoea and many other bacteria. Fungal keratitis causes deep and severe corneal ulcer. It is caused by Aspergillus sp., Fusarium sp., Candida sp., as also Rhizopus, Mucor, and other fungi. The typical feature of fungal keratitis is slow onset and gradual progression, where signs are much more than the symptoms. Small satellite lesions around the ulcer are a common feature of fungal keratitis and hypopyon is usually seen. Viral keratitis causes corneal ulceration. It is caused most commonly by Herpes simplex, Herpes zoster and Adenoviruses. Also it can be caused by coronaviruses & many other viruses. Herpes virus cause a dendritic ulcer, which can recur and relapse over the lifetime of an individual." }, { "id": "pubmed23n1013_5283", "title": "Epipremnum aureum Keratopathy: Case Report and Review of the Literature.", "score": 0.012355356476297125, "content": "To report a novel case of Epipremnum aureum toxicity masquerading as bilateral infectious keratitis and review the literature on ocular manifestations of Epipremnum exposure. Case report and literature review. A 70-year-old man with a history of photorefractive keratectomy presented with a 3-day history of bilateral eye pain. The patient reported exposure to plant debris while performing yard work and also water exposure while cleaning his coral fish tanks. Clinical examination revealed bilateral epitheliopathy progressing to frank epithelial defects with underlying stromal necrosis 6 days after exposure. Empiric topical antibiotic drops were initiated, but multiple cultures, corneal biopsy, and confocal microscopy were all negative for an infectious agent. Over a 2-week period, the epithelial defects worsened and a suspicion for a toxic etiology was raised. The patient later recalled rubbing his eyes after exposure to Epipremnum aureum (Golden Pothos/Devils Ivy) sap. He was thus treated conservatively with artificial tears, topical corticosteroids, and amniotic membrane. After 3 months, the epithelial defects resolved, but with corneal scarring, prominently in the left eye and underwent penetrating keratoplasty. Five years after presentation, best-corrected visual acuity with hard contact lenses was 20/25 in the right eye and 20/20 in the left eye. Epipremnum aureum toxicity is a rare cause of keratitis. It can mimic acanthamoeba keratitis or anesthetic abuse and should be considered in cases of culture negative nonhealing corneal ulcerations. Eliciting a history of plant sap exposure can facilitate appropriate supportive care for this toxic keratitis." }, { "id": "wiki20220301en386_27944", "title": "Herpes simplex keratitis", "score": 0.012139689578713968, "content": "Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea. It begins with infection of epithelial cells on the surface of the eye and retrograde infection of nerves serving the cornea. Primary infection typically presents as swelling of the conjunctiva and eyelids (blepharoconjunctivitis), accompanied by small white itchy lesions on the corneal surface. The effect of the lesions varies, from minor damage to the epithelium (superficial punctate keratitis), to more serious consequences such as the formation of dendritic ulcers. Infection is unilateral, affecting one eye at a time. Additional symptoms include dull pain deep inside the eye, mild to acute dryness, and sinusitis. Most primary infections resolve spontaneously in a few weeks. Healing can be aided by the use of oral and topical antivirals." }, { "id": "wiki20220301en103_19791", "title": "Fungal keratitis", "score": 0.011707700366684129, "content": "Fungal keratitis is a fungal infection of the cornea, which can lead to blindness. It generally presents with a red, painful eye and blurred vision. There is also increased sensitivity to light, and excessive tears or discharge. It is caused by fungal organisms such as Fusarium, Aspergillus or Candida. Fungal keratitis has a worldwide distribution, but is more common in the tropics. Around 1 million people become blind every year due to fungal keratitis. Theodor Leber first described a case of fungal keratitis caused by Aspergillus in 1879. Signs and symptoms The symptoms of fungal keratitis typically emerge over 5-10 days and present with a painful eye, blurred vision, and redness of eye. There is increased sensitivity to light, and excessive tears or discharge. The symptoms are markedly less as compared to a similar bacterial ulcer. Symptoms may be noted to persist after contact lenses are removed, or following antibiotic treatment." }, { "id": "wiki20220301en386_27948", "title": "Herpes simplex keratitis", "score": 0.011537729565134647, "content": "In immune deficient patients or with the use of corticosteroids the ulcer may become large and in these cases it is called geographic ulcer. Disciform keratitis (Endothelial keratitis) Endothelial keratitis manifests a central endothelitis in a disc-shaped manner. Longstanding corneal edema leads to permanent scarring and is the major cause of decreased vision associated with HSV. Localized endothelitis (localized inflammation of corneal endothelial layer) is the cause of disciform keratitis. Other forms Metaherpetic ulcer : is not due to live virus, results from inability of the corneal surface to heal. Necrotizing keratitis Keratouveitis : is usually granulomatous uveitis with large keratic precipitates on the corneal endothelium. Cause HSV is a double-stranded DNA virus that has icosahedral capsid. HSV-1 infections are found more commonly in the oral area and HSV-2 in the genital area. Ocular herpes simplex is usually caused by HSV-1. Diagnosis" }, { "id": "wiki20220301en103_19792", "title": "Fungal keratitis", "score": 0.011204481792717087, "content": "Signs: The eyelids and adnexa involved shows edema and redness, conjunctiva is chemosed. Ulcer may be present. It is a dry looking corneal ulcer with satellite lesions in the surrounding cornea. Usually associated with fungal ulcer is hypopyon, which is mostly white fluffy in appearance. Rarely, it may extend to the posterior segment to cause endophthalmitis in later stages, leading to the destruction of the eye. (Note: Fungal endophthalmitis is extremely rare) Causes Fungal keratitis has been reported to be caused by more than 70 different fungi, of which Fusarium, Aspergillus and Candida are responsible for 95% of cases. A. flavus and A. fumigatus are the most common types of Aspergillus to cause fungal keratitis. F. Solani is the most common type of Fusarium and others include Curvularia and Acremonium. C. albicans, C. guilliermondii and C. parapsilosis are the main types of Candida to cause fungal keratitis." }, { "id": "article-23858_54", "title": "Herpes Simplex Keratitis -- History and Physical -- Corneal Epithelial Disease (Dendritic/Geographical Keratitis)", "score": 0.011188876664872076, "content": "A past history of epithelial dendrite or a geographical is not always present, and a differential diagnosis of acanthamoeba and fungal keratitis should always be kept in mind." }, { "id": "article-23857_29", "title": "Fungal Keratitis -- Differential Diagnosis", "score": 0.010897435897435897, "content": "Bacterial keratitis Acanthamoeba keratitis Necrotizing herpetic keratitis" }, { "id": "wiki20220301en103_19796", "title": "Fungal keratitis", "score": 0.010533927454659163, "content": "Prognosis The infection typically takes a long time to heal, since the fungus itself is slow growing. Corneal perforation can occur in patients with untreated or partially treated infectious keratitis and requires surgical intervention in the form of corneal transplantation. Epidemiology This disease is quite common in the tropics and with large agrarian population. India has a high number of cases with fungal keratitis, but poor reporting system prevents accurate data collection. Florida in US regularly reports cases of fungal keratitis, with Aspergillus and Fusarium spp. as the most common causes. According to the Global Action Fund for Fungal Infections, every year there are around 1 million cases of blindness due to fungal keratitis. History A case of fungal keratitis caused by Aspergillus was first described by Theodor Leber in 1879, in a 54 year old farmer who injured his eye." }, { "id": "wiki20220301en063_19362", "title": "Corneal abrasion", "score": 0.0104767336248231, "content": "About 3 per 1,000 people are affected a year in the United States. Males are more often affected than females. The typical age group affected is those in their 20s and 30s. Complications can include bacterial keratitis, corneal ulcer, and iritis. Complications may occur in up to 8% of people. Signs and symptoms Signs and symptoms of corneal abrasion include pain, trouble with bright lights, a foreign-body sensation, excessive squinting, and reflex production of tears. Signs include epithelial defects and edema, and often redness of the eye. The vision may be blurred, both from any swelling of the cornea and from excess tears. Crusty buildup from excess tears may also be present. Complications Complications are the exception rather than the rule from simple corneal abrasions. It is important that any foreign body be identified and removed, especially if containing iron as rusting will occur." }, { "id": "article-81120_55", "title": "Acanthamoeba Keratitis -- Differential Diagnosis", "score": 0.010358291226458429, "content": "Unlike patients with uncomplicated bacterial or fungal keratitis, patients with AK tend to be younger and often experience a more extended duration of symptoms at the initial presentation. [60] However, AK has been observed to coexist frequently with bacterial and fungal keratitis. [61] Consequently, the degree to which patients’ demographic factors should be considered in formulating a differential diagnosis remains unclear. The differential diagnosis for AK includes the following: Contact lens-associated keratitis Conjunctivitis Dry eye HSK: presents with dendritic or geographic ulcers Recurrent corneal erosion Staphylococcal marginal keratitis Fungal keratitis: has thicker infiltrates and is typically monofocal Bacterial keratitis" }, { "id": "article-140029_67", "title": "Bacterial Keratitis -- Differential Diagnosis -- Non- infective", "score": 0.010026737967914439, "content": "Peripheral Ulcerative keratitis Marginal keratitis Mooren’s Ulcer Toxic keratitis Sterile inflammatory corneal infiltrate" }, { "id": "wiki20220301en386_27945", "title": "Herpes simplex keratitis", "score": 0.009936065401949482, "content": "Subsequent recurrences may be more severe, with infected epithelial cells showing larger dendritic ulceration, and lesions forming white plaques. The epithelial layer is sloughed off as the dendritic ulcer grows, and mild inflammation (iritis) may occur in the underlying stroma of iris. Sensation loss occurs in lesional areas, producing generalised corneal anaesthesia with repeated recurrences. Recurrence can be accompanied by chronic dry eye, low grade intermittent conjunctivitis, or chronic unexplained sinusitis. Following persistent infection the concentration of viral DNA reaches a critical limit. Antibody responses against the viral antigen expression in the stroma can trigger a massive immune response in the eye. The response may result in the destruction of the corneal stroma, resulting in loss of vision due to opacification of the cornea. This is known as immune-mediated stromal keratitis." }, { "id": "wiki20220301en100_5678", "title": "List of MeSH codes (C11)", "score": 0.00980392156862745, "content": "– eye hemorrhage – choroid hemorrhage – hyphema – retinal hemorrhage – vitreous hemorrhage – eye infections – corneal ulcer – eye infections, bacterial – conjunctivitis, bacterial – conjunctivitis, inclusion – ophthalmia neonatorum – trachoma – hordeolum – keratoconjunctivitis, infectious – tuberculosis, ocular – uveitis, suppurative – endophthalmitis – panophthalmitis – eye infections, fungal – uveitis, suppurative – endophthalmitis – panophthalmitis – eye infections, parasitic – acanthamoeba keratitis – onchocerciasis, ocular – toxoplasmosis, ocular – eye infections, viral – conjunctivitis, viral – conjunctivitis, acute hemorrhagic – cytomegalovirus retinitis – herpes zoster ophthalmicus – keratitis, herpetic – keratitis, dendritic – eye manifestations" }, { "id": "pubmed23n0896_19762", "title": "Successful Medical Management of Presumptive Pythium insidiosum Keratitis.", "score": 0.00980392156862745, "content": "To describe the previously unreported successful treatment of presumptive Pythium keratitis (PK) with medical therapy alone. A 42-year-old female homemaker presented to us with a 15-day history of pain and redness in the right eye after a trivial injury. Her vision was 20/80 at presentation. Slit-lamp biomicroscopy revealed a central, dense and dry-looking, grayish-white infiltrate reaching mid stroma. The infiltrate had feathery margins and was surrounded by multiple tentacle-like lesions and peripherally expanding pinhead-sized subepithelial lesions. The contralateral eye was essentially normal. Diagnostic corneal scraping on smears revealed broad, aseptate, hyaline filaments with ribbon-like folds; very characteristic of Pythium species. Confocal imaging revealed fungal filaments. Based on corroborative evidence, a diagnosis of presumptive PK was made. She was administered a combination therapy consisting of eye drop linezolid 0.2% 1 hourly, azithromycin 1% 2 hourly, atropine sulfate 1% thrice daily, and oral azithromycin 500 mg once daily for 3 days in a week. After initial worsening in the form of stromal expansion, regression of pinhead-sized lesions was seen with onset of scarring by as early as day 4 of intense medical therapy. The tentacle-like lesions did not worsen. On day 8, significant resolution was noted with scarring, and by the end of 2 weeks, the entire stromal lesion had scarred and complete resolution of expanding tentacles was observed in 3 weeks. Presumptive Pythium keratitis of the patient completely resolved with antibacterial treatment alone. It is pertinent for ophthalmologists to be aware of this new treatment regimen." }, { "id": "wiki20220301en100_5676", "title": "List of MeSH codes (C11)", "score": 0.009615384615384616, "content": "– corneal diseases – corneal dystrophies, hereditary – Fuchs' endothelial dystrophy – corneal edema – corneal neovascularization – corneal opacity – arcus senilis – keratitis – acanthamoeba keratitis – corneal ulcer – keratitis, herpetic – keratitis, dendritic – keratoconjunctivitis – keratoconjunctivitis, infectious – keratoconjunctivitis sicca – keratoconus – trachoma – eye abnormalities – aniridia – WAGR syndrome – anophthalmos – blepharophimosis – coloboma – ectopia lentis – hydrophthalmos – microphthalmos – retinal dysplasia" }, { "id": "pubmed23n0392_1627", "title": "[The clinical features and study on therapeutic effects of fungal keratitis].", "score": 0.009615384615384616, "content": "To review the clinical features and therapeutic effects of fungal keratitis (FK). 110 cases (110 eyes) with the disease were divided into two types: hyphomycetic keratitis in 94 eyes and candida keratitis in 16 eyes. The clinical features and therapeutic effects of the two types were observed and compared. The hyphomycetic keratitis generally had a plant traumatic history. The border of corneal infiltration was not clear with feather edges, and had a tendency to penetrate into the deep stroma of cornea. There were endothelial plaques, hypopyon and bad therapeutic effects. The pathogenicity of cardida keratitis (CK) was related to the local long-term use of glucocorticoid, the fungus seldom expanded into the deep corneal layers and infiltrated into the inner eye. Its therapeutic effects were better. The border of CK was characterized with limitations, and was clear. The clinical features of the two types are different. The clinical features caused by different or the same pathogenic fungi show great variations. Early diagnoses, correct use of medicine and operation are the key points to increase the curative rate." }, { "id": "article-135487_30", "title": "Pythium Keratitis -- Differential Diagnosis", "score": 0.009523809523809525, "content": "Fungal keratitis Bacterial keratitis Atypical Mycobacterial keratitis Acanthamoeba keratitis Necrotizing viral keratitis" }, { "id": "article-30728_11", "title": "Corneal Ulcer -- Evaluation", "score": 0.009434703986162434, "content": "The patient with HSV keratitis or corneal ulcer will usually present similarly to the patient with bacterial keratitis. They will often have foreign body sensation, photophobia, conjunctival injection, and blurred vision. Slit lamp exam will classically reveal dendritic lesions with fluorescein uptake. [5]" }, { "id": "pubmed23n0567_18014", "title": "[Severe microbial keratitis: report of 100 cases].", "score": 0.009433962264150943, "content": "To study predisposing factors, clinical aspects, and microbiological diagnosis in severe microbial keratitis, and to discuss the therapy and visual outcome. and methods: A prospective and retrospective study concerning patients presenting microbial keratitis hospitalized in department B of the Hedi Raies Ophthalmology Institute (Tunis, Tunisia), from August 1996 to November 2004. One hundred patients with microbial keratitis were hospitalized (45 females and 55 males; ranging in age from 11 to 87 years). The principal predisposing factors were ocular surface pathology (30%), ocular trauma (28%), prior ocular surgery (17%), and contact lens wear (8%). The corneal scraping culture was positive in 42% of cases, isolating Gram-positive bacteria (48.6%), Gram-negative bacteria (29.7%), and fungi (21.6%). The majority of our patients (93%) had broad-spectrum topical antibiotics with therapeutic success in 53.8% of cases. Systemic antifungal agents were indicated in 17 cases. Surgery was necessary in 25.8% of cases: therapeutic keratoplasty in five cases and deleted keratoplasty in nine cases. Final visual acuity was equal to or better than at admission in 81% of cases. Anatomic loss of the eye was observed in eight cases (evisceration, six cases; enucleation, two cases). microbial keratitis is a frequent and severe pathology that can lead to blindness. Only early and adapted management can improve the prognosis of severe microbial keratitis." }, { "id": "pubmed23n0562_13964", "title": "[Painless acanthamoeba keratitis].", "score": 0.009345794392523364, "content": "A 37-year-old contact lens wearer was treated for herpes simplex keratitis. After an initial improvement the keratitis became much worse. An annular infiltrate gave rise to the suspicion of acanthamoeba keratitis even though the patient was not in pain. This diagnosis was confirmed by histological and microbiological examination of the corneal disc after keratoplasty. Acanthamoeba keratitis should be considered even in the absence of pain, especially when the patients are contact lens wearers." }, { "id": "wiki20220301en019_39403", "title": "Keratitis", "score": 0.00933641975308642, "content": "Keratitis is a condition in which the eye's cornea, the clear dome on the front surface of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves any of the following symptoms: pain, impaired eyesight, photophobia (light sensitivity), red eye and a 'gritty' sensation. Classification (by chronicity) Acute Acute epithelial keratitis Nummular keratitis Interstitial keratitis Disciform keratitis Chronic Neurotrophic keratitis Mucous plaque keratitis Classification (infective) Viral Herpes simplex keratitis (dendritic keratitis). Viral infection of the cornea is often caused by the herpes simplex virus (HSV) which frequently leaves what is called a 'dendritic ulcer'. Herpes zoster keratitis, associated with herpes zoster ophthalmicus, which is a form of shingles." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 209, 284 ] ], "word_ranges": [ [ 28, 41 ] ], "text": "Aspergillus is resistant to fluconazole, so it would not be a valid option." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 26, 208 ] ], "word_ranges": [ [ 3, 28 ] ], "text": "This is a patient undergoing chemotherapy with respiratory symptoms and the \"halo sign\" on X-ray, very suggestive of invasive pulmonary aspergillosis. Treatment is with voriconazole." } }

{ "1": "Ganciclovir.", "2": "Caspofungin.", "3": "Fluconazole.", "4": "Piperacillin-tazobactam.", "5": "Voriconazole." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0823_20755", "title": "[Pulmonary infection in neutropenia].", "score": 0.018967997123336928, "content": "MEDICAL HISTORY AND CLINICAL COURSE: A 42-year-old patient with hairy cell leukemia had been treated for 3 years by a hematologist in private practice. Initially the patient received 1 course of cladribine upon which the disease went into complete remission. 6 weeks ago a relapse was diagnosed and combination therapy with cladibrin and rituximab was initiated. Now the patient presented to the emergency room with shortness of breath and pain when breathing. In the chest x-ray, patchy infiltrates and pleural effusions were found on both sides. The subsequently performed computed tomography showed bilateral compactions with an Halo suspicious for fungal infiltrates. Upon admission to the hospital, an empirical antibiotic therapy with clarithromycin and piperacillin/tazobactam was initiated, which was later escalated to meropenem and linezolid. Additionally, an antifungal therapy with voriconazole was started and later switched to liposomal amphotericin B. At his admission, a positive aspergillus antigen could be detected in the microbiological laboratory. Under antimycotic treatment the aspergillus antigen was repeatedly negative. The patient presented with pronounced cytopenias and after a switch of therapy to vemurafenib and filgrastim, the hematopoiesis could only be stimulated insufficiently. The patient was transferred to the intensive care unit three days after admission with severe respiratory failure. He died on day 8 after admission. AUTOPSY AND DIAGNOSIS: Diagnosis was consistent with relapse of hairy cell leukemia with positive BRAF mutation and a bone marrow infiltration &gt; 80 %. Autopsy revealed a significant hepato-splenomegaly, a lack of erythro-, granulo- and thrombopoiesis. Clots interspersed with fungal hyphae were found in both lungs and an infarction of the spleen with evidence of fungal hyphae was detected. The cultural findings post mortem on yeast or mold were negative. Patients with refractory hairy cell leukemia and prolonged neutropenia are at increased risk for systemic fungal infections. Therefore, prohylactic antimycotic therapy should be considered early in this group of patients. The therapeutic approach of vemurafenib in treatment-refractory hairy cell leukemia is promising and offers an additional treatment option. In the present case, the patient could unfortunately not be stabilized due to the septic complications." }, { "id": "pubmed23n0630_17318", "title": "Likelihood of inadequate treatment: a novel approach to evaluating drug-resistance patterns.", "score": 0.01487612247105918, "content": "To provide a novel way to predict the likelihood that antibiotic therapy will result in prompt, adequate therapy on the basis of local microbiological data. Prospective study conducted at 3 medical intensive care units at the Viennese General Hospital, a tertiary care medical university teaching hospital in Vienna, Austria. One hundred one patients who received mechanical ventilation and who met the criteria for having ventilator-associated pneumonia. Fiberoptic bronchoscopic examination was performed, and bronchoalveolar samples were collected. Samples were analyzed immediately by a single technician. Minimum inhibitory concentrations were determined for imipenem, cephalosporins (cefepime and cefpirome), ciprofloxacin, and piperacillin-tazobactam, and drug resistance rates were calculated. These drug resistance rates were translated into the likelihood of inadequate therapy (LIT; the frequency of inadequately treated patients per antibiotic and drug-resistant strain), cumulative LIT (the cumulative frequency of inadequately treated patients), and syndrome-specific LIT. Among the 101 bronchoalveolar samples, culture yielded significant (at least 1 x 10(4) colony-forming units per mL) polymicrobial findings for 34 and significant monomicrobial findings for 31; 36 culture results were negative. Of the isolates from patients with ventilator-associated pneumonia who had monomicrobial culture findings, 33% were gram-positive bacteria and 20% were gram-negative bacteria. LIT suggested that 1 of 2 patients was treated inadequately for Pseudomonas aeruginosa infection. The LIT for patients with ventilator-associated pneumonia revealed that the rank order of antibiotics for appropriate therapy was (1) imipenem, (2) cephalosporins, (3) ciprofloxacin, and (4) piperacillin-tazobactam. These calculations were based solely on microbiological data. The novel ratio LIT may help clinicians use microbiological data on drug resistance to predict which antimicrobial agents will provide adequate therapy. In daily practice, this new approach may be helpful for choosing adequate antimicrobial therapy." }, { "id": "wiki20220301en116_5569", "title": "Hospital-acquired pneumonia", "score": 0.013834154351395732, "content": "In 2005, the American Thoracic Society and Infectious Diseases Society of America have published guidelines suggesting antibiotics specifically for HCAP. The guidelines recommend combination therapy with an agent from each of the following groups to cover for both Pseudomonas aeruginosa and MRSA. This is based on studies using sputum samples and intensive care patients, in whom these bacteria were commonly found. cefepime, ceftazidime, imipenem, meropenem or piperacillin–tazobactam; plus ciprofloxacin, levofloxacin, amikacin, gentamicin, or tobramycin; plus linezolid or vancomycin In one observational study, empirical antibiotic treatment that was not according to international treatment guidelines was an independent predictor of worse outcome among HCAP patients." }, { "id": "pubmed23n0637_14928", "title": "Successful voriconazole treatment of invasive pulmonary aspergillosis in a patient with acute biphenotypic leukemia.", "score": 0.013602941176470588, "content": "A 23-year old woman with acute biphenotypic leukemia (ABL) complained of chest pain with cough, high fever and hemoptysis during induction chemotherapy, although she had been treated with anti-biotics and micafungin. We made a clinical diagnosis of invasive pulmonary aspergillosis (IPA) based on a consolidation in the right upper lung field on a chest radiograph as well as a high level of serum beta-D-glucan (with no evidence of tuberculosis and candidiasis). We changed her treatment from micafungin to voriconazole. Later, we discovered an air-crescent sign by CT scan that supported the diagnosis of IPA. Following voriconazole treatment, clinical symptoms ceased and abnormal chest shadows improved gradually and concurrently with a recovery of neutrophils. IPA must be considered in immunocompromised patients with pulmonary infiltrates who do not respond to broad-spectrum antibiotics. Serological tests and CT findings can aid in early diagnosis of IPA, which, along with treatment for IPA, will improve clinical outcomes." }, { "id": "pubmed23n0881_711", "title": "[A well-inked pneumonia… can you decrypt it?]", "score": 0.011976477337923121, "content": "We report a case of pneumonia associated with necrotic mediastinal lymph nodes in an immunocompetent patient. The case report illustrates the difficulties in making a diagnosis in necrotic mediastinal lymph nodes and discusses strategies to optimize sampling. A 21-year-old immunocompetent woman was admitted to hospital with dyspnea and fever occurring ten days after delivery. Physical examination, biological results and chest X-ray led to the diagnosis of right upper lobe pneumonia. Treatment with three broad-spectrum antibiotics was ineffective. Thoracic CT-scan showed compressive mediastinal and hilar necrotic adenopathies and consolidation of the right upper lobe. Bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration was non-diagnostic. A second bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration performed in close collaboration with the mycology laboratory led to the diagnosis of cryptococcosis. Antifungal therapy with fluconazole resulted in a complete resolution of clinical and radiological signs. Although it is extremely rare, pulmonary cryptococcosis should be considered in immunocompetent patients presenting with necrotic pneumonia. Effectiveness of lymph node sampling can be improved by collaboration between clinicians and microbiologists." }, { "id": "wiki20220301en045_78672", "title": "Aspiration pneumonia", "score": 0.010400616332819723, "content": "Treatment The main treatment of aspiration pneumonia revolves around the use of antibiotics to remove the bacteria causing the infection. Broad antibiotic coverage is required to account for the diverse types of bacteria possibly causing the infection. Currently recommended antibiotics include clindamycin, meropenem, ertapenem, ampicillin/sulbactam, and moxifloxacin. Treatment with piperacillin/tazobactam, cefepime, levofloxacin, imipenem, or meropenem is recommended in cases of potential antibiotic resistance. The typical duration of antibiotic therapy is about 5 to 7 days. If there is a large accumulation of fluid within the lungs, drainage of the fluid may also aid in the healing process." }, { "id": "wiki20220301en428_31920", "title": "Phialemonium curvatum", "score": 0.010023877100509077, "content": "Other infections Phialemonium curvatum is known to cause vascular infection in patients undergoing hemodialysis. One of the sources of contamination was found to be contaminated water; other sources may have been renal grafts and bone marrow transplants. There was a report of P. curvatum affecting the lower spine and respiratory system and causing an abscess with purulent material in the middle. The course of treatment included antifungal medications, such amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole and caspofungin, as well as removal of the cyst. References Fungi described in 1983 Sordariales" }, { "id": "wiki20220301en195_22213", "title": "Febrile neutropenia", "score": 0.009900990099009901, "content": "In 2010, updated guidelines were issued by the Infectious Diseases Society of America, recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), or piperacillin/tazobactam for high-risk patients and amoxicillin-clavulanic acid and ciprofloxacin for low-risk patients. Patients who do not strictly fulfill the criteria of low-risk patients should be admitted to the hospital and treated as high-risk patients. Research to compare antibiotic treatments currently recommended in consensus guidelines identified 44 studies comparing different antibiotics. Significantly higher mortality was reported for cefepime compared to all other antibiotics combined. Piperacillin/tazobactam resulted in lower mortality than other antibiotics. Piperacillin/tazobactam might be the preferred antibiotic for the treatment of cancer patients with fever and neutropenia, while cefepime should not be used." }, { "id": "pubmed23n0660_8848", "title": "[A case of ventilator-associated pneumonia caused by Cupriavidus pauculus].", "score": 0.009900990099009901, "content": "Cupriavidus pauculus (formerly CDC Group IVc-2) is a non-fermentative, motile, gram-negative bacillus, rarely associated with human infections. It has been isolated from water, water from ultrafiltration systems and bottled mineral water. To date, 19 cases of bacteremia, two cases of peritonitis and one case of tenosynovitis associated with C. pauculus have been reported in English literature. In this paper, we report the first case of C. pauculus ventilator-associated pneumonia (VAP) in Turkey. A 47 years-old female with breast cancer was performed total mastectomy six years ago and received six cures of chemotherapy after surgery. The patient was hospitalized in medical oncology clinic with complaints of weight loss, nausea and vomiting for one year. Since she had problems of consiousness, dysphagia and pitosis, lumbar puncture was performed to rule out central nervous system infection or metastasis. Cryptococcal meningitis was diagnosed upon the examination of Indian-ink stained smear of cerebrospinal fluid and amphotericin B was initiated. On the 11th day of her follow up, she developed respiratory distress and was transferred to pulmonary intensive care and underwent invasive mechanical ventilator (IMV) therapy. On the 4th day of IMV; a new infiltration was detected on the upper zone of chest X-ray in addition to fever (38.3 degrees C) and intense endotracheal secretion. Therefore, bronchoscopic examination was performed and bronchoalveolar lavage and bronchoscope aspiration materials were obtained and cultivated. Bacteria grown at blood agar and EMB agar after 48 hours of incubation were stained as gram-negative bacilli and identified as C. pauculus by VITEK 2 compact system (bioMérieux Inc, USA). The strain was susceptible to ceftazidime, ciprofloxacin, imipenem, trimethoprim-sulfamethoxazole, piperacilin/tazobactam and resistant to amikacin. The case was considered as C. pauculus VAP and imipenem (500 mg, 4 x 1) for 14 days was initiated. Clinical and microbiological resolution was achieved by imipenem therapy. In conclusion, rare pathogens like C. pauculus should be considered among the possible causative agents in infections that develop in immunocompromised host." }, { "id": "wiki20220301en059_34175", "title": "Piperacillin", "score": 0.00980392156862745, "content": "Pneumonia The piperacillin-tazobactam (piptaz) antibiotic commonly used with an aminoglycoside retains similar levels of drug safety and efficacy as other antibiotic combinations such as ceftazidime with the aminoglycoside tobramycin in the treatment of patients with hospital acquired pneumonia. In a clinical comparison primarily targeting patients not initially placed in intensive care units, piperacillin-tazobactam was found to produce higher clinical and microbiological rates of success. By contrast, the drug efficacy of ceftazidime and piperacillin-tazobactam resulted in similar response rates (61.5% and 63.9 respectively) when tobramycin was added into both groups. Identical evaluations are shown when compared to the imipenem and tobramycin combination, where the administration of piperacillin-tazobactam on patients (especially those under mechanical ventilation) was only consisted of a slightly higher response rate." }, { "id": "pubmed23n1161_14635", "title": "Case report: Simultaneous occurrence of primary pulmonary lymphoma and opportunistic infections in a patient with chronic myeloid leukemia.", "score": 0.00980392156862745, "content": "The occurrence of primary pulmonary lymphoma (PPL) as a secondary malignancy in patients diagnosed with chronic myeloid leukemia (CML) is extremely rare. As the clinical manifestations are atypical, most patients with PPL tend to be misdiagnosed with pneumonia. When the radiographic features of PPL and pulmonary infection overlap, clinicians can be confused about the diagnosis. Here, we report the first case of coexistence of PPL and opportunistic infections in a patient with CML in chronic phase (CML-CP). A 55-year-old woman presented with three weeks of hemorrhage of the oral mucosa at the Department of Hematology. After undergoing various examinations, she was diagnosed with CML-CP and was started on imatinib (400 mg/daily). Due to sudden respiratory distress, the patient was admitted to the respiratory intensive care unit 11 months later. Chest computed tomography (CT) revealed ground-glass opacities, patchy shadows, and multiple nodules in both lungs and enlarged mediastinal lymph nodes. The combination of biapenem and voriconazole antibiotic treatments was effective. The patient's respiratory distress was relieved, but there was intermittent coughing. In the following time, the patient developed a fever, and the imaging findings indicated progression of the disease in both lungs. Bronchoalveolar lavage (BAL) identified pathogens of multiple opportunistic infections. The coexistence of lymphomatoid granulomatosis (LYG) was not confirmed in this patient until a second CT-guided biopsy was performed. Ultimately, the patient underwent chemotherapy in time and is currently alive today. When the patient's recurrent respiratory symptoms and imaging findings do not coincide, secondary tumors should be considered in addition to infection as a diagnosis. In these cases, multiple pathological tissue biopsies should be performed." }, { "id": "wiki20220301en028_70423", "title": "Coccidioides immitis", "score": 0.009773291676680285, "content": "Several case reports have studied caspofungin, with differing results. Caspofungin 50 mg/day following administration of amphotericin B in a patient with acute pulmonary coccidioidomycosis who had undergone transplantation showed promising results. In a patient with disseminated coccidioidomycosis, first-line therapy with amphotericin B and caspofungin alone failed to elicit a response, but the patient was then given caspofungin combined with fluconazole, with good results. A published report described a patient with disseminated and meningeal coccidioidomycosis in whom conventional therapy with fluconazole, voriconazole, and amphotericin B failed; caspofungin 50 mg/day after a loading dose of 70 mg intravenously was also unsuccessful." }, { "id": "pubmed23n0394_6733", "title": "[Invasive aspergillosis in the leukemic patient].", "score": 0.009724170172978028, "content": "Invasive pulmonary aspergillosis (IPA) remains a life threatening complication in immuno-compromised and especially in neutropenic patients. We report our experience in the diagnosis and therapeutic management of IPA in 8 patients with acute leukemia. All patients were neutropenic (PNN &lt; 100/mm3, mean duration = 37 days) when IPA was diagnosed. Clinical signs included fever above 39 degrees and cough in all cases, chest pain in 4 cases, hemoptysis in 3 cases, rales in 5 cases. Chest x ray showed one lesion in 4 cases and multiple lesions in 4 cases. The diagnosis of IPA was established by bronchoalveolar lavage (BAL) in 5 cases, tissue biopsy in one case, positive sputum in one case and it was highly probable in one case. Thoracic computed tomographic (CT) scans were preformed after diagnosis confirmation of IPA and showed one or multiple lesions with air crescent signs. Serological tests were positive in 4 cases late in the course of IPA. All patients were treated with i.v. Amphotericin B. Outcome was favorable in 5 cases and three patients died by massive hemoptysis (in two cases) and systemic aspergillosis (in one case). Early diagnosis and appropriate treatment are essential to improve IPA prognosis." }, { "id": "pubmed23n1037_13802", "title": "Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy.", "score": 0.009708737864077669, "content": "Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir." }, { "id": "pubmed23n0128_10207", "title": "Invasive pulmonary aspergillosis in acute leukemia: characteristic findings on CT, the CT halo sign, and the role of CT in early diagnosis.", "score": 0.009615384615384616, "content": "Invasive pulmonary aspergillosis (IPA) in immunocompromised patients is often difficult to diagnose. Many pathogens present initially with similar, nonspecific pulmonary findings. Air crescent formation has been reported to be highly suggestive of IPA in the appropriate clinical setting, but this is a late sign in an otherwise rapidly fatal infection. The authors reviewed the available chest computed tomography (CT) scans of nine patients with acute leukemia and documented IPA, including four patients with serial scans obtained during the course of infection. Typical CT findings of IPA were multiple inflammatory nodules, often with one large dominant mass, or a single peripheral masslike infiltrate. Cavitation or air crescent formation occurred late in the course of infection, usually at the time of bone marrow recovery from chemotherapy. CT scans obtained early in the course of infection in two patients demonstrated a distinctive feature of one or more pulmonary masslike infiltrates surrounded by a halo of low attenuation. These lesions subsequently progressed to cavitation or air crescent formation typical of IPA. While this CT halo sign may not be pathognomonic for Aspergillus, seen in the appropriate host, it may suggest early on the possibility of IPA." }, { "id": "pubmed23n0908_5559", "title": "[A case of coccidioidomycosis in Turkey imported from the United States of America].", "score": 0.009615384615384616, "content": "Coccidioidomycosis caused by Coccidioides immitis or Coccidioides posadasii is a rare infectious disease except in endemic regions. In this report the third documented imported case of coccidioidomycosis in Turkey was presented. A thirty-year-old male patient was admitted to our hospital with fever and purulent drainage from his chest tube. He had worked in Arizona, USA, until 4 months before this presentation. While in Arizona, he experienced cough and hemoptysis and was diagnosed as pulmonary coccidioidomycosis. He was treated with itraconazole for two months and he had no symptoms for 3 years. He then returned to Turkey and 2 months after his return to Turkey, he was admitted to another hospital in Istanbul with dyspnea and diagnosed as hydro-pneumothorax, and pleural fluid obtained from the inserted chest tube was found to be purulent. One gram of BID amoxicillin-clavulanate was given. Physical examination on admission revealed a purulent drainage on the right side chest tube, a temperature of 38.5°C and decreased breath sounds on the right lung. Piperacillin-tazobactam 3 x 4.5 g intravenous and fluconazole 400 mg intravenous once daily were started. Human immunodeficiency virus test was negative. Gram-negative diplococci and rods, gram-positive cocci and septate hyphae were seen in the Gram stain of his pleural fluid. Pleural fluid culture revealed Moraxella catarrhalis after 24 hours incubation and a mold after 72 hours of incubation. Anti-coccidioidal antibodies were found positive in a titer of 1/2. Hydro-pneumothorax, atelectasis and a 3 mm nodules in the right lung were seen in his thorax CT. The patient's pleural fluid and the culture plates were sent to the Public Health Institute of Turkey, Mycology Reference Laboratory (PHIT-MRL), with a clinical suspicion of coccidioidomycosis. The specimen and plates were submitted to the PHIT-MRL Bio Safety Level-3 laboratory for mycological evaluation. The microscopic examination of 15% KOH preparations of pleural fluid specimens revealed septate hyphae which appear to be in the early stages of forming arthroconidia. The pleural fluid culture grew buff-white coloured colonies with aerial hyphae, which were suspected of being a Coccidioides spp. The strain was identified as C.immitis/posadasii by direct microscopy and culture, and subsequently confirmed by the FDA-approved DNA probe. DNA sequence analysis of the ITS and D1/D2 rDNA regions confirmed the isolate to be C.posadasii species [ITS 100% match to GenBank Accession No. AB232901 (630/630 base pair match), and D1/D2 100% match to GenBank Accession No. AB232884 (617/617 base pair match)]. ITS1 and ITS2 barcode analysis also confirmed the species to be C.posadasii, which is the species endemic in Arizona. Susceptibility testing was performed according to Clinical and Laboratory Standards Institute M38-A2 guidelines in the Fungus Testing Laboratory of the University of Texas Health Science Center at San Antonio and minimal inhibitory concentration values were; 0.125 µg/ml for amphotericin B, posaconazole and voriconazole, 0.5 µg/ml for itraconazole and 8 µg/ml for fluconazole. He had decortication of the pleura and was discharged from hospital after six weeks treatment with intravenous fluconazole which was continued orally for one year. Anti-coccidioidal antibodies were negative after two months of treatment. The patient is currently asymptomatic. The presented case is the third case reported from Turkey and provides additional contribution to the existing literature with regard to the appearance of arthroconidium, which is the unusual hyphal form, instead of the expected spherules in the infected tissue." }, { "id": "pubmed23n0387_565", "title": "[Diagnosis and therapy of abscess forming pneumonia].", "score": 0.009523809523809525, "content": "Aspiration of oro-pharyngeal secretions and gastric content is the most frequent cause of formation of primary lung abscess. A compromised mental status (e.g. alcoholism, sedatives, stroke) and esophageal dysfunction (e.g. herniation, vomiting) are important risk factors. Aspiration pneumonia presents as a subacute disease and is usually not distinguishable from other causes of pneumonia, until typical radiological signs of cavitation and putrid sputum appear 8 to 14 days after the initial event of aspiration. Anaerobic bacteria play a pivotal role in an almost exclusively mixed spectrum of causative organisms. Aerobic pathogens are also frequently isolated, but whether they are an active part of infection or merely represent colonizers remains unclear in many instances. Differential diagnosis includes bronchial neoplasms, either as necrotizing carcinoma or as the cause of poststenotic cavernous pneumonia, other infectious diseases like tuberculosis, Pneumocystis carinii pneumonia or endocarditis with septic metastases, and lung artery embolism or vasculitis (M. Wegener). Fiberoptic bronchoscopy is extremely helpful in determining cause and etiology of the disease and should be carried out in all patients presenting with cavernous lung lesions. Bacteriological sampling should be performed using protected specimen brushing (PSB) technique. Broncho-alveolar lavage might serve as a less expensive but also less sensitive alternative measure. Since anaerobic bacteria resemble ubiquitous commensals of the oral cavity, sputum is of no use in anaerobic culture. Principal therapeutic strategy is antibiotic therapy for an extended period, usually four weeks to four months, unless radiologic changes and as well laboratory as clinical indicators of infection are completely resolved. Clindamycin, optionally supplemented with a second or third generation cephalosporin and Ampicillin/Sulbactam proved equally effective in treating aspiration pneumonia and primary lung abscess. The role of Moxifloxacin and other new flouroquinolones with their favorable pharmacodynamics is currently evaluated. Provided that antibiotics are prescribed for a sufficient period of time and patients' compliance is ensured, surgical procedures are limited to a negligible number of complications, e.g. recurrent severe hemoptysis, empyema or broncho-pleural fistula." }, { "id": "wiki20220301en028_70422", "title": "Coccidioides immitis", "score": 0.009487391484084333, "content": "In very severe cases, combination therapy with amphotericin B and an azole have been postulated, although no trials have been conducted. Caspofungin in combination with fluconazole has been cited as beneficial in a case report of a 31-year-old Asian patient with coccidioidal pneumonia. In a case report of a 23-year-old Black male with HIV and coccidioidal meningitis, combination therapy of amphotericin B and posaconazole led to clinical improvement. Posaconazole has been approved by the European Commission as a salvage therapy for refractory coccidioidomycosis. Clinical trials are now ongoing for further evaluation. Voriconazole is also being studied in salvage therapy for refractory cases. A case report indicated that voriconazole in combination with amphotericin B as salvage therapy for disseminated coccidioidomycosis was successful." }, { "id": "wiki20220301en337_7076", "title": "Anaerobic infection", "score": 0.009433962264150943, "content": "Empiric antibiotic therapy for health care-associated intra-abdominal should be driven by local microbiologic results. Empiric coverage of likely pathogens may require multidrug regimens that include agents with expanded spectra of activity against gram-negative aerobic and facultative bacilli. These include meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. Aminoglycosides or colistin may be required. Antimicrobial regimens for children include an aminoglycoside-based regimen, a carbapenem (imipenem, meropenem, or ertapenem), a beta-lactam/beta-lactamase-inhibitor combination (piperacillin-tazobactam or ticarcillin-clavulanate), or an advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole." }, { "id": "pubmed23n0378_2162", "title": "[Pneumonia in patients with chronic lymphocytic leukemia. Study of 30 episodes].", "score": 0.009433962264150943, "content": "To analyse the etiology, diagnostic methods and response to therapy in 30 episodes of pneumonia diagnosed in 17 patients with chronic lymphocytic leukemia (CLL) between 1995 and 2000. In each episode of pneumonia the following data were analysed: age, gender, treatment of CLL, antiinfectious prophylaxis, granulocytopenia, CD4/CD8 lymphocytes ratio, hipogammaglobulinemia, origin of pneumonia (nosocomial or community-acquired), localisation, respiratory insufficiency, need for mechanical ventilation, antimicrobial therapy and response. Diagnostic methods included blood and sputum cultures, fiberoptic bronchoscopy and search for antigens in urine (Legionella pneumophila serogroup 1, galactomannan, and Streptococcus pneumoniae). Median age of the series was 60 yr. (range 50-86) and 12 patients were male. Chlorambucil and prednisone were used in 13 cases and fludarabine in 8. Granulocytopenia was present in 14 episodes, hypogammaglobulinemia was seen in 22 and CD4/CD8 ratio was lower than 1 in 8 out of 14 evaluable cases. Etiology of pneumonia was established in 16 episodes (53%). Fiberoptic bronchoscopy was the most useful technique (83% of positive diagnoses) followed by blood cultures (38%). Two patients were diagnosed of aspergillosis at autopsy. Pneumococcus was the most frequent agent (5 cases) followed by Pseudomonas aeruginosa (4), Pneumocystis carinii (2) and Aspergillus fumigatus (2). One out of the two patients with P. carinii pneumonia had received fludarabin and the remaining was treated with prednisone for long time. Ten patients (30%) had died: P. aeruginosa (3 cases), P. carinii (2), A. fumigatus (2), Mycobacterium xenopi (1), and unknown microorganism (2). In this series of CLL patients the frequency of etiologic diagnosis of pneumonias was good. Pneumococcus was the most frequent microorganism. Pneumonias caused by opportunistic microorganisms were associated to the treatment with fludarabin or prednisone and were associated to a high mortality rate." }, { "id": "wiki20220301en005_255", "title": "Cancer", "score": 0.009345794392523364, "content": "A low-carbohydrate diet (ketogenic diet) has been sometimes been recommended as a supportive therapy for cancer treatment. Diagnosis Most cancers are initially recognized either because of the appearance of signs or symptoms or through screening. Neither of these leads to a definitive diagnosis, which requires the examination of a tissue sample by a pathologist. People with suspected cancer are investigated with medical tests. These commonly include blood tests, X-rays, (contrast) CT scans and endoscopy. The tissue diagnosis from the biopsy indicates the type of cell that is proliferating, its histological grade, genetic abnormalities and other features. Together, this information is useful to evaluate the prognosis and to choose the best treatment." }, { "id": "First_Aid_Step2_464", "title": "First_Aid_Step2", "score": 0.009345794392523364, "content": "CSF analysis is not necessary and may precipitate a herniation syndrome. Lab values may show peripheral leukocytosis, ↑ ESR, and ↑ CRP. Initiate broad-spectrum IV antibiotics and surgical drainage (aspiration or excision) if necessary for diagnostic and/or therapeutic purposes. Lesions < 2 cm can often be treated medically. Administer a third-generation cephalosporin + metronidazole +/– vancomycin; give IV therapy for 6–8 weeks followed by 2–3 weeks PO. Obtain serial CT/MRIs to follow resolution. Dexamethasone with taper may be used in severe cases to ↓ cerebral edema; IV mannitol may be used to ↓ ICP. CNS lymphoma, toxoplasmosis, or PML P. jiroveci pneumonia or recurrent bacterial pneumonia A retrovirus that targets and destroys CD4+ T lymphocytes. Infection is characterized by a progressively high rate of viral replication that leads to a progressive decline in CD4+ count (see Figure 2.8-6)." }, { "id": "pubmed23n0758_23403", "title": "[Invasive aspergillosis in hematooncological patients: advantages and disadvantages of various diagnostic methods, treatment options and financial costs of therapy].", "score": 0.009259259259259259, "content": "Invasive aspergillosis (IA) is a leading invasive fungal infection in hematooncological patients. The aim of this study was to analyse the incidence, diagnostic procedures and treatment of IA in hematooncological department in large hospital in the Czech Republic. A retrospective analysis of medical and laboratory records from patients hospitalised in our department with proven/probable IA between January 2000 and December 2006 was performed. 52 cases of IA in 51 patients were identified (17.3% proven IA/82.7% probable IA). Number of IA cases notably increased during study period (1 case of IA in 2000 vs 21 cases of IA in 2006) and majority of them was of nosocomial origin (61.5%). Pulmonary aspergillosis was diagnosed in 46 cases (88.5%). Patients treated for acute leukemia or undergoing allogeneic stem cell transplantation represent the group at the highest risk of IA (in total 52% of cases). Fever and signs of pulmonary involvement were the most common clinical signs of infection (presented in 92.3% and 69.2 cases respectively). Conventional diagnostic methods including autopsy were able to diagnose only 15 cases of IA (28.8%). In all other cases (71.2%) the diagnosis was done by detection of galactomannan (GM) in serum. Introduction of GM monitoring enabled erlier initiation of antifungal treatment by 4 days. Initial therapy of IA led to the treatment response (partial and complete) in 18 (34.6%) of infections--the highest percentage of response has been seen in voriconazole monotherapy group (42%) and when combination of voriconazole and caspofungin has been used (83%). Salvage therapy was initiated due to the failure of initial treatment in 21 (40.3%) of cases. Patients were treated mostly with combination ofvoriconazole and caspofungin and/or monotherapy with voriconazole has been used with treatment response 55% and 50% respectively. Introduction of new antifungal drugs together with increased number of patients with IA led to the marked increase of total costs spent on treatment of IA per year--from 11,5 thousands CZK in 2000 to 6,2 millions CZK in 2006. IA is the most frequent cause of infection-related mortality in patients with haematological malignancies. Routine use of non-culture base methods in diagnosis of IA together with treatment using new, effective antifungals can improve prognosis of patients with this life threatening infection." }, { "id": "wiki20220301en071_56095", "title": "Ventilator-associated pneumonia", "score": 0.009174311926605505, "content": "Risk factors for infection with an MDR strain include ventilation for more than five days, recent hospitalization (last 90 days), residence in a nursing home, treatment in a hemodialysis clinic, and prior antibiotic use (last 90 days). Possible empirical therapy combinations include (but are not limited to): vancomycin/linezolid and ciprofloxacin, cefepime and gentamicin/amikacin/tobramycin vancomycin/linezolid and ceftazidime Ureidopenicillin plus β-lactamase inhibitor such as piperacillin/tazobactam or ticarcillin/clavulanate a carbapenem (e.g., imipenem or meropenem) Therapy is typically changed once the causative bacteria are known and continued until symptoms resolve (often 7 to 14 days). For patients with VAP not caused by nonfermenting Gram-negative bacilli (like Acinetobacter, Pseudomonas aeruginosa) the available evidence seems to support the use of short-course antimicrobial treatments (< or =10 days)." }, { "id": "pubmed23n0252_7725", "title": "[Treatment of pneumonia under hospital conditions].", "score": 0.009174311926605505, "content": "A random sample of 24 patients affected by bacterial pneumonia has been investigated whether their illness is treated etiologically. The agents have been detected from the endoscopically obtained samples of blood or chest punctate (percutaneous needle aspirate--PNA) and their sensitivity to antibacterial drugs, used in our institution, have been investigated. The obtained results have been compared to the empirically applied drugs. In only three patients the first given drug corresponded to the later obtained finding of the agent's sensitivity and in one patient third and the fourth drug has been adequate. The rational initial therapy has been proposed on the basis of investigation of the sensitivity of the bacterial pneumonia agents." }, { "id": "pubmed23n0720_22679", "title": "Rates and appropriateness of antimicrobial prescribing at an academic children's hospital, 2007-2010.", "score": 0.00909090909090909, "content": "Antimicrobial use in hospitalized children has not been well described. To identify targets for antimicrobial stewardship interventions, we retrospectively examined pediatric utilization rates for 48 antimicrobials from 2007 to 2010 as well as appropriateness of vancomycin and cefepime use in 2010. All children hospitalized between 2007 and 2010 at the Mayo Clinic Children's Hospital, a 120-bed facility within a larger adult hospital in Rochester, Minnesota. We calculated antimicrobial utilization rates in days of therapy per 1,000 patient-days. Details of vancomycin and cefepime use in 2010 were abstracted by chart review. Two pediatric infectious disease physicians independently assessed appropriateness of antibiotic use. From 2007 to 2010, 9,880 of 17,242 (57%) hospitalized children received 1 or more antimicrobials. Antimicrobials (days of therapy per 1,000 patient-days) used most frequently in 2010 were cefazolin (97.8), vancomycin (97.1), fluconazole (76.4), piperacillin-tazobactam (70.7), and cefepime (67.6). Utilization rates increased significantly from 2007 to 2010 for 10 antimicrobials, including vancomycin, fluconazole, piperacillin-tazobactam, cefepime, trimethoprim-sulfamethoxazole, caspofungin, and cefotaxime. In 2010, inappropriate use of vancomycin and cefepime was greater in the pediatric intensive care unit than ward (vancomycin: 17.8% vs 6.4%, P = .001; cefepime: 9.2% vs 3.9%, P = .142) and on surgical versus medical services (vancomycin: 20.5% vs 8.0%, P = .001; cefepime: 19.4% vs 3.4%, P ≤ .001). The most common reason for inappropriate antibiotic use was failure to discontinue or de-escalate therapy. In our children's hospital, use of 10 antimicrobials increased during the study period. Inappropriate use of vancomycin and cefepime was greatest on the critical care and surgical services, largely as a result of failure to de-escalate therapy, suggesting targets for future antimicrobial stewardship interventions." }, { "id": "pubmed23n0103_18773", "title": "Pneumonias acquired from others. 2. Radiographic findings, treatment.", "score": 0.00909090909090909, "content": "Although patterns found on the chest film of a patient suspected to have pneumonia are usually nonspecific by themselves, they are useful in eliminating or narrowing diagnostic possibilities. For example, a miliary pattern suggests miliary tuberculosis, but it may also be caused by several noninfectious diseases (table 1). Other clues, such as the presence or absence of fever, must also be considered to arrive at a likely diagnosis. Cavitary lesions, bilateral hilar adenopathy, pleural effusions, and pulmonary nodules are other findings that are commonly seen on the chest film of these patients. Possible infectious and noninfectious causes are listed in tables 2 through 5. Antimicrobial therapy that is appropriate, free from side effects, and cost-effective must be chosen. The frequency of administration of a drug can make a great difference in the total cost of treatment, since hospitals charge for each intravenous dose. The clinician should consider which drug is effective against the infective organism and also the least expensive to administer (table 6)." }, { "id": "pubmed23n1109_25103", "title": "Cytomegalovirus pneumonia in an immunosuppressed sarcoidosis patient; a rare case of cytomegalovirus infection in a sarcoidosis patient.", "score": 0.009009009009009009, "content": "Sarcoidosis is a multisystemic granulomatosis disease that is mostly treated with immunosuppressive regimens. Studies demonstrated that these patients are prone to develop various infections. However, some infections including viral severe pneumonia is rare complications in sarcoidosis patients. In the present report, we described for cytomegalovirus (CMV) pneumonia in a female patient with sarcoidosis which has been successfully managed by ganciclovir. Herein, we present a known case of sarcoidosis admitted to the emergency department because of fever, dyspnea, and productive cough. The patient was receiving prednisolone and methotrexate for months. The primary chest x-ray imaging revealed bilateral infiltration, especially in the upper lobes and hilar lymphadenopathy. The lung high resolution computed tomography showed a bilateral diffuse nodular pattern. After 72 hours of antimicrobial treatment, the fever was still present and the patient became a candidate for fiberoptic bronchoscopy. The gram staining of the bronchial fluid, polymerase chain reaction for tuberculosis, and PCP was also unremarkable. However, the PCR-CMV was positive. The quantitative PCR for CMV form blood sample was taken and the result came back as 3.6*10<sup3</sup. With the impression of CMV pneumonia, a daily dose of 5mg of ganciclovir was prescribed. After 3 weeks of receiving 5mg/kg of ganciclovir twice daily (600mg daily), clinical symptoms, and dyspnea improved. Also, the radiological findings improved. In the present report, we demonstrated that sarcoidosis patients' receiving immunosuppressives are prone to develop CMV pneumonia, and fever and dyspnea were the alarm signs of CMV pneumonia is our patient which was successfully managed by ganciclovir." }, { "id": "pubmed23n0368_8428", "title": "[Rapid development of multiple meniscal signs complicating invasive pulmonary aspergillosis in a patient receiving chemotherapy for acute leukemia].", "score": 0.009009009009009009, "content": "This report describes the rapid development of multiple meniscal signs complicating invasive pulmonary aspergillosis in a 53-year-old man receiving chemotherapy for acute leukemia. While undergoing first induction therapy for AML, he developed chest pain, and multiple bilateral infiltrations were seen in chest roentgenograms. Administration of antibiotics, antifungal agents, steroid pulse therapy and G-CSF was begun. Pulmonary cavities with meniscal signs developed. The next day, pneumothorax and hemothorax were noted. Although drainage and mechanical ventilation were performed, the patient died after massive hemoptysis. Invasive pulmonary aspergillosis was diagnosed at autopsy." }, { "id": "wiki20220301en372_8546", "title": "Pulmonary capillary hemangiomatosis", "score": 0.008928571428571428, "content": "Diagnosis Lung biopsy is essential to make this diagnosis. This can be difficult if the pulmonary pressure is high. Investigations Chest X ray may show enlargement of the heart and ill-defined patchy lesions in the lung fields. CT chest typically shows wide spread ill-defined centrilobular nodules of ground glass opacity. This is a nonspecific finding and may be seen in a number of pulmonary diseases. CT pulmonary angiography usually shows enlargement of the main pulmonary artery. When measured by echocardiography or pulmonary angiography, the pulmonary arterial pressure is typically elevated. Differential diagnosis Pulmonary veno-occlusive disease Associations This condition has been reported in patients with Ehlers Danlos syndrome, CREST syndrome and scimitar syndrome. Treatment The only definitive treatment for this condition currently is lung transplantation. Median survival without treatment is 3 years. Imatinib may be of use." }, { "id": "pubmed23n0567_8563", "title": "Disseminated cutaneous Fusarium moniliforme infections in a leukemic child.", "score": 0.008928571428571428, "content": "A 5-year-old boy had a 10-month remission of acute lymphocytic leukemia (ALL) after chemotherapy. Re-induction chemotherapy was performed for relapse of ALL. Thereafter, he suffered from an episode of neutropenic fever with pneumonia. One week following control of the condition with antibiotics, a 1 x 1-cm, red, painful nodule appeared on the left thigh, which was initially suspected to be Pseudomonas infection. Parenteral ceftazidime and amikacin were administered, but persistent high fever, mild cough, and a few painful erythematous papulonodules on the face and lower extremities appeared several days later (Fig. 1). These lesions increased insidiously in diameter up to 2-5 cm with central necrosis. Hemogram showed neutropenia with a shift to the left [white blood cell (WBC) count, 2.1 x 10(9)/L; neutrophil count, 0.21 x 10(9)/L]. A skin biopsy showed heavy growth of hyaline branching septate hyphae in the deep dermis and subcutis, together with fat necrosis (Fig. 2). Invasion of molds into vessels and sweat glands was also seen. A culture from a lesion yielded Fusarium moniliforme, but no fungi were isolated from blood specimens. Only mild infiltrations on bilateral lower lung fields were detected by chest roentgenography. The skin lesions gradually healed and the fever subsided 2 weeks after the initiation of therapy with amphotericin B 30 mg and itraconazole 200 mg daily. Meanwhile, relapse of leukemia was detected by hemogram showing atypical leukocytosis (WBC count of 24,400 x 10(9)/L, with blast cells representing 78%). A course of chemotherapy with cytarabine, mitoxantrone, and VP-16 was prescribed, subsequently resulting in neutropenia (WBC count, &lt; 0.1 x 10(9)/L; neutrophil count, 0/L) and spiking fever. Although the aforementioned antifungal therapy was continued, the centers of the originally healed lesions turned dusky red, swollen, necrotic, and ulcerative. There were more than 10 such ecthymiform lesions. After administration for 22 days, itraconazole was discontinued because of no appreciable effects. Granulocyte colony-stimulating factor (G-CSF) salvage was used, and the neutropenia gradually subsided 20 days later. In addition, the ecthymiform lesions gradually resolved. Amphotericin B was discontinued 1 week following neutrophil recovery. The patient died of Acinetobacter baumannii and Stenotrophomonas maltophilia sepsis 8 months later." }, { "id": "pubmed23n0526_13895", "title": "Galactomannan does not precede major signs on a pulmonary computerized tomographic scan suggestive of invasive aspergillosis in patients with hematological malignancies.", "score": 0.008849557522123894, "content": "Detection of serum galactomannan (GM) antigen and presence of the halo sign on a pulmonary computerized tomographic (CT) scan have a high specificity but a low sensitivity to diagnose invasive aspergillosis (IA) in patients at risk for this disease. To our knowledge, the relationship between the time at which pulmonary infiltrates are detected by CT and the time at which GM antigens are detected by enzyme immunoassay (EIA) has not been studied. In a prospective study, tests for detection of GM were performed twice weekly for patients with hematological malignancies who had undergone hematopoetic stem cell transplantation (HSCT) or had received induction and/or consolidation chemotherapy. A pulmonary CT scan was performed once weekly. Infiltrates were defined as either major or minor signs. IA was classified as proven, probable, or possible, in accordance with the definition stated by the European Organization for Research and Treatment of Cancer-Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group. We analyzed 161 episodes of infection in 107 patients (65 allogeneic HSCT recipients, 30 autologous HSCT recipients, and 66 induction and/or consolidation chemotherapy recipients). A total of 109 episodes with no IA, 32 episodes with possible IA, and 20 episodes with probable or proven IA were identified. Minor pulmonary signs were detected by CT in 70 episodes (43%), and major pulmonary signs were detected by CT in 11 episodes (7%). Univariate and multivariate analyses revealed no significant association between detection of GM by EIA and detection of abnormal pulmonary signs by CT. A significant association was found between GM levels and receipt of piperacillin-tazobactam. GM test results were not positive before major signs were seen on CT images. Only 7 (10%) of 70 patients with minor pulmonary signs had positive GM test results before detection of the greatest pathologic change by CT. We show that detection of GM by EIA does not precede detection of major lesions by pulmonary CT. In the clinical setting, the decision to administer mold-active treatment should based on detection of new pulmonary infiltrates on CT performed early during infection, rather than on results of EIA for detection of GM." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 264 ] ], "word_ranges": [ [ 0, 41 ] ], "text": "Child with multiple family history of allergy (asthma, atopy), who has received artificial milk in the first hours of life (sensitization to cow's milk protein) and who, coinciding with the intake of artificial milk, starts digestive symptoms and exanthema = APLV." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Celiac disease.", "2": "Acute gastroenteritis.", "3": "Cow's milk protein allergy.", "4": "Bottle allergy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1111_18134", "title": "Complementary bottles during the first month and risk of cow's milk allergy in breastfed infants.", "score": 0.016297428062133947, "content": "To assess the impact of complementary feeding bottles given at maternity hospital and/or over the first month after discharge from the maternity ward on cow's milk allergy (CMA) risk in breastfed infants. Case-control study involving infants aged 6-9 months and who were breastfed for at least 1 month. In 554 cases with a diagnosis of CMA and 211 controls, feeding bottles at maternity hospital, feeding bottles during the first month of life, avoidance of dairy products during pregnancy or breastfeeding, family history of allergy, intake of antibiotics and consumption of proton-pump inhibitors or antacids by the infant during the first month of life were associated with increased risk of CMA in a univariate model. In a multivariate model, only feeding bottle at maternity hospital (OR = 1.81 [1.27; 2.59]), family history of allergy (OR = 2.83 [2.01; 3.99]) and avoidance of dairy products during pregnancy or breastfeeding (OR = 5.62 [1.99; 15.87]) were independent risk factors of CMA. Complementary bottles given at maternity hospital to newborns who will be exclusively breastfed increases the later risk of CMA. Similarly, avoidance of dairy products during pregnancy or breastfeeding should be discouraged." }, { "id": "pubmed23n1076_22621", "title": "[ALLERGY PREVENTION AND TREATMENT DURING THE FIRST YEAR].", "score": 0.01625226625226625, "content": "The effect of the pregnant mother's nutrition and the effect of the baby's nutrition during the first-year on the development of allergy and atopic disease in the baby have been studied extensively in recent years. Key recommendations for healthcare bodies in Europe and the United States include: • Allergy prevention in at-risk infants (parent or sibling with allergy): Currently, there is a consensus of healthcare organizations around the world that the recommended exclusive breastfeeding duration is the first 6 months of life for the overall health benefit of the baby. Allergy prevention in non-breastfed infants at risk: There are studies showing that fully hydrolyzed formula can reduce the risk of allergic reactions, especially atopic dermatitis, in high-risk non-breastfed babies. Some recommendations for high-risk non-breastfed infants support feeding up to 4 to 6 months with hydrolyzed formulas. Further research is needed on this subject. Soy formulas failed to prevent allergy in high-risk infants. • In case of cow's milk allergy symptoms in breastfed babies: Although a small amount of food allergens may be present in the milk, mothers should be encouraged to continue breastfeeding while avoiding consumption of cow's milk and products. • In case of cow's milk allergy symptoms in non-breastfed babies: Under six months of age, extensively hydrolyzed formula is suitable for most cases of cow's milk allergy, except for severe clinical conditions, which require amino acid formulas. Over six months, soy formulas can be considered. Exposure to solid foods: The current recommendations are to start on solids at the age of 4-6 months and there is no recommendation for avoiding known allergens, despite family history. Later introduction of peanut, fish or egg does not prevent, and may even increase, the risk of developing food allergy. In order to provide a professional and appropriate response to infants and parents, it is important to know the latest guidelines, based on research from recent years as clinical recommendations have changed over the past few decades." }, { "id": "pubmed23n0111_11053", "title": "Development of atopic disease after early administration of cow milk formula.", "score": 0.016233766233766232, "content": "We prospectively studied the incidence of atopic disease in healthy term infants with a birth weight between -1 and -2 SD who were fed a cow milk formula during the first few days of life. A total of 216 infants were randomized to receive either early feeding with formula before normal breastfeeding was started (n = 112) or \"normal feeding\" with breastmilk (n = 104). Symptoms of allergy developed in 18% of the infants before 18 months of age in the formula fed group, as compared to 33% in the breastfed group (P less than 0.05). The difference was confined to the group of infants with a history of allergy in two family members. Thus, 11% of the formula-fed infants developed allergy symptoms, as compared to 61% of the control infants (P less than 0.01). Our study implies that early feeding during the first days of life with a cow milk formula, before the introduction of breastmilk, may reduce the incidence of allergy symptoms before 18 months of age in infants with a family history of allergy." }, { "id": "pubmed23n0867_5246", "title": "The Association of the Delayed Introduction of Cow's Milk with IgE-Mediated Cow's Milk Allergies.", "score": 0.01582512315270936, "content": "Although exclusive breastfeeding at least 4 to 6 months has been recommended to prevent IgE-mediated cow's milk allergy (IgE-CMA), early introduction of food allergens has received a lot of attention in recent years for the prevention of food allergies. We aimed to determine whether IgE-CMA is associated with a feeding pattern in early infancy. In a case-control study, we retrospectively compared the patient background, past history of atopic dermatitis, bronchial asthma, family history of allergic diseases, feeding patterns in early infancy, and the reason for choosing early infancy feeding patterns of patients with IgE-CMA with age- and sex-matched healthy controls using a questionnaire completed by their mothers. To minimize the influence of confounders, we also compared patients with IgE-CMA with those with IgE-mediated egg allergy (IgE-EA). A total of 51 patients with IgE-CMA were compared with 102 controls (1:2 matching) and 32 unmatched patients with IgE-EA. In a multivariable logistic regression analysis, the adjusted odds ratio of delayed (started more than 1 month after birth) or no regular cow's milk formula (less than once daily) was 23.74 (95% CI, 5.39-104.52) comparing the CMA group with the Control group, and 10.16 (95% CI, 2.48-41.64) comparing the CMA group with the EA group. Only 3 (6.5%), 2 (4.8%), and 3 (14.3%) mothers in the CMA group, the Control group, and the EA group chose \"To prevent allergic disease\" as a reason for choosing exclusive or almost exclusive breastfeeding in the first month of life, respectively. The early introduction of cow's milk formula is associated with lower incidence of IgE-CMA." }, { "id": "pubmed23n0881_8651", "title": "[Clinical characteristics and management of infants less than 1-year-old suspected with allergy to cow's milk protein].", "score": 0.015396368337544809, "content": "Cow's milk protein allergy (CMPA) is highly prevalent in infants (2-5%). It has a wide clinical spectrum, and confirmation through an oral food challenge (OFC) is relevant for its differential diagnosis. Information on this topic is scarce in Chile. To describe the demographic and clinical features of infants with suspected CMPA. A retrospective study of patients&lt;1 year-old, treated for suspected CMPA between 2009 and 2011. Demographic data, symptoms of atopy, nutrition at the time of diagnosis, CMPA symptoms, diagnostic studies, and response to treatment were recorded. Diet response at least 4 weeks after milk modification, and clinical behavior when suspected foods were added back to the diet were considered standard diagnostic criteria. Descriptive statistics were performed using Epiinfo ™ software. The study included 106 infants, of whom, 51% male, 80% term newborns, 74% with≥1 atopic parent, and 34% with ≥1 parent/sibling with food allergy. The median age at onset of symptoms was 1.5 months (range 1.5-2m). Almost half (46%) were breast-feeding≥6m, with 15% receiving formula milk since the neonatal period, and 49% before the third month. Common symptoms were: vomiting (63%), colic (49%), and bleeding on passing stools (41%). No anaphylaxis was identified, and 61% had≥2 symptoms at debut. Only 34% were subjected to OFC. The most frequently requested tests were, test patch (43%), prick test (40%), and blood in stools (37%). 43% breast feeding with exclusion diet, 24% extensively hydrolysed formula, 26% amino acid formula, and 7% others. Demographic characteristics and risk factors were similar to those previously described in international literature. Clinical presentation was early in life, and digestive symptoms predominated. OFC was underused for diagnosis, and most of the tests requested did not change management." }, { "id": "pubmed23n0089_10162", "title": "[Food allergies].", "score": 0.014821272885789015, "content": "Food allergy in childhood presents with different clinical manifestations depending on the age of the affected child. Whereas toddlers and children with food allergy or pseudo-allergy present with similar symptoms as adults, two different forms have been identified in the newborn and infant period. One can occur as allergic colitis in breast or bottle fed infants. In breast fed infants the bloody mucoid stools are produced because of an allergic reaction of the colonic mucosa to foreign proteins which are delivered to the baby via breast milk. In bottle fed infants the given foreign protein itself can trigger the allergic reaction. The clinical, endoscopical and histological appearance is similar to that of ulcerative colitis. Elimination of foreign proteins from the diet of the mother or in bottle fed infants from the child is the therapy of choice. The second manifestation of food allergy in this age group is the cow's milk protein intolerance with predominantly gastrointestinal symptoms such as vomiting, diarrhea and failure to thrive. The diagnosis is based on the clinical picture alone. The usual laboratory tests don't discriminate enough and can therefore not confirm the diagnosis. Elimination of the affecting protein and replacement by a semi-elementary diet are recommended for therapy. The prevention of allergies by dietetic means has become of great importance since it was possible to identify newborns at risk for allergies. The prolonged breast feeding and the late introduction of solids later than the sixth month of life is the preventive measure. \"Hypoallergenic\" formulae are not recommended because not enough solid data are available to confirm their preventive effect." }, { "id": "pubmed23n0739_17500", "title": "[Association of dietary patterns and food allergy in infants during the first year of life].", "score": 0.014288630332720964, "content": "There is controversy about the effect of dietary patterns during the first year of life and the occurrence of food allergy. The objective of this study was to evaluate the association between family history of allergy, allergic manifestations and dietary patterns during the first year of life in infants with and without food allergy. We performed a descriptive cross-sectional study in children under 2 years of age (n= 99), sorted in two groups: allergic group (n= 50) and control group (n= 49), matched by socioeconomic status, age and gender. Food allergy was deifned by internationally approved clinical criteria, prick and patch tests, and response to diet. Information on diet, clinical data and history of allergy in the parents were collected. The sample size was estimated for logistic regression (Freeman), and Student X² and Mann-Withney tests were used. The study and consent forms were approved by the Ethics Committee of the Institute of Nutrition and Food Technology (Instituto de Nutrición y Tecnología de los Alimentos, INTA) and the Universidad de Chile. The allergic group showed a significantly higher prevalence (p &lt;0.0001) of family history of allergy (84%) than the control group (16%). Diarrhea was the symptom most frequently reported by the mothers of allergic infants during the first year of life. Bottle feeding was introduced earlier in the allergic group than in the control group (3 versus 6 months [p &lt; 0.03]); no differences regarding the start age for supplementary feeding was found. When performing logistic regression, only the family history of allergy was associated with a higher risk of food allergy (OR: 48.2; CI= 14.2-164; p &lt; 0.001). The early introduction of milk formula could promote the occurrence of food allergy in infants frequently presenting family history of allergy." }, { "id": "pubmed23n0102_9062", "title": "Cow's milk allergy in the first year of life. An Italian Collaborative Study.", "score": 0.013699245418613008, "content": "The diagnosis of Cow's Milk Protein Allergy was considered in 303 infants aged less than 1 year, who presented with one or more of the following symptoms: acute reaction related to cow's milk proteins (CMP) ingestion, severe colics, persisting vomiting, protracted diarrhea with or without blood and mucus, failure to thrive, eczema, respiratory symptoms, such as chronic rhinitis and wheezing. A diagnosis of CMPA was confirmed in 148 cases (60%): 125 relapsed on milk challenge, 23 were not challenged because of acute reactions at onset, presence of specific IgE (RAST and prick), and improvement on milk free diet. Familial atopy, familial history of CMPA and previous acute gastroenteritis were significantly more frequent in cases than in 191 age matched controls. Breast feeding was not more common or of longer duration in controls, compared to cases. Mean IgE serum levels were higher (46.3 U/ml) in cases than in controls (17 U/ml), while specific Cow's Milk Protein IgE were found in 71/148 cases (48%). 15 infants entered the study while on breast milk, because of the confirmed relation between their symptoms and CMP on the maternal diet. These infants had a higher prevalence of IgE mediated problems. All cases improved on a milk free diet but in 26 (17.8%) a further modification of the diet was required after the first prescription. Milk challenge was monitored by simple laboratory tests: all cases who had symptoms on challenge showed at least one test modification. Six infants, with no history of acute reaction, showed severe self-limited clinical symptoms at challenge. Key words: cow's milk allergy, milk, allergy, prick test, eczema, diarrhea." }, { "id": "wiki20220301en041_20356", "title": "Food intolerance", "score": 0.013645552560646899, "content": "A Cochrane review has concluded feeding with a soy formula cannot be recommended for prevention of allergy or food intolerance in infants. Further research may be warranted to determine the role of soy formulas for prevention of allergy or food intolerance in infants unable to be breast fed with a strong family history of allergy or cow's milk protein intolerance. In the case of allergy and celiac disease others recommend a dietary regimen that is effective in the prevention of allergic diseases in high-risk infants, particularly in early infancy. The most effective dietary regimen is exclusive breastfeeding for at least 4–6 months or, in absence of breast milk, formulas with documented reduced allergenicity for at least the first 4 months, combined with avoidance of solid food and cow's milk for the first 4 months." }, { "id": "pubmed23n0288_4495", "title": "The effect of hypo-allergenic formulas in infants at risk of allergic disease.", "score": 0.013347873500545256, "content": "Development of atopic disease seems to depend on both genetic factors and exposure to several environmental factors. At present ther is evidence that the mode of early infant feeding influences the development of food allergy, whereas daily exposure to inhalant allergens and daily exposure to tobacco smoke is found to be associated with an increased risk of recurrent wheezing/asthma and inhalant allergy. In infants with atopic predisposition (first-degree relatives), exclusively breastfeeding &gt; or = four months is found associated with a significant reduction of the cumulative prevalence of cow's milk allergy/intolerance (CMA/CMI) during the first 1-2 years of age. When breastmilk is insufficient or lacking a substitute formula is needed. Several recent prospective studies show a preventative effect of extensively hydrolysed formula (eHF) in combination with avoidance of cow's milk proteins and solid foods during &gt; or = 4 months in high-risk infants on the cumulative prevalence of food allergy and atopic dermatitis during the first 2-4 years of life. Partially hydrolysed formulas (pHF) may be effective in allergy prevention, but due to drawbacks of study design and lack of documentation pHF cannot be recommended at present. The results of studies comparing the preventive effect of eHF and pHF are awaited. The protective effect on the development of cow's milk allergy is a real prevention and not only a postponement of the onset of symptoms. No studies have demonstrated a preventive effect of dietary measures as regards asthma/inhalant allergy, at present until the age of four years. As no studies concerning the preventive effect of avoidance of milk and other foods after the age of 4-6 months of life have been performed, recommendation of preventive elimination diets beyond this age is empirically based. In order to reduce the costs, to minimize the risk of stigmatisation and the risk of malnutrition it is important to avoid unnecessary restrictive and prolonged diets. A diet period of 4-6 months seems sufficient in most infants. At present eHF are recommended for avoidance of cow's milk. Some high risk infants may benefit from maternal diet during lactation, but there is no documented beneficial effect of maternal diet during pregnancy." }, { "id": "pubmed23n0089_19498", "title": "[Incidence and symptoms of cow's milk protein intolerance following acute gastroenteritis in young infants. Effect of a hypoallergenic diet].", "score": 0.01295941328444037, "content": "In a prospective randomized study we investigated in 28 mainly bottle-fed infants younger than 60 days whether in acute gastroenteritis a hypoallergenic formula could prevent the development of cow's milk protein intolerance. Group 1 (14 infants) was fed with a formula adapted to human milk, Group 2 (14 infants) got a semi-elementary formula (Alfaré). After 3 months group II was exposed to cow's milk protein with a standardized challenge and the incidence of CMPI in both groups was calculated. All cases with the acute form of CMPI occurred in group II (5/12) whereas in group I only one infant suffered from the protracted mild form of the disease. Inspite of the relatively small number of probands we conclude from our results that in infants who are not totally breast-fed in the post-enteritic period feeding with a formula adapted to human milk is preferable to hypoallergenic semi-elementary preparations. An allergen free period of 3 months seems to induce symptoms of cow's milk intolerance, probably as a booster-effect to early sensibilisation." }, { "id": "pubmed23n0050_11611", "title": "Allergic symptoms up to 4-6 years of age in children given cow milk neonatally. A prospective study.", "score": 0.012685074029611845, "content": "In a previously published prospective study, we followed the development of allergic symptoms in term infants with a slightly reduced birthweight (-1 SD to -2 SD). These children received, according to local routine, early feeding with cow milk formula in order to diminish such neonatal problems as hypoglycemia and hyperbilirubinemia. Of 216 infants 207 were observed for allergic symptoms up to 18 months of age. One group (F) received cow milk formula during the first days of life before the mother's breastmilk production started and was then breastfed; the other (B) was not given any formula before normal breastfeeding started. Unexpectedly, we found fewer allergic symptoms, in particular allergic skin problems, in the group fed cow milk, the difference being concentrated to children with a family history of allergic symptoms. At 5 years of age 183 of the 207 children have been reinvestigated. Mild symptoms of allergy (suspected and obvious) were found in 22% (F) and 27% (B) respectively (NS). Moderate and severe symptoms of allergy (obvious) were found in 4.2% (F) and 4.5% (B). In the subgroup with a double family history of allergic symptoms, 28% (7/25, F) and 59% (10/17, B) had symptoms of allergy (p less than 0.05). This difference was even more pronounced when laboratory tests in favour of atopic diagnosis were included, 14% (F) and 53% (B) respectively (p less than 0.05). Thus at 5 years we still find a significantly lower frequency of allergic symptoms in the subgroup fed cow milk formula early with a family history of allergic symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en235_43975", "title": "Breastfeeding", "score": 0.012378520252536, "content": "Allergic diseases In children who are at risk for developing allergic diseases (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through 4-month exclusive breastfeeding, though these benefits may not persist. Other health effects Breastfeeding may reduce the risk of necrotizing enterocolitis (NEC). Breastfeeding or introduction of gluten while breastfeeding don't protect against celiac disease among at-risk children. Breast milk of healthy human mothers who eat gluten-containing foods presents high levels of non-degraded gliadin (the main gluten protein). Early introduction of traces of gluten in babies to potentially induce tolerance doesn't reduce the risk of developing celiac disease. Delaying the introduction of gluten does not prevent, but is associated with a delayed onset of the disease." }, { "id": "pubmed23n0889_14671", "title": "Consensus statement on diagnosis, treatment and follow-up of cow's milk protein allergy among infants and children in Turkey.", "score": 0.012010932105868816, "content": "The present paper aims to provide experts' consensus on diagnosis and management of cow's milk protein allergy (CMPA) among infants and children in Turkey, based on review of available evidence-based guidelines, publications and experts' clinical experience. The experts agreed that CMPA diagnosis should be based on symptomatic evaluation and diagnostic elimination diet as followed by implementation of an open challenge test after disappearance of symptoms and confirmation of CMPA diagnosis in re-appearance of symptoms. For breastfed infants, differential diagnosis involves withdrawal of cow's milk-containing products from the mother's diet, while calcium supplements and appropriate dietary advice are given to mothers to prevent nutritional deficiency. For infants not breastfed exclusively, cow's milk-based formula and any complementary food containing cow's milk protein (CMP) should be avoided. The first line treatment should be extensively hydrolyzed formula (eHF) with use of amino acid-based formula (AAF) in severe cases such as anaphylaxis, enteropathy, eosinophilic esophagitis and food protein induced enterocolitis along with cases of multiple system involvement, multiple food allergies and intolerance to eHF. Introduction of supplementary foods should not be delayed in CMPA, while should be made one by one in small amounts and only after the infant is at least 17 weeks of age. Infants who are at-risk can be identified by family history of atopic disease. Exclusive breastfeeding for 4-6 months (17-27 weeks) is recommended as the best method of infant allergy prevention. There is no evidence that modifying the mother's diet during pregnancy and/or breast-feeding and delaying solid or even potentially allergic foods beyond 4-6 months in infants may be protective against allergy among at-risk infants. When exclusive breastfeeding is not possible, at-risk infants should get a partially or extensively hydrolyzed formula (pHF or eHF) to prevent allergy until risk evaluation by a health professional. In conclusion, the present consensus statement provides recommendations regarding diagnosis, prevention and management of CMPA in infants and children in Turkey, and thus expected to guide physicians to optimize their approach to CMPA and decrease burden of the disease on infants and their caregivers." }, { "id": "pubmed23n0102_1105", "title": "Allergy to cow's milk in the first year of life and its prevention.", "score": 0.010609857978279031, "content": "Cow's milk allergy in the first year of life is one of the most common problems faced by pediatricians. Both over and under diagnosis is seen. Cow's milk allergy, which is IgE-mediated should be differentiated from milk intolerance due to lactase deficiency or other causes. Cow's milk allergy may effect the gastrointestinal tract, respiratory tract, skin or blood. Anaphylaxis may occur. Diagnosis is made primarily on clinical grounds but skin tests and/or RAST are of value. Elimination and subsequent challenge confirms the diagnosis but challenge is not always necessary. Challenge should not be performed if there is evidence of anaphylaxis. Avoidance is the mainstay of treatment and breastfeeding is the optimal choice. Since antigenically intact cow's milk protein can pass into the breast milk, the mother should avoid excessive intake of milk products herself while breast feeding. Alternatives to breast milk such as soy formulas or hydrolysed casein or whey formulas may be used. Twenty-five percent of milk-sensitive infants are also allergic to soy protein. Hydrolysed casein formulas are more hypoallergenic but are expensive and less palatable. Hydrolysed whey formula, which is comparable in expense to soy formulas but is less allergenic, may prove of value in the management of the milk-allergic infant as well as for prophylaxis in infants from susceptible parents. Parents of infants born to families with bilateral atopic histories may be able to prevent milk allergy by using dietary manipulations which include decreased prenatal maternal milk intake and while breast feeding as well as careful avoidance of milk products in the infant's diet during the first year of life." }, { "id": "pubmed23n0751_23062", "title": "Nutrition, growth, and allergic diseases among very preterm infants after hospital discharge.", "score": 0.009900990099009901, "content": "The aims of this PhD thesis were: 1. Primarily to investigate the effect, of adding human milk fortifier to mother's milk while breastfeeding very preterm infants after hospital discharge, on growth until 1 year corrected age (CA) 2. Secondarily to describe breastfeeding rate and factors associated with breastfeeding among very preterm infants at hospital discharge. 3. To describe possible feeding-problems during the intervention-period, and allergic diseases during the first year of life, among very preterm infants related to their nutrition after hospital discharge. 4. To describe the content of macronutrients in human milk from mothers delivering very preterm. This PhD thesis is based on a prospective, randomized, and controlled interventional birth cohort study. A total of 633 very preterm infants with a gestational age (GA) ≤ 32 + 0 weeks were recruited consecutively from July 2004 until August 2008 of whom 157 were excluded due to diseases or circumstances influencing nutrition. Further 156 refused participation in the interventional part of the study, but data on breastfeeding, weight, and some epidemiological data until discharge were available. Results on breastfeeding rate at discharge were therefore based on data from 478 infants, and parents of 320 infants accepted participation in the intervention study. Of these 320 infants, 207 were exclusively breastfed and they were shortly before hospital discharge randomized to either breastfeeding without (group A) or with fortification (group B) until 4 months CA. Infants (n = 113) who were bottle-fed at discharge (group C) were given a preterm formula (PF) until 4 months CA. Infants were examined at the outpatient clinics at term, and at 2, 4, 6, and 12 months CA, where parameters on growth, allergic diseases, possible feeding problems, blood-samples, and milk samples were obtained. Data on duration of exclusively breastfeeding and time of introduction to formula and/or complementary food were also recorded. Among the 478 infants 60% (n = 285) were exclusively breastfed, 35% (n = 167) were exclusively bottle-fed, and 5% (n=26) were both breast- and bottle-fed at discharge. Compared to mothers in lower social groups and mothers who smoked, mothers in higher social groups and \"non-smokers\" were significantly (p = 0.000 and p = 0.003 respectively) more often breastfeeding their very preterm infants at discharge. Single birth infants tended more often to be breastfed (p = 0.09). Infant age at discharge and duration of hospitalization did not influence breastfeeding at discharge. Increase in weight Z-score from birth to discharge was largest in the bottle-fed group compared to the breastfed group (p = 0.000), probably due to feeding practice the last week(s) of hospitalization. In the intervention study, 207 exclusively breastfed very preterm infants were randomized to group A (n = 102) and B (n = 105) respectively. The duration of breastfeeding was not influenced by fortification of mother's milk after hospital discharge. There was no significant difference on growth comparing group A and B at 12 months CA. Both boys and girls in group C achieved catch-up in weight and length earlier as compared to group A and B. Per protocol (PP) analysis showed that girls, but not boys, were longer and had a larger head circumference but were not heavier in group B (n = 51) compared to group A (n = 73) at 2 and 4 months CA (p&lt;0.05). Protein-concentration in mothers' milk declined significantly from 2 weeks (1.8 g/100 ml) to 6 weeks after birth (1.4 g/100 ml) and declined further to 1.2 g/100 ml 12 weeks after birth. The incidence and the prevalence at 12 months CA of recurrent wheezing was 39.2% and 32.7% respectively, while atopic dermatitis was 18.0% and 12.1% respectively. Predisposition to allergic disease increased the risk of developing atopic dermatitis (p = 0.04) (OR 2.6 (95% CI 1.0-6.4)), and the risk of developing recurrent wheezing (p = 0.02) (OR 2.7 (95% CI 1.2-6.3)). Boys had an increased risk of developing recurrent wheezing (p = 0.003) (OR 3.1 (95% CI 1.5-6.5)). In conclusion breastfeeding can successfully be established in very preterm infants. Fortification of human milk after hospital discharge while breastfeeding was possible without influencing the duration of breastfeeding. Fortification in the amount given in this study did, however, not affect growth significantly at 1 year of age. An increased amount of protein was correlated with increased BUN-values indicating a better growth potential. Fortification of mother's milk or preterm formula was not associated with an increased risk of developing allergic diseases. Future follow-up of this cohort investigating e.g. growth, allergic diseases, and neuropsychological development is planned at 6 years of age. The definition of optimal growth and nutrition of preterm infants is though still a question for debate and further investigations are needed." }, { "id": "pubmed23n0239_11021", "title": "Changing pattern of cow's milk intolerance. An analysis of the occurrence and clinical course in the 60s and mid-70s.", "score": 0.009900990099009901, "content": "The rapid changeover to commercial adapted infant formulae which took place in Finland between 1973 and 1975 was studied as a factor in the occurrence of severe intestinal cow's milk intolerance (CMI). Of infants treated for CMI in 1962-73, ninety-three percent (25/27) were on homemade or unadapted formulae. The admission rate for CMI in these years was 0.22/1 000 liveborn infants breast fed less than six months. During 1974-77 the corresponding figure was 0.56, with 85% of the patients (18/26) on adapted cow's milk formulae. The patients treated before 1974 had a longer symptomatic period before admission, greater growth retardation and more severe intestinal damage than those seen during and after 1974. This is believed to reflect mainly the increasing awareness of CMI on the part of both laymen and the medical profession. In the history of 2/3 of the patients at least one of the following conditions was noted: non-breast feeding, infectious gastroenteritis, praematurity, 21-trisomy, prior intra-abdominal surgery, Hirschsprung's disease, and atopic disease in family members. The long follow-up averaging over four years revealed four patients with coeliac disease. In one of these the proximal jejunal mucosa was normal after two years on gluten-containing diet, but he showed a mucosal relapse as late as between 2 to 4 years on normal diet." }, { "id": "pubmed23n0929_5601", "title": "Celiac Disease by the Age of 13 Years Is Not Associated With Probiotics Administration in Infancy.", "score": 0.00980392156862745, "content": "Probiotics are theoretically promising in primary prevention of celiac disease (CD), but research evidence on the topic is scarce. We used the data and material of a clinical double-blind randomized placebo-controlled trial on primary allergy prevention (n = 1223) to investigate in an exploratory study whether administration of a mix of pro- and prebiotics during late pregnancy and first 6 months of life was associated with prevalence of CD during 13-year follow-up. Children who fulfilled diagnostic criteria for CD (n = 11) and subjects with a serum sample available for analyzing CD antibodies (n = 867) were included. CD or elevated tissue transglutaminase IgA antibodies were not associated with probiotics or placebo. Nor were there any associations with the mode of delivery, the duration of exclusive or total breast-feeding, or respiratory infections during the first 2 years of life. Allergic diseases or sensitization by the age of 2 or 5 years were not clearly associated with the development of CD." }, { "id": "pubmed23n0886_19613", "title": "Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder.", "score": 0.009708737864077669, "content": "Kendra is a 4-year-old girl with autism spectrum disorder (ASD) who presents for follow-up of feeding problems to her pediatric clinician. She is an only child in a family where both parents are scientists. Feeding concerns date to infancy, when she was diagnosed with Gastroesophageal Reflux Disease (GERD) associated with persistent bottle refusal and the acceptance of few pureed foods. At 13 months, milk and peanut allergies were diagnosed. Following a feeding clinic evaluation at 24 months, she was prescribed a soy milk supplement and an H2 blocker. There was no concern for oral-motor dysfunction. She was also referred to early intervention for feeding therapy. However, her parents terminated participation after 6 months because she became anxious and had tantrum prior to treatment groups.She was seen in another feeding program at 3 years; zinc, folate, thyroid, and a celiac panel were normal, and an endoscopy was negative for eosinophilic esophagitis. She began individual feeding therapy, where concerns for rigidity, difficulty transitioning, and limited peer interactions led to a neuropsychological evaluation. Kendra was diagnosed with an ASD and avoidant/restrictive food intake disorder (ARFID). Her cognitive skills were average, and expressive and receptive language skills were low average.Her diet consisted of French fries, Ritz crackers, pretzels, and 32 ounces of soy formula daily. She had stopped accepting Cheerios and saltines 2 months prior. She controlled other aspects of feeding, insisting on a specific parking spot at a fast food restaurant and drinking from a particular sippy cup. Her parents accepted these demands with concern about her caloric intake, which they tracked daily.Following diagnosis with ARFID, she resumed feeding therapy using a systematic desensitization approach with rewards. At the first session, she kissed and licked 2 new foods without gagging. Her mother appeared receptive to recommendations that included continuing the \"food game\" at home, replacing 1 ounce of soy formula by offering water each day, limiting between-meal grazing, and refusing specific feeding demands.Currently, her parents plan to discontinue feeding therapy with concerns that the treatment was \"too harsh.\" Her father produces logs of her caloric and micronutrient intake as evidence that she did not replace missed formula with other foods and reports that she subsequently became more difficult to manage behaviorally. Her father now demands to see randomized controlled trials of feeding therapy approaches. Her weight is stable, but she has now limited her pretzel intake to a specific brand. How would you approach her continued care?" }, { "id": "pubmed23n0729_2078", "title": "Prevalence and natural history of potential celiac disease in at-family-risk infants prospectively investigated from birth.", "score": 0.009708737864077669, "content": "To evaluate the frequency and the natural history of potential (serology positive/Marsh 0-1 histology) celiac disease (CD) in children with a family risk of CD and factors associated with potential instead of overt (serology positive/Marsh 2-3 histology) CD expression. Two-year follow-up study of 96 children (57 females; mean age: 29 ± 12 months) prospectively investigated from birth with: (1) a CD-affected first-degree relative; (2) positivity of serum IgA anti-tissue transglutaminase (tTG) or IgG antigliadin and IgA deficiency; and (3) the results of small intestinal biopsy. Children with potential CD were advised to remain on a gluten containing diet, repeat the celiac antibodies every 6 months, and to have an intestinal biopsy performed in case of persistently high anti-tTG level. Factors discriminating between potential and overt CD were analyzed by decision tree analysis based on the C4.5 algorithm. Twenty-four children had potential and 72 overt CD. The stronger predictors of potential CD were lack of symptoms, anti-tTG level lower than 11-fold the upper normal limit, age lower than 24 months, and breastfeeding longer than 8 months. Eighteen out of 21 (86%) patients with potential CD continuing a gluten-containing diet became antibody negative, 1/21 (5%) developed overt CD, and 2/21 (9%) had fluctuating antibodies levels after 2 years. The prevalence of potential CD and the percentage of short-term loss of CD-related-antibodies are high in infants at-family-risk for CD. In symptomless children with a positive celiac serology, the decision of performing an intestinal biopsy should be preceded by a period of repeated serological testing." }, { "id": "pubmed23n1053_3374", "title": "FPIES in exclusively breastfed infants: two case reports and review of the literature.", "score": 0.009615384615384616, "content": "Food Protein-Induced Enterocolitis Syndrome (FPIES) is a non IgE-mediated food allergy that generally affects children in the first year of life. Usually symptoms break out when formula milk or solid foods are introduced for the first time but they might also appear in exclusively breastfed infants, since the trigger elements, especially cow's milk proteins, can be conveyed by maternal milk as well. FPIES in exclusively breastfed babies is a very rare clinical condition and only few cases have been reported in the medical literature. We describe two cases of FPIES in exclusively breastfed babies. The first one is a two-month-old infant with a brief history of vomit and diarrhea that presented to the Emergency Department in septic-like conditions. The main laboratory finding was a significant increase in methemoglobin (13%). Clinically, we noted that, when breastfeeding was suspended, diarrhea drastically improved, and vice versa when maternal milk was reintroduced. An amino acid-based formula allowed a complete normalization of the symptoms. The second one is a three-month-old infant admitted for a 3 days history of persistent vomit and diarrhea. Blood tests showed a raised level of methemoglobin (7%). An esophagogastroduodenoscopy was performed and biopsies showed an eosinophilic infiltration of the duodenal mucosa. A maternal exclusion diet and an amino acid-based formula allowed a rapid regularization of the bowel function. We searched all the cases of FPIES in exclusively breastfed babies reported in the medical literature, identifying eight patients, with an average age of 3 months (range 15 days - 6 months). The majority of the cases were initially diagnosed as gastroenteritis or sepsis, five cases were characterized by an acute on chronic scenario and cow's milk was the most frequently involved food. Methemoglobin was never tested. An oral food challenge test was performed in two patients. FPIES in exclusively breastfed infants is a rare condition that, in the presence of compatible history and symptoms, should be considered also in exclusively breastfed babies. The evaluation of methemoglobin can simplify the diagnostic process." }, { "id": "pubmed23n0810_7841", "title": "[Late diagnosed celiac disease in a mother and thre doughters].", "score": 0.009615384615384616, "content": "A family of seven members with lately diagnosed celiac disease in mother and three doughters was described in the present work. In mother, atypical celiac disease was diagnosed at the age of 39 yers. In two twin dughters potential celiac disease was diagnosed at the age of 4,5 years and in 18-years old daughter- atypical celiac disease. In father and two sons celiac disease was excluded. In genetic studies, in mother and three daughters the presence of HLA DQ2 or DQ8 was confirmed. In father and one son HLA DQ8 was present and in the remaining son HLA DQ2/DQ8 haplotyp was absent. In all family members with diagnosed celiac disease free-gluten diet was introduced." }, { "id": "pubmed23n0659_1442", "title": "11 month-old twins with food avoidance.", "score": 0.009523809523809525, "content": "Maggie and Lily are 11 month-old twins who are brought by their parents to the Developmental-Behavioral Pediatric Clinic for a life-long history of feeding difficulties. The twins are this couple's first children. Their mother is tearful as she recounts a stressful pregnancy complicated by pre-term labor beginning at 24 weeks gestation with strict bed rest for the remainder of the pregnancy. The twins were delivered at 35 weeks gestation by Caesarian Section. Lily weighed 5 lbs 11 oz; Maggie was small-for-gestational age with a birth weight of 3 lbs 13 oz. Maggie required oxygen with nasal prongs for only a few hours after birth. She remained in the Neonatal Intensive Care Unit (NICU) with initial nasogastric tube feeding; she was advanced to bottle feeding prior to discharge. Both Maggie and Lily were slow to initiate and sustain formula feeding. They required over 1 hour to consume 2 ounces of formula and \"tire easily\". At 1 month of age, Maggie resisted feedings by crying and arching her back. By 5 months of age, both children cried at the sight of the bottle and tried to push it away. However, they never lost weight. Maggie was treated with intermittent naso-gastric tube feeding at 5-6 months of age in order to gain adequate weight. At 11 months of age, both girls continued to resist feeding, but their mother was able to \"get in\" 24 ounces each day of a 31-calorie/ounce formula \"with a lot of work\". Dad observed that his wife's entire day revolved around getting the twins to eat and that became a significant stress for her as well as on their relationship. The children had a gastroenterology evaluation including an upper gastrointestinal series, pH probe and gastro-duodenal endoscopy with biopsies. All studies were normal. Trials of omeprazole, metoclopramide and thickened feeds did not improve their feeding problem. They are currently not on any medications. They have not had a history of vomiting, diarrhea, or diaphoresis with feeds, and they have experienced only 1 mild upper respiratory infection. One or two soft bowel movements occur each day. Developmentally, they are on track for their age. The parents report that they can pull up to a stand and cruise, use a pincer grasps, and speak \"mama\" discriminately. A review of their growth charts reveal that their weight is consistently between the 10-25% percentiles; weight is currently at the 25% percentile. Head circumference and height are between the 25-50% percentiles." }, { "id": "pubmed23n0292_21993", "title": "Infant feeding history shows distinct differences between Swedish celiac and reference children.", "score": 0.009523809523809525, "content": "Infant feeding history was investigated in 72 celiac and 288 age-matched reference children in a retrospective questionnaire study. The reply rate was 100% in celiac and 91.6% in reference children. The celiac children were breast-fed for a significantly shorter time than reference children, and they were less often breast-fed at the introduction of gluten. The age of the children at gluten introduction was similar, but the celiac children were significantly more often introduced by a gluten-containing follow-up formula, while the reference children more often started on a gluten-containing porridge. The results can be interpreted in two ways. First, it could be argued that breast milk per se protects against symptoms of celiac disease in childhood. It could, however, also be claimed that breast-feeding merely modulates the gluten introduction, causing a less abrupt introduction of gluten in the baby diet and thereby fewer overt symptoms of the disease." }, { "id": "pubmed23n0801_14682", "title": "[Breastfeeding: health benefits for child and mother].", "score": 0.009433962264150943, "content": "The prevalence of breastfeeding in France is one of the lowest in Europe: 65% of infants born in France in 2010 were breastfed when leaving the maternity ward. Exclusive breastfeeding allows normal growth until at least 6 months of age, and can be prolonged until the age of 2 years or more, provided that complementary feeding is started after 6 months. Breast milk contains hormones, growth factors, cytokines, immunocompetent cells, etc., and has many biological properties. The composition of breast milk is influenced by gestational and postnatal age, as well as by the moment of the feed. Breastfeeding is associated with slightly enhanced performance on tests of cognitive development. Exclusive breastfeeding for at least 3 months is associated with a lower incidence and severity of diarrhoea, otitis media and respiratory infection. Exclusive breastfeeding for at least 4 months is associated with a lower incidence of allergic disease (asthma, atopic dermatitis) during the first 2 to 3 years of life in at-risk infants (infants with at least one first-degree relative presenting with allergy). Breastfeeding is also associated with a lower incidence of obesity during childhood and adolescence, as well as with a lower blood pressure and cholesterolemia in adulthood. However, no beneficial effect of breastfeeding on cardiovascular morbidity and mortality has been shown. Maternal infection with hepatitis B and C virus is not a contraindication to breastfeeding, as opposed to HIV infection and galactosemia. A supplementation with vitamin D and K is necessary in the breastfed infant. Very few medications contraindicate breastfeeding. Premature babies can be breastfed and/or receive mother's milk and/or bank milk, provided they receive energy, protein and mineral supplements. Return to prepregnancy weight is earlier in breastfeeding mothers during the 6 months following delivery. Breastfeeding is also associated with a decreased risk of breast and ovarian cancer in the premenopausal period, and of osteoporosis in the postmenopausal period. " }, { "id": "pubmed23n0132_18364", "title": "The effect of early feeding on the onset of symptoms in celiac disease.", "score": 0.009433962264150943, "content": "The appearance of celiac disease in infancy has often been related to the time when gluten is introduced into the diet, and more recently, to the kind of milk received in the early months. This retrospective study attempts to clarify the relation between breast-feeding and gluten introduction to the onset of symptoms of the disease. One hundred forty-six children with celiac disease, aged from 4 months to 11 years, were studied. The timing and types of feeds were recorded as well as the presenting symptoms of the disease. Data were analyzed by nonparametric statistical methods, as well as by parametric analysis after appropriate transformation. Children breast-fed for 3 months or more showed a marked delay in the onset of the disease and a longer latency time from gluten introduction to onset of disease, when compared with bottle-fed children. This relationship was present for both statistical analyses and was unrelated to the age at gluten introduction into the diet. Onset of disease was positively correlated to the duration of breast-feeding and not related to the age at gluten introduction." }, { "id": "pubmed23n0294_4757", "title": "Effects of a dietary and environmental prevention programme on the incidence of allergic symptoms in high atopic risk infants: three years' follow-up.", "score": 0.009345794392523364, "content": "A prospective case-control study is presented to assess an allergy prevention programme in children up to 36 months of age. Infants born at three maternity hospitals were followed from birth: 279 infants with high atopic risk (intervention group) were compared with 80 infants with similar atopic risk but no intervention (non-intervention group). The intervention programme included dietary measures (exclusive and prolonged milk feeding diet followed by a hypoantigenic weaning diet) and environmental measures (avoidance of parental smoking in the presence of the babies, day care &gt; 2 years of life). Mothers in this group who had insufficient breast milk were randomly assigned to one of two coded formulas: either a hydrolysed milk formula (Nidina HA, Nestlé) or a conventional adapted formula (Nan, Nestlé). Other environmental measures remained the same as for the breastfeeding mothers. The non-intervention group were either breastfed or received the usual Italian milk feeding and weaning diet, without environmental advice. The main outcome measures were anthropometric measurements and allergic disease manifestations. Normal anthropometric data were observed both in the intervention group and in the non-intervention group. The incidence of allergic manifestations was much lower in the intervention group than in the non-intervention group at 1 year (11.5 versus 54.4%, respectively) and at 2 years (14.9 versus 65.6%) and 3 years (20.6 versus 74.1%). Atopic dermatitis and recurrent wheezing were found in both the intervention group and the non-intervention group from birth up to the second year of life, while urticaria and gastrointestinal disorders were only present in the non-intervention group in the first year of life. Conjunctivitis and rhinitis were present after the second year in both the intervention group and the non-intervention group. Relapse of the same allergic symptom was less in the intervention group (13.0%) than in the non-intervention group (36.9%). In comparison to the non-intervention group, there were fewer intervention group cases with two or more different allergic symptoms (8.7 versus 32.6%), and they were more likely to avoid steroid treatment (0 versus 10.8%) and hospital admission (0 versus 6.5%). Babies in the non-intervention group fed with adapted formula were more likely to develop allergies than breastfed babies in the same group. In the intervention group the breastfed infants had the lowest incidence of allergic symptoms, followed by the infants fed the hydrolysed formula (ns). Infants in the intervention group fed the adapted formula had significantly more allergies than the breastfed and hydrolysed milk fed infants, although less than their counterparts in the non-intervention group. Of the affected subjects in the intervention group, 80.4% were RAST and/or Prick positive to food or inhalant allergens. Total serum IgE values detected at birth in the intervention group were not predictive, but at 1 and 2 years of age, IgE values more than 2 SD above the mean in asymptomatic babies were found to predictive for later allergy. In breastfed babies the total IgE level at 1 and 2 years of age was lower than in the other two feeding groups. Of the various factors tested in the non-intervention group, the following were the most important in the pathogenesis of allergic symptoms: (i) formula implementation begun in the first week of life; (ii) early weaning (&lt; 4 months); (iii) feeding beef (&lt; 6 months); (iv) early introduction of cow's milk (&lt; 6 months); and (v) parental smoking in the presence of the babies and early day care admission (&lt; 2 years of life). All the preventive measures used in this study (exclusive breastfeeding and/or hydrolysed milk feeding, delayed and selective introduction of solid foods, and environmental advice) were effective at the third year of follow-up, greatly reducing allergic manifestations in high atopic risk babies in comparison with those not receiving these interventions" }, { "id": "pubmed23n0944_23707", "title": "Ten years of follow-up of the Spanish cohort of the European PreventCD study: the lessons learned.", "score": 0.009345794392523364, "content": "to evaluate the influence of gluten consumption on celiac disease development and to describe its natural history in the Spanish cohort of the European PreventCD study. prospective multi-center double blind study of 225 children that were followed up from birth. All cases were HLA-DQ2/HLA-DQ8 positive with a 1st degree relative with celiac disease and were followed up in three centers from Madrid, Reus and Valencia. Gluten intake was determined between four and ten months according to the protocol. Gluten intake was ad libitum between eleven and 36 months and was prospectively quantified by means of dietary records. Clinical visits and specific antibody analysis for celiac disease were performed periodically. twenty-six cases were diagnosed, all had a positive biopsy and serology; 21 had gastrointestinal symptoms and five were asymptomatic. In addition, 2,565 food records were analyzed and statistically significant differences (p &lt; 0.001) were found with regard to gluten consumption among the three centers, although not between celiac and non-celiac children (p = 0.025). The HLA-DQ2.5/DQ2.5 and DQ2.5/DQ2.2 genotypes had a relative risk of 4.7 (95% CI: 0.80-27.55; p = 0.08), which was higher than for the rest of genotypes. Female gender also had a relative risk that was five times higher than that for males. the amount of gluten intake between 11 and 36 months or the duration of breast feeding were not risk factors for the development of CD in the Spanish population. The HLA genotype and gender were the most relevant associated factors. In this at-risk group, the disease presented before two years of age in the majority of the cases with a weak clinical expression." }, { "id": "pubmed23n0068_182", "title": "[Celiac disease and dietary habits in the 1st year of life].", "score": 0.009259259259259259, "content": "The Authors have performed a study on the dietary habits of 74 celiac children and have analysed retrospectively the type of nursing (breast-feeding or bottle-feeding), the time and the age of gluten introduction. Then they related these data to the age of onset of symptoms. Children breast-fed for 3 months or more showed a marked delay in the onset of the disease and a longer latency time from gluten introduction when compared with bottle-fed children; on the contrary early gluten introduction was not positively correlated to risk of celiac disease. This observations induce to think that breast-feeding may be a protective factor towards coeliac disease, while the precocious gluten introduction is not an important factor of risk correlated to this disease." }, { "id": "pubmed23n1155_5224", "title": "Applying suggested new terminology and definitions for human milk feeding in the Alberta Pregnancy Outcomes and Nutrition (APrON) longitudinal pregnancy cohort.", "score": 0.009174311926605505, "content": "The complexity of human milk-feeding behaviours may not be captured using simpler definitions of \"exclusive\" and \"non-exclusive\" breastfeeding. New definitions have been suggested to describe variation in these behaviours more fully but have not been widely applied. We applied the new definitions to data derived from 3-day human milk-feeding diaries. Participants (<in</i = 1091) recorded the number, beginning/end time, and modes of feeding of infants aged 3 months. Data were used to create six exclusive groups according to feeding mode(s): (1) human milk at-breast only; (2) human milk at-breast and human milk in a bottle; (3) human milk at-breast and infant formula in a bottle; (4) human milk at-breast and human milk and infant formula mixed in the same bottle; (5) human milk at-breast, human milk in a bottle, and infant formula in a bottle (not mixed); and (6) a bottle that sometimes contained human milk and sometimes infant formula (not mixed), never at-breast. Differences in maternal and infant characteristics were examined among groups. Fifty-seven percent fed at-breast only (Group 1). Those in Group 1 spent a similar amount of time feeding directly at-breast (median 132 (IQR 98-172) min/day) as those in Groups 2 (124 (95-158)), 3 (143 (100-190)), and 5 (114 (84-142)) (<ip</i &gt; 0.05), indicating that adding bottle feeding did not always reduce the time infants were fed at-breast. Applying new suggested definitions to describe human milk-feeding behaviours from the mothers' perspective highlights the complexity of patterns used and warrants further application and research to explore impacts on health outcomes." }, { "id": "pubmed23n0061_13763", "title": "[Clinical data on celiac disease with an early or late onset].", "score": 0.009174311926605505, "content": "Typical symptoms in celiac disease (CD) are usually associated with early onset of the disease, whereas an atypical symptomatology has more often a later onset. The aim of this study was to evaluate the prevalence of some clinical signs and symptoms in children whose CD started before one year of age (\"early onset\" 135 children, M/F 50/85, mean age at onset 6.9 +/- 1.9 months) and in children whose disease started later (\"late onset\", M/F 14/26, mean age at onset 26.3 +/- 26.7 months). We analyzed: a) time lapse between gluten introduction and onset of symptoms, b) prevalence of patients with gastrointestinal symptoms alone and that of patients with gastrointestinal plus extraintestinal symptoms, c) frequency of each symptom. We then evaluated the influence of breast feeding and age of gluten introduction on time lapse. Our results showed that typical gastrointestinal symptoms, like diarrhea anorexia and abdominal distension prevailed both in children with early and late onset; whereas failure to thrive was significantly more frequent in children with an early onset CD (p &lt; 0.01). Breast feeding delayed onset of symptoms: time lapse was significantly longer in children breast fed for a longer time (p &lt; 0.001). On the contrary, age at first gluten ingestion seemed to have no influence on age at onset, since it was similar in both groups." }, { "id": "pubmed23n0893_12027", "title": "Early Infant Feeding Practices May Influence the Onset of Symptomatic Celiac Disease.", "score": 0.00909090909090909, "content": "To study whether breastfeeding and breastfeeding status during gluten introduction influences the age at diagnosis of celiac disease (CD). In addition to study, whether the timing of gluten introduction influences the age at diagnosis of CD. It was a hospital based observational study. Total 198 patients diagnosed with CD as per modified European Society of Pediatric Gastroenterology, Hepatology and Nutrition (2012) criteria, aged between 6 months to 6 years were included. Detail history taken with special emphasis on breastfeeding and age of gluten introduction. Standard statistical methods used to analyze the data. Mean±standard deviation age of onset and diagnosis of CD in breastfed cases was 2.81±1.42 years and 3.68 ±1.55 years respectively as compared to 1.84±1.36 years and 2.70±1.65 years respectively in not breastfed cases (<ip</i&lt;0.05). Those who had continued breastfeeding during gluten introduction and of longer duration had significantly delayed onset of disease. The age at onset of CD was under one year in 40.42% of the cases, who had started gluten before 6 months of age compared to only 12.58% of those who had started gluten later (<ip</i&lt;0.001). The proposed statistical model showed that two variables, i.e., breast feeding status during gluten introduction and age at gluten introduction positively influencing the age at diagnosis of CD. Delayed gluten introduction to infant's diet along with continuing breastfeeding, delays symptomatic CD. However, it is not clear from our study that these infant feeding practices provide permanent protection against the disease or merely delays the symptoms." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 214 ] ], "word_ranges": [ [ 0, 39 ] ], "text": "This patient is in serious condition. The trismus and fever suggest a deep cervical space infection and that is not a game because the airway can become obstructed. Knowing this, options 1, 2 and 5 are out of place" }, "2": { "exist": true, "char_ranges": [ [ 0, 214 ] ], "word_ranges": [ [ 0, 39 ] ], "text": "This patient is in serious condition. The trismus and fever suggest a deep cervical space infection and that is not a game because the airway can become obstructed. Knowing this, options 1, 2 and 5 are out of place" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 0, 214 ] ], "word_ranges": [ [ 0, 39 ] ], "text": "This patient is in serious condition. The trismus and fever suggest a deep cervical space infection and that is not a game because the airway can become obstructed. Knowing this, options 1, 2 and 5 are out of place" } }

{ "1": "The first diagnostic probability is carcinoma of the floor of the mouth with bilateral cervical metastases.", "2": "The therapeutic priority is to ensure the patient's nutrition.", "3": "We are almost certainly facing a mediastinitis.", "4": "We must consider as a priority the risk of airway obstruction.", "5": "We must perform as a first diagnostic measure a cytology by fine needle aspiration puncture." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0089_19952", "title": "[The value of ultrasound-controlled fine-needle biopsy in the diagnosis of possible neck tumors].", "score": 0.015463337831758885, "content": "From October 1985 to July 1988 we performed a study to examine 106 patients with head and neck tumours, by using ultrasound as a guiding system for fine-needle aspiration biopsy. It could be shown that this method has a high diagnostic significance at the neck with a low rate of risks. In a first step puncture was effected to obtain material for cytology, if necessary also for a bacteriological examination. Normally, in a second step a fine-needle cutting biopsy was done to obtain histological material. The combined use of aspiration and cutting needle biopsy achieved correct tumour status in 91.5%, whereas in 73.6% the correct type of lesion was diagnosed. A false status assessment and errors in identifying the lesions occurred in 2 of 106 cases; there of was one false negative status assessment. In cases of benign neck cysts, neck abscesses and non-specific lymphadenopathy, a cutting neck biopsy is not required, provided the clinical diagnosis is in accordance with the result of aspiration cytology and the further clinical progress. The advantage of the ultrasound-guided puncture compared with palpation-guided puncture is the certainty of locating the region of interest even in deep lesions without an appreciable risk of complications. In our opinion, ultrasound-guided fine needle aspiration biopsy is indicated in all cases of unclear head and neck tumours which could be treated conservatively if the result of the puncture is non-malignant." }, { "id": "pubmed23n0788_23917", "title": "[Cervical node fine needle aspiration: factors influencing the failure rate].", "score": 0.013911007025761125, "content": "We had for aim to study the factors influencing the rate of non satisfactory (NS) cervical node fine needle aspirations (CNFNA). We prospectively included 272 CNFNA, performed over 2 years (2010-2012). NS results were studied according to the following criteria: age, size and location of the node, number of punctures performed, and the operating physician's experience. Fifty-six (20.6%) of the 272 CNFNA were NS because they were acellular or paucicellular. The rate of NS CNFNA was not correlated with the patient's age: 63.6% for small lymph nodes (≤1 cm: P=0.01). Submandibular and jugulodigastric locations were observed in 28% of NS CNFNA and in 5% of satisfactory ones (P=0.001). The rate of NS CNFNA was 67% if 1 or 2 punctures were performed; it decreased to 18% for 3 or more punctures (P=0.01). This rate was 77% for the first study semester, and 8% for the fourth semester (P=0.001). CNFNA has been repeated for 19 patients. The second CNFNA was contributive for 14 patients. Repeating the CNFNA increased its efficiency by 73.7% (14/19). The rate of NS CNFNA depends on the size and location of the lymph node, and the operating physician's experience. Repeating the CNFNA significantly improves its efficiency." }, { "id": "pubmed23n0238_9474", "title": "Cervical cysts: cancer until proven otherwise?", "score": 0.012793775567498195, "content": "A cystic neck mass can be either malignant or benign; 22% of patients (4/18) admitted with the tentative diagnosis of branchial cyst in a recent 2-year period (1977-1979) had metastatic carcinoma: epidermoid, thyroid or salivary gland. Preoperative fine needle aspiration was diagnostic in 1 instance and unhelpful in 2. Frozen section analysis of the gross specimen invariably provided the correct diagnosis. All patients with malignancies had subclinical primary disease and in 1 instance random biopsies identified its origin. The prudent surgeon will avoid untoward results if he approaches a neck cyst in an adult as if it were malignant. Guidelines he can follow to prevent the inadvertent removal of a metastasis under the misapprehension that it is a benign neck cyst include: 1. Prior to operation, perform a thorough head and neck examination to identify a primary carcinoma; 2. Do a fine needle aspiration of the mass for cytology. A negative report must be considered inconclusive; 3. Make a gross examination in the operating room of the opened cyst and frozen section processing of suspicious areas; 4. Follow with a panendoscopy and random biopsies of appropriate areas and complete the neck dissection on the involved side, after a metastatic deposit has been recognized. The preoperative procurement of contingency consent for these procedures is understood." }, { "id": "wiki20220301en105_18342", "title": "Sialadenitis", "score": 0.010127803231251507, "content": "Common key diagnostic factors 1. Fever – may present with an acute infective sialadenitis or autoimmune aetiology suggestive of an infection or inflammation. 2. Pain and dysphagia (ie. difficulty swallowing) – usually unilateral affecting the parotid or submandibular regions, with worse pain during eating and swallowing. 3. Facial swelling – usually unilaterally and affecting parotid region, under the tongue, or below the jaw. May have acute onset and may have a history of repeated episodes. 4. Recurrent painful swellings – indicative of chronic recurrent sialadenitis, may have similar signs and symptoms to an acute episode. 5. Pus exudation from salivary gland openings – indicative of bacterial infection, may occur on manipulation of the affected gland or spontaneously. Other common diagnostic factors to consider" }, { "id": "wiki20220301en056_36318", "title": "Ludwig's angina", "score": 0.009900990099009901, "content": "Signs and symptoms Ludwig's angina is a form of severe, widespread cellulitis of the floor of the mouth, usually with bilateral involvement. Infection is usually primarily within the submandibular space, and the sublingual and submental spaces can also be involved. It presents with an acute onset and spreads very rapidly, therefor early diagnosis and immediate treatment planning is vital and lifesaving. The external signs may include bilateral lower facial swelling around the jaw and upper neck. Signs inside the mouth may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway. Additional symptoms may include painful neck swelling, drooling, tooth pain, dysphagia, shortness of breath, fever, and general malaise. Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing." }, { "id": "pubmed23n0530_6717", "title": "[Necrotizing mediastinitis in deep neck infections].", "score": 0.009900990099009901, "content": "Mediastinitis is a rare complication of deep neck abscesses with a high mortality. An accelerated extension to the mediastinum can happen before the identification of the primary site of infection, delaying diagnosis and treatment. To report the results of treatment of patients with mediastinitis as a complication of deep neck infection. Case series. Consecutive patients with mediastinitis secondary to deep neck abscesses, from March 2001 to February 2004. We studied five patients: three males (60%) and two females (40%), mean age 42.2 +/- 18.4 years. In all patients there was at least a 3-day delay before appropriate diagnosis was made. Hospitalization ranged between 1 and 56 days. Symptoms were fever in five cases (100%), dysphagia in four (80%), dyspnea in four (80%), retrosternal pain in three (60%), orthopnea in two (40%), and tachycardia in one (20%). Primary infection sites were of dental origin in four cases (80%) and upper respiratory tract infection in one. Surgical management consisted of cervical and mediastinal drainage with tracheotomy in all patients (100%). Three also required pleurostomy and two required gastrostomy to improve nutritional status. Mean number of surgical procedures was 5.4 +/- 1.8. All patients developed respiratory insufficiency requiring mechanical ventilation. Mortality was 60%. The delayed diagnosis was common in this case series. The length of hospitalization was long because patients required management with ventilatory support and multiple surgical procedures to limit the infectious process. High mortality is an indication for the early identification and treatment of all cases." }, { "id": "wiki20220301en407_27887", "title": "Submandibular space", "score": 0.00980392156862745, "content": "Signs and symptoms of a submandibular space infection might include trismus (difficulty opening the mouth), inability to palpate (feel) the inferior border of the mandible and swelling of the face over the submandibular region. If the space contains pus, the usual treatment is by incision and drainage. The site of the incision is extra-oral, and usually made 2–3 cm below, and parallel to, the inferior border of the mandible. Ludwig's angina is a serious infection involving the submandibular, sublingual and submental spaces bilaterally. Ludwig's angina may extend into the pharyngeal and cervical spaces, and the swelling can compress the airway and cause dyspnoea (difficulty breathing). References Fascial spaces of the head and neck Otorhinolaryngology Oral and maxillofacial surgery Mouth" }, { "id": "pubmed23n0228_10362", "title": "[Diagnosis and surgical treatment of metastatic cervical adenopathies].", "score": 0.00980392156862745, "content": "Needle biopsy is preferable to open biopsy for several reasons; no tumor spread, no inconvenient scars hampering future surgical intervention, no delay between diagnostic procedure and definitive therapy as well as its simplicity. A conclusive histological diagnosis of malignancy is only made in 70 to 80% of the cases by this technic. In the other cases however, the macroscopic and microscopic aspect usually very strongly suggests the nature of the disease. When a definite diagnosis of malignancy cannot be made this way an open biopsy is mandatory and to be performed under general anesthesia by a surgeon who is able to proceed immediately with the appropriate surgical therapy as soon as a peroperatory positive histological diagnosis is obtained. The classical therapy consists of a unilateral or bilateral radical neck dissection with or without resection of the primary tumor. The postoperative follow-up is usually simple. The incidence of postoperative complications is higher when the cervical region has been irradiated with a dose equal or higher to 5,500 tumor rads or when the larynx, pharynx and/or buccal cavity have been entered." }, { "id": "pubmed23n1157_9975", "title": "A Unique Presentation of Ectopic Thyroid Tissue: Case Report and Management Principles.", "score": 0.009708737864077669, "content": "Ectopic thyroid is a rare clinical presentation to encounter in day-to-day clinical practice. It occurs due to developmental defects in the early stages of the thyroid gland embryogenesis during its descent from the floor of the primitive foregut to its final pre-tracheal position. It is usually present along the extent of the thyroglossal duct as well as in distant locations such as sub-diaphragmatic or mediastinal spaces. The diverse clinical presentation of this rare entity often causes a diagnostic dilemma. A thyroid scintigraphy scan is pivotal in the diagnosis of ectopy, but ultrasonography is done more frequently. Surgical management is preferred for symptomatic cases, followed by radioactive iodine ablation and levothyroxine supportive therapy for refractory cases. We present a case of a 62-year-old female patient who presented with pain and swelling of the right submandibular region. On ultrasonography, a 5*4 cm firm mobile swelling of the right submandibular region was found, suggestive of right submandibular sialadenitis. Fine needle aspiration cytology (FNAC) was subsequently done, and it showed features of basaloid neoplasm like pleomorphic adenoma, and as the thyroid tissue was in an ectopic location, it must have been misdiagnosed. The patient was then taken up for right submandibular sialoadenectomy, and the histopathological examination of the operative specimen showed nodular colloidal goiter and mild chronic sialadenitis. Ectopic thyroid can present at various anatomical locations and thereby has varied clinical presentations which makes it a diagnostic dilemma for clinicians. The usual radiological investigations done include USG and CT scan, whereas thyroid scintigraphy is more precise in reaching the diagnosis of ectopic thyroid. The confirmatory diagnostic method is the histopathological examination of the excised specimen. Most cases of ectopic thyroid are asymptomatic and require regular follow-up. Symptomatic cases are managed by surgical excision followed by periodic monitoring and adequate thyroxine replacement." }, { "id": "pubmed23n0370_9856", "title": "The value of elective neck dissection in treatment of cancer of the tongue.", "score": 0.009708737864077669, "content": "The \"adequate\" therapy of tongue cancer has not yet been determined. The authors report their experience with 58 N(0) patients to elucidate the role of elective neck dissection in surgical treatment of cancer of the tongue. The files of 58 N(0) patients with tongue cancer were evaluated retrospectively. In every patient, partial glossectomy continuous with neck dissection was the mainstay of the treatment. TNM staging, intraoperative N staging, pathologically confirmed cervical lymph node metastases and their levels, and clinical outcomes (local and regional recurrences) were recorded. The sensitivity and specificity of intraoperative staging was determined. Fifty-four percent (31/58) of the patients presented as T(1), and 26% (15/58) as T(2). The overall occult metastasis rate was 29.3% (17/58). The occult metastasis rate for T(1) and T(2) lesions was 19.4% (6/31) and 26.7% (4/15), respectively. The sensitivity of intraoperative staging was 76.5%, and the specificity was 51.2%. The rate of occult metastasis to the neck is too high in all tongue cancer cases to take the risk of regional recurrence, and the surgeon can not solely depend on neck palpation for determination of neck metastasis. Radiologic investigations and fine-needle aspiration decrease, but never reduce to zero the rate of false-negative examination. There is an obvious indication for neck dissection, even in early cases." }, { "id": "Surgery_Schwartz_4338", "title": "Surgery_Schwartz", "score": 0.009685462217107787, "content": "advanced disease with pterygoid involvement. As previously mentioned, because of the epidemic rise in incidence of oropharyngeal cancers, secondary to HPV-associated tumors, and the high regional metastatic rate for these tumors, the pre-senting symptom is often a nontender cervical lymphadenopa-thy, which should be investigated with a fine-needle aspiration (FNA) biopsy. Approximately 50% of patients have metastases at the time of diagnosis. Bilateral metastases are common in patients with soft palate and base of tongue tumors. Treatment of the neck should include the upper jugulodigastric nodes to which these tumors most commonly metastasize to, followed by levels II, IV, V, and the retropharyngeal lymph nodes.A discussion about oropharyngeal cancer cannot be had without discussing the important prognostic information pro-vided by the HPV status of these tumors. The incidence of oro-pharyngeal squamous cell carcinoma has increased significantly over the last four decades secondary" }, { "id": "pubmed23n0287_13962", "title": "Dermoid cyst of the floor of the mouth diagnosed by fine needle aspiration cytology: a case report.", "score": 0.009615384615384616, "content": "Dermoid cyst of the floor of the mouth is a rare, benign lesion requiring surgical intervention. To our knowledge, the preoperative diagnosis of this entity by fine needle aspiration (FNA) cytology has not been previously reported in the cytologic literature. The patient presented with a massive swelling of the floor of the mouth that displaced the tongue superiorly. A computed tomographic (CT) scan demonstrated a cystic lesion thought to be consistent with a lymphangioma. FNA was performed without complications and demonstrated numerous anucleated and some nucleated squames consistent with a diagnosis of dermoid cyst. Establishment of the correct diagnosis by FNA enabled the surgeon to proceed with the appropriate operation; that outcome might not have been possible had the erroneous CT diagnosis of lymphangioma been trusted. A preoperative diagnosis of dermoid cyst of the floor of the mouth was established by FNA. In contrast to reports in the older literature, the FNA procedure caused no complications. In patients presenting with lesions of the floor of the mouth, FNA should be the diagnostic procedure of first choice." }, { "id": "pubmed23n1133_4308", "title": "Management of Ludwig's Angina at a Tertiary Care Hospital in Western Region of India.", "score": 0.009523809523809525, "content": "Introduction Ludwig's angina is cellulitis of submandibular space, submental space, and sublingual space. The main causative factors include dental infections (dental caries with atypical periodontitis, pericoronitis, and dental procedures). Other predisposing conditions include poor dental hygiene, dental caries, malnutrition, diabetes mellitus, AIDS, and various other immunocompromised states. It presents as an acute onset and spreads very rapidly causing bilateral diffuse neck swelling, edema of floor of mouth, pain, fever, trismus, foul-smelling pus discharge, difficulty in swallowing, airway edema, and tongue displacement creating a compromised airway with stridor. So it requires early diagnosis and aggressive management. Material and methods Clinical data of all patients with clinical diagnosis of Ludwig's angina managed at the Department of Otorhinolaryngology-Head and Neck Surgery, Sir Takhatsinhji (T) General Hospital and Government Medical College, Bhavnagar, India, from 2015 to 2019 were analyzed retrospectively in this study. Result Over the review period, 30 cases were diagnosed as Ludwig's angina, out of which 12 (40%) were males and 18 (60%) were females; male to female ratio was 1:1.5. The age of the patients ranged from six months to 64 years, with a mean age of 38.86 years. Fever, neck swelling, and neck pain were present in all patients. In 16 patients, incision and drainage were done under general anesthesia while the rest five patients required only local anesthesia. In six patients (20%), for maintenance of airway, tracheostomy was required. The most common complication was necrotizing fasciitis and death followed by septicemia. Mortality was observed in three patients (10%) in this study. Conclusion Despite improved outcomes compare to pre-antibiotic era, Ludwig's angina still remains a potentially life-threatening disease in ENT at present. Dental caries, uncontrolled diabetes mellitus, and malnutrition are commonly associated conditions. With early diagnosis, close airway observation, aggressive intravenous antibiotic treatment, and timely surgical intervention, morbidity, and mortality can be reduced." }, { "id": "pubmed23n0278_5688", "title": "Squamous carcinoma presenting as an enlarged cervical lymph node.", "score": 0.009523809523809525, "content": "Patients presenting with an enlarged cervical lymph node containing squamous cell carcinoma are a difficult problem for head and neck surgeons. In most cases, the primary site lies in the head and neck region. The advent of fine-needle aspiration cytologic study means that this group of patients can be accurately identified in the clinic and investigated accordingly. The current report studies the records of 267 such patients presenting to the Head and Neck Unit at The University of Liverpool over a 29-year period. The 5-year survival rate for all patients presenting with a cervical lymph node metastasis was 27%. The 5-year survival rate for patients with a detected primary in the head and neck was 31% and the primary site was identified during the patient's life time in all but 36 patients (13%). In 53% of patients, the primary site was discovered during routine clinical examination, and in a further 16% it was discovered at panendoscopy. Most diagnostic tests proved relatively unhelpful but 10 patients in our series had the primary site discovered by radiograph and 9 of these had carcinoma of the lung. In the current study when the primary site was discovered it was in the head and neck region in 74% of patients. Primary sites other than head and neck occurred in 11% of the patients and no 5-year survivors existed. Multivariate analysis suggested that open biopsy of the lymph node metastasis appeared to have an adverse effect on survival as did advanced age and advanced N stage. The late diagnosis of the primary site, if it proved to be in the head and neck region, on the other hand, had a positive association with survival. Patients presenting with a lymph node metastasis in the head and neck region from an unknown primary have a prognosis identical to that of other patients with head and neck squamous carcinoma with neck node metastases. The prognosis for patients in whom the primary site is never discovered or in whom the primary site is not head and neck, however, is disastrous. If the primary tumor proves to be in the head and neck region, treatment is worthwhile since almost a third of patients are cured of their disease. When the primary carcinoma is not in the head and neck region, treatment must be considered palliative." }, { "id": "pubmed23n1094_11212", "title": "Fine needle aspiration in COVID-19 vaccine-associated lymphadenopathy.", "score": 0.009433962264150943, "content": "With ongoing intensive vaccination programme against COVID-19, numerous cases of adverse reactions occur, some of which represent rare events. Enlargement of the injection site&amp;rsquo;s draining lymph nodes is increasingly reported, but is not yet widely recognised as being possibly associated with recent vaccination. As patients at risk of a severe course of COVID-19, indicated by their medical history such as a previous diagnosis of malignancy, receive priority vaccination, newly palpable lymph nodes raise concerns of disease progression. In this case series, we report on five patients who presented with enlarged lymph nodes after COVID-19 vaccination. Sonography guided fine needle aspiration (FNA) was performed in five patients presenting with PET-positive and/or enlarged lymph nodes after COVID-19 vaccination with either the Pfizer-BioNTech or Moderna vaccine. COVID-19 vaccination had been carried out in all cases, with an interval of between 3 and 33 days prior to FNA. Three of five patients had a history of neoplasms. The vaccine was administered into the deltoid muscle, with subsequent enlargement of either the cervical, supra-, infra- or retroclavicular, or axillary lymph nodes, in four out of five cases ipsilaterally. In all cases, cytology and additional analyses showed a reactive lymphadenopathy without any sign of malignancy. Evidence of newly enlarged lymph nodes after recent COVID-19 vaccination should be considered reactive in the first instance, occurring owing to stimulation of the immune system. A clinical follow-up according to the patient&amp;rsquo;s risk profile without further diagnostic measures is justified. In the case of preexisting unilateral cancer, vaccination should be given contralaterally whenever possible. Persistently enlarged lymph nodes should be re-evaluated (2 to) 6 weeks after the second dose, with additional diagnostic tests tailored to the clinical context. Fine needle aspiration is a well established, safe, rapid and cost-effective method to investigate an underlying malignancy, especially metastasis. Recording vaccination history, including date of injection, site and vaccine type, as well as communicating this information to treating physicians of different specialties is paramount for properly handling COVID-19 vaccine-associated lymphadenopathy." }, { "id": "pubmed23n0940_7626", "title": "A Clinical, Radiological, and Histopathological Correlation of Neck Nodes in Patients Undergoing Neck Dissection.", "score": 0.009433962264150943, "content": "Management of neck metastases in terms of diagnosis and treatment has always been a controversial issue in patients of head and neck malignancy. The main area of debate in case of diagnosis lies with the fact that whether we should rely on ultrasound, as a diagnostic modality for diagnosing micrometastases in the neck in head and neck malignancy patients? The second controversial issue is the management of N0 neck, whether to be radical or conservative? This study was conducted on 70 diagnosed patients of head and neck carcinoma who were planned for resection of the primary. An appropriate neck dissection was performed in all the patients, and their clinical, ultrasonography, and postoperative histopathological neck findings were correlated. In our center, the most common site of the primary tumor was oral cavity with most involving buccal mucosa. As expected, T4 lesions were commonly associated with nodal metastasis (71%). The sensitivity of clinical examination and ultrasound was 80% and 93.3%, respectively, and specificity of clinical examination and ultrasound was 57% and 27.2%, respectively. Histopathologically positive but clinically nonpalpable metastases in the study group were more frequent in levels Ib, II, and III, respectively. We concluded that ultrasonography being a low cost and a highly sensitive investigation can act in tandem with clinical examination for diagnosing the neck for metastases preoperatively in head and neck malignancy patients. However, due to its low specificity, we cannot completely rely on it, hence doing a neck dissection in selective form, will definitely improve the clinical course of the disease in N0 necks." }, { "id": "pubmed23n0285_18756", "title": "Unusual small bone metastases from epithelial malignancies: diagnosis by fine-needle aspiration cytology with histologic confirmation.", "score": 0.009345794392523364, "content": "Although epithelial malignancies can have bone metastases, involvement of small bones is exceedingly rare, representing either first manifestation of an occult carcinoma or late disseminated disease. Small bone metastases may mimic primary skeletal diseases leading to misdiagnosis and delayed treatment. We report three cases of metastatic epithelial malignancies diagnosed by computed tomography (CT)-guided fine-needle aspiration (FNA) biopsy in two patients with lytic calcaneal lesions and a patellar lesion in a third patient; all with histologic confirmation. Case 1, a 63-year-old female, presented with heel pain. FNA and tissue biopsy of the calcaneus revealed a clear cell malignancy consistent with a renal primary. Follow-up abdominal CT scan revealed a renal lesion consistent with renal cell carcinoma. Case 2, a 37-yr-old male with squamous cell carcinoma of the esophagus, presented with foot pain. FNA and tissue biopsy of the calcaneous revealed metastatic squamous cell carcinoma. Case 3, a 52-yr-old male with a history of squamous cell carcinoma of floor of mouth, presented with knee pain and swelling. FNA and tissue biopsy of the patella revealed metastastic squamous cell carcinoma. To the best of our knowledge, this is the first complete FNA cytology report with histologic confirmation of unusual small bone metastases of the feet and patella from epithelial malignancies and shows the value of FNA cytology in establishing a correct diagnosis, and excluding primary skeletal diseases." }, { "id": "pubmed23n0514_11706", "title": "The role of second opinion pathology in the management of lesions of the head and neck.", "score": 0.009345794392523364, "content": "Medical error is a common problem, and its human cost in terms of disability, suffering, and death is stunning. Steps toward reducing medical error will require the identification of mistake-prone practices within a complex health care system. Erroneous pathologic diagnosis has been identified as one source of error. This review was undertaken to assess the magnitude of diagnostic imprecision in lesions of the head and neck, and to address the validity of mandatory review of pathology material for patients who are referred from one institution to another for management of tumors involving the head and neck. Mandatory second opinion pathology consistently uncovers discrepancies across all major organ systems and has a profound impact on management and prognosis. Site-specific studies have implicated the head and neck as a high-risk area that is prone to diagnostic error. Diagnostic discrepancy rates have ranged from 1 to 53% for surgical pathology studies and from 17 to 60% for cytopathology studies. Major changes (affecting treatment or prognosis) occur in 5 to 7% of surgical pathology cases. The thyroid is consistently identified as a site that is particularly prone to diagnostic discrepancies; and no specific head and neck sites are immune to diagnostic error. Limited studies addressing the site-specific impact of second opinion pathology implicate the head and neck as a high-risk area that is prone to major changes in diagnoses. Accordingly, mandatory second opinion pathology makes good clinical and risk management sense for all patients referred to head and neck surgery or oncology services before a major therapeutic endeavor is undertaken." }, { "id": "pubmed23n0678_12721", "title": "Diagnosis of adult rhabdomyoma by fine needle aspiration cytology: a report of 2 cases.", "score": 0.009259259259259259, "content": "Adult rhabdomyoma (ARh) is a rare, benign tumor originating in striated muscle cells. Ninety-three percent of the tumors occur in the head and neck region and sometimes mimic malignant tumors clinically. The preoperative correct diagnosis of this tumor is important as it can help in deciding on management. We report two cases of ARh diagnosed by fine needle aspiration cytology (FNAC). Case 1 was a 43-year-old male who presented with a recurrent tumor in the region of the floor of the mouth. Case 2 was a 37-year-old male who presented with soft tissue swellings in bilateral submandibular regions. On cytology in both cases, the smears showed numerous large tissue fragments of tumor cells, which were large, polygonal cells with abundant, vacuolated cytoplasm and bland, eccentrically placed nuclei. Characteristic cross-striation and intracytoplasmic inclusions were not conspicuous on cytosmears. However, a primary cytodiagnosis of ARh could be offered based on characteristic morphologic features. ARh has characteristic cytomorphologic features, which are described in detail in the present report, and they can help in diagnosing this tumor on FNAC." }, { "id": "pubmed23n0277_4285", "title": "[Value of irradiation of neck nodes metastases. Part I. Treatment of palpable nodes].", "score": 0.009259259259259259, "content": "Medical records of 222 patients with neck nodes metastases from squamous cell carcinoma of supraglottic larynx (122 cases), tonsil (63 cases) and base of tongue (37 cases) were analyzed. All cases were treated with definitive irradiation between 1970-1981. One hundred ten patients were treated with orthovoltage technique with total doses of 5000-6000 rads, 150-180 rads per fraction; 112 patients with Co60 with total doses 6000-7000 rads, 180-230 rads per fraction. Local-regional control was achieved in 28% of cases. Failures in the neck nodes with primary tumour controlled, were recorded in 10% of patients. Failures in a primary tumour alone were observed in 26% of patients, in primary tumour and neck nodes in 36%. Radiocurability of primary tumour and involved neck nodes was similar. In cases with primary tumour controlled, the probability of eradication of neck nodes metastases is high, even in N3 stage patients. Residual neck nodes palpable 1 to 3 months after irradiation were unfavourable prognostic factor indicated 50% risk of neck recurrence. In patients with complete regression of primary and nodal disease, failure in neck nodes was recorded in 5% of cases. The role of surgery following irradiation in patients with cervical nodes metastases is discussed." }, { "id": "pubmed23n1138_21876", "title": "Mucoepidermoid carcinoma: Analysis of 76 cytologic cases and correlation with histologic grade.", "score": 0.009174311926605505, "content": "Mucoepidermoid carcinoma (MEC) is the most common salivary gland (SG) malignancy. In this study, the author undertook analysis of a large collection of MEC cytologic cases. Cytopathology files were searched for MEC cases with histopathologic confirmation. Fine-needle aspiration (FNA) smears used standard technique. Seventy-six cases (63 patients [M:F = 1:1; age range, 23-87 years; mean age, 58 years]) met inclusion criteria. Aspirates were primary (54 [71%]), metastatic (18 [24%]), and locally recurrent (4 [5%]). FNA sites included parotid gland (49 [64%]), regional lymph nodes (11 [14%]), submandibular gland (5 [7%]), inner canthus of eye (2 [3%]), and lung (2 [3%]); and single specimens from palate, jaw, shoulder, paranasal sinus, floor of mouth, ear canal, and effusion. Cytologic diagnoses included MEC (30 cases [39%]), suspicious for MEC (16 [21%]), non-MEC carcinoma (9 [12%]), suspicious for malignancy (SM) (2 [3%], malignant (M) (1 [1%]), SG and/or suspicious SG neoplasm (7 [8%]), atypical (3 [5%]), nonneoplastic (5 [6%]), nondiagnostic (2 [3%]), and benign SG neoplasm (1 [1%]). A total of 26% of low-grade (LG) cases were diagnosed as malignant in contrast to 87% malignant in high-grade (HG) cases. Cytomorphology depended on tumor grade. LG MEC contained intra- and/or extra-cellular mucin and more uniform cell and/or nuclear morphology, whereas cytologic atypia, anisonucleosis, and keratotic cells were more typical of HG tumors. A malignant (M) or suspicious for malignancy (SM) cytologic interpretation was made in 76% of mucoepidermoid carcinoma (MEC) cases. In contrast to high-grade MEC (97% identified as M/SM), only 59% of low-grade (LG) MEC cases were interpreted as such, illustrating the continued diagnostic challenge posed by LG MEC using fine-needle aspiration biopsy." }, { "id": "pubmed23n0818_24090", "title": "Treatment and prognosis of deep neck infections.", "score": 0.009174311926605505, "content": "Deep neck infections could have serious threats for life of patients, if not noticed adequately. Early diagnosis and correct treatment planning can save the patient's lives and prevent complications of disease extension and also surgical procedures that in some instances may be performed in an emergent situation with higher complication rates. Herein, we have studied 815 cases of deep neck abscesses and infections with especial consideration to treatment and prognosis. In a retrospective case review, we studied 815 cases admitted in our medical center from 1998 until the year 2013. Only patients with abscesses or infections deeper than superficial layer of deep cervical fascia were included in this study, based on the review of their medical records. From 815 cases (485 males and 330 females) surgery was indicated and performed in 428 cases and the rest were treated medically. In cases with dental infections as the etiologic factor, dental procedures were performed as early as possible (extraction in almost all cases). Tracheostomy was performed in five cases. All of the patients in medical treatment group and most of the surgically managed patients were discharged while were stable with relative or complete resolution of their symptoms. One of our patients, a 15 year old boy died with symptoms suggestive for mediastinitis and air way compromise. Early diagnosis and medical management can be effective in treating deep neck infections. Dental infections and also procedures are the major cause in our patients, although tonsillitis and peritonsillar abscess also were important leading causes with almost equal numbers in our series. Extraction of the infected tooth as early as possible while medical treatment is continued can be very helpful. In some cases it may be necessary to perform surgical exploration of the neck more than once, and finally, malignant neoplasia, somewhere in the head and neck should be considered in some cases, as in one of our patients with left side submandibular abscess whose underlying disorder was tongue SCC with neck metastasis. Prognosis can be excellent in both medically and surgically managed groups if started and designed early and promptly. " }, { "id": "pubmed23n0422_999", "title": "[Endosonographically controlled transluminal fine needle aspiration biopsy: diagnostic quality by cytologic and histopathologic classification].", "score": 0.00909090909090909, "content": "EUS-guided fine needle aspiration (EUS-FNA) has emerged as a highly accurate technique for detecting and classifying mediastinal and pancreatic lesions as well as abdominal and recently retroperitoneal masses with a minimum of risk for the patient. To objectify these statements, we evaluated the quality of 72 EUS-FNA specimens by cytologic and histopathologic classification, investigated their contamination with tissue from the needle pathway and observed puncture-related complications in a retrospective study of 44 EUS-FNA in 41 consecutive patients (56 +/- 14 years, m = 24, f = 17; 13 pancreatic, 9 adrenal, 6 abdominal and 13 mediastinal masses). EUS-FNA was performed using a PENTAX 32 UA endosonoscope (longitudinal 7.5 MHz sector array) in combination with a needle system type \"Hancke-Vilmann\". 16 vs. 11 of 34 histopathologic and 38 cytologic specimens were classified \"excellent\", 7 vs. 10 \"sufficient\", 7 vs. 13 \"poor\" and 4 vs. 4 \"failed\". Analysis of contamination with tissue from the needle pathway showed 4 vs. 2 specimens \"highly\", 3 vs. 14 \"clearly\", 8 vs. 19 \"slightly\" and 19 vs. 3 \"not\" contaminated. Specimens classified \"excellent\" were less contaminated (p = 0,037). EUS-FNA identified 35 benign and 24 malignant masses. Definite diagnosis failed in 13 specimens. One nonfatal complication occurred. EUS-FNA is an accurate (89 %) and low-risk procedure to examine primary undiagnosed mediastinal, pancreatic, intraabdominal and especially adrenal lesions in most of the cases. Contamination with tissue from the needle pathway seems to be a major predictive factor of poor specimen quality and failed diagnosis. EUS-FNA expands the diagnostic approach of mediastinal, abdominal, pancreatic and adrenal masses and provides accurate specimens for reaching new differential-diagnostic competence, especially in endocrinologic cases." }, { "id": "pubmed23n0523_22120", "title": "Diagnosis and management of neck metastases from an unknown primary.", "score": 0.00909090909090909, "content": "Neck lymph node metastases from occult primary constitute about 5%-10% of all patients with carcinoma of unknown primary site. Metastases in the upper and middle neck (levels I-II-III-V) are generally attributed to head and neck cancers, whereas the lower neck (level IV) involvement is often associated with primaries below the clavicles. Diagnostic procedures include a careful clinical evaluation and a fiberoptic endoscopic examination of the head and neck mucosa, biopsies from all suspicious sites or blindly from the sites of possible origin of the primary, computerized tomography scan, and magnetic resonance. The most frequent histological finding is Squamous Cell Carcinoma, particularly when the upper neck is involved. In these cases, a systematic tonsillectomy in the absence of suspicious lesions is discussed since up to 25% of primary tumours can be detected in this site. Thoracic, and abdominal primaries (especially from lung, oesophagus, stomach, ovary or pancreas) should be sought in the case of adenocarcinoma and involvement of the lower neck. Positron emission tomography with fluoro-2-deoxy-D-glucose allows detection of primary tumour in about 25% of cases, but this procedure is still considered investigational. Therapeutic approaches include surgery (neck dissection), with or without post-operative radiotherapy, radiotherapy alone and radiotherapy followed by surgery as reported by several guide-lines. In early stages (N1), neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases (N2, N3) require combined approaches. The extent of radiotherapy (irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy) remains debatable. A potential benefit from extensive radiotherapy should be weighed against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence. The role of other methods, such as chemotherapy and hyperthermia, remains to be determined." }, { "id": "wiki20220301en086_47796", "title": "Dental emergency", "score": 0.009009009009009009, "content": "Cellulitis Bacterial infection in the oro-facial region can lead to abscess and swelling. The rapid spread of this infection through connective tissue spaces, is often referred to as cellulitis. The clinical features of cellulitis are a painful, diffuse, brawny swelling. The overlying skin is red, tense and shiny. There is usually an associated trismus, cervical lymphadenopathy, malaise and pyrexia. Cellulitis usually develops quickly, over the course of hours, and may follow an inadequately managed or ignored local dental infection. If the infection spreads to involve the floor of mouth and pharyngeal spaces, then the airway can be compromised. Initially, the floor of the mouth will be raised and the patient will have difficulty in swallowing saliva; this" }, { "id": "pubmed23n0062_10895", "title": "Obstructing laryngeal carcinoma with a simultaneous lung lesion.", "score": 0.009009009009009009, "content": "The consultants all agree to treat this patient who has a seemingly poor prognosis. However, they disagree as to the method and order of treatment. A patient's nutritional status is taken seriously by all 3 experts, although no one would delay surgery to correct a patient's weight loss. Drs. Komisar and Miller consider a weight loss of 10% significant and prefer to assess a patient with lymphocyte counts, serum albumin and transferrin levels, and creatinine/height index. Dr. Osguthorope follows serum hemoglobin, transferrin, prealbumin, and albumin levels. All the experts prefer an enteral route for weight gain. With regard to diagnosis, the experts agree that endoscopy plays an important role in tumor staging. Drs. Komisar and Osguthorpe believe that a tracheotomy should be performed prior to endoscopy. Dr. Miller would prefer intubation with an endotracheal tube but if there were any question of safety, he would proceed with a tracheotomy under local anesthesia. Confirming the histology of the pulmonary lesion is important. Dr. Komisar would proceed with flexible bronchoscopy and if tissue could not be obtained with this method he would obtain a fine-needle biopsy. He believes that if the histology matches that of the larynx, the pulmonary lesion is a metastasis. Dr. Osguthorpe would also obtain a needle biopsy of the lung lesion. If no other lesions are seen on the CT, he would consider this a second primary. Dr. Miller states that unless the histologies are different, the question of primary vs metastatic disease is unanswerable.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0493_5570", "title": "Lymphangiomas in infancy and childhood.", "score": 0.008928571428571428, "content": "Lymphangiomas are rare congenital malformations, commonly seen in the head and neck. This is a review of our experience in the management of 22 children with lymphangiomas. The medical records of children with lymphangioma admitted to Qatif Central Hospital, Qatif, Kingdom of Saudi Arabia over a period of 10 years from August 1989 to July 2000 were retrospectively reviewed for age at diagnosis, gender, mode of presentation, site of lymphangioma, method of treatment and outcome. We treated 22 children (12 females and 10 males) with lymphangioma. Their ages ranged from birth to 12 years, but majority (73%) were 4 years of age or younger. In 10 (45.5%), the lymphangioma involved the neck, 5 of them presented with sudden neck swelling as a result of hemorrhage into a lymphangioma, which caused diagnostic confusion. One patient had extensive lymphangioma involving the floor of the mouth, tongue, and left parotid gland. The remaining 11 patients had lymphangioma involving the parotid gland in 2, floor of the mouth in 3, and one each in the abdominal wall, above the right knee, mediastinum, breast, scrotum, and mesentery. All were treated surgically except 3 who were treated with intralesional bleomycin and showed complete disappearance of their lesions. There was recurrence in the child with mediastinal lymphangioma and a small recurrence in the child with bilateral lesions in the floor of the mouth. Lymphangiomas are relatively rare, involving mainly the head and neck, but they can be rarely seen at other sites. An important observation is the sudden appearance of cervical lymphangioma as a result of hemorrhage, which should be kept in mind. Our experience in the treatment of lymphangiomas using bleomycin is limited to draw any conclusions. We therefore considered surgery as treatment of choice for lymphangiomas. However, sclerotherapy can be used when there is a risk of damaging surrounding structures, and also to obviate the poor cosmetic results." }, { "id": "pubmed23n0419_4302", "title": "Fine needle aspiration cytology of head and neck masses. Seven years' experience in a secondary care hospital.", "score": 0.008928571428571428, "content": "To study the value of fine needle aspiration (FNA) in the diagnosis of head and neck masses in a secondary care hospital. FNA from 225 patients with head and neck masses were reviewed. The results were analyzed, according to anatomic location, into 3 groups: inflammatory, congenital and neoplastic. FNA diagnoses were retrospectively correlated with available histologic findings or with the outcome of treatment. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value in the diagnosis were computed. The numbers of lymph node biopsies performed before and after introduction of the procedure were compared. The most common diagnoses were reactive/nonspecific lymphadenitis and tuberculous (TB) lymphadenitis (33% and 21%, respectively). Sensitivity and negative predictive value for TB were 97% and 93%, respectively. The next most common masses were malignant neoplasms, cysts, benign neoplasms and sialadenitis, in 13%, 11%, 9% and 5%, respectively. Carcinomas metastatic to the lymph node were the most common type of cancer, followed by lymphoma and salivary gland carcinoma. The primary site of metastatic carcinomas were nasopharynx (44%) and thyroid (22%). The sensitivity and negative predictive values for the diagnosis of cancer were 95% and 96%, respectively, but reached 100% when lymphoma was excluded. The introduction of FNA reduced the number of lymph node biopsies performed in this hospital by 90%. FNA of head and neck masses proved to be a very useful diagnostic tool in separating inflammatory lesions (no surgical excision required) from cystic and neoplastic lesions. It enhanced surgical planning for malignant diseases, allowing rapid referral of lymphomas and cancer cases to tertiary care centers for management. FNA is simple, cost effective and suitable for developing countries and small, secondary care hospitals with limited resources. Skilled personnel and routine audits are the keys to success." }, { "id": "wiki20220301en105_18341", "title": "Sialadenitis", "score": 0.008849557522123894, "content": "Chronic sclerosing sialadenitis Typically presents unilaterally in submandibular gland that cannot be differentiated clinically from a neoplasm, with pain an inconsistent finding. Obstructive sialadenitis Formation of stones in glandular ducts (sialoliths) can result in the development of obstructive sialadenitis. There may be a history of abrupt episodic swelling of the parotid or submandibular gland which is usually painful. These episodes typically occur around meal times, lasting 2 – 3 hours and gradually subsides. Autoimmune sialadenitis Characterised by persistent, asymptomatic bilateral swelling of parotid glands, and may represent as a manifestation of more widespread systemic disease. Dry eyes and dry mouth are commonly present and may be indicative of concomitant connective tissue disease (e.g. SLE, RA, or scleroderma). Oral candidiasis may also be present. Common key diagnostic factors" }, { "id": "pubmed23n0311_6752", "title": "The occult head and neck primary: to treat or not to treat?", "score": 0.008849557522123894, "content": "In patients with cervical node metastases from an unknown primary malignancy, there is unresolved controversy regarding the utility of elective irradiation of putative pharyngeal primary sites as part of the management plan. We analysed the experience of the Peter MacCallum Cancer Institute to assess the risk of withholding mucosal irradiation in relation to the diagnostic algorithm used to exclude a primary lesion at the time of initial presentation. Between 1983 and 1992, 69 patients were seen with metastatic squamous or undifferentiated carcinoma in cervical nodes from an unknown primary site. Neck nodal stage was NX or N1 13%; N2 52%; N3 35%. Nodal disease was bilateral in 12% of patients. Investigations included examination under anaesthesia, with or without random biopsies, in 84%, and CT scanning of the head and neck in 55%. Treatment was by surgery alone in four patients, by radiotherapy alone in 23, and by combined modalities in 40. Two patients received no treatment. Seventeen were treated with palliative intent. The radiotherapy fields provided comprehensive coverage of the pharynx in only eight patients and partial coverage in five. The estimated overall 5-year survival was 36%. Eleven primary tumours were detected between 7 months and 7 years after the initial treatment, of which nine were in head and neck sites. This yielded an estimated incidence of 30% at 10 years, which is similar to the risk of the development of a second primary after the successful treatment of a known head and neck cancer. Only three patients (none of whom had a CT scan as part of their initial evaluation) manifested a primary in an unirradiated pharyngeal site within 2 years of treatment. As the accuracy of imaging improves, the risk of missing an occult primary lesion will decrease further. We conclude that the use of standardized diagnostic investigations incorporating modern imaging substantially eliminates the indication for comprehensive elective mucosal irradiation with its consequent morbidity. The overriding priority in patients who present with advanced neck disease is to secure regional control." }, { "id": "pubmed23n1064_24613", "title": "Diagnosis and management of Ludwig's angina: An evidence-based review.", "score": 0.008771929824561403, "content": "Ludwig's angina is a potentially deadly condition that must not be missed in the emergency department (ED). The purpose of this narrative review article is to provide a summary of the epidemiology, pathophysiology, diagnosis, and management of Ludwig's angina with a focus on emergency clinicians. Ludwig's angina is a rapidly spreading infection that involves the floor of the mouth. It occurs more commonly in those with poor dentition or immunosuppression. Patients may have a woody or indurated floor of the mouth with submandibular swelling. Trismus is a late finding. Computed tomography of the neck soft tissue with contrast is preferred if the patient is able to safely leave the ED and can tolerate lying supine. Point-of-care ultrasound can be a useful adjunct, particularly in those who cannot tolerate lying supine. Due to the threat of rapid airway compromise, emergent consultation to anesthesia and otolaryngology, if available, may be helpful if a definitive airway is required. The first line approach for airway intervention in the ED is flexible intubating endoscopy with preparation for a surgical airway. Broad spectrum antibiotics and surgical source control are keys in treating the infection. These patients should then be admitted to the intensive care unit for close airway observation. Ludwig's angina is a life-threatening condition that all emergency clinicians need to consider. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients." }, { "id": "pubmed23n0564_8373", "title": "Usefulness of cutting needle biopsy in recurrent and advanced staged head and neck malignancies in a palliative setting.", "score": 0.008771929824561403, "content": "Advanced staged and recurrent head and neck malignancies require histological confirmation before planning further treatment. The purpose of this article is to focus on the clinical usefulness of cutting needle biopsies in the head and neck as a minimal invasive procedure to establish a tissue diagnosis in a palliative setting. A retrospective analysis on 74 core needle biopsies in 32 patients with recurrent and advanced staged head and neck malignancies was performed to determine the advantages of ultrasound-guided cutting needle biopsies compared to open biopsy and fine-needle aspiration cytology in palliative cancer treatment. We experienced 100% success in obtaining high-quality histopathologic specimens. In 93.8% of the patients, a tissue core of the target organ was successfully obtained. All of the patients tolerated the procedure well without any minor or major complications. Cutting needle biopsy in the head and neck is a safe and minimal-invasive procedure that can be performed in local anaesthesia on an outpatient basis. In a palliative setting, it can be recommended as an attractive alternative to both fine needle aspiration and open biopsy. It represents a simple and fast device for obtaining a tissue diagnosis with high diagnostic yield and accuracy and low morbidity." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 52, 252 ] ], "word_ranges": [ [ 7, 37 ] ], "text": "Although the cardiopathies and the alteration of the foot that he describes are common to several chromosomopathies, the alteration of the fingers and toes is very characteristic of Edwards' syndrome." }, "2": { "exist": true, "char_ranges": [ [ 52, 252 ] ], "word_ranges": [ [ 7, 37 ] ], "text": "Although the cardiopathies and the alteration of the foot that he describes are common to several chromosomopathies, the alteration of the fingers and toes is very characteristic of Edwards' syndrome." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 52, 252 ] ], "word_ranges": [ [ 7, 37 ] ], "text": "Although the cardiopathies and the alteration of the foot that he describes are common to several chromosomopathies, the alteration of the fingers and toes is very characteristic of Edwards' syndrome." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Trisomy 18 (Edwards' syndrome).", "2": "Trisomy 13 (Patau's syndrome).", "3": "Trisomy 21 (Down syndrome).", "4": "Trisomy 9.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1101_23096", "title": "Goyal-Naqvi Syndrome (Concurrent Trisomy 10p and Terminal 14q Deletion): A Review of the Literature.", "score": 0.01676094699350513, "content": "Goyal-Naqvi syndrome (GNS) is a newly documented clinical entity that comprises trisomy 10p and terminal 14q deletion, though trisomy 10p and terminal 14q deletion have been discovered as distinct conditions in 1974 and 1997, respectively. Nevertheless, to date, the total number of reported cases of each of these conditions is estimated to be in double digits. Both manifest as a constellation of features like craniofacial dysmorphism, hypotonia, intellectual impairment and global developmental delay. Characteristic facies include protruded forehead, hypertelorism, epicanthic folds, down slanting palpebral fissures, flat nasal bridge, long philtrum, thin upper lip, carp-shaped mouth, retro-micrognathia and low set ears. Besides, trisomy 10p is strikingly associated with clinodactyly and camptodactyly which aids in clinical diagnosis, apart from other musculoskeletal deformities like hip dysplasia and pes planus. Intersex conditions have been found to commonly co-exist. As other systems also display involvement frequently, trisomy 10p is a discernible multiple congenital anomalies/mental retardation (MCA/MR) syndrome. On the other hand, with terminal 14q deletion, increased risk of certain types of cancer was predicted as specific tumor suppressor genes are lost in the deletion and thus, screening was recommended. Genetic workup using techniques like fluorescence in situ hybridization (FISH), spectral karyotyping (SKY) and chromosomal microarray-based comparative genomic hybridization (CGH) was found to be helpful in diagnosis of trisomy 10p and 14q deletion. Prenatal diagnosis of these conditions has been well documented too. Intrauterine growth retardation has been observed to be related to trisomy 10p. There is a paucity of literature on the management of children diagnosed with trisomy 10p or with terminal 14q deletion. Although management of a child diagnosed with concomitant occurrence of trisomy 10p and terminal 14q deletion by a multidisciplinary approach emphasizing physiotherapeutic intervention has shown remarkable improvement in motor skills, the care of children diagnosed with these genetic aberrations needs further investigation. Documentation of more such cases will help to expand phenotypic spectrum for early identification and to delineate natural history for a life span approach. Early identification and intervention facilitate tapping of the maximum neuroplastic potential for better neurodevelopmental outcomes. We present a review of current literature on this novel syndrome to identify gaps in knowledge to build future research." }, { "id": "article-25932_13", "title": "Genetics, Nondisjunction -- Clinical Significance -- Autosomal Trisomies", "score": 0.01656215921483097, "content": "Patau syndrome: Trisomy of chromosome 13 Clinical Features: Rocker-bottom feet, microphthalmia (abnormally small eyes), microcephaly (abnormally small head), polydactyly, holoprosencephaly, cleft lip and palate, congenital heart disease, and severe intellectual disability. Life expectancy is seldom longer than one year. Edwards syndrome: Trisomy of chromosome 18 Clinical Features: Rocker-bottom feet, low set ears, micrognathia (abnormally small jaw), clenched hands with overlapping fingers, congenital heart disease, and severe intellectual disability. Life expectancy is normally less than one year. Down syndrome: Trisomy of chromosome 21 The most common viable aneuploidy. Clinical Features: Single palmar crease, flat facies, prominent epicanthal folds, duodenal atresia, congenital heart disease, Hirschsprung disease, intellectual disability. Notably increased risk to develop Alzheimer's disease or leukemia. Life expectancy is about 60 years." }, { "id": "wiki20220301en068_60864", "title": "Trisomy 9", "score": 0.016530054644808743, "content": "Full trisomy 9 is a lethal chromosomal disorder caused by having three copies (trisomy) of chromosome number 9. It can be a viable condition if trisomy affects only part of the cells of the body (mosaicism) or in cases of partial trisomy (trisomy 9p) in which cells have a normal set of two entire chromosomes 9 plus part of a third copy, usually of the short arm of the chromosome (arm p). Presentation Symptoms vary, but usually result in dysmorphisms in the skull, nervous system problems, and developmental delay. Dysmorphisms in the heart, kidneys, and musculoskeletal system may also occur. An infant with complete trisomy 9 surviving 20 days after birth showed clinical features including a small face, wide fontanelle, prominent occiput, micrognathia, low set ears, upslanting palpebral fissures, high-arched palate, short sternum, overlapping fingers, limited hip abduction, rocker bottom feet, heart murmurs and a webbed neck." }, { "id": "pubmed23n0030_8269", "title": "Trisomy 9 syndrome.", "score": 0.015566323440339189, "content": "An infant is described with multiple congenital anomalies associated with mosaic trisomy 9. Review of the three previously reported cases of trisomy 9 shows that these patients have several common features which make trisomy 9 a clinically distinct syndrome. The frequently encountered findings are: upward-slanted eyes, small palpebral fissures, enophthalmos or microphthalmos, broad base and prominent tip of the nose, microcephaly, micrognathia, low-set malformed ears, high-arched palate, congenital heart disease, skeletal and genito-urinary anomalies, abnormal palmar creases, failure to thrive, hypotonia and retardation." }, { "id": "Pathology_Robbins_1606", "title": "Pathology_Robbins", "score": 0.015563732882910056, "content": "Mental retardation Prominent occiput Mental retardation Micrognathia Low set ears Epicanthic folds and flat facial profile Congenital heart defects Intestinal stenosis Gap between first and second toe Umbilical hernia Hypotonia Abundant neck skin Simian crease Predisposition to leukemia TRISOMY 21: DOWN SYNDROME Incidence: 1 in 700 births Karyotypes: Trisomy 21 type: 47,XX, +21 Translocation type: 46,XX,der(14;21)(q10;q10),+21 Mosaic type: 46,XX/47,XX, +21 TRISOMY 13: PATAU SYNDROME Incidence: 1 in 15,000 births Karyotypes: Trisomy 13 type: 47,XX, +13 Translocation type: 46,XX,+13,der(13;14)(q10;q10) Mosaic type: 46,XX/47,XX, +13 TRISOMY 18: EDWARDS SYNDROME Incidence: 1 in 8000 births Karyotypes: Trisomy 18 type: 47,XX, +18 Mosaic type: 46,XX/47,XX, +18 Short neck Overlapping fingers Congenital heart defects Renal malformations Limited hip abduction Microphthalmia Polydactyly Cardiac defects Umbilical hernia Rocker-bottom feet Microcephaly and mental retardation Cleft lip and palate" }, { "id": "pubmed23n0630_791", "title": "Clinical manifestations in trisomy 9.", "score": 0.015316315205327414, "content": "Complete trisomy 9 is a lethal diagnosis and most fetuses diagnosed thus die prenatally or during the early postnatal period and majority of such cases have been known to end in spontaneous abortion in the first trimester itself. One such rare survival of fetus ending in normal delivery and surviving until 20 days is reported here detailing the clinical manifestations of the child during the period of survival. The salient clinical features observed were small face, wide fontanel, prominent occiput, micrognathia, low set ears, upslanting palpebral fissures, high arched palate, short sternum, overlapping fingers, limited hip abduction, rocker bottom feet, heart murmurs and also webbed neck, characteristic of this trisomy 9 syndrome." }, { "id": "wiki20220301en099_1297", "title": "Dermatoglyphics", "score": 0.014385353095030515, "content": "Trisomy 18 (Edward's syndrome): 6–10 arches on fingertips and single transverse palmar creases in 30% of patients. Trisomy 21 (Down syndrome): people with Down syndrome have a fingerprint pattern with mainly ulnar loops, and a distinct angle between the triradia a, t, and d (the 'adt angle'). Other differences include a single transverse palmar crease (\"Simian line\") (in 50% of patients), patterns in the hypothenar and interdigital areas, and lower ridge counts along digital midlines, especially in little fingers, which corresponds to finger shortening in those with Down syndrome. There is less variation in dermatoglyphic patterns between people with Down syndrome than between controls, and dermatoglyphic patterns can be used to determine correlations with congenital heart defects in individuals with Down syndrome by examining the left hand digit ridge count minus the right hand digit ridge count, and the number of ridges on the fifth digit of the left hand." }, { "id": "wiki20220301en263_5965", "title": "Rocker bottom foot", "score": 0.013852504564578868, "content": "Unlike the flexible flat foot that is commonly encountered in young children, congenital vertical talus is characterized by presence of a very rigid foot deformity. The foot deformity in congenital vertical talus consists of various components, namely a prominent calcaneus caused by the ankle equines or planter flexion, a convex and rounded sole of the foot caused by prominence of the head of the talus, and a dorsiflexion and abduction of the forefoot and midfoot on the hindfoot. It gets its name from the foot's resemblance to the bottom of a rocking chair. There are two subcategories of congenital vertical talus namely idiopathic or isolated type and non-idiopathic type which may be seen in association with arthrogryposis multiplex congenital, genetic syndromes and other neuromuscular disorders. It can be associated with Edwards' syndrome (trisomy 18), Patau syndrome (trisomy 13), Trisomy 9 and mutation in the gene HOXD10." }, { "id": "wiki20220301en263_5966", "title": "Rocker bottom foot", "score": 0.013782051282051282, "content": "It can be associated with Edwards' syndrome (trisomy 18), Patau syndrome (trisomy 13), Trisomy 9 and mutation in the gene HOXD10. Treatment The treatment of congenital vertical talus can be broadly classified into conservative and surgical. Serial casting The mainstay of management of congenital vertical talus is serial manipulative casting also known as the reversed Ponseti technique. This technique involves gradual step-wise correction of the deformity usually on a weekly basis. In the event there is residual deformity or incomplete correction at the end of the serial castings, the orthopedic surgeon may resort to a minimally invasive surgery at the talo-navicular joint to achieve full correction. The results of the serial manipulative casting technique or reversed Ponseti technique are satisfactory especially if started shortly after birth." }, { "id": "pubmed23n0043_8435", "title": "Trisomy 18 (Edwards syndrome): report of two cases.", "score": 0.013542376732560781, "content": "Edwards syndrome is the second most common autosomal trisomy syndrome, resulting from an extra chromosome in chromosome 18. Recently we encountered two cases with the following representative features: intrauterine growth retardation, polyhydramnios, low-set ears, micrognathia and clenched hands. Both cases were female newborns and had an abnormal karyotype 47, XX, 18." }, { "id": "pubmed23n0718_6223", "title": "[Prenatal diagnosis of trisomy 18 syndrome with sonogram index scoring system].", "score": 0.01325565687267815, "content": "To explore the value of sonogram index scoring system in the prenatal diagnosis of trisomy 18 syndrome. Neonates who had prenatal sonographic screening in our tertiary center were followed up from January 2004 to December 2009. The fetuses who were suspected with abnormalities received karyotype analysis. All fetuses were divided into case group (trisomy 18 group) and the control group (non-trisomy 18 group). The latter group was constituted of fetuses with trisomy 21, trisomy 13, other chromosomal abnormalitis and fetuses with normal karyotype. Logistic regression analysis was done to decide the individual sonographic features of trisomy 18. A score was assigned for ultrasound markers according to their likelihood ratios for trisomy 18 syndrome. A score of 3 was assigned for the sonographic features with likelihood ratio over 200, 2 for those with likelihood ratio between 100 and 200, and 1 for those with likelihood ratio less than 100. The diagnostic efficacy of the ultrasound index scoring system was evaluated by diagnostic test. The optimal cutoff value was determined by receiver operating characteristic (ROC) curve. The study group included 59 fetuses with trisomy 18. And 26 486 fetuses did not have trisomy 18 syndrome, including 93 fetuses with trismoy 21, 19 fetuses with trisomy 13, 134 fetuses with other chromosomal abnormalities, 3739 fetuses with normal karyotype and 22 501 fetuses with normal appearance after birth. Two or more structural defects were observed in each trisomy 18 fetus. The highest incidence of sonogram abnormalities was extremities abnormalities (85%, 50/59), followed by cardiac defects (83%, 49/59) and central nervous system (CNS) malformations (75%, 44/59). Overlapping fingers, ventricular septal defect and strawberry-shaped skull were the most common abnormalities in extremities abnormalities, cardiac defects and CNS malformations, respectively. Logistic regression identified 16 markers, including choroid plexus cyst, strawberry-shaped skull, enlarged cisterna magna, holoprosencephaly, low-set ears, ventricular septal defect, hypoplastic left heart syndrome, etc. Different scores were assigned according to the likelihood ratios of these markers. In trisomy 18 group, fetuses with the sonographic score of 1, 4, 9, 10 to 16 were 2% (1/59), 9% (5/59), 10% (6/59) and 32% (19/59) respectively, whereas in non-trisomy 18 group they were 2.549% (675/26 486), 0.215% (57/26 486), 0.004% (1/26 486) and zero, respectively. When a score of 4 was used as the cutoff value for diagnosing fetal trisomy 18, the sensitivity and specificity were 0.966 and 0.997, respectively. The area under ROC curve was 0.999. The ultrasound index scoring system may help to quantify the ultrasound features and has a good diagnostic value for fetal trisomy 18 syndrome. The cutoff value of 4 has the best diagnostic efficacy." }, { "id": "wiki20220301en111_43467", "title": "Palpebral fissure", "score": 0.013165305547733033, "content": "The palpebral fissure is the elliptic space between the medial and lateral canthi of the two open eyelids. In simple terms, it is the opening between the eyelids. In adult humans, this measures about 10 mm vertically and 30 mm horizontally. Variations Congenital dysmorphisms It can be reduced (short, \"narrow\") in horizontal size by fetal alcohol syndrome and in Williams syndrome. The chromosomal conditions trisomy 9 and trisomy 21 (Down syndrome) can cause the palpebral fissures to be upslanted, whereas Marfan syndrome can cause a downslant. An increase in vertical height can be seen in genetic disorders such as cri-du-chat syndrome. Acquired The fissure may be increased in vertical height in Graves' disease, which is manifested as Dalrymple's sign. It is seen in disorders such as cri-du-chat syndrome." }, { "id": "pubmed23n0740_5464", "title": "The trisomy 18 syndrome.", "score": 0.013121665806229563, "content": "The trisomy 18 syndrome, also known as Edwards syndrome, is a common chromosomal disorder due to the presence of an extra chromosome 18, either full, mosaic trisomy, or partial trisomy 18q. The condition is the second most common autosomal trisomy syndrome after trisomy 21. The live born prevalence is estimated as 1/6,000-1/8,000, but the overall prevalence is higher (1/2500-1/2600) due to the high frequency of fetal loss and pregnancy termination after prenatal diagnosis. The prevalence of trisomy 18 rises with the increasing maternal age. The recurrence risk for a family with a child with full trisomy 18 is about 1%. Currently most cases of trisomy 18 are prenatally diagnosed, based on screening by maternal age, maternal serum marker screening, or detection of sonographic abnormalities (e.g., increased nuchal translucency thickness, growth retardation, choroid plexus cyst, overlapping of fingers, and congenital heart defects ). The recognizable syndrome pattern consists of major and minor anomalies, prenatal and postnatal growth deficiency, an increased risk of neonatal and infant mortality, and marked psychomotor and cognitive disability. Typical minor anomalies include characteristic craniofacial features, clenched fist with overriding fingers, small fingernails, underdeveloped thumbs, and short sternum. The presence of major malformations is common, and the most frequent are heart and kidney anomalies. Feeding problems occur consistently and may require enteral nutrition. Despite the well known infant mortality, approximately 50% of babies with trisomy 18 live longer than 1 week and about 5-10% of children beyond the first year. The major causes of death include central apnea, cardiac failure due to cardiac malformations, respiratory insufficiency due to hypoventilation, aspiration, or upper airway obstruction and, likely, the combination of these and other factors (including decisions regarding aggressive care). Upper airway obstruction is likely more common than previously realized and should be investigated when full care is opted by the family and medical team. The complexity and the severity of the clinical presentation at birth and the high neonatal and infant mortality make the perinatal and neonatal management of babies with trisomy 18 particularly challenging, controversial, and unique among multiple congenital anomaly syndromes. Health supervision should be diligent, especially in the first 12 months of life, and can require multiple pediatric and specialist evaluations." }, { "id": "pubmed23n1124_3349", "title": "Prenatal phenotypic spectrum of full trisomy 18 in an Indian cohort.", "score": 0.013047138047138047, "content": "Trisomy 18 or Edward syndrome is a chromosomal disorder due to the presence of an extra chromosome 18. We describe the phenotype of five fetuses at different gestational ages, each highlighting a different aspect of trisomy 18. The clinical spectrum included increased nuchal translucency, fetal hydrops, congenital malformations of the central nervous system, congenital heart disease, radial ray defects, and characteristic facial gestalt. We made a comparison of prenatal ultrasonography and the autopsy findings. The fetal autopsy defined the craniofacial and digit anomalies better compared with sonography. The facial features of tall forehead, hypoplastic nares, microstomia, micrognathia, low set abnormal ears along with clenched hands, and short hallux are typical for trisomy 18 and help in planning the targeted cytogenetic or molecular tests. The diagnosis was established by either fluorescence in situ hybridization or quantitative fluorescent polymerase chain reaction or chromosomal microarray in the patients. This communication emphasizes the importance of detailed assessment for craniofacial and limb anomalies on prenatal ultrasonography which can prompt an early evaluation for trisomy 18." }, { "id": "pubmed23n0002_11929", "title": "Familial 'partial 9p' trisomy: six cases and four carriers in three generations.", "score": 0.012981030945102803, "content": "Six cases of translocation trisomy for the distal half of the short arm of a number 9 chromosome and four asymptomatic balanced translocation carriers are presented in a three-generation pedigree. The clinical features are remarkably similar to those recently recognized and increasingly reported in full short arm (9p) trisomy and should be considered a modification of the same syndrome. In addition to non-specific mental retardation and short stature, there is, in common, a characteristic facies, including down-turned corners of the mouth, a slightly bulbous nose, moderately large ears, suggestively wide-set eyes with an antimongoloid slant, dysplasia and hypolasis of the nails, clindactyly of the 5th fingers, and abnormal dermatoglyphs. It appears that the 'trisomy 9p syndrome' in its variant forms, including trisomies for more or less than just the short (p) arm, is one of the most common clinical autosome anomalies in humans, exceeded only by trisomy 21 (Down's syndrome) and possibly trisomies of chromosomes 13 and 18." }, { "id": "wiki20220301en017_105635", "title": "Patau syndrome", "score": 0.012924520798536548, "content": "Recurrence risk Unless one of the parents is a carrier of a translocation, the chances of a couple having another trisomy 13 affected child is less than 1%, below that of Down syndrome. Diagnosis Diagnosis is usually based on clinical findings, although fetal chromosome testing will show trisomy 13. While many of the physical findings are similar to Edwards syndrome, there are a few unique traits, such as polydactyly. However, unlike Edwards syndrome and Down syndrome, the quad screen does not provide a reliable means of screening for this disorder. This is due to the variability of the results seen in fetuses with Patau." }, { "id": "wiki20220301en017_105638", "title": "Patau syndrome", "score": 0.0127928281638529, "content": "In England and Wales during 2008–09, there were 172 diagnoses of Patau syndrome (trisomy 13), with 91% of diagnoses made prenatally. There were 111 elective abortions, 14 stillbirth/miscarriage/fetal deaths, 30 outcomes unknown, and 17 live births. Approximately 4% of Patau syndrome with unknown outcomes are likely to result in a live birth, therefore the total number of live births is estimated to be 18. References External links Trisomy 13 at WebMD Autosomal trisomies Syndromes with microcephaly Syndromes with cleft lip and/or palate Syndromes affecting the nervous system Syndromes with dysmelia Syndromes affecting the heart" }, { "id": "wiki20220301en001_288420", "title": "Trisomy", "score": 0.012776222526654356, "content": "Human trisomy Trisomies can occur with any chromosome, but often result in miscarriage, rather than live birth. For example, Trisomy 16 is the most common trisomy in human pregnancies, occurring in more than 1% of pregnancies; only those pregnancies in which some normal cells occur in addition to the trisomic cells, or mosaic trisomy 16, survive. This condition, however, usually results in spontaneous miscarriage in the first trimester. The most common types of autosomal trisomy that survive to birth in humans are: Trisomy 21 (Down syndrome) Trisomy 18 (Edwards syndrome) Trisomy 13 (Patau syndrome) Trisomy 9 Trisomy 8 (Warkany syndrome 2) Of these, Trisomy 21 and Trisomy 18 are the most common. In rare cases, a fetus with Trisomy 13 can survive, giving rise to Patau syndrome. Autosomal trisomy can be associated with birth defects, intellectual disability and shortened life expectancy. Trisomy of sex chromosomes can also occur and include:" }, { "id": "article-32619_16", "title": "Genetics, Chromosome Abnormalities -- Clinical Significance -- Trisomy 18 (Edwards Syndrome)", "score": 0.012749615975422427, "content": "Incidence: Approximately 1/3000 to 1:5000  live births (second most common autosomal trisomy) Karyotype: 47, XX or XY, +18 Clinical features: Low birth weight, microcephaly, micrognathia, low-set, malformed ears, clenched fists with overlapping fingers, congenital heart and renal abnormalities, rocker-bottom feet, severe intellectual disability, survival about one year. Prognosis: miscarriage, stillbirth, or early death (median survival around one year of age). [4] [6]" }, { "id": "pubmed23n0247_11192", "title": "Clinical delineation of trisomy 9 syndrome.", "score": 0.012295574795574795, "content": "A rare but typical case of trisomy 9 mosaicism is reported. The infant showed the characteristic phenotype of this syndrome: low-set malformed ears, micrognathia, broad nose with bulbous tip, abnormal brain, congenital heart disease, abnormal hands and feet, cryptorchidism, micropenis, and early death. This infant, however, did not have dislocation of joints or microcephaly; the head was larger than normal and had almost a cloverleaf shape." }, { "id": "wiki20220301en008_108419", "title": "Karyotype", "score": 0.012183383991894631, "content": "In humans Chromosomal abnormalities that lead to disease in humans include Turner syndrome results from a single X chromosome (45,X or 45,X0). Klinefelter syndrome, the most common male chromosomal disease, otherwise known as 47,XXY, is caused by an extra X chromosome. Edwards syndrome is caused by trisomy (three copies) of chromosome 18. Down syndrome, a common chromosomal disease, is caused by trisomy of chromosome 21. Patau syndrome is caused by trisomy of chromosome 13. Trisomy 9, believed to be the 4th most common trisomy, has many long lived affected individuals but only in a form other than a full trisomy, such as trisomy 9p syndrome or mosaic trisomy 9. They often function quite well, but tend to have trouble with speech. Also documented are trisomy 8 and trisomy 16, although they generally do not survive to birth. Some disorders arise from loss of just a piece of one chromosome, including" }, { "id": "wiki20220301en118_39212", "title": "Micrognathism", "score": 0.01217329036877909, "content": "Causes While not always pathological, it can present as a birth defect in multiple syndromes including: Catel–Manzke syndrome Bloom syndrome Coffin–Lowry syndrome Congenital rubella syndrome Cri du chat syndrome DiGeorge syndrome Ehlers–Danlos syndrome Fetal alcohol syndrome Hallermann–Streiff syndrome Hemifacial microsomia (as part of Goldenhar syndrome) Incontinentia pigmenti Juvenile idiopathic arthritis Marfan syndrome Möbius syndrome Noonan syndrome Pierre Robin syndrome Prader–Willi syndrome Progeria Silver–Russell syndrome Seckel syndrome Smith–Lemli–Opitz syndrome Treacher Collins syndrome Trisomy 13 (Patau syndrome) Trisomy 18 (Edwards syndrome) Trisomy 21 (Down syndrome) Wolf–Hirschhorn syndrome X0 syndrome (Turner syndrome) Diagnosis It can be detected by the naked eye as well as dental or skull X-Ray testing. See also Human mandible Macrognathism Retrognathism References External links Jaw disorders" }, { "id": "pubmed23n0574_18347", "title": "Maternal balanced translocation (4;21) leading to an offspring with partial duplication of 4q and 21q without phenotypic manifestations of Down syndrome.", "score": 0.012061174834897463, "content": "We describe an 8-years old female with supernumerary chromosome der(21)t(4;21)(q25;q22) resulting in partial trisomy 4q25-qter and partial trisomy 21(pter-q22). The extra material was originated from a reciprocal balanced translocation carrier mother (4q;21q). Karyotyping was confirmed by FISH using whole chromosome painting probes for 4 and 21q and using 21q22.13-q22.2 specific probe to rule out trisomy of Down syndrome critical region. Phenotypic and cytogenetic findings were compared with previously published cases of partial trisomy 4q and 21q. Our patient had the major criteria of distal trisomy 4q namely severe psychomotor retardation, growth retardation, microcephaly, hearing impairment, specific facies (broad nasal root, hypertelorism, ptosis, narrow palpebral fissures, long eye lashes, long philtrum, carp like mouth and malformed ears) and thumbs and minor feet anomalies. In spite of detection of most of the 3 copies of chromosome 21, specific features of Down syndrome (DS) were lacked in this patient, except for notable bilateral symmetrical calcification of basal ganglia. This report represents further delineation of the phenotype-genotype correlation of trisomy 4q syndrome. It also supports that DS phenotype is closely linked to 21q22. Nevertheless, presence of basal ganglia calcification in this patient may point out to a more proximal region contributing in its development in DS, or that genes outside the critical region may influence or control manifestations of DS features." }, { "id": "pubmed23n0591_5956", "title": "Trisomy 18: a case study.", "score": 0.011884961884961884, "content": "Trisomy 18 is a devastating genetic disorder that can be characterized by multiple congenital anomalies. Some of these anomalies have no medical significance, but merely provide clues to suggest the diagnosis. The most common form of trisomy 18 is the nondisjunction type, which affects every cell of the body with an extra chromosome 18. Mfected infants are typically born with a prominent occiput, short eye fissures with droopy eyelids, micrognathia, external ear variations, clenched fist with index finger overlapping the third finger and fifth finger overlapping the fourth, small fingernails and toenails, underdeveloped or altered thumbs, \"rocker-bottom\" feet, and redundant skin at the back of the neck. Congenital heart defects are common. The mortality rate among infants with trisomy 18 is high as a result of cardiac and renal malformations, feeding difficulties, sepsis, and central apnea caused by central nervous system defects. A case study is provided." }, { "id": "wiki20220301en076_48560", "title": "Dandy–Walker malformation", "score": 0.011714310691494013, "content": "Other genes that have been linked to DWM include ZIC1, ZIC4, FOXC1, FGF17, LAMC1 and NID1. Chromosomal abnormalities In those who are diagnosed with DWM before birth on ultrasound, up to half are found to have a chromosomal abnormality, with the most common being Edwards syndrome (trisomy 18), at roughly 26% of prenatal DWM cases. 6.5% of those diagnosed with DWM after birth also have Edwards syndrome. Other chromosomal abnormalities that can lead to DWM include triploidy, Patau syndrome (trisomy 13), trisomy 9 and partial 3q deletion or duplication. The 3q24 region contains the ZIC1 and ZIC4 genes, known to be associated with DWM. External toxins Warfarin use during pregnancy has been known to lead to systemic defects in the fetus, including ocular dysgenesis, microcephaly, agenesis of the corpus callosum, skeletal abnormalities and heart defects. In 1985, it was also linked to DWM. Pathophysiology" }, { "id": "wiki20220301en018_28433", "title": "Edwards syndrome", "score": 0.011596703086064787, "content": "Edwards syndrome, also known as trisomy 18, is a genetic disorder caused by the presence of a third copy of all or part of chromosome 18. Many parts of the body are affected. Babies are often born small and have heart defects. Other features include a small head, small jaw, clenched fists with overlapping fingers, and severe intellectual disability. Most cases of Edwards syndrome occur due to problems during the formation of the reproductive cells or during early development. The rate of disease increases with the mother's age. Rarely, cases may be inherited from a person's parents. Occasionally, not all cells have the extra chromosome, known as mosaic trisomy, and symptoms in these cases may be less severe. An ultrasound during pregnancy can increase suspicion for the condition, which can be confirmed by amniocentesis." }, { "id": "pubmed23n0016_13108", "title": "Features of trisomy 18 and 18p- syndromes in an infant with 45,XY,i(18q).", "score": 0.011594917972122858, "content": "An isochromosome for the long arm of chromosome number 18 - 46,XY,i(18q) - was found in an infant who had features of both trisomy 18 and 18p- syndromes. Findings compatible with trisomy 18 included postmature delivery, prominent occiput, severe congenital heart disease, overlapping fingers, and rocker-bottom feet. Those of 18p- syndrome, which frequently resembles Turner syndrome, were downward obliquity to the palpebral fissures, short, webbed neck, low posterior hairline, and widely-spaced nipples. The infant died of heart failure at 3.5 months of age. Parental karyotypes were normal." }, { "id": "pubmed23n0648_5258", "title": "Prenatal evaluation of a fetus with trisomy 18 and additional balanced de novo Rob(13;14).", "score": 0.011497641509433963, "content": "The main aim of this work is to present unusual case with full trisomy 18 and additional robertsonian translocation- Rob (13;14) detected through abnormalities found in prenatal ultrasound examination. A 26 years-old pregnant women with no family history of any reproductive failure underwent level II ultrasound screening in 19 weeks of gestation. Polyhydramnios, intrauterine growth retardation, hydrocephalus, enlarged lateral ventricles, club foot and cardiac defect were found. Amniocentesis was indicated considering the high likelihood of a chromosomal aberration. Abnormal karyotype was detected 46, XY, der(13;14)(q10;q10), +18. Karyotypes of parents were normal, what confirmed de novo origin of this aberration. Pregnancy was terminated. In postnatal examination fetus demonstrated intrauterine groth retardation and a lot of dysmorphic features characteristic for trisomy 18: microcephaly, prominent occiput, very low set and posteriorly rotated ears, hypertelorism, small mouth, small recessed mandible, a high narrow palate, broad nasal bridge, low-set ears, preauricilar skin appendage, clenched fingers clinodactyly of Vth fingers and club foot. In conclusion it is worth to say that our described fetus demonstrated rather typical for trisomy 18 ultrasonographic features. Balanced Rob (13;14) gives no phenotypic expression. Possible interchromosomal effect in complex chromosomal aberration formation such as Rob (13;14) with trisomy 18 was discussed." }, { "id": "pubmed23n0748_3598", "title": "Bilateral radial agenesis with absent thumbs, complex heart defect, short stature, and facial dysmorphism in a patient with pure distal microduplication of 5q35.2-5q35.3.", "score": 0.011407205551506702, "content": "A partial duplication of the distal long arm of chromosome 5 (5q35--&gt;qter) is known to be associated with a distinct phenotype referred to as Hunter-McAlpine syndrome. Clinical spectrum of this disorder mainly consists of mental retardation, microcephaly, short stature, skeletal anomalies, and craniofacial dysmorphism featuring flat facies, micrognathia, large, low-set dysplastic ears, hypertelorism, almond-shaped, down-slanted palpebral fissures, epicanthal folds, small nose, long philtrum, small mouth, and thin upper lip. Less frequent remarkable findings include craniosynostosis, heart defect, hypoplastic phalanges, preaxial polydactyly, hypospadias, cryptorchidism, and inguinal hernia. In most patients with a partial duplication of 5q the aberration occurred due to an inherited unbalanced translocation, therefore the phenotype was not reflective of pure trisomy 5q. We report on a 9.5-year-old boy with some feature of Hunter-McAlpine syndrome including short stature, complex heart defect (dextrocardia, dextroversion, PFO), bilateral cryptorchidism, hypothyroidism, and craniofacial dysmorphism. Additionally, bilateral radial agenesis with complete absence of Ist digital rays, ulnar hypoplasia with bowing, choroidal and retinal coloboma, abnormal biliary vesicle were identified, which have never been noted in 5q trisomy patients. Karyotype analysis, sequencing and MLPA for TBX5 and SALL4 genes were unremarkable. Array comparative genomic hybridization detected a duplication on 5q35.2-5q35.3, resulting from a de novo chromosomal rearrangement. Our proband carried the smallest of all previously reported pure distal 5q trisomies encompassing terminal 5.4-5.6 Mb and presented with the most severe limb malformation attributed to the increased number of distal 5q copies. We postulate that a terminal distal trisomy of 5q35.2-5q35.3, which maps 1.1 Mb telomeric to the MSX2 gene is causative for both radial agenesis and complex heart defect in our proband. A potential candidate gene causative for limb malformation in our proband could be FGFR4, which maps relatively in the closest position to the chromosomal breakage site (about 1.3 Mb) from all known 5q duplications. Since the limb malformation as well as the underlying genetic defect are distinct from other 5q trisomy patient we propose that a position effect resulting in altered long-range regulation of the FGFR4 (alternatively MSX2) may be responsible for the limb malformation in our proband." }, { "id": "wiki20220301en627_7763", "title": "Trisomy X", "score": 0.011248326141943163, "content": "Due to overlapping dysmorphic features, such as epicanthic folds and upslanting palpebral fissures, some cases of trisomy X may be ascertained due to suspicion of Down syndrome. When the primary symptom is tall stature, trisomy X may be considered alongside other conditions depending on the rest of the phenotype. Marfan syndrome may be considered due to the disproportion between limb and torso length observed in both syndromes, as well as both experiencing joint issues. Beckwith-Wiedemann syndrome, another disproportionate tall stature syndrome, can cause developmental disability similar to that seen in some cases of trisomy X." }, { "id": "wiki20220301en000_93395", "title": "Chromosome", "score": 0.011222500696184906, "content": "Edwards syndrome, or trisomy-18, the second most common trisomy. Symptoms include motor retardation, developmental disability and numerous congenital anomalies causing serious health problems. Ninety percent of those affected die in infancy. They have characteristic clenched hands and overlapping fingers. Isodicentric 15, also called idic(15), partial tetrasomy 15q, or inverted duplication 15 (inv dup 15). Jacobsen syndrome, which is very rare. It is also called the terminal 11q deletion disorder. Those affected have normal intelligence or mild developmental disability, with poor expressive language skills. Most have a bleeding disorder called Paris-Trousseau syndrome." }, { "id": "pubmed23n0210_17059", "title": "Autosomal trisomy 18 and 13 syndromes in Ibadan, Nigeria.", "score": 0.010730697369085492, "content": "The clinical, cytogenetic, dermatoglyphic and autopsy findings in 14 cases of trisomy 18 as well as in seven cases of trisomy 13 seen in the Paediatric Department of University College Hospital (UCH), Ibadan, Nigeria, from 1972 to 1981 are presented. The incidence was 0.12 and 0.08 per 1000 livebirths for trisomies 18 and 13 respectively. All the patients were of regular trisomies except two; one case was mosaic for trisomy 18 and another case of trisomy 13 seemed to have derived an extra chromosome of the D group from a reciprocal D/D translocation that was maternally carried. Both syndromes have certain physical features in common which sometimes made clinical diagnosis difficult, but each had diagnostic features of its own. While the combination of microcephaly, cleft lip and/or palate, microphthalmos, capillary haemangioma and polydactyly form the hallmark of trisomy 13, the presence of prominent occipit, micrognathia, clenched fist together with protruding heel make the appearance of trisomy 18 unmistakable. The prognosis in both syndromes is poor and those who survive beyond infancy exhibit severe mental retardation. It is therefore important to establish the diagnosis early so as to conserve limited resources in an attempt to prolong the lives of neonates with these syndromes." } ] } } }

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{ "1": "Acute lymphoblastic leukemia.", "2": "Burkitt's lymphoma.", "3": "Visceral leishmaniasis.", "4": "Miliary tuberculosis.", "5": "Chronic malaria." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1043_7936", "title": "[A Case of Simultaneous Acute Lymphoblastic Leukemia Diagnosis with Crimean-Congo Hemorrhagic Fever].", "score": 0.018750547621133797, "content": "Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease that can be presented with fever, fatigue, generalized joint/body pain, diarrhea and bleeding in various parts of the body. The risk of developing a severe fatal disease in humans, the possibility of being infected with aerosols and the risk of being used as a biological weapon make the disease still an important health problem all over the world as there is no a specific treatment and vaccine that has proven effective againt the virus today. The pathogenesis of the disease is not known, but vascular endothelial damage is prominent. Therefore, it progresses with thrombocytopenia, anemia, leukopenia and this hematological findings can be confused with hematological malignancies. Acute lymphoblastic leukemia (ALL) is a malignancy included in differential diagnoses and occurs as a result of mutations occuring at a stage of differentiation in the lymphoid precursor cells in the bone marrow. In this study, we present a case of ALL who was diagnosed with CCHF simultaneously. A 43-year old female patient who works in the library and does not have a chronic disease other than asthma and thyroid disorder, has admitted to our hospital with the complaints of intermittent fever, weakness, generalized joint and body pain for about 3 weeks. She had fever and the physical examination revealed bilateral cervical and right postauricular lymphadenopathies. Her aspartate aminotransferase: 77 U/L, alanine aminotransferase: 117 U/L, lactate dehydrogenase: 616 U/L, hemoglobin: 8.27 g/dl, leukocyte count: 15.690/mm3 , neutrophil count: 550/mm3 (%3.5), lymphocyte count: 6690/mm3 (%42.6), platelet count: 102.100/mm3 , C-reactive protein: 163.6 mg/L was detected and the patient was hospitalized on 5 August 2019 for further examination and treatment. Considering that the patient may have viral infection in the foreground the requested test results were detected as; anti-CMV IgM negative, anti-CMV IgG positive, anti-toxoplasma IgM negative, anti-toxoplasma IgG positive, anti-rubella IgM negative, anti-rubella IgG positive, HBsAg negative, anti-HBc IgM negative, antiHBs positive, anti-HAV IgM negative, anti-HAV IgG positive, anti-HCV negative, anti-HIV negative, EpsteinBarr virus (EBV) VCA IgM negative, EBV VCA IgG positive, EBV EBNA IgG positive. Brucella Rose Bengal and Coombs tube agglutination was found be negative. As the cytopenia of the patient deepened, the patient was accepted to have neutropenic fever and it was planned to start piperacillin-tazobactam 4 x 4.5 g/day and two units of erythrocyte replacement therapy. When the patient's history was questioned again, it was learned that she had a tick on her neck about three weeks ago and she had removed the tick herself; 4-5 days later she had the complaints of fever and flu like symptoms and also diarrhea complaints lasting for 3-4 days. Considering the current anamnesis and laboratory findings, the patient was thought to have CCHF and the patient was isolated. The serum sample taken from patient with an initial diagnosis of CCHF and sent to Department of Microbiology Reference Laboratory Public Health Agency of Turkey. The patient was referred to the Antalya Training and Research Hospital. The patient's CCHF serum result was positive. Ribavirin treatment was not initiated in the patient who was accepted to be in the convalescence period, piperacillin-tazobactam 4 x 4.5 g/day treatment was continued and supportive treatment was given. In the follow-up, as the patient's neutropenia, thrombocytopenia and lymphocytopenia still continuing, she was transferred to hematology clinic for malignancy examination and bone marrow biopsy performed by hematology and B cell ALL was diagnosed. She was accepted to be convalescent in terms of CCHF and chemotherapy was started for ALL treatment by hematology. The patient is still being followed up by the hematology clinic and allogenic hematopoietic stem cell tranplantation is planned for the patient. As a result, CCHF is a disease that can be confused with many differential diagnosis. With this case, it is aimed to draw attention to the diagnostic difficulties of CCHF and ALL and to be the first case in the literature." }, { "id": "pubmed23n0798_6254", "title": "Case 207: Hodgkin lymphoma with paraneoplastic hypercalcemic pancreatitis.", "score": 0.0158033890157433, "content": "A 15-year-old girl presented with a 2-month history of 30-lb (13.6 kg) weight loss, chest and abdominal pain, nausea, bilious emesis, cough, and shortness of breath. Initial blood count (performed at an outside hospital) showed elevated white blood cell and platelet counts but low hemoglobin and hematocrit levels. On examination, she had adenopathy in the left axillary and supraclavicular regions, fullness in the left chest, and abdominal guarding. Ultrasonography (US)-guided fine-needle aspiration biopsy of the left anterior chest wall mass was nondiagnostic, and lumbar puncture and bone marrow biopsies were negative. At that time, the patient underwent several imaging studies-including chest radiography; bone scanning; contrast material-enhanced computed tomography (CT) of the chest, abdomen, and pelvis; and fluorine 18 ((18)F) fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT-all performed within 1 week of each other. Pertinent serum laboratory values at the time of these tests were as follows: calcium level, 17 mg/dL (4.25 mmol/L) (normal range, 8.5-10.5 mg/dL [2.1-2.6 mmol/L]); ionized calcium level, 2.3 mmol/L (normal range, 1.1-1.3 mmol/L); lipase level, 2423 U/L (normal level, &lt;300 U/L); amylase level, 1435 U/L (normal level, &lt;140 U/L); lactate dehydrogenase level, 253 U/L (normal level, &lt;240 U/L), albumin level, 2.6 g/dL (26 g/L) (normal level, 3.5-5.0 g/dL [35-50 g/L]), and creatinine level, 1.7 mg/dL (150.3 μmol/L) (normal level, &lt;1.2 mg/dL [&lt;106.1 μmol/L]). A follow-up PET/CT scan was performed approximately 2 months later after initial therapy." }, { "id": "pubmed23n0869_2211", "title": "Acute Lymphoblastic Leukemia in Adults - an Analysis of 51 Cases from a Tertiary Care Center in Pakistan.", "score": 0.01501831501831502, "content": "Acute lymphoblastic leukemia (ALL) is a malignant disease in which early lymphoid precursors proliferate and replace the normal hematopoiesis. It has distinctive clinical and biological features. In respect to adult ALL, available data from Pakistan are limited. Therefore we reviewed the demographical and clinico- hematological profiles along with FAB stratification of adult patients with ALL presented at our hospital. In this cross sectional study, 51 adults (≥15 years) patients with ALL were enrolled from January 2010 to December 2014. The mean age was 23.8±12.9 years with the median age of 18.0 years. The male to female ratio was 2:1. The major complaints were fever (60.7%), generalized weakness (47.0%), overt bleeding (19.6%) and weight loss (13.7%). Physical examination revealed lymphodenopathy as a predominant finding detected in 43.1% followed by splenomegaly and hepatomegaly in 23.5% and 21.5%, respectively. The mean hemoglobin level was 9.0±2.75g/dl with a mean MCV of 82.2±15.4 fl, a mean total leukocyte count of 31.1±64.0x109/l, a mean ANC of 2.1±3.0 x109/l and a mean platelet count of 71.7±85.7x109/l. According to FAB classification, 47.1% were L1 type, 45.1% L2 and 7.8% L3 variant. Clinico-pathological features appeared comparable to published data. Febrile illness associated with lymphodenopathy was the commonest presentation. FAB classification revealed a predominance of ALL-L1 variant in Pakistani adult patients with ALL." }, { "id": "pubmed23n0980_15639", "title": "Revisiting the complete blood count and clinical findings at diagnosis of childhood acute lymphoblastic leukemia: 10-year experience at a single center.", "score": 0.013338496622348435, "content": "Heterogeneity regarding clinical and laboratory findings at diagnosis of acute lymphoblastic leukemia exists. The frequency of complete blood count abnormalities and its combinations, symptoms and physical findings were investigated in Hispanic children from an open population at the diagnosis of acute lymphoblastic leukemia. The patient charts and electronic records of under 16-year-old children diagnosed with acute lymphoblastic leukemia over 10 years at a regional hematology center of a university hospital were analyzed to retrieve data concerning the complete blood count at first evaluation. Type and distribution of abnormal data, frequency of symptoms and physical findings at presentation were documented. The records of 203 children aged 0-15 years diagnosed with acute lymphoblastic leukemia from 2006 to 2016 were revisited. The results of the blood workup showed a median white blood cell count of 7120 × 10<sup9</sup/L (range: 450-600,000 × 10<sup9</sup/L), and a median hemoglobin concentration of 7.5 g/dL (range: 2.4-15.3 g/dL), whereas the median platelet count was 47,400 × 10<sup9</sup/L (range: 4000-544,000 × 10<sup9</sup/L). Leukocytosis and leukopenia were present in 36.6% and 36.1% of cases, respectively; anemia was diagnosed in 82.9% children. The order of frequency for major clinical symptoms was fatigue 62%, fever 60%, bone and joint pain 39%, hyporexia 33% and weight loss 21%, while main physical findings were hepatomegaly 78%, splenomegaly 63%, lymphadenopathy 57%, pallor 48%, and purpura 30%. Data differing from those classically expected at diagnosis of acute lymphoblastic leukemia in children were documented in a cohort of Hispanic children over one decade with a wide spectrum of complete blood count abnormalities, forms of presentation and frequency of physical findings." }, { "id": "pubmed23n0818_22421", "title": "[A case of autoimmune lymphoproliferactive syndrome and literature review].", "score": 0.010973084886128364, "content": "To summarize the clinical characteristics, diagnosis and treatment of a case with autoimmune lymphoproliferative syndrome (ALPS) . The patient was diagnosed as autoimmune lymphoproliferactive syndrome (ALPS) after being admitted to the Department of Rheumatism and Immunology of Tianjin Children's Hospital in February 20, 2014. The clinical characteristics, physical examination, laboratory tests, gene tests, and treatment process were analyzed and related literature was reviewed. The patient was a 16-month- old boy.Since the first month of life, he started to have repeatedly fever, diarrhea, shortness of breath, lymphadenopathy, hepatosplenomegaly, anemia (HGBmin 50 g/L) and thrombocytopenia (min 35 × 10⁹/L) . But multiple exams showed a normal peripheral blood leukocyte count, hypergammaglobulinemia (IgG 19 800 mg/L, IgA 1 710 mg/L, IgM 2 590 mg/L) and significantly increased serum vitamin B12. Flow cytometric measures showed that CD3⁺ CD4⁻ CD8⁻ T lymphocytes significantly increased ( &gt; 10%) at four times. The count of CD3⁺ TCRαβ⁺ CD4⁻ CD8⁻T lymphocytes (double negative T cells; DNTs) &gt;3% twice. The genetic test showed that 309th FAS gene area showed heterozygous mutations, the boy was diagnosed as ALPS. Added examinations of lymphocytes apoptosis induced by FAS was positive. He was treated with prednisone 15 mg once daily and immunomodulator 150 mg three times a day, while in maintaining period with normal levels of hemoglobin and platelet, the dose of prednisone was reduced gradually. Till now, the patient has been treated and observed for 8 months. We retrieved the reports of ALPS in the databases at home and abroad published in recent 10 years, more than 400 cases reported from foreign countries, but there were only 5 domestic cases. Among those, 4 had onset in infancy and 1 at 6-years of age. All the cases presented servere lymphadenopathy and hepatosplenomegaly with anemia (4 of them with hemolytic anemia) and thrombocytopenia. Three cases had a history of frequent infection, one of them had glomerulonephritis. All patient with significant high level of serum immunoglobulin ( &gt; 1.5 times upper limit of normal range), in 3 of them serum vitamin B12 was &gt; 1.5 pg/L (the other 2 cases missed the exam). In 5 cases CD3⁺ CD4⁻ CD8⁻T cells &gt; 10%, and in 2 case DNTs were 8.9% and 15.7% respectively (the other 3 cases missed the exam). Three cases were clearly detected with FAS mutations. All patients were treated with corticosteroid, 2 of them were added with mycophenolate mofetil. The therapy presented effective result in early 1-3 months, but no long-term follow-up reports were available. ALPS is a disorder of disrupted lymphocyte homeostasis caused by defective Fas-mediated apoptosis, and it is one of the primary immunodeficiency diseases. The onset of the disease occurs during infancy mainly. Clinical lymphoid hyperplasia and autoimmune phenomena are outstanding signs, which can be associated with frequent infections and allergies. The level of serum vitamin B12 &gt; 1.5 pg/L and the count of CD3⁺ CD4⁻ CD8⁻ T cell show important significance. Exact diagnosis should depend on detecting DNTs and FAS gene." }, { "id": "wiki20220301en071_42263", "title": "Follicular lymphoma", "score": 0.010479256080114449, "content": "FL progresses at a rate of 2-3% per year for at least the first 10 years after diagnosis to a more aggressive form, principally diffuse large B-cell lymphoma (~93% of cases) or Burkitt-like lymphoma (~7% of cases) or in rare cases exhibit the histology resembling precursor B-cell lymphoblastic leukemia, plasmablastic lymphoma, the high grade subtype of B-cell lymphoma, Hodgkin lymphoma of the B-cell type, chronic lymphocytic leukemia/small cell lymphcytic lymphoma, or histiocytic sarcoma. t-FL is almost always diagnosed in patients being followed for FL. These FL patients present with the: fast growth of lymph nodes; formation of extra-nodal lesions in extra-nodal sites such as the central nervous system, liver or bone; the onset of B-symptoms (i.e. fever, night sweats, weight loss); development of hypercalcemia (i.e. high serum levels of calcium); and/or sudden rises in serum levels of the enzyme lactate dehydrogenase. A minority of t-FL patients present without a history of FL." }, { "id": "wiki20220301en108_39512", "title": "Autoimmune lymphoproliferative syndrome", "score": 0.009900990099009901, "content": "Diagnostic algorithm The old diagnostic criteria for the illness included: Chronic non-malignant lymphoproliferation, elevated peripheral blood DNTs and defective in vitro Fas mediated apoptosis. The new criteria require chronic non-malignant lymphoproliferation (over six months lymphadenopathy and/or splenomegaly), elevated peripheral blood DNTs. A primary accessory in diagnosis is defective in vitro Fas mediated apoptosis and somatic or germline mutation in ALPS causative gene (FAS, FASL, CASP10). The secondary accessory in diagnosis are elevated biomarkers (plasma sFASL over 200 pg/ml, plasma IL-10 >20 pg/ml, plasma or serum vitamin B12 >1500 ng/L, Plasma IL-18 >500pg/ml) and immunohistochemical findings on biopsy consistent with ALPS as determined by an experienced hematopathologist. Another sign is autoimmune cytopenias and polyclonal hypergammaglobulinemia and a family history of ALPS or non-malignant lymphoproliferation." }, { "id": "wiki20220301en113_39648", "title": "Macrophage activation syndrome", "score": 0.00980392156862745, "content": "Cause In many cases a trigger is identified, often a viral infection, or a medication. There is uncontrolled activation and proliferation of macrophages, and T lymphocytes, with a marked increase in circulating cytokines, such as IFN-gamma, and GM-CSF. The underlying causative event is unclear, and is the subject of ongoing research. In many cases of MAS, a decreased natural killer cell (NK-cell) function is found. Diagnosis A febrile patient with known or suspected sJia must be considered for macrophage activation if: Ferritin >684 ng/ml and any 2 of the following: Hemoglobin <90g/L (in infants <4 weeks: <100g/L) Platelets <100 x 109/L Neutrophils <1.0 x 109/L Fasting triglycerides ≥3.0 mmol/L (i.e., ≥ 265 mg/dl) Fibrinogen ≤1.5 g/L" }, { "id": "pubmed23n0937_12198", "title": "Non-Hodgkin lymphoma, diagnostic, and prognostic particularities in children - a series of case reports and a review of the literature (CARE compliant).", "score": 0.00980392156862745, "content": "Non-Hodgkin lymphoma remains an unpredictable condition in pediatric patients. Our first case describes an 8-year-old boy with a history of iron deficiency anemia, admitted in our clinic for recurrent abdominal pain, weight loss, loss of appetite, diarrheic stools, and fever. The second case also describes an 8-year-old boy admitted for abdominal pain and vomiting. The 3rd case refers to a 4 years and 10 months old boy admitted in our clinic with abdominal pain and loss of appetite, who was initially admitted in the Pediatrics Surgery Clinic with the suspicion of appendicitis. Our 4th patient was a 5-year-old boy admitted in our clinic for abdominal pain and intermittent diarrheic stools. In the first case, the laboratory tests showed anemia, thrombocytosis, elevated inflammatory biomarkers, a low level of iron, and hypoproteinemia. The abdominal ultrasound and CT exam revealed an abdominal mass, and the histopathological exam established the diagnosis of diffuse large B-cell lymphoma of the bowel. In the second case, the laboratory tests pointed out anemia, elevated ESR and lactate dehydrogenase level, while both abdominal ultrasound and CT exams showed an abdominal mass. The histopathological exam confirmed the diagnosis of Burkitt lymphoma. Regarding our 3rd case, the laboratory findings revealed leukocytosis, anemia, thrombocytosis, increased inflammatory biomarkers, elevated LDH, and a low level of iron. The abdominal ultrasound and the CT scan revealed an abdominal mass which, according to the histopathological exam, was a Burkitt lymphoma. Due to the cranial CT findings the patient was diagnosed with IV stage Burkitt lymphoma with central nervous system metastases. In our 4th patients we found leukocytosis, anemia, mildly increased inflammatory biomarkers, a high level of LDH, hypoproteinemia, and a low level of serum Ir. Both ultrasound and abdominal CT exams were negative, but the exploratory laparotomy identified an abdominal mass, and according to the histopathological exam the patient was diagnosed with Burkitt lymphoma. All the patients followed chemotherapy (B-NHL BFM 04 protocol) and supportive treatment. The first patient died approximately 4 months after the completion of chemotherapy due to tumor relapse, the second patient died after the first cure of chemotherapy and the fourth patient died at approximately 2 years after the diagnosis. The third patient is recurrence-free after 2 years. Despite the advances in the management, NHL remains a fatal condition in pediatrics." }, { "id": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009708737864077669, "content": "Acute pancreatitis not secondary to gallstones At admission: Blood glucose > 11.11 mmol/L (> 200 mg/dL) Age > 55 years Serum LDH > 350 IU/L Serum AST > 250 IU/L WBC count > 16000 cells/mm3 Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit decreased by > 10% Oxygen (hypoxemia with PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L Acute pancreatitis secondary to gallstones At admission: Glucose > 220 mg/dl Age > 70 years LDH > 400 IU/L AST > 250 IU/ 100 ml WBC count > 18000 cells/mm3 Within 48 hours: Serum calcium < 8 mg/dL Hematocrit decreased by > 10% Base deficit > 4 mEq/L BUN increased by > 2 mg/dL Sequestered fluid > 6L" }, { "id": "pubmed23n0760_21653", "title": "[WHIM syndrome: a case report and literature review].", "score": 0.009708737864077669, "content": "To study the clinical and laboratory characteristics of cases with warts, hypogammaglobulinemia, infections and myelokathexis (WHIM) syndrome. An 11-year-old boy was diagnosed as WHIM syndrome and CXCR4 gene mutation analysis was performed. Since 3 years of age, the patient had recurrent fever and persistent cough. Since 6 years of age, he had warts on his fingers, the warts increased gradually. His complete blood count showed: white blood cell (WBC) 0.65×10(9)/L, neutrophil 0.15×10(9)/L, hemoglobin 116 g/L, platelet 200×10(9)/L, reticulocyte 0.62%. Results of serum biochemical tests: total protein (TP) 72.2 g/L (reference value 60 - 80 g/L), albumin 20.4 g/L (reference value 20 - 35 g/L), gammaglobulin 20.4 g/L (reference value 20 - 35 g/L). IgG 5.56 g/L (reference value 7.51 - 15.6 g/L), IgA 0.48 g/L (reference value 0.82 - 4.53 g/L), IgM 0.29 g/L (reference value 0.46 - 3.04 g/L). Peripheral blood lymphocyte subsets: CD3(+)T lymphocyte 43.6% (reference value 64.01% - 75.95%), CD19(+)B lymphocyte 1.00% (reference value 9.02% - 14.1%). Bone marrow smears showed that many of the neutrophils had a reactive appearance, with cytoplasmic vacuolation. Most neutrophils had hypersegmentation with four or five nuclear lobules. In some cells, the filaments connecting the nuclear lobes were long. CXCR4 mutation was detected. WHIM syndrome is a rare immunodeficiency disorder with an autosomal-dominant pattern of inheritance. The disease is less progressive, and may accompany the patients' whole life." }, { "id": "wiki20220301en127_31759", "title": "Hemophagocytic lymphohistiocytosis", "score": 0.009615384615384616, "content": "1. A molecular diagnosis consistent with HLH. These include the identification of pathologic mutations of PRF1, UNC13D, or STX11. OR 2. Fulfillment of five out of the eight criteria below: Fever (defined as a temperature >100.3 °F, >38 °C) Enlargement of the spleen Decreased blood cell counts affecting at least two of three lineages in the peripheral blood: Haemoglobin <9 g/100 ml (in infants <4 weeks: haemoglobin <10 g/100 ml) (anemia) Platelets <100×109/L (thrombocytopenia) Neutrophils <1×109/L (neutropenia) High blood levels of triglycerides (fasting, greater than or equal to 265 mg/100 ml) and/or decreased amounts of fibrinogen in the blood (≤ 150 mg/100 ml) Ferritin ≥ 500 ng/ml Haemophagocytosis in the bone marrow, spleen or lymph nodes Low or absent natural killer cell activity Soluble CD25 (soluble IL-2 receptor) >2400 U/ml (or per local reference laboratory) In addition, in the case of familial HLH, no evidence of malignancy should be apparent." }, { "id": "pubmed23n0603_15769", "title": "Visceral leishmanisis in paediatrics: a study of 367 cases in southwest Iran.", "score": 0.009615384615384616, "content": "Kala-azar (visceral leishmaniasis [VL]) is endemic in southern Iran. We retrospectively evaluated 367 infants and children suffering from VL at hospitals affiliated to the Shiraz University of Medical Sciences in Fars Province, southwest Iran). Seasonal variations were observed with more cases presenting in late winter, spring and fewer in summer. The predominant clinical features in these patients were chronic fever, pallor, weight loss, abdominal distention and hepatosplenomegaly. Lymphadenopathy was less common. Common laboratory abnormalities included anaemia, leukopenia, thrombocytopenia, hypoalbuminaemia and hypergammaglobulinaemia. Liver function tests were deranged in two-thirds of the patients. The immunofluorescence antibody test was positive in all patients and all of them had a positive bone marrow smear or a culture for Leishmania donovani. Patients responded well to glucantim therapy with a cure rate of 96.7%. Relapse was observed in 8.2% (30). Mortality in this series was 7.3%. Twenty patients died during their therapy period. Jaundice and grossly deranged liver function tests were found to be bad prognostic signs." }, { "id": "pubmed23n0756_22389", "title": "[A predisposing clinical condition for disseminated tuberculosis: hairy cell leukemia].", "score": 0.009523809523809525, "content": "Hairy cell leukemia (HCL), a rare and slow-progressive B-cell lymphoproliferative disease, enhances predisposition to infectious complications, especially to disseminated mycobacterial infections. Although the association between HCL and mycobacterial disease has been established, disseminated Mycobacterium tuberculosis infection has been reported only in a few case series. In this report, a disseminated tuberculosis (TB) case who had been diagnosed as HCL with histopathologic examination of the bone marrow after being investigated for the etiology of fever of unknown origin, was presented. A 56-year-old male patient who was admitted to our clinic with the complaints of three weeks' duration fever, chills, night sweats and cough was hospitalized. On physical examination, the body temperature of the patient who appeared very ill, was 39°C. Dispersed macular rash that turned pale when pressure was applied, was detected on the legs, arms and back. There were no signs of peripheral lymphadenopathy, hepatomegaly or splenomegaly. Laboratory results revealed haemoglobin 10 g/dl, white blood cell count 1000/mm3, thrombocytes 143.000/mm3, erythrocyte sedimentation rate 41 mm/h, CRP 200 mg/L, uric acid 9.5 mg/dl, AST 118 IU/L, ALT 102 IU/L and LDH 429 IU/L. Thorax computed tomography showed mediastinal and bilateral hilary lymphadenopathy. Although preliminary diagnosis was lymphoma, examination of acid-fast bacilli in three days sequential sputum samples and sputum culture for the growth of mycobacteria (Bactec MGIT 960 TB system, Becton Dickinson, Md) were performed to rule out miliary TB. Blood cultures were also performed with non-radiometric fully automated TB hemoculture bottles (Bactec TB, Becton Dickinson, Md). Sputum cultures yielded no mycobacterial growth, however M.tuberculosis growth was detected in blood culture on the 27th day of inoculation. Bone marrow biopsy revealed HCL. However the patient died on the 14th day of hospitalization. In conclusion, disseminated tuberculosis should be considered for differentional diagnosis in patients with HCL or similar hematologic malignancies since TB is endemic in Turkey." }, { "id": "pubmed23n1039_3218", "title": "Clinico-Hematological Findings of Acute Pediatric Visceral Leishmaniasis Referred to the Northeast of Iran during 2005-2015.", "score": 0.009433962264150943, "content": "To characterize the epidemiological, clinical, hematological and biochemical features of 33 cases hospitalized with pediatric visceral leishmaniasis (PVL) in North Khorasan Province of Iran from 2005 to 2015. The serological, hematological and biochemical tests were employed in 33 children between 8 months to 6 yr with a final diagnosis of acute visceral leishmaniasis (VL). The diagnosis of VL was established by microscopic demonstration of <iLeishmania</i spp. amastigotes inactive bone marrow aspiration (BMA). The most common presenting features were anemia (82.5%), fever (75%), and hepatosplenomegaly (45.4%). Various hematological parameters showed that most patients were suffering from moderate to severe microcytic hypochromic anemia (78.8% had RBC count less than 4 million cells/ul, 67.7% Hb less than 8 fl). 66.7% of them were leukopenic (WBC: less than 5× 10 <b<sup3</sup</b /μL) and 24.2% had decreased platelet counts. Pancytopenia was observed in 18.2% of cases. MCV, MCH, and MCHC levels were below the reference range in 88%, 90% and 85.1% of the patients respectively. Moreover, aspartate transaminase (AST) and alanine transaminase (ALT) levels were increased in 53.33% and 6.66% of the patients respectively. 92.9% of cases were C-reactive protein (CRP) positive. Bone marrow was found hyper-cellular in all of them, and myeloid to erythroid ratio (M/E) was more than 4 in 39.1% of cases. Plasma cells slightly were increased in 60% of patients and megakaryocytes were decreased in thrombocytopenic patients. Bone marrow/splenic aspiration still remains the gold standard test despite its risk and pain for patients." }, { "id": "pubmed23n0501_23829", "title": "Klinefelter's syndrome presenting with leg ulcers.", "score": 0.009345794392523364, "content": "A 54-year-old man of Persian origin presented to our department with a 1-year history of ulcers on the right leg that had been unresponsive to numerous topical treatments, accompanied by lymphedema of the right leg. Medical history included hypergonadotropic hypogonadism, which had not been further investigated. He was treated for 20 years with testosterone IM once monthly, which he stopped a year before the current hospitalization for unclear reasons. The patient reported no congenital lymphedema. Physical examination revealed two deep skin ulcers (Figure 1) on the right leg measuring 10 cm in diameter with raised irregular inflammatory borders and a boggy, necrotic base discharging a purulent hemorrhagic exudate. Bilateral leg pitting edema and right lymphangitis with lymphadenitis were noted. He had low head hair implantment, sparse hair on the body and head, hyperpigmentation on both legs, onychodystrophia of the toenails (mainly the large toe and less prominent on the other toes), which was atrophic lichen-planus-like in appearance and needed no trimming (Figure 2), normal hand nails, oral thrush, and angular cheilitis. Other physical findings were gynecomastia, pectus excavatum, small and firm testicles, long extremities, asymmetrical goiter, systolic murmur 2/6 in left sternal border, and slow and inappropriate behavior. The patient's temperature on admission was 39 degrees C. Blood cultures were negative for bacterial growth. Results of laboratory investigations included hemoglobin (11.2 g/dL), hematocrit (26.8%), normal mean corpuscular volume and mean corpuscular hemoglobin volume, and red blood cell distribution width (16%). Blood smear showed spherocytes, slight hypochromia, anisocytosis, macrocytosis, and microcytosis. Blood chemistry values were taken for iron (4 micro g/dL [normal range 40-150 micro g/dL]), transferrin (193 mg/dL [normal range 220-400 mg/dL]), ferritin (1128 ng/mL [normal range 14-160 ng/mL]), transferrin saturation (1.5% [normal range 20%-55%]), serum folate (within normal limits), and vitamin B12 (within normal limits). Direct Coombs' test equaled positive 2 + IgG. All these values indicated anemia of chronic diseases combined with hemolytic anemia. Further blood work-up tested antinuclear antibody (positive &lt;1:80 homogeneous pattern), rheumatoid factors (143 IU/mL [positive &gt;8.5 IU/mL]), C-reactive protein (286 mg/L [normal range 0-5 mg/L]), anticardiolipin IgM antibody (9.0 monophosphoryl lipid U/mL [normal range 0-7.00 MPL U/mL]) and antithrombin III activity (135% [normal range 74%-114%]). Results of other blood tests were within normal limits or negative, including lupus anticoagulant, beta2 glycoprotein, anticardiolipin IgG Ab, anti-ss DNA Ab, C3, C4, anti-RO, anti-LA, anti-SC-70, anti-SM Ab, P-ANCA, C-ANCA, TSH, FT4, anti-T microsomal, antithyroglobulin, protein C activity, protein S free, cryoglobulins, serum immunoelectrophoresis, VDRL, hepatitis C antibodies, hepatitis B antigen, and human immunodeficiency virus. Endocrinological work-up examined luteinizing hormone (22.9 mIU/mL [normal range for adult men 0.8-6 mIU/mL]), follicle stimulating hormone (49.7 mIU/mL [normal range for adult men 1-11 mIU/mL]), testosterone (0.24 ng/mL [normal range for adult men 2.5-8.0 ng/mL]), bioavailable testosterone (0.02 ng/mL [normal range for adult men &gt;0.6 ng/mL]), and percent bioavailable test (8.1% [normal value &gt;20%]). These results indicate hypergonadotropic hypogonadism. Plasminogen activator inhibitor 1 was 6 U (normal value 5-20 U/mL). Karyotyping performed by G-banding technique revealed a 47 XXY karyotype, which is diagnostic of Klinefelter's syndrome. Doppler ultrasound of the leg ulcers disclosed partial thrombus in the distal right femoral vein. X-rays and bone scan displayed osteomyelitis along the right tibia. Histological examination of a 4-mm punch biopsy from the ulcer border revealed hyperkeratosis, acanthosis, hypergranulosis, and mixed inflammatory infiltrate containing eosinophils compatible with chronic ulcer. Multiple vessels were seen, compatible with a healing process. Direct immunofluorescence of the biopsy revealed granular IgM in the dermo-epidermal junction. Indirect immunofluorescence was negative. Thyroid function tests showed normal thyroid stimulating hormone and free throxine4. Multinodular goiter was seen on thyroid scan and ultrasound. Thyroid fine needle aspiration was compatible with multinodular goiter (normal follicular cells, free colloid, macrophages with pigment). IV treatment with amoxicillin-clavulanic acid 1 g t.i.d. was administered for 2 weeks, with a decrease in temperature and normalization of the leukocyte level. Oral antibiotic treatment with amoxicillin-clavulanic acid was continued for 10 more days, followed by 25 days of ciprofloxacin for the osteomyelitis. Local treatment included saline soakings followed by application of Promogran (Johnson &amp; Johnson, New Brunswick, NJ) and Kaltostat (ConvaTec Ltd., a Bristol-Myers Squibb Company, New York, NY) with slight improvement. At the same time, the patient was treated with warfarin sodium due to deep vein thrombosis under international normalized ratio 2-3. The patient was treated with IM testosterone once monthly for 1 year, which resulted in a reduction in the diameter and depth of the leg ulcers (Figure 3). Blood tests were not performed for follow-up of the immune state." }, { "id": "pubmed23n0854_8532", "title": "The clinical and biochemical characteristics of Yemeni adults and children with visceral leishmaniasis and the differences between them: a prospective cross-sectional study before and after treatment.", "score": 0.009345794392523364, "content": "To determine the clinical and biochemical characteristics of Yemeni adults and children with visceral leishmaniasis (VL) and the differences between them. A prospective cross-sectional study on patients with bone marrow aspirate confirmed VL evaluated at Al-Jomhori Teaching Hospital in Sana'a, Yemen. Twenty-eight (59.6%) patients were adults with a mean age (± SD) of 24.3 years ± 9.2 and 19 (40.4%) patients were children with a mean age (± SD) of 7.1 years ± 4.7. Fever, pallor, splenomegaly and hepatomegaly were the most common clinical findings. Hypoalbuminaemia, hyperglobulinaemia, elevated LDH, hypocalcaemia and elevated CRP were common biochemical abnormalities. There was no significant difference in splenomegaly size or biochemical parameters with regard to grade of parasitic load. Both children and adults showed similar significant improvement after treatment. Biochemical abnormalities were not related to degree of parasitic load and there were no clinical, biochemical or treatment differences between adults and children." }, { "id": "InternalMed_Harrison_16561", "title": "InternalMed_Harrison", "score": 0.009293394777265745, "content": "Differential Diagnosis VL is easily mistaken for malaria. Other febrile illnesses that may mimic VL include typhoid fever, tuberculosis, brucellosis, schistosomiasis, and histoplasmosis. Splenomegaly due to portal hypertension, chronic myeloid leukemia, tropical splenomegaly syndrome, and (in Africa) schistosomiasis may also be confused with VL. Fever with neutropenia or pancytopenia in patients from an endemic region strongly suggests a diagnosis of VL; hypergammaglobulinemia in patients with long-standing illness strengthens the diagnosis. In nonendemic countries, a careful travel history is essential when any patient presents with fever." }, { "id": "pubmed23n0572_730", "title": "End-stage renal disease due to delayed diagnosis of renal tuberculosis: a fatal case report.", "score": 0.009259259259259259, "content": "Renal TB is difficult to diagnose, because many patients present themselves with lower urinary symptoms which are typical of bacterial cystitis. We report a case of a young woman with renal TB and ESRD. She was admitted with complaints of adynamia, anorexia, fever, weight loss, dysuria and generalized edema for 10 months. At physical examination she was febrile (39 degrees C), and her abdomen had increased volume and was painful at palpation. Laboratorial tests showed serum urea = 220 mg/dL, creatinine = 6.6 mg/dL, hemoglobin = 7.9 g/dL, hematocrit = 24.3%, leukocytes = 33,600/mm(3) and platelets = 664,000/mm(3). Urinalysis showed an acid urine (pH = 5.0), leukocyturia (2+/4+) and mild proteinuria (1+/4+). She was also oliguric (urinary volume &lt; 400 mL/day). Abdominal echography showed thick and contracted bladder walls and heterogeneous liquid collection in the left pelvic region. Two laparotomies were performed, in which abscess in pelvic region was found. Anti-peritoneal tuberculosis treatment with rifampin, isoniazid and pyrazinamide was started. During the follow-up, the urine culture was found to be positive for M. tuberculosis. Six months later the patient had complaints of abdominal pain and dysuria. New laboratorial tests showed serum urea = 187 mg/dL, creatinine = 8.0 mg/dL, potassium = 6.5 mEq/L. Hemodialysis was then started. The CT scan showed signs of chronic nephropathy, dilated calyces and thinning of renal cortex in both kidneys and severe dilation of ureter. The patient developed neurologic symptoms, suggesting tuberculous meningoencephalitis, and died despite of support measures adopted. The patient had ESRD due to secondary uropathy to prolonged tuberculosis of urinary tract that was caused by delayed clinical and laboratorial diagnosis, and probably also due to inadequate antituberculous drugs administration." }, { "id": "InternalMed_Harrison_1605", "title": "InternalMed_Harrison", "score": 0.009259259259259259, "content": "Some infections have characteristic patterns in which febrile episodes are separated by intervals of normal temperature. For example, Plasmodium vivax causes fever every third day, whereas fever occurs every fourth day with P. malariae. Another relapsing fever is related to Borrelia infection, with days of fever followed by a several-day afebrile period and then a relapse into additional days of fever. In the Pel-Ebstein pattern, fever lasting 3–10 days is followed by afebrile periods of 3–10 days; this pattern can be classic for Hodgkin’s disease and other lymphomas. In cyclic neutropenia, fevers occur every 21 days and accompany the neutropenia. There is no periodicity of fever in patients with familial Mediterranean fever. However, these patterns have limited or no diagnostic value compared with specific and rapid laboratory tests." }, { "id": "wiki20220301en033_21959", "title": "Acute pancreatitis", "score": 0.009174311926605505, "content": "Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT) Interpretation If the score ≥ 3, severe pancreatitis likely. If the score < 3, severe pancreatitis is unlikely Or Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality Score 5 to 6 : 40% mortality Score 7 to 8 : 100% mortality APACHE II score \"Acute Physiology And Chronic Health Evaluation\" (APACHE II) score > 8 points predicts 11% to 18% mortality Hemorrhagic peritoneal fluid Obesity Indicators of organ failure Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min PO2 <60 mmHg Oliguria (<50 mL/h) or increasing BUN and creatinine Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>" }, { "id": "pubmed23n0520_9178", "title": "[Immunophenotype of lymphoblastic leukaemia in children in relation to clinical symptoms and laboratory tests, preceding its diagnosis].", "score": 0.009174311926605505, "content": "The aim of study was to compare the clinical picture and results of laboratory tests according to the acute lymphoblastic leukaemia (ALL) immunophenotype. The observation was carried out on a group of 67 patients treated in the IIIrd Department of Paediatrics and Department of Children Oncology in the Medical Academy of Białystok from January 1994 to April 2001. This group consists of 4 children with pro-B acute lymphoblastic leukaemia, 52 children with pre-B cell ALL, 1 child with B-cell acute lymphoblastic leukaemia and 9 children with T-cell acute lymphoblastic leukaemia. Haemorrhagic diathesis. splenomegaly, enlargement of peripheral lymph nodes as well as higher values of white blood cells count, blasts count, haemoglobin concentration, haematocrit and LDH activity were observed more frequently in patients with T-cell leukaemia than in others." }, { "id": "pubmed23n0779_14972", "title": "[Acute hepatitis due to infectious mononucleosis in a 21-year-old-man].", "score": 0.00909090909090909, "content": "A 21-year-old mole was admitted because of fever, fatigue, headache, pharyngitis, abdominal pain, loss of appetite, vomiting and dark urine for three days. The patient denied recent use of medicines or any other drug. His physical examination disclosed jaundice, hepato-splenomegaly, whitish-yellow covered tonsils, bilateral anterior and posterior cervical lymph node enlargement associated with edema on the face and neck. Routine blood tests detected abnormalities in serum bilirubins and liver enzymes (total bilirubin: 14.5 mg/dl, direct-reacting bilirubin: 12.9 mg/dl, AST: 697 U/l, ALT: 619 U/l, alkaline phosphatases: 260 U/l, and GGT: 413 U/l). Serological tests showed negative results for viral hepatitis, cytomegalovirus, HIV-1 and HIV-2, and toxoplasmosis markers, while serology for recent infection by EBV was positive (IgM: 70 and 29 U/ml; EBV IgG: 25 and 156 U/ml). Although infrequently, EBV infection can cause acute hepatitis with accentuated cholestatic jaundice (5% of cases), which may constitute an additional diagnostic challenge for primary care physicians. The patient improved with supportive management and was discharged after 12 days. This case study might contribute to increase the suspicion index about acute hepatitis related to EBV. " }, { "id": "pubmed23n1051_13966", "title": "False Positivity of rK39 Test in Five Chronic Myeloid Leukemia Cases from Bihar, India: A Possible Challenge to Leishmaniasis Diagnosis.", "score": 0.00909090909090909, "content": "A rapid and noninvasive rK39 rapid diagnostic test (RDT) is the best and most reliable tool for visceral leishmaniasis (VL) screening in the field. However, splenic and bone marrow aspiration remain two gold standard methods for microscopic identification of <iLeishmania donovani</i (LD) bodies and confirmatory diagnosis of VL. Five patients with signs and symptoms of fever, loss of appetite, loss of weight, hepatomegaly, and massive splenomegaly were found to be false positive with the rK39 RDT. These patients were suspected to have chronic myeloid leukemia (CML) because their blood pictures showed a total white blood cell count of &gt; 100,000/mm<sup3</sup and abnormal cells such as stab, segmented promyelocytes, myelocytes, metamyelocytes, and blast cells. Splenic aspirate and bone marrow were negative for <iLeishmania donovani</i bodies. The bone marrow showed myeloid series of cells, that is, myelocytes, metamyelocytes, stab and segmented cells, blast cells, and markedly increased myeloid:erythroid ratio. Later, the CML diagnosis was confirmed in all cases by breakpoint cluster region-tyrosine protein kinase (BCR-ABL) gene positive test results. In this study, the rK39 RDT's false positivity was observed in CML cases. It could have important implications for the differential diagnosis of VL with CML. The rK39 positive test result in CML cases was a serendipitous occurrence; this should be validated further to determine the utility of the rK39 test in the differential diagnosis of VL with CML." }, { "id": "pubmed23n0973_3484", "title": "The Role of Advanced Practitioners in Optimizing Clinical Management and Support of Patients With Polycythemia Vera.", "score": 0.009009009009009009, "content": "<bCASE STUDY</b Mr. M, a 65-year-old male, presented to his primary care physician with progressive fatigue, difficulty sleeping, and daily headaches for the past 3 weeks. His headaches were not associated with visual disturbances, cognitive deficits, or nausea/vomiting, and he had no history of migraines. He had a history of hypertension and hyperlipidemia, did not smoke, rarely drank alcohol, and had no recent illnesses or hospitalizations. His previous physical examination and laboratory studies 2 years ago were normal. The current physical examination revealed a plethoric yet well-appearing, well-nourished male in no acute distress. His lungs were clear to auscultation bilaterally without wheezes, rales, or rhonchi. He had a regular heart rate and rhythm without murmur. His abdomen was soft, without tenderness, distension, or palpable hepatosplenomegaly. Examination of the extremities was negative for edema. Distal pulses and sensation in the hands and feet were intact and equal bilaterally. Cranial nerves II to XII were deemed intact, and no gross focal deficits were observed. Complete blood count (CBC) revealed a slightly elevated white blood cell (WBC) count (14.6 × 10<sup9</sup/L [normal range, 3.9-10.7 × 10<sup9</sup/L; Wians, 2015]), erythrocytosis (red blood cell [RBC] count, 6.5 × 1012/L [normal range, 4.2-5.9 × 1012/L; Wians, 2015], hemoglobin, 19 g/dL [normal range, 14-17 g/dL; Wians, 2015], and hematocrit, 54.3% [normal range, 41%-51%; Wians, 2015]), thrombocytosis (platelet count, 500 × 109/L [normal range, 150-350 × 10<sup9</sup/L; Wians, 2015]), and microcytosis (mean cell volume [MCV], 75 fL [80-100 fL; Wians, 2015]), which combined were cause for referral to a hematology/oncology clinic. During his hematology/oncology evaluation, Mr. M described \"never feeling rested\" and being unable to sleep with uncertain snoring habits. He was experiencing itching during hot showers yet did not have rashes and had not recently introduced a new soap. He had no family history of blood disorders and no personal history of blood clots. The second CBC and laboratory tests confirmed erythrocytosis (RBC count, 6.5 × 1012/L; hemoglobin, 18.9 g/dL; hematocrit, 54%) and microcytosis (MCV, 75 fL). Serum iron (22 μg/dL [normal range, 60-160 μg/dL]) and ferritin (5 ng/mL [normal range, 15-200 ng/mL]) were suggestive of iron deficiency, serum erythropoietin was 8 mU/mL (normal range, 4.0-18.5 mU/mL), and a Janus kinase 2 (JAK2) mutation analysis was positive for JAK2V617F. Platelet count remained 500 × 109/L and WBC count was 10.2 × 10<sup9</sup/L." }, { "id": "pubmed23n1051_24690", "title": "[Clinical analysis of 14 cases with childhood acute lymphoblastic leukemia complicated with tropical candidemia].", "score": 0.009009009009009009, "content": "<bObjective:</b To investigate the clinical feature, diagnosis, treatment and prognosis of childhood acute lymphoblastic leukemia (ALL) complicated with candida tropicalis bloodstream infection (CTBI), so as to improve the understanding of this disease. <bMethods:</b The general information, clinical manifestation, auxiliary examination, treatment and outcome of 14 childhood ALL who were diagnosed with tropical candidemia between January 2015 and December 2018 in 6 hospitals were analyzed retrospectively. Clinical data of non invasive fungal disease (IFD) ALL (28 cases) and other IFD children (9 cases) admitted in the same period were collected as control group. Logistic regression model was used to analyze the risk factor of CTBI. <bResults:</b Among 14 cases, there were 7 males and 7 females, with the age ranged from 17 months to 13 years. All the cases had fever, 9 cases had digestive system symptoms and stool fungal culture were positive in 3 of them; 7 cases had respiratory system symptoms and sputum fungal culture was positive in 1 of them; 2 cases had central nervous system symptoms and 10 cases progressed into septic shock. All 14 cases had neutropenia and the neutropenia duration was 1 to 53 days. Among 14 cases, the C-reactive protein was&gt;50 mg/L in 8 cases, in which the proportion was significantly higher than that in other invasive fungal disease(IFD) (8/14 <ivs.</i 1/9, <iP&lt;</i0.05), meanwhile the 1, 3-β-D-glucan detection, galactomannan detection and pulmonary imaging were not remarkable in all 14 cases. The blood culture results of 14 cases were all candida tropicalis, among which 13 cases finished drug susceptibility tests, the isolates of all cases were sensitive to flucytosine and amphotericin B, and the isolates of 4 cases were sensitive to fluconazole, voriconazole and itraconazole. Among 14 cases, 1 case lost to follow-up after giving up treatment, 1 case died before antifungal therapy and the remaining 12 cases received antifungal therapy; 7 of the 14 cases died. Univariate analysis showed that between ALL with CTBI group (14 cases) and ALL without invasive fungal disease (IFD) group (28 cases), the differences in variables such as ALL not in remission (χ²=37.847, <iP</i&lt;0.01), length of hospital stay&gt;15 days (χ<sup2</sup=8.351, <iP</i=0.004), neutropenia (χ²=14.280, <iP</i&lt;0.01), neutropenia duratio<in&gt;</i10 days (χ²=10.254, <iP</i=0.001), use of broad-spectrum antibiotics (χ²=13.888, <iP</i&lt;0.01), skin and mucous membrane damage (χ²= 5.923, <iP=</i0.015) were statistically significant. <bConclusions:</b In childhood ALL complicated with tropical candidemia, the drug resistance rate and mortality rate were high. For azole-resistant tropical candida, amphotericin B liposome or echinocandins(caspofungin) -fluorocytosine combined therapy was recommended to reduce treatment-related deaths." }, { "id": "wiki20220301en085_59103", "title": "Contrast-induced nephropathy", "score": 0.008928571428571428, "content": "Roxana Mehran score The Roxana Mehran score is a clinical prediction rule to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h): Risk Factors: Systolic blood pressure <80 mm Hg - 5 points (if systolic BP less than 80 mmHg for at least one hour requiring inotropic support) Intra-arterial balloon pump - 5 points Congestive heart failure, counting as NYHA class III (marked limitation in activity due to symptoms, even during less-than-ordinary activity) or worse, or history of pulmonary edema - 5 points Age >75 y - 4 points Hematocrit level <39% for men and <35% for women - 3 points Diabetes mellitus- 3 points Contrast media volume - 1 point for each 100 mL Decreased kidney function: Serum creatinine level >1.5 g/dL - 4 points or Estimated Glomerular filtration rate (online calculator) 2 for 40–60 mL/min/1.73 m2 4 for 20–40 mL/min/1.73 m2 6 for < 20 mL/min/1.73 m2" }, { "id": "pubmed23n0092_13535", "title": "Persistent generalized lymphadenopathy syndrome vs \"AIDS\"--unrelated malignant lymphoma: comparison of presenting clinical and laboratory findings in 88 patients. AIDS and Related Syndromes Study Group.", "score": 0.008928571428571428, "content": "The purpose of this report is to document and compare the presenting clinical and laboratory findings of 38 patients, all intravenous drug abusers, with pathologically documented persistent generalized lymphadenopathy (PGL), and of 50 patients with AIDS-unrelated malignant lymphoma (30 with Hodgkin's disease and 20 with non-Hodgkin's lymphoma). All patients, aged 40 years or less, consecutively seen since May 1984 in a single institution in Italy, have prospectively undergone a similar clinico-pathologic approach. In addition to a history of intravenous drug abuse and HIV serology, the results indicate that a history of infection in the previous year, night sweats, weight loss, generalized lymphadenopathy, beta 2 microglobuline, transaminase, T4/T8 ratio less than 1, and polyclonal hypergamma-globulinemia significantly increased among PGL patients compared with patients with AIDS-unrelated malignant lymphoma. In contrast, patients with malignant lymphoma had a significant increase in mediastinal lymph nodes, sedimentation rate, LDH, fibrinogen and anemia. Therefore, at this time of an AIDS epidemic, after histologic diagnosis of reactive lymphadenopathy has been performed in young patients presenting with generalized lymphadenopathy, a request for a second biopsy and other invasive procedures may be avoided if clinical and laboratory data suggest a PGL syndrome. If not already performed, HIV antibody detection should be carried out in this setting." }, { "id": "pubmed23n0069_17938", "title": "[Comparison of symptoms and clinical and laboratory findings in the first and last weeks of typhoid fever].", "score": 0.008849557522123894, "content": "In this study we examined the clinical and laboratory findings of 80 in-patients. There is an important difference between sexes (p greater than 0.05). Comparison of ages showed that 7-30 age is more vulnerable than the older group. We found clinical symptoms of fever, chills, headache, abdominal pain, disturbances in bowel function, nausea, vomiting, anorexia, and lassitude in the first two weeks more frequently when compared with the 3rd, 4th, 5th weeks of illness (p less than 0.001). Where physical finding of rose spots, discordant pulse rate are important in the first two weeks (p less than 0.001). Abdominal discomfort is an important symptom both in the first two and in the last three weeks (% 40.3 and % 36 respectively). Hepatomegaly and splenomegaly, were found more frequently in the last three weeks. According to laboratory findings of anemia, leukopenia, increased erythrocyte sedimentation rate and positive blood and feces cultures there is no important difference between the first two and last three weeks (p greater than 0.05). Increase in polynuclear leucocytes is important for the first two weeks, and increase in lymphocytes is important in the last three weeks (p less than 0.001). Positivity of group agglutination tests is 57%, in the first two weeks and 83% in the last three weeks. This difference is found to be important." }, { "id": "pubmed23n0371_6560", "title": "[Life threatening hypercalcemia in a young man with ALL].", "score": 0.008771929824561403, "content": "A 16-year-old man experienced fatigue, vomiting and diffuse abdominal pain. Since 4 days he had myalgia in both arms and legs. On examination only a tachycardia of 110/min was noticed. Laboratory tests revealed hemoglobin 12.7 g/dl, leucocytes 10,300/microliter, platelets 89,000/microliter, LDH 191 U/l, sodium 134 mmol/l, potassium 2.76 mmol/l, calcium 4.52 mmol/l (I), creatinine 1.13 mg/dl, urea 72 mg/dl, uric acid 11.2 mg/dl. The levels of PTH (0 pg/ml), PTH-related peptide, vitamin D, vitamin A, IGF-1, STH, 5-HIES and interleukin 6 were within normal limits. TNF-alpha 25.9 pg/ml (&lt; 8.1). The electrocardiography revealed a sinus rythm with a QT-time of 0.28 s (= 100%). Multiple osteolytic bone leasions were seen in thoracic CT-scan. Abdominal sonography showed normal liver structure, multiple subhepatic lymph nodes without splenomegaly. The cytologic examination of the bone marrow demonstrated a diffuse infiltration by a common acute leukemia. The rehydration with physiologic saline (3500 ml/d) was initiated in the ICU. Furosemide was added for further renal excretion. Additionally prednisone (100 mg/d) and calcitonin (300 I.E./d) were given. The calcium level fell within two days. No cardiac arrhythmia nor acute renal failure were seen. After definitive diagnosing the patient was treated corresponding to a specific protocol. One year later the relapsing ALL was diagnosed also by hypercalcemia (5.9 mmol/l). The level of TNF-alpha before and after correction of hypercalcemia was 20 pg/ml. The acute treatment of hypercalcemia is independent of the underlying cause (rehydration with physiologic saline, renal excretion with furosemide, inhibition of osteoclastic activity). The main causes are hyperparathyreoidism or malignancys (90%). We describe TNF-alpha as a possible marker of tumoral load of a common ALL but we are not able to reveal a correlation between TNF-alpha and the calcium level." }, { "id": "InternalMed_Harrison_31252", "title": "InternalMed_Harrison", "score": 0.008771929824561403, "content": "Laboratory Features CSF findings are distinctive, consisting of an elevated CSF protein level (1–10 g/L [100–1000 mg/dL]) without accompanying pleocytosis. The CSF is often normal when symptoms have been present for ≤48 h; by the end of the first week, the level of protein is usually elevated. A transient increase in the CSF white cell count (10–100/μL) occurs on occasion in otherwise typical GBS; however, a sustained CSF pleocytosis suggests an alternative diagnosis (viral myelitis) or a concurrent diagnosis such as unrecognized HIV infection, leukemia or lymphoma with infiltration of nerves, or neurosarcoidosis. Edx features are mild or absent in the early stages of GBS and lag behind the clinical evolution. In AIDP, the earliest features are prolonged F-wave latencies, prolonged distal latencies, and reduced amplitudes of compound muscle action potentials (CMAPs), probably owing to the predilection for involvement of nerve roots and distal motor nerve terminals early in the course." }, { "id": "pubmed23n0728_20616", "title": "PCR use in miliary tuberculosis presenting with acute respiratory distress syndrome.", "score": 0.008695652173913044, "content": "A 30-year-old pregnant woman admitted to the hospital for rapidly progressive dyspnoea, non-productive cough and altered general status evolving over 1-month period. Her vital signs showed a low blood pressure 90/60 mm Hg, pulse rate 100 beats/min, respiratory rate 32 breaths/min and oxygen saturation on room air of 88%. Laboratory findings showed haemoglobin 9.7 g/dl, white blood cells 15 000/mm(3) (neutrophils 82%), C reactive protein 74 mg/l, alkaline phosphatase 320 U/l, alanine aminotransferase 62 IU/l, aspartate aminotransferase 120 IU/l, γ glutamyl transpeptidase 125 U/l; brain natriuretic peptide 25.4 pg/ml, procalcitonine &gt;2, lactate dehydrogenase 1618 U/l. Chest radiographics showed diffuse bilateral micronodular pulmonary infiltrates and CT of the chest confirmed 1-3 mm diffuse bilateral micronodular infiltrates with ground glass opacities. Complete investigation including bronchoalveolar lavage (BAL) for any viral, bacteriologic, acid-fast bacilli and full serum antibodies panel were all negative. DNA amplification for mycobacterium using PCR on the BAL rapidly rectified the diagnosis of tuberculosis." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 107 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "The other antecedents and findings are very directly related to the increased risk of thrombotic phenomena." }, "2": { "exist": true, "char_ranges": [ [ 108, 157 ] ], "word_ranges": [ [ 16, 24 ] ], "text": "Osteoporosis is not a risk factor for thrombosis." }, "3": { "exist": true, "char_ranges": [ [ 0, 107 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "The other antecedents and findings are very directly related to the increased risk of thrombotic phenomena." }, "4": { "exist": true, "char_ranges": [ [ 0, 107 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "The other antecedents and findings are very directly related to the increased risk of thrombotic phenomena." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "History of breast cancer.", "2": "History of osteoporosis.", "3": "History of having been at rest for more than 3 days.", "4": "Presence of unilateral edema of the right calf.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0906_12679", "title": "Subacute pulmonary embolism in a hemodialysis patient, successfully treated with surgical thrombectomy.", "score": 0.014515163607342379, "content": "A 53-year-old woman was admitted to our hospital with a 1-month history of gradually progressive resting dyspnea and lumbar backache. For the preceding 6 years, she had received regular hemodialysis for end-stage renal disease caused by autosomal dominant polycystic kidney disease and had taken tamoxifen for 3 years as post-operative chemotherapy for breast cancer. Before admission, the patient's symptoms had been attributed to volume overload, based on right thoracic fluid and leg edema. However, despite volume correction by dialysis therapy, her symptoms had not improved. The patient was transferred to our hospital, where she was diagnosed with subacute pulmonary embolism (PE). Emergent pulmonary thrombectomy was performed using cardio-pulmonary bypass. The patient was discharged from our hospital on post-operative day 23. Recent reports have shown that hemodialysis patients have a relatively higher risk of PE compared with the general population. Our case had additional risk factors for PE: female sex, decreased protein C level, tamoxifen use, and autosomal dominant polycystic kidney disease. These factors may have had a synergistic effect on the onset of PE." }, { "id": "wiki20220301en532_4583", "title": "Marie Keating Foundation", "score": 0.013699204021784667, "content": "In 1994 Keating experienced breast pain and her doctor diagnosed her with mastitis, providing her with a prescription for antibiotics and telling her to come back if the pain persisted. As she was a sufferer of nosocomephobia, she didn't go back to the doctors even though she was in pain. She discovered a breast lump, and her doctor immediately sent her to Beaumont Hospital in the north of Dublin city for a biopsy where she was told that it was cancer even before tests were run. Over a year and a half later, on , Marie was diagnosed with Paget's disease of the breast which developed into breast cancer as it was not detected early enough. Although this was a shock to both her and her family, she underwent a full mastectomy the following month and began chemotherapy treatment. A year later, in September 1997, she was told that the cancer had gone but, because she rarely did her exercises, she developed lymphedema in her legs, and in the following month, she began to experience back pain" }, { "id": "pubmed23n0822_10817", "title": "[Determination of treatment strategies for a 43-year-old single woman with Stage IV breast cancer].", "score": 0.013571954361428044, "content": "The patient was a 43-year-old single woman. Her family history included schizophrenia in her mother and manic-depression in her father. Remicade® (infliximab) had been administered for 3 years to treat rheumatoid arthritis. The patient initially presented to our hospital with dyspnea. Computed tomography revealed left-sided breast cancer associated with multiple bone tumors and multiple pulmonary nodules. A poorly mobile mass with an ulcer was found in left breast. Core-needle biopsy and fluorescent in situ hybridization (FISH)revealed an invasive ductal carcinoma that was positive for estrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2, 2 +). The clinical diagnosis was Stage IV T4bN3M1 cancer (metastases to the lungs, liver, and bone). Because of the presence of bone metastasis, the patient was admitted and she received complete bed rest as supportive therapy. However, the patient decided to receive treatment on an outpatient basis after carefully discussing the following points: 1) treatment of pulmonary metastasis with dyspnea should receive priority; 2) anticancer agents not causing nausea were required; 3) the risk of bone fractures as a complication (spinal cord injury); 4) how she wanted to spend the limited time available with her family; and 5) how the patient wanted to." }, { "id": "pubmed23n0046_12706", "title": "[A case of phlebothrombosis of lower extremity and pulmonary embolism due to progesterone].", "score": 0.012610837438423644, "content": "A case with lower extremity phlebothrombosis and pulmonary embolism caused by progesterone is reported in this paper. The patient is a 64-year-old woman who had been operated on for right breast cancer 22 years before. It was noticed that there was a relapsing cancer on her right shoulder 6 months before this episode. After effective treatment of 5-FU, she had received 1,200mg of Medroxyprogesterone acetate and 30mg of Tamoxifen daily for 4 months. With the complaint of dyspnea and left leg swelling 4 months after above treatment, she was admitted in our hospital. Laboratory data and angiograms showed venous thrombosis in her left leg and pulmonary embolism. Relapsing cancer had already disappeared by the time she was admitted. After discontinuance of these medicines, her condition had improved. Considering these observations, the patient's phlebothrombosis and embolism seem to have been caused by Medroxyprogesterone acetate." }, { "id": "wiki20220301en028_1465", "title": "Sandra Lee (chef)", "score": 0.011901315577857119, "content": "Cancer and advocacy Lee announced on May 12, 2015, that she had been diagnosed with early-stage breast cancer. By then she had undergone a lumpectomy, and was scheduled to have a double mastectomy later in the week. Governor Cuomo was to take some personal time to be with her during and after the surgery. In August 2015, she contracted an infection in her right breast that resulted in her going on bed rest and intravenous drugs for three months. Lee announced that she is cancer free in late 2015." }, { "id": "InternalMed_Harrison_27581", "title": "InternalMed_Harrison", "score": 0.011281512605042017, "content": "Long-term use (≥5 years for estrogen-progestogen and ≥7 years for estrogen alone) is more problematic because a heightened risk of breast cancer must be factored into the decision, especially for estrogen-progestogen. Reasonable candidates for such use include the small percentage of postmenopausal women who have persistent severe vasomotor symptoms along with an increased risk of osteoporosis (e.g., those with osteopenia, a personal or family history of nontraumatic fracture, or a weight below 125 lbs), who also have no personal or family history of breast cancer in a first-degree relative or other contraindications, and who have a strong personal preference for therapy. Poor candidates are women with elevated cardiovascular risk, those at increased risk of breast cancer (e.g., women who have a first-degree relative with breast cancer, susceptibility genes such as BRCA1 or BRCA2, or a personal history of cellular atypia detected by breast biopsy), and those at low risk of" }, { "id": "pubmed23n0418_1565", "title": "Cases from the Osler medical service at Johns Hopkins University.", "score": 0.010773944845309875, "content": "A 56-year-old black woman with diabetes mellitus was admitted for hypoglycemia and confusion. Her past medical history included breast cancer, for which she had undergone a left lumpectomy and then mastectomy for in-breast recurrence. Her oral intake had decreased during the past month because of increasing discomfort from left-sided chest pain. During this period, she continued to take pioglitazone for diabetes at her originally prescribed dose. The patient's mental status improved quickly after taking orange juice and intravenous glucose, but the chest pain persisted. The pain, which was described as an ache along the left costal margin, increased with palpation, deep inspiration, or coughing. She had recently presented with similar complaints at another hospital where she had been prescribed a muscle relaxant that provided no relief from the pain. She also reported a 14-lb weight loss during the previous 3 months, as well as fatigue, weakness, and aches in her legs and arms. She denied fevers, chills, sweats, abdominal pain, nausea, or recent trauma. Laboratory values at the time of admission were: calcium, 11.8 mg/dL; total protein, 11.1 mg/dL; albumin, 3.2 g/dL; creatinine, 1.0 mg/dL; and hematocrit, 29.3%, with a mean corpuscular volume of 89.3. Chest radiography revealed a lytic lesion in the left lateral fourth rib and left humerus (). Serum and urine protein electrophoresis revealed a monoclonal spike in the gamma region consistent with monoclonal gammopathy. The serum spike was quantified at 3.78 g/dL. A skeletal survey showed many small well-defined lytic lesions in the skull (with one 1.5-cm lytic lesion in the upper posterior parietal bone), arms, and legs. A bone scan showed multiple foci of increased uptake in the right and left ribs as well as the proximal portion of the left femur. The peripheral blood smear revealed rouleaux formation () and plasma cells (). What is the diagnosis?" }, { "id": "pubmed23n0916_11623", "title": "Insufficiency Fractures of the Distal Tibia and Fibula Following Total Hip Arthroplasty: A Case Report.", "score": 0.009900990099009901, "content": "Although periprosthetic fractures of the femur have been well documented, insufficiency fractures following total hip arthroplasty (THA) have been rarely described. We report a case of an insufficiency fracture in the distal tibia and fibula that occurred after THA. A 54-year-old woman presented with severe pain in the bilateral hip joints and was diagnosed with end-stage osteoarthritis. She underwent THA on the right side. Although the postoperative course was uneventful, she suddenly experienced severe pain and swelling in the right leg without any history of trauma 22 weeks after the surgery. She was first diagnosed with cellulitis by her local doctor and was treated with oral antibiotics. Her symptoms persisted, and she returned to our hospital 1 month later. Her right distal leg and ankle were diffusely swollen and tender. Plain radiographs revealed a sclerotic linear zone in the distal tibia and fibula. She was diagnosed with insufficiency fractures in the distal tibia and fibula following THA. Local disuse osteoporosis and increased mechanical stress after THA as a result of pain relief could be the causes for her fracture. Her right leg and ankle were immobilized with a splint for another 4 weeks. Her symptoms subsided gradually, and fracture union was confirmed on the follow-up X-ray. Insufficiency fractures should be suspected in patients complaining of unexplainable pain, even in the distant area of the affected limb, for at least 6 months following THA." }, { "id": "article-20301_6", "title": "Deep Venous Thrombosis of the Lower Extremity -- History and Physical", "score": 0.009900990099009901, "content": "Specific historical features that assist in the diagnosis of a DVT are those related to DVT risk factors and include a history of cancer, exogenous estrogen therapy, recent surgery, smoking tobacco, previous history of DVT, immobility, age, history of a hypercoagulable state, and other comorbidities. Patients often will present with a chief complaint of unilateral leg swelling and discomfort. Be mindful to ask about symptoms related to a PE as well, such as chest pain, shortness of breath, and syncope. The physical exam most commonly demonstrates unilateral extremity swelling, warmth and discomfort over the vein, and, perhaps, a palpable \"cord\" where the DVT is located." }, { "id": "pubmed23n0598_12174", "title": "Post-partum sacral fracture associated with heparin treatment.", "score": 0.00980392156862745, "content": "We report the case of a 19-year-old woman who consulted for low-back pain 3 weeks after her first delivery. This young woman had a personal history of protein C deficiency and was treated daily during her pregnancy with low-molecular-weight heparin. Her body mass index was 34 and she only gained 10 kg during her pregnancy. Since the delivery - which occurred without any complication - she had suffered from a gradually increasing right-buttock pain and limp. Magnetic resonance imaging (MRI) revealed a fracture of the right sacral ala. After analgesia and 1 month of home relative bed rest, the patient recovered her functional capacities. Regarding our patient, who had no potential clinical risk factors for osteoporosis, the causal effect of heparin is thus possible but not certain. This case report illustrates the fact that clinicians should have a high suspicion of pelvic fracture in post-partum women, even in very young ones, presenting sudden onset of low back and pelvic pain, especially when they have received heparin during pregnancy. MRI seems to be the key exam because it is able to detect and stage fractures or microfractures." }, { "id": "article-19382_6", "title": "Chest Pain -- History and Physical -- History", "score": 0.00980392156862745, "content": "Shortness of breath Nausea and vomiting Fever Diaphoresis Cough Dyspepsia Edema Calf pain or swelling Recent illness Evaluate for any of the following risk factors: ACS risks: prior myocardial infarction(MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD), and diabetes Pulmonary embolism (PE) risks: prior deep venous thrombosis (DVT) or PE, hormone use (including oral birth control), recent surgery, cancer, or periods of non-ambulation Recent gastrointestinal (GI) procedures like scopes Drug abuse (cocaine and methamphetamines)" }, { "id": "pubmed23n0409_21402", "title": "Leg ulcers and hydroxyurea: report of three cases with essential thrombocythemia.", "score": 0.009708737864077669, "content": "CASE 1: A 65-year-old woman with essential thrombocythemia (ET) had been taking oral hydroxyurea (HU), 1,000 mg daily, for 7 years. Six months ago, she developed an ulcer on the outer part of her left ankle, which healed spontaneously within 2 months. She presented with a new, tender, shallow ulcer, 2 cm x 2 cm in size, at the same site. Doppler examination revealed thrombosis of the left common femoral vein and a calcified atheroma plaque of the left common femoral artery. The dosage of HU was decreased to 500 mg daily when the platelet counts were found to be within normal levels. The ulcer completely healed within 2 months with occlusive wound dressings, and has not recurred within the follow-up period of 1 year. CASE 2: A 56-year-old women presented with multiple, painful, leg ulcers of 1 year duration. She had been diagnosed as having ET and had been on HU therapy, 1,500 mg/day, for the past 5 years. Interferon-alpha-2b was started 3 months ago, in addition to HU, which was tapered to 1,000 mg daily. She had suffered from hypertension for 20 years treated with nifedipine and enalapril, and had recently been diagnosed with diabetes mellitus which was controlled by diet. Examination revealed three ulcers located on the lateral aspects of both ankles and right distal toe. Arterial and venous Doppler examinations were within normal limits. Histopathology of the ulcer revealed nonspecific changes with a mixed inflammatory cell infiltrate around dermal vessels. The ulcers completely healed within 10 weeks with topical hydrocolloid dressings. After healing, she was lost to follow-up. A year later, it was learned that she had developed a new ulcer at her right heel, 3 months after her last visit (by phone call). This ulcer persisted for 8 months until HU was withdrawn. CASE 3: A 64-year-old woman with ET presented with a painful leg ulcer of 6 months' duration. She had been taking oral HU for 5 years. She had a 20-year history of hypertension treated with lisinopril. Examination revealed a punched-out ulcer of 2 cm x 2 cm over the right lateral malleolus. Doppler examination of the veins revealed insufficiency of the right greater saphenous and femoral veins. Angiography showed multiple stenoses of the right popliteal and femoral arteries. As her platelet count remained high, HU was continued. During the follow-up period of 13 months, the ulcer showed only partial improvement with local wound care." }, { "id": "wiki20220301en624_4990", "title": "Leo Stern (historian)", "score": 0.009708737864077669, "content": "Later years" }, { "id": "pubmed23n0694_7473", "title": "A case of quadruple primary malignancies including breast, tongue, and thyroid cancers and osteosarcoma in a young female without karyotype abnormality.", "score": 0.009615384615384616, "content": "The patient was a 41-year-old, premenopausal woman with a chief complaint of well-circumscribed palpable, right breast mass without nipple discharge. Although she noticed the lump 3 months previously, the size of the tumor (1.1 × 0.9 cm(2)) had been stable. The patient's mother suffered from gastric cancer. Her previous history of the triple different malignancies was as follows: (1) left osteosarcoma [amputation of left lower leg at 15 years old (y/o)]. After the operation, she was treated with various kinds of anticancer drugs including a total of 45 g ifosphamide and 342 g methotrexate; (2) tongue cancer (right radical neck resection; 23 y/o); and (3) thyroid cancer (right lobectomy; 40 y/o). There was no evidence of recurrence of these malignancies at the present consultation. At the time of tongue cancer operation, chromosome abnormality was investigated, but the results were normal. Physical examination showed a well-delimited, elastic-firm, mobile tumor in the central outer right breast. Regional lymph nodes were not palpable. Mammography showed a focal asymmetry in the right upper breast on the mediolateral oblique view. Ultrasonography revealed a hypoechoic mass with irregular margins. Distant metastases could not be detected by whole-body computed tomography scan. The histology of the Mammotome(®) (vacuum-assisted core needle biopsy) specimen revealed that this tumor was low-grade ductal carcinoma in situ (DCIS). She underwent breast-conserving surgery with sentinel lymph node biopsy. On permanent histopathological examination, the diagnosis of the tumor was intracystic papilloma with low-grade DCIS. Surgical margin was negative, and sentinel lymph node metastases could not be observed. Estrogen and progesterone receptor (ER/PR) were strongly positive, but human epidermal growth factor receptor-2 (HER-2) overexpression was not tested because the lesion was DCIS. She has received no adjuvant therapy and is currently disease free 3 months after surgery." }, { "id": "pubmed23n0028_13935", "title": "Value of the history in the office diagnosis of breast cancer.", "score": 0.009615384615384616, "content": "A review of the histories of 1059 patients with breast problems seen consecutively in office consultation revealed an incidence of breast cancer of 13%. Patients over 50 years of age or whose mother or sister had had breast cancer had a substantially greater likelihood of having breast cancer. The finding of the problem on routine examination, a family history of breast cancer in a relative other than the mother or a sister, or prominent breast pain or nipple discharge made the diagnosis of cancer less likely. Menstrual status, a history of previous benign disease, nulliparity, current hormone therapy and duration of symptoms did not help identify the patient likely to have breast cancer. Much time could be saved for both doctor and patient in taking the history from patients with breast disorders. Only the patient's age and the history of the mother and sisters with regard to breast cancer will help identify the \"high-risk\" patient. Other historical findings are either valueless or should be used to reassure these usually anxious women." }, { "id": "pubmed23n0887_24495", "title": "Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) in an osteoporotic patient chronically treated with bisphosphonates.", "score": 0.009523809523809525, "content": "The aim of the study is to report the rare association of two complications of long-term treatment of osteoporosis with bisphosphonates in the same Caucasian elderly patient. A female patient of Italian descent, age 87 years, consulted in February 2013. She had a history of osteoporosis and had taken alendronate weekly for 7 years (1999-2006). Due to low back pain, an orthopedist had indicated i.v. zoledronic acid, 5 mg/year for 3 years (2006-2008). She received occasional supplements of ergocalciferol. In 2009, she suffered a fall and sustained a subtrochanteric fracture of the left femur. She was operated on and recovered uneventfully. In 2012, she consulted a dentist due to loose teeth. She underwent the removal of a molar and was given a denture. She had discomfort when using the prosthesis, and developed an ulceration in the gum of the mandible, which exposed the bone and did not heal for 2 months. After radiologic studies, the diagnosis was osteonecrosis of the jaw. She improved after surgical debridement and local and systemic antibiotics. In early 2013, laboratory tests were normal except for a slight elevation of serum PTH and CTX-I. Calcitriol 0.25 mcg/day was prescribed; after 3 months serum calcium, phosphate, PTH, and CTX-I showed no variation. Two years later, she experienced acute low back pain after a fall; MRI showed recent crushing of D12, and chronic deformities of D11 and L1. Bone densitometry of her right hip (DXA) showed a T-score of -2.3 at the femoral neck. An X-ray film of the right femur showed diffuse thickening of both cortices. She was treated with nasal calcitonin and analgesics. After the back pain subsided, she was treated with s.c. denosumab. Although the association of ONJ and AFF was known in cancer patients treated with high doses of bisphosphonates, it is very rare in patients with osteoporosis receiving these drugs at usual doses. Only three cases have been reported, all in oriental women. This appears to be the first reported case in a Caucasian woman." }, { "id": "wiki20220301en017_55235", "title": "Julia Carson", "score": 0.009523809523809525, "content": "Illness and death On September 29, 2007, the Indianapolis Star reported that Carson had been an in-patient at Indianapolis's Methodist Hospital for the preceding eight days. She was being treated for an infection in her leg near the area where a vein was removed in 1996 during double bypass heart surgery. Year-to-date, Carson had participated in 87 percent of the House votes, but had missed 42 of 77 votes during the month. Carson had battled lung cancer before, but it had gone into remission before being re-diagnosed during the leg vein treatment, as the Star announced on November 25. She died on December 15, at the age of 69; her death was announced by her friend, former U.S. Representative Andrew Jacobs Jr." }, { "id": "pubmed23n0955_8639", "title": "Palliative Chemotherapy: Does It Only Provide False Hope? The Role of Palliative Care in a Young Patient With Newly Diagnosed Metastatic Adenocarcinoma.", "score": 0.009433962264150943, "content": "<bCase Study</b A 48-year-old female with recent diagnosis of adenocarcinoma of unknown origin and metastatic disease to the peritoneum initially presented to a nearby academic hospital with abdominal pain. She underwent exploratory laparotomy with tumor debulking surgery at that time. Shortly thereafter, she was readmitted to the same hospital with evidence of partial small bowel obstruction and treated conservatively with bowel rest, nasogastric (NG) tube placement, and intravenous (IV) fluid administration. Eventually the NG tube was removed, and she was discharged home. The following day, she received cycle one of palliative chemotherapy with cisplatin and gemcitabine at her local outpatient oncology clinic. She experienced persistent nausea and intermittent vomiting throughout the night and presented to our local community hospital for evaluation. At the time of admission, she was passing minimal flatus and had passed only a small bowel movement that morning. She had experienced nausea, vomiting, and poor oral intake for over a week. Other presenting symptoms included mild to moderate abdominal pain involving the upper abdomen. Upon evaluation, abdominal x-ray revealed dilated loops of small bowel, consistent with partial small bowel obstruction. An NG tube was placed, and the patient's symptoms were initially improved with bowel rest. Her medical history was significant for pulmonary embolism detected at the time of her adenocarcinoma diagnosis, and she was on oral anticoagulation and home oxygen. She also had a history of depression and total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) due to fibroids. Her social history revealed she was an office worker and married with two sons, ages 18 and 24. The 18-year-old son lived at home with the patient and her husband. The patient was eagerly awaiting the birth of a granddaughter, due in a few weeks' time. Her mother and father were also present daily during her hospitalization and were a major source of support for her and her family. At the time of hospital admission, a surgical team consultation concluded she was not a candidate for palliative surgery due to extensive disease burden. She was seen in consultation by medical oncology, who recommended resuming chemotherapy once the acute partial small- bowel obstruction resolved. <bPalliative Care Consult</b A palliative care consultation was requested to assist with symptom management, including pain and nausea relief. At the time of consultation, the patient appeared in mild distress due to abdominal pain and distention. Vital signs were stable. Physical exam was significant for absent bowel sounds and a mildly distended but nontender abdomen. The NG tube was in place, draining bilious gastric fluid. She had mild nonpitting edema involving the bilateral lower extremities. Discussion with the patient revealed values consistent with improving symptoms and extending life expectancy as long as possible. The patient expressed wishes for \"aggressive treatment,\" which she defined as continuation of chemotherapy and full resuscitation. The palliative care team discussed symptom management options with the patient. Nonsurgical management of partial bowel obstruction was continued, including bowel rest, NG tube decompression, and IV fluids. Pain was controlled initially with IV morphine as needed. After symptom improvement and evidence of bowel function recovery, the NG tube was removed. However, after a short time, she required NG tube replacement due to recurrent nausea and vomiting. Discussion was initiated with the patient, who opted for placement of a venting gastrostomy tube (G-tube) and total parenteral nutrition (TPN), with the goal of symptom relief and administration of nutrition, which would allow for continuation of chemotherapy. During placement of the venting G-tube, the gastroenterology (GI) team noted extensive tumor involving the stomach, which made placement of the tube difficult. Additionally, anticoagulation was held during G-tube placement, and postoperatively, the patient experienced acute, right-sided chest pain and shortness of breath. Computed tomography (CT) scan with pulmonary embolus (PE) protocol revealed a new PE, and anticoagulation was changed to enoxaparin. Shortly thereafter, she became febrile and developed leukocytosis. Blood cultures revealed coagulase-negative staphylococcus from a Port-a-Cath source. She was treated with appropriate antibiotic therapy; however, follow-up blood cultures revealed persistent coagulase-negative staphylococcus bacteremia. Her indwelling Port-a-Cath was removed. After appropriate antibiotic therapy, a peripherally inserted central catheter line was inserted and TPN restarted. <bReinstituting Palliative Chemotherapy</b Palliative care discussion with the patient confirmed her desire to reinstitute palliative chemotherapy, with the goal of restoring bowel function and returning home. Chemotherapy was resumed on day 15, despite concerns and even objections from several nursing staff members. The patient experienced treatment side effects, including prolonged thrombocytopenia. A platelet function antibody returned positive, consistent with heparin-induced thrombocytopenia. Enoxaparin was discontinued, and fondaparinux (Arixtra) was initiated. Platelet count recovered shortly thereafter. The patient required intense symptom management due to intractable abdominal pain and nausea and vomiting despite adequate venting G-tube decompression. Medical management was maximized with antiemetics, antisecretory agents, steroids, and antipsychotic agents, and symptoms eventually improved after cycle 2 of chemotherapy. Thereafter, the patient was discharged home. At the time of discharge, her symptoms were well controlled on minimal pain medications. She was still experiencing intermittent nausea but was passing flatus. By reducing the tumor burden, chemotherapy significantly improved her quality of life. She spent a total of 7 weeks in the hospital. During that time, she received two cycles of chemotherapy plus best supportive care and symptom management. Despite intermittent nausea and vomiting, administration of palliative chemotherapy allowed this patient to achieve her primary goals, which included returning home to her family and regaining some bowel function. Over the next several months, she received several more cycles of outpatient palliative chemotherapy. She experienced mild to moderate nausea and intermittent vomiting despite G-tube venting. Eventually, her disease progressed, and the patient chose to forgo any further intervention or chemotherapy. She was enrolled in hospice care and died comfortably at home surrounded by her family." }, { "id": "wiki20220301en137_42614", "title": "Ruth Lyons (broadcaster)", "score": 0.009433962264150943, "content": "Later years, retirement and death The mid-1960s were a time of illness and sorrow for Lyons and her family. She had maintained close ties with her younger sister, Rose; her sister died in 1964 after a ten-year battle with cancer. Lyons suffered a minor stroke in December 1964 and had to take a leave of absence from her television program. In January 1965, there was another family medical crisis; 20-year-old Candy had discovered a lump in her breast which turned out to be malignant. She underwent surgery and radiation; by September, she was well enough to join the cast of The 50-50 Club on a permanent basis. In early 1966, it became apparent that Candy's illness was now terminal; she wanted to return to Europe one last time. The Newman family left New York in early June. When they arrived in Italy, Candy was quite ill and was hospitalized; they began preparations for their return to the US on June 14. On June 19, 1966, Candy died aboard the ship before it reached New York." }, { "id": "pubmed23n0912_852", "title": "Mesenteric cysts and mesenteric venous thrombosis leading to intestinal necrosis in pregnancy managed with laparotomy: a case report and review of the literature.", "score": 0.009345794392523364, "content": "Mesenteric cyst is a rare clinical entity especially in pregnancy; therefore, few cases have been reported in the literature. The standard method of their treatment is surgical excision either with laparotomy or laparoscopy. In addition, mesenteric vein thrombosis is a rare and life-threatening condition in pregnancy and needs immediate treatment because it can lead to intestinal necrotic ischemia. This is the first report of the coexistence of mesenteric cysts and mesenteric vein thrombosis during gestation. A 27-year-old Greek woman, gravida 2 para 1, presented at 10 weeks' gestation to the Emergency Unit of our hospital complaining of diffuse abdominal pain which deteriorated the last 3 days, which was localized in her right iliac fossa, along with vomiting. She had undergone open laparotomy and right salpingo-oophorectomy at the age of 23 due to an ovarian cyst. Besides this, her personal and family medical history was unremarkable. She had never received oral contraceptives or any hormone therapy. On arrival, a clinical examination revealed tenderness on palpation of her right iliac fossa, without rebound tenderness or muscle guarding. Within 10 hours of hospitalization, her symptoms deteriorated further with rebound tenderness during the examination, tachycardia, and a drop of 12 units in her hematocrit value. An emergency laparotomy was performed. Two mesenteric cysts and a 60 cm necrotic part of her intestine were revealed intraoperatively. In the postoperative period, she complained of acute abdominal pain, tachycardia, and dyspnea. Computed tomography imaging revealed mesenteric vein thrombosis and pulmonary thromboembolism. She was treated with low molecular weight heparin and she was discharged on the 11th postoperative day. To the best of our knowledge, this is the first report in the literature of a simultaneous mesenteric cyst and mesenteric vein thrombosis in pregnancy. It is known that pregnancy is a state of hypercoagulation and clinicians should bear in mind this rare clinical condition in their diagnostic algorithm for acute abdominal pain." }, { "id": "pubmed23n0033_6417", "title": "[Usefulness of detection of breast cancer: the part played by the internist].", "score": 0.009345794392523364, "content": "The prognosis of breast cancer is the result of many factors, among which the mass of the tumor at the time of diagnosis remains the most significant: small tumors have a better prognosis than larger ones and are less often accompanied by positive lymph nodes. It is therefore justifiable to search for them systematically by breast examination of all patients over 30. Large-scale mass screening campains in the USA, with clinical and mammographic examination of tens of thousands of women, have proven that it is possible to detect more \"early\" cancers and reduce general mortality in the groups studied. The number of cancers thus detected is nevertheless so small that it does not justify the investment of so much labour and money in this kind of campaign. Systematic breast examination at regular intervals (6 months to 1 year) with regular mammographies should be confined to patients in the high risk groups: women who have already undergone surgery for cancer of one breast, and patients with a marked family history of breast cancer. For the rest of the female population, the solution seems obvious: every physician should get into the habit of performing regular clinical examination of the breasts. Most gynecologists are already doing so, but they only examine a small part of the population. The most important role in the detection of breast cancer falls to the internists and the general practitioners: they should assume responsibility for all their patients' breasts, in the same manner as they do for heart and lung examinations. They will then request additional examinations (mammography, thermography) as soon as clinical examination reveals a pathological finding. The results of GILBERTSEN [5] confirm that clinical examination remains the most valuable and least expensive method for breast cancer detection." }, { "id": "pubmed23n0788_11342", "title": "Sickle cell disease with osteogenesis imperfecta.", "score": 0.009259259259259259, "content": "A 16 yr old female presented with generalized weakness and easy fatigability since 2 months. Her medical history included that she had sickle cell disease (ss pattern) on regular treatment. She denied smoking and consumption of alcohol. She had adequate calcium intake and her menstrual history was non-contributory. History of right tibial diaphysial fracture 1 year back followed by refracture at the same site 6 months later. On examination patient was 146 cm tall &amp; weighed 48 kg. She had pallor, blue-grey sclera,scar mark of previous operation on right leg. Her mother and two maternal aunts also had blue-gray sclera. She had normal dentition and other systems were normal. Radiological screening showed diffuse osteopenia of all visualized skeleton, biconcave vertebral bodies in lumbar spine, Old healed fracture of right tibial diaphysis with intra-medullary nail in situ, wormian bones seen along the lambdoid suture, old healed fracture with sclerosis noted involving diaphysis of first metatarsal. Secondary causes of osteoporosis were ruled out. Skeletal involvement is sickle cell disease is usually in the form of avascular necrosis, dactylitis, joint effusions or osteomyelitis however osteoporosis and long bone fractures are not known in sickle cell disease. Owing to high index of suspicion a diagnosis of osteogenesis imperfecta was pursued, since the patient presented at 16 years age with relatively minor symptoms type 1A osteogenesis imperfecta (mildest form) was established. Systemic screening for disease complications included osteopontogram, audiogram and consultation with ophthalmologist and geneticist. Therapy with calcium and vit D was initiated and an in depth discussion regarding biphosphonates was pursued. Anaemia was corrected with blood transfusion and treatment of sickle cell disease was continued. Family screening was offered. Fractures particularly adults older than 45 are associated with osteoporosis. This case illustrates the importance of family history, fracture history and clinical correlation when assessing patients with osteoporosis. Mild OI most often presents after infancy and should be considered whenever children or adults have recurrent fractures. Early diagnosis of this disease by family physicians will enable initiation of therapy as well as patients education regarding management of modifiable risk factors linked with osteoporosis (e.g. diet, smoking, alcohol). Genetic counseling and family screening could also be offered." }, { "id": "article-23548_25", "title": "Innocent Murmur -- History and Physical -- Benign Continuous Murmurs", "score": 0.009259259259259259, "content": "Venous Hum [3] Most common continuous benign murmur, most often seen between 2 to 8 years of life Soft, whirling, low-pitched murmur, grade 1 to 3/6, heard best in high right sternal border and the right infraclavicular area in the upright position. Murmur does not radiate, disappears completely when supine or when patient extends the neck and turns to the right. Mammary Souffle [3] Least common, usually heard primarily in young adult women, especially when pregnant or lactating. Soft, blowing, high-pitched systolic murmur, grade 1 to 2/6, heard best over anterior chest, specifically over the breasts, softer when upright or with high stethoscope pressure." }, { "id": "pubmed23n1065_5245", "title": "Treatment of Pregnancy-Associated Breast Cancer.", "score": 0.009174311926605505, "content": "KS is a 33-year-old Caucasian married woman who works full time as an accountant and has one daughter who is 2 years old. She enjoys reading and exercising in her spare time. She initially presented in July 2015 at the age of 31 years with a 1-cm breast mass in the left inner breast, which prompted a mammogram to be obtained. The mammogram revealed diffuse and occasionally grouped left breast calcifications. Additionally, there was focal edema at the site of the mass. A follow-up mammogram was recommended to document stability in 6 months, which demonstrated an interval increase in number and size of segmental pleomorphic calcifications in the lower inner breast spanning 6 cm in size. A stereotactic core needle biopsy was completed and revealed high-grade ductal carcinoma in situ (DCIS) that was estrogen receptor (ER) and progesterone receptor (PR) positive. KS underwent genetic testing due to her young age at diagnosis of noninvasive breast cancer. She was tested with the breast/ovarian cancer panel, which was negative for mutation.She preceded to bilateral nipple-sparing mastectomy with left sentinel node biopsy and immediate implant reconstruction in February 2016. The operative pathology revealed 3.3 cm of high-grade DCIS. The surgical margins were negative (less than 1 mm posteriorly and less than 2 mm anteriorly). There was 1 sentinel node and 2 nonsentinel nodes negative for malignancy. The right breast was negative for cancer and both retro areolar margins were negative.KS did well during the ensuing routine follow-up every 6 to 12 months in surgical oncology at an academic medical center. She was not recommended to take adjuvant endocrine therapy given the benefit of bilateral mastectomy.In 2017, at a routine oncology follow-up visit, she expressed a desire to have more children. After a negative clinical exam, she and her husband were advised that future contraception may be pursued. KS was in her usual state of good health when she noticed a left breast mass in the inferior reconstructed breast in June 2017. She presented to the nurse practitioner (NP) in the surgical oncology clinic for evaluation. At that time, she was 17 weeks pregnant and being seen in the same facility for high-risk obstetrics and gynecology care. KS had no other concerning symptoms for recurrent cancer, and her pregnancy had been progressing smoothly.The surgical oncology NP noted a 1-cm firm superficial mass in the breast at 6 o'clock. She had no other bilateral breast findings or adenopathy. Upon review of systems, she denied new persistent headache, shortness of breath, abdominal pain, weight loss, night sweats, or fatigue.Due to her pregnancy and the superficial presentation of the breast mass, a left breast ultrasound was ordered. It revealed an 8-mm irregular hypoechoic mass 7 cm from the nipple at the 6 o'clock position in the reconstructed breast.A diagnostic workup ensued with a left breast ultrasound-guided core needle biopsy. KS was given a diagnosis of clinical stage T1b, N0, grade 2 invasive micropapillary carcinoma: ER positive (Allred 6), PR positive (Allred 8), HER2/<ineu</i, immunohistochemistry 3+, and fluorescence in situ hybridization amplified.After discussion of this recurrent cancer diagnosis, her team opted for a bilateral diagnostic mammogram (with abdominal shielding) and bilateral axillary and breast ultrasound to evaluate the contralateral breast and lymph nodes. There was no adenopathy, a small amount of accessory breast tissue in the right axillary tail region, and a biopsy clip was noted in the left inferior breast at 6 o'clock. The new cancer was not seen on mammogram, likely due to the proximity to the implant." }, { "id": "pubmed23n1130_20912", "title": "A 20-Year-Old Woman With Thoracic Pain and Progressive Dyspnea on Exertion.", "score": 0.009174311926605505, "content": "A 20-year-old woman presented with dry cough, right-sided thoracic pain, and gradually progressive dyspnea on exertion. She had no hemoptysis or fever. There was no relevant medical history. She was a never smoker and used no medication besides oral contraceptives. There were no other risk factors for a pulmonary embolism. There was a family history of ovarian and breast cancer. Physical examination showed a mildly ill-looking woman, with shallow breathing and normal blood oxygen saturation. Auscultation revealed normal breath sounds without crackles or wheezing. Laboratory testing showed a significantly increased D-dimer (4,560 μg/L [normal, &lt; 500 μg/L]), elevated C-reactive protein (131 mg/L [normal, &lt; 5 mg/L]), normal leucocytes, and elevated lactate dehydrogenase (825 units/L [normal, 50 to 250 units/L)." }, { "id": "pubmed23n0906_16829", "title": "Case 242: Radiation-induced Angiosarcoma.", "score": 0.00909090909090909, "content": "History In 2004, this woman received a diagnosis of invasive mammillary carcinoma, tubular variant, strongly positive for estrogen and progesterone receptors. Her lesion was found at screening mammography performed at an outside institution when she was 59 years old. She underwent partial mastectomy, with partial axillary node dissection and sentinel node mapping. A 0.6 × 0.5 cm Nottingham grade 1 infiltrating ductal carcinoma was removed from the right upper outer quadrant, margins were free of tumor, and there was no angiolymphatic invasion. The six dissected lymph nodes were negative for malignancy. Her surgical history was otherwise unremarkable. Her medical history was positive for hypercholesterolemia and depression. Pertinent family history included breast cancer in both her mother and her sister. Given the patient's age, tumor size, lack of nodal involvement, and clear surgical margins, she met recommended MammoSite criteria, and she underwent accelerated partial breast radiation. She subsequently received 340 cGy of radiation twice a day for a total dose of 3400 cGy in 10 administrations in February 2005. Accelerated partial breast radiation treatment was completed in February 2005, and she received subsequent routine care. Prior to 2014, the only postoperative complication was a chronic radiation bed seroma, which required periodic percutaneous drainage. She did not develop postsurgical lymphedema. In December 2013, 9 years after accelerated partial breast radiation treatment, she experienced progressive painful pruritic breast fullness, skin dimpling, and skin discoloration of the mastectomy scar and radiation bed. She sought medical care in January 2014 after she noticed a periareolar ulcerating skin plaque, more noticeable nipple retraction, and new onset of retroareolar aching. At physical examination ( Fig 1 ), there was generalized periareolar erythema, dimpling, firmness, and fixation involving the central breast and right upper outer quadrant. There was more conspicuous retraction of the nipple when compared with that seen at prior examinations. Nipple discharge was not present. There was a 1-cm periareolar ulcerating skin plaque. The only discrete palpable finding was lumpectomy bed seroma. There was no palpable axillary adenopathy. [Figure: see text] A diagnostic mammogram was obtained and compared with the most recent studies available. Ultrasonography (US) and magnetic resonance (MR) imaging were performed. Her most recent mammogram, obtained 3 months earlier in September 2013, reported Breast Imaging Reporting and Data System (BI-RADS) category 2 findings (ie, stable postoperative benign findings)." }, { "id": "pubmed23n1097_25750", "title": "Novel Mutation in <i>CACNA1A</i> Associated with Activity-Induced Dystonia, Cervical Dystonia, and Mild Ataxia.", "score": 0.009009009009009009, "content": "<iCACNA1A</i encodes the pore-forming <iα</i1 subunit of the neuronal voltage-gated Cav2.1 (P/Q-type) channels, which are predominantly localized at the presynaptic terminals of the brain and cerebellar neurons and play an important role in controlling neurotransmitter release. Mutations in <iCACNA1A</i have been associated with several autosomal dominant neurologic disorders, including familial hemiplegic migraine type 1, episodic ataxia type 2 (EA2), and spinocerebellar ataxia type 6. A 37-year-old woman presented with a history of slowly progressive, activity-induced stiffness, and pain in her right leg since age 15 and cervical dystonia since age 20. She denied any right leg stiffness or pain at rest, but when she began to walk, her right foot turned in and her right leg stiffened up. She also had neck pain, stiffness, and spams. There was no family history of similar symptoms. On physical exam, her strength, tone, and reflexes were normal in all extremities at rest. There was mild head titubation and very mild past pointing on finger-to-nose testing. MRI of the brain and spinal cord was unremarkable. This patient's clinical picture was felt to be most consistent with paroxysmal kinesigenic dyskinesia, as she has attacks of dystonia that are triggered by voluntary movement, last from a few seconds to a minute, and are relieved with rest. She was trialed on carbidopa/levodopa without improvement. A dystonia panel showed two potentially pathologic mutations, one in <iCACNA1A</i and the other in <iPNKP</i, along with a variant of unknown significance in <iATP7B</i. The mutation in <iCACNA1A</i is C2324 G &lt; A. It is heterozygous, autosomal dominant, and computer modeling suggests pathogenicity. This mutation has not been reported previously and is likely the cause of her paroxysmal dystonia; dystonia is sometimes seen during episodes of ataxia in EA2, and <iCACNA1A</i knockout mice exhibit dystonia and cerebellar atrophy. After receiving her genetic diagnosis, the patient was trialed on acetazolamide without improvement in her dystonia symptoms. This is the second case report of a patient with cervical dystonia and cerebellar ataxia associated with a mutation in <iCACNA1A</i." }, { "id": "wiki20220301en499_12261", "title": "Episode 5276", "score": 0.009009009009009009, "content": "Sonia Fowler (Natalie Cassidy) prepares to visit a doctor after finding a lump in her breast. She is accompanied by her girlfriend Tina Carter (Luisa Bradshaw-White), and the doctor refers Sonia for further tests. Back at home, Sonia tells her step-grandmother Dot Branning (June Brown) that she could have cancer and cries in Dot's arms. She admits she is also worried that Tina will no longer love her if she loses her breasts. Dot tells her to be strong and fight it. Sonia then tells Tina that she will have a double mastectomy, regardless of the results." }, { "id": "pubmed23n0760_23310", "title": "Isolated pulmonary veno-occlusive disease and pulmonary arterial thrombosis in systemic sclerosis - a lethal combination.", "score": 0.008849557522123894, "content": "Isolated pulmonary hypertension secondary to systemic sclerosis is not uncommon. Our patient with systemic sclerosis presented with a very aggressive form of pulmonary hypertension due to a lethal combination of pulmonary veno-occlusive disease (PVOD) and pulmonary arterial thrombosis. This combined presentation has never before been reported in medical literature. A 75-year-old woman with a 4-month history of atypical chest pains was admitted with a 3-week history of worsening symptoms of shortness of breath, reduced exercise tolerance, and bilateral pitting edema. On examination she had thickened skin in her hands, telangiectasia on her face, maculopapular rash in her legs, raised jugular venous pressure, and bilateral pitting edema. Her autoimmune profile revealed positive anticentromere antibodies, and her echocardiogram showed right ventricular systolic pressure of 91 mmHg. She also had renal impairment secondary to hypoperfusion. A diagnosis of isolated pulmonary hypertension secondary to limited systemic sclerosis was made. As she was clinically improving on slow diuretic infusion and awaiting transfer to a specialist center for management of pulmonary hypertension, our patient died due to cardiopulmonary arrest. Her postmortem revealed that she died of a combination of PVOD and pulmonary arteriopathy due to thrombosis. This is clearly a unique case both in presentation and difficulty of management. Pulmonary vasodilators used in therapy of pulmonary arteriopathy can be detrimental in patients with PVOD. There is no definitive investigation, curative treatment, or management, that exists for a combination of PVOD and pulmonary arteriopathy due to thrombosis secondary to systemic sclerosis." }, { "id": "wiki20220301en136_34970", "title": "Alicia Parlette", "score": 0.008849557522123894, "content": "Alicia Rose Parlette (January 11, 1982 – April 22, 2010) was a journalist and copy editor who was diagnosed with alveolar soft part sarcoma in 2005 while employed by the San Francisco Chronicle newspaper. At the age of 16, Parlette began experiencing pain in the area of her right hip that forced her to drop out of cross country running. An MRI scan revealed a spot that was interpreted as a hemangioma. Six years later, after she developed a severe cough, further scans showed spots in her lungs. Half a year later, she developed a lump in her right breast, which was excised and biopsied, leading to the correct diagnosis of the cancer she had probably been carrying for at least seven years." }, { "id": "pubmed23n0788_8875", "title": "High altitude pulmonary edema (HAPE) in a Himalayan trekker: a case report.", "score": 0.008771929824561403, "content": "High altitude pulmonary edema is a non-cardiogenic form of pulmonary edema that develops in unacclimatized individuals at altitudes over 2500 m. Early recognition of symptoms and immediate descent are important for successful treatment. Despite early signs and symptoms of high altitude illness, many trekkers tend to push themselves to the maximum limit. Some of them, such as the case reported here, choose to ascend on horse-back which is extremely dangerous and can be fatal. A 55 years of age Indian ethnic South African lady was emergency air-lifted from 4410 m altitude in the Nepal Himalayas to Kathamandu (1300 m) with a suspected case of high altitude pulmonary edema. She had continued ascending despite experiencing mild altitude symptoms at Namche (3440 m), and these symptoms worsened considerably at Tengboche (3860 m). At the very start of her trek, just after Lukla (2800 m), she suffered from sore throat, and had consequently begun a course of antibiotics (azithromycin) for a suspected throat infection. She had planned to continue ascending on horse back to complete the trek, however her condition deteriorated further and she had to be medically evacuated.On admission to the clinic her axillary temperature was 99.4 F, blood pressure 120/60 mmHg, pulse rate 72/min, respiratory rate of 25 breaths/min, and pulse oximeter showed saturation of 90% on room air at rest. Right sided crackles on the axillary and posterior region were heard on chest auscultation. Heel to toe test showed no signs of ataxia. The chest radiograph showed patchy infiltrates on the right side. An echocardiogram was done which revealed a high pulmonary artery pressure of 50 mm of Hg. She was diagnosed as resolving high altitude pulmornay edema. She was treated with bed rest, supplemental oxygen and sustained release nifedipine 20 mg (orally) twice a day. On the third day her crackles had cleared significantly and repeat chest radiograph as shown showed remarkable improvement. She felt much better. A repeat echocardiogram revealed a normal pulmonary artery pressure. The case report highlights numerous points:1) Many high altitude trekkers have invested significant time, money and physical efforts in in their ventures and are determined to ascend despite early warning and illnesses. 2) Despite no history of altitude illnesses in previous altitude exposure,inter-current illness (in this case a nonspecific respiratory tract infection) may contribute to the development of high altitude pulmonary edema. 3) Continuing ascent using other transport means, whilst suffering from symptoms of high altitude illness, worsens the condition and could be life threatening. 4) Acetazolamide does not prevent high altitude pulmonary edema-perhaps more so in the cases that have inter-current illness. 5) Descent is the golden rule in all altitude illnesses. Actually 'descent' is advised in any undiagnosed illness at high altitude among sojourners. 6) Finally, an experienced guide who has mountain medicine training is essential. They can be crucial in noticing early signs and symptoms of altitude illnesses to inform the client's safety as in this case." }, { "id": "wiki20220301en624_4964", "title": "Leo Stern (historian)", "score": 0.008771929824561403, "content": "Halle" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 119 ] ], "word_ranges": [ [ 0, 15 ] ], "text": "Cardiac surgery for aortic valve replacement by mechanical prosthesis with antibiotic therapy according to antibiogram." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Cardiac surgery for aortic valve replacement by mechanical prosthesis with antibiotic therapy according to antibiogram.", "2": "Antibiotic therapy according to antibiogram and implantation of intra-aortic balloon counterpulsation and transient pacemaker for up to 3 weeks, after which a permanent pacemaker will be implanted.", "3": "Implantation of transient pacemaker, antibiotic therapy according to antibiogram and percutaneous implantation of aortic valve prosthesis.", "4": "Urgent implantation of definitive pacemaker with antibiotic therapy according to antibiogram for 6 weeks.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0413_8692", "title": "Complete heart block resulting from quadricuspid aortic valve penicillin-resistant pneumococcal endocarditis: a case report.", "score": 0.01905453225660103, "content": "A 62-year-old woman was referred to hospital to be treated for complete heart block with syncope. A quadricuspid aortic valve without vegetation and aortic valve regurgitation (AR) were observed by transesophageal echocardiography. Blood culture showed penicillin-resistant Streptococcus pneumoniae. The patient received a permanent pacemaker implantation (VDD type) and was given antibiotics. Although infection improved, heart failure was not improved because AR hemodynamic changes became worse. An aortic valve replacement was performed using a prosthesis on the 26th day of hospitalization. The patient recovered and was discharged." }, { "id": "pubmed23n0841_12612", "title": "Urgent splenectomy in the course of prosthetic valve endocarditis.", "score": 0.01774915573706118, "content": "We present a case of a 51-year-old male patient hospitalized due to acute coronary syndrome requiring stent implantation to the left main stem. Double antiplatelet therapy was commenced. After 2-3 days, the patient presented with high fever, dyspnea on exertion, pain in the chest, myalgia, and general weakness. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed abnormal, turbulent flow across the aortic prosthesis, which was probably caused by the presence of a pathological smooth and mobile structure (10 × 9 × 5 mm) in front of the aortic annulus. Blood cultures were positive and staphylococcal prosthetic valve endocarditis (PVE) was diagnosed. Despite antibiotic treatment, the patient's condition deteriorated, and he was referred for prosthesis reimplantation. After being transferred to the Cardiac Surgery Clinic, he presented with nausea, vomiting, and abdominal pain. The results of imaging examinations suggested spleen hematoma. The patient underwent an urgent splenectomy. Histopathological examination revealed a spleen infarction consequent to an embolic event and subscapular hematoma. On the 10(th) day after the laparotomy, cardiac surgery was performed. No large vegetations were found on the aortic prosthesis. The mechanical valve, implanted 20 years earlier, was functioning properly; it was intact and well healed. Several fragments of a thrombus and fibrous tissue, resembling a pannus and covered with minor calcifications, were removed from the ventricular surface of the discs. A decision was reached to leave the aortic prosthesis in situ. The valvular material culture revealed the presence of Streptococcus anginosus, and the antibiotic scheme was modified. The postoperative period was uneventful. " }, { "id": "pubmed23n0599_11711", "title": "[Aortic homograft implantation in severe endocarditis].", "score": 0.016892373485388454, "content": "Severe endocarditis of the native aortic valve or a prosthetic valve with destruction of the cusps, paravalvular abscess formation and/or fistulas caused by aggressive bacteria has a mortality of almost 100% without surgery. The objective was to evaluate the results of treatment with an aortic homograft in combination with antibiotics. 24 patients with either aortic prosthetic valve endocarditis (n = 16) or severe aortic endocarditis (n = 8) were operated with implantation of an aortic homograft at a Danish university hospital from 1997-2006. Staphylococcus species were the most common pathogens followed by streptococcus. Intravenous antibiotic therapy was started before surgery and continued for 4-6 weeks. The patients were followed-up for (1/2)-10 years (mean 5 years). 3 patients with prosthetic valve endocarditis died within the first 24 hours from heart failure. 2 of these patients required in addition implantation of mitral valve prostheses. 5 patients died 1-7 years after the operation from non-cardiac causes. Within the follow-up period no patients had relapse of endocarditis, and only one episode of recurrence endocarditis in an intravenous drug abuser was registered after 4 years. An aortic homograft in combination with intravenous antibiotics is an excellent treatment of severe endocarditis in the aortic valve or an aortic valve prosthesis." }, { "id": "pubmed23n0229_8371", "title": "Surgical management of late prosthetic valve endocarditis.", "score": 0.015213675213675216, "content": "Among 32 patients with late prosthetic valve endocarditis selected from two cooperative retrospective studies, ten had valve replacement: six men and four women, mean age being 48 years, ranging from 23 to 65 years old. An emergency reoperation was undertaken for refractory heart failure in seven out of ten cases, with an average delay of 6.6 days after the beginning of antibiotic therapy. In the other three cases, the operation was carried out at the end of 40 days of antibiotic therapy, once for recurrent endocarditis and twice for severe aortic insufficiency. The most common causative micro organism was the staphylococcus (7 out of 10 cases). The infected prosthetic valves were, in 8 out of the 10 cases, in the aortic position. The outcome was poor as the mortality rate was 60% (6 out of the 7 patients operated on in an emergency). Death was attributed to heart failure with conduction disturbances and severe aortic regurgitation (2 cases), cerebral emboli (2 cases), septicopyemia (2 cases). Four patients of the ten, after a mean follow up of 10 months, are cured without prosthetic valve dysfunction. The extreme gravity of prognosis seems related to the microorganism (staphylococcus), to the delay between the beginning of antibiotic therapy and the onset of the fever, and finally to the extension of destructive lesions under the prosthetic valve implantation base; the reimplantation of the prosthesis on frail and abscessed tissue implies a substantial risk of disinsertion. The indications for systematic early reoperation in cases of severe acute heart failure are discussed." }, { "id": "pubmed23n0309_7603", "title": "[Pedicled aortic wall flap for the reconstruction of aortico-ventricular discontinuity--a case report].", "score": 0.013109617842272334, "content": "A 55-year-old man was operated on urgently for aortic valve endocarditis complicated by an annular abscess at the base of the non-coronary leaflet extending down to the left ventricle. Rapidly progressive heart failure and presence of a friable-appearing vegetation on echocardiography were the indications for urgent operation. Preoperative electrocardiogram showed first degree A-V block. At operation the aortic valve was generally thickened with mild calcification about the commissures. Non-coronary cusp was severely deformed and was nearly detached at its base due to annular abscess formation. Native valve was completely excised and the abscess was debrided. A club or a tongue-shaped pedicled aortic wall flap was prepared to the left of the oblique aortotomy incision with its free end to the distal side of the aorta. The flap was folded inward at its pedicle about 1 cm above the non-coronary annulus and was used to patch the abscess cavity. The aortic valve was replaced with a SJM 23 mm aortic valve prosthesis. The remaining defect of the aortic wall was repaired with a patch of woven-dacron vascular prosthesis. Post-operative hemodynamics of the patient was uneventful and he was given a 6-week course of parenteral antibiotics. He developed complete A-V block during the operation, and a permanent pacemaker was implanted on the 6th postoperative day. One year after operation he has not had recurrent infection and is leading a normal life. When used in the repair of ventriculo-aortic discontinuity created by infective endocarditis, the pedicled aortic wall flap has several advantages. It is easily obtainable and can cover abscesses of almost any shape and size. Unlike aortic root homograft, there is no problem of availability. Technically it is relatively simple to prepare a flap, bring it down through the non-coronary sinus and suture over the abscess. Aortic wall has just appropriate thickness and strength to reinforce the weakened periannular area, and if the debrided cavity is deep, the flap can be folded to obtain double thickness. By using this flap, potentially infected cavity is covered and packed by autologous tissue alone, and the synthetic patch to repair the aortic wall defect is placed well away from the site of possible contamination. In addition to the use in infective endocarditis, the aortic wall flap can predictably be used in the repair of aortic annular defect created by over-zealous removal of calcium in the surgery of calcific aortic stenosis, and in intracardiac patching in aortic annular enlargement operation such as Manouguian operation. To our knowledge, the use of pedicled aortic wall flap for aortic annular reconstruction has not been reported in the literature." }, { "id": "article-613_22", "title": "Bioprosthetic Stented Pericardial Porcine Aortic Valve Replacement -- Indications", "score": 0.011870255348516219, "content": "A full culture-driven course of antibiotics should be the first-line treatment until one of the following scenarios pushes the multidisciplinary team toward early surgical source control: deteriorating heart failure, highly virulent or resistant organisms, new heart block, annular abscess, relapsing infection, persistent bacteremia for five to seven days, presence of a prosthetic valve infection, infected defibrillator, pacemaker, or leads, recurrent emboli, persistent vegetations, or mobile vegetation >1.0 cm." }, { "id": "article-619_10", "title": "Aortic Valve Endocarditis Surgical Treatment -- Treatment / Management", "score": 0.011655592469545957, "content": "Infective endocarditis management is with prolonged duration of bactericidal antibiotics. The choice of antibiotic regimen (whether single or combination therapy) and the treatment duration are selected according to the pathogen’s susceptibility and resistance patterns, whether it’s a native or prosthetic valve endocarditis. Accordingly, the duration can vary from two weeks to as long as six weeks. Treatment is usually started in the hospital and completed as an outpatient once the fever subsides and the blood cultures are negative. But in some instances, antibiotic therapy alone is insufficient, and patients require surgery. Class I indications for surgery in patients with infective endocarditis include valvular dysfunction with symptoms of congestive heart failure, left-sided IE caused by S. aureus , fungal, or other highly resistant microorganisms, IE with conduction defects or heart block, annular or aortic abscess, persistent infection 5 to 7 days after initiation of antibiotic therapy. [2]" }, { "id": "InternalMed_Harrison_10314", "title": "InternalMed_Harrison", "score": 0.0111128300330033, "content": "Timing of Cardiac Surgery With the more life-threatening indications for surgery (valve dysfunction and severe CHF, paravalvular abscess, major prosthesis dehiscence), early surgery—i.e., during the initial week of therapy—is associated with a greater chance of survival than later surgery. With less compelling indications, surgery may reasonably be delayed to allow further treatment as well as improvement in overall health (Table 155-6). After 14 days of recommended antibiotic therapy, excised valves are culture-negative in 99% and 50% of patients with streptococcal and S. aureus endocarditis, 826 respectively. Recrudescent endocarditis on a new implanted prosthetic valve follows surgery for active NVE and PVE in 2% and 6–15% of patients, respectively. These frequencies do not justify the risk of an adverse outcome due to a delay in surgery, particularly in patients with severe heart failure, valve dysfunction, and uncontrolled staphylococcal infections. Delay is justified when" }, { "id": "pubmed23n0579_6416", "title": "Outcome of aortic homograft implantation in 24 cases of severe infective endocarditis.", "score": 0.011036992116434201, "content": "The objective of the study was to evaluate the results of treatment of severe aortic endocarditis with an aortic homograft (an aortic valve and root from a donor) in combination with antibiotic therapy. 24 patients with either aortic prosthetic valve endocarditis (n=16) or severe aortic native valve endocarditis (n=8) with destruction of 1 or more cusps, paravalvular abscess formation and/or cardiac fistulas caused by aggressive bacteria, underwent surgery in 1997-2006. Staphylococcal species were the most common pathogens followed by streptococci. Intravenous antibiotic therapy was started before surgery and continued for at least 4-6 weeks. Three patients with prosthetic valve endocarditis died within the first 24 h after surgery from heart failure. Two of these patients required an additional implantation of a mitral valve prosthesis. Five patients died from non-cardiac causes within 1-7 y of surgery. Within the follow-up period no patients had relapse of endocarditis, and only 1 episode of recurrent endocarditis in an intravenous drug abuser was registered. In conclusion, an aortic homograft in combination with intravenous antibiotics is an excellent option for treatment of severe aortic endocarditis." }, { "id": "wiki20220301en035_7528", "title": "Aortic valve replacement", "score": 0.010689188045042756, "content": "Hospital stay and recovery time After aortic valve replacement, the patient will usually stay in an intensive care unit for 12–36 hours. Unless complications arise, the patient is then able to go home after approximately four to seven days. Common complications include disturbances to the heart’s rhythm (heart block), which typically require the permanent insertion of a cardiac pacemaker. Recovery from aortic valve replacement takes about three months if the patient is in good health. Patients are advised not to lift anything heavier than 10 lbs for several weeks, and not to do any heavy lifting for 4–6 months after surgery to avoid damaging their breastbone. Often patients will be referred to participate in cardiopulmonary rehabilitation, which optimizes recovery and physical function in patients with recent cardiac surgeries. This can be done in an outpatient setting. Outcomes" }, { "id": "wiki20220301en035_7530", "title": "Aortic valve replacement", "score": 0.010665679430223538, "content": "The risk of dying as a result of aortic valve replacement is estimated at 1–3%. Combining aortic valve replacement with coronary artery bypass grafting increases the risk of mortality. Older patients, as well as those who are frail and/or have other health problems (comorbidities), have a higher risk of experiencing complications. Possible problems include cardiac infarction/failure, arrhythmia or heart block (typically requires the permanent insertion of a cardiac pacemaker), mediastinal bleeding, stroke and infection. Late complications include endocarditis, thromboembolic events (blood clots), prosthetic valve dysfunction and paravalvular leak (blood flowing between the edge of the prosthetic valve and the cardiac tissue). Patient–prosthesis mismatch" }, { "id": "pubmed23n0405_16091", "title": "Thrombosis and endocarditis in prosthetic heart valves, a case report.", "score": 0.009900990099009901, "content": "The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy." }, { "id": "pubmed23n0075_8813", "title": "[Prosthesis-endocarditis in the aortic position in a 22-year case load. Surgical versus conservative treatment].", "score": 0.009900990099009901, "content": "During the period 1965-1986, a total of 852 patients underwent isolated aortic valve replacement. With 4,875 patients-years at risk, 24 patients developed prosthetic valve endocarditis (PE; 0.49% per patient-year). The five, ten and fifteen year cumulative freedoms from PE were 98.2%, 95.4% and 93.0%, respectively. PE was unrelated to pre- or intraoperative data. No patients submitted to operation for acute/subacute bacterial endocarditis of the native aortic valve developed PE. Out of the 12 episodes of PE within two years of the operation, seven (58%) were caused by Staphylococcus albus compared with two out of 12 (17%; p less than 0.05) subsequent episodes of PE. Seven of the nine infections with Staphylococcus albus were caused by a highly resistant nosocomial variant. Ten of the PE patients underwent replacement of the prosthesis while 14 were treated conservatively. The two therapeutic groups were comparable, although the surgically treated patients tended to be younger and to have more impaired cardiac status. All surgically treated patients and all patients treated conservatively and in whom post mortem verification was possible had paravalvular defects, annular abscesses and/or vegetations on the prosthesis. The thirty-day, one year and ten year cumulative survivals were 80%, 80% and 50%, respectively, after replacement of the prosthesis and 64%, 21% and 7%, respectively, after conservative treatment (p = 0.02). A Cox regression analysis identified conservative treatment, infection with Escherichia coli or Haemophilus influenzae and the need to intensify digitalis/diuretic treatment for congestive heart failure as independent risk factors. It is concluded that replacement of the prosthesis early in the course of the disease should be considered as the treatment of choice." }, { "id": "pubmed23n0652_15638", "title": "Factors associated with cardiac conduction disorders and permanent pacemaker implantation after percutaneous aortic valve implantation with the CoreValve prosthesis.", "score": 0.00980392156862745, "content": "Cardiac conduction disorders and requirement for permanent pacemaker implantation (PPI) are not uncommon after surgical aortic valve replacement and have important clinical implications. We aimed to investigate the incidence of cardiac conduction disorders after percutaneous aortic valve implantation (PAVI) and to identify possible clinical factors associated with their development. We studied 34 patients (mean age 80 +/- 8 years, 18 male) who underwent PAVI with the CoreValve bioprosthesis (Corevalve Inc, Irvine, CA). Electrocardiographic evaluation was performed pre- and postprocedurally, and at 1-week and 1-month follow-up. Other clinical variables were obtained from the medical history, echocardiography, and angiography. After PAVI, 7 patients required PPI, all of whom developed total atrioventricular block within 3 days postprocedurally. A smaller left ventricular outflow tract diameter (20.3 +/- 0.5 vs 21.6 +/- 1.8 cm, P = .01), more left-sided heart axis (-20 degrees +/- 29 degrees vs 19 degrees +/- 36 degrees , P = .02), more mitral annular calcification (10 +/- 1 vs 5 +/- 4 mm, P = .008), and a smaller postimplantation indexed effective orifice area (0.86 +/- 0.20 vs 1.10 +/- 0.26 cm(2)/m(2), P = .04) were associated with PPI. The incidence of new left bundle-branch block (LBBB) was 65% and was associated with a deeper implantation of the prosthesis: 10.2 +/- 2.3 mm in the new-LBBB group versus 7.7 +/- 3.1 mm in the non-LBBB group (P = .02). Percutaneous aortic valve implantation with the CoreValve prosthesis results in a high incidence of total atrioventricular block requiring PPI and new-onset LBBB. Preexisting disturbance of cardiac conduction, a narrow left ventricular outflow tract, and the severity of mitral annular calcification predict the need for permanent pacing, whereas the only factor shown to be predictive for new-onset LBBB is the depth of prosthesis implantation." }, { "id": "pubmed23n0321_6185", "title": "[Right-heart endocarditis after pacemaker implantation as a cause of a round pulmonary infiltrate].", "score": 0.00980392156862745, "content": "A 57-year-old man developed intermittent fever and fatigue 11 months after a two-chamber cardiac pacemaker had been implanted because of 2 degrees and 3 degrees A-V block. Antituberculosis treatment was initiated as tuberculosis was suspected. The infiltrate regressed, but the other symptoms persisted. Four months later he was admitted as an emergency because of septicaemia. In addition to a recently discovered cardiac murmur there was a raised erythrocyte sedimentation rate (116 mm) and leucocytosis (13 600/microliters) with shift to the left. Coagulase-negative staphylococci were grown on several blood cultures. Transoesophageal echocardiography (TOE) demonstrated vegetation on the tricuspid valve, the pacing wires and the right ventricular outflow tract. After the diagnosis of infective endocarditis had been established, antibiotic treatment was give with imipenem, gentamycin and teicoplanin, the pacemaker system and adherent thrombotic material were removed and a DDD pacemaker implanted from the other side. The patient remained free of symptoms during a follow-up period of 12 months. Delayed diagnosis of infective endocarditis is not uncommon, because of the scarcity of typical symptoms. Repeated blood cultures and TOE are essential for the diagnosis." }, { "id": "pubmed23n0640_22039", "title": "[Results of surgical treatment of aortic root infection].", "score": 0.009708737864077669, "content": "To investigate preoperative status and results of surgery of patients with confirmed diagnosis of aortic root infection. We have analyzed data of 21 patients who were operated on at the Heart Surgery Center, Vilnius University, since January 1, 1997, till December 31, 2006. All these patients underwent surgery because of aortic root infection. The patients were aged 25-72 years (mean age, 53+/-14 years). There were 17 (80.9%) male patients. Sixteen patients (76%) preoperatively were in NYHA class IV. The abscesses of aortic root were confirmed preoperatively by means of esophageal echocardiography in 18 patients (86%). Blood cultures positive for Staphylococcus aureus were found in four patients (19.9%). All the patients underwent replacement of the aortic valve by mechanic prosthesis; one of these patients was reoperated because of persistent sepsis, and replacement of the aortic root with homograft was performed. The duration of follow-up of the patients was 1 to 10 years. Inhospital mortality rate was 14.3%. The causes of death included sustained heart failure and sepsis. All these patients were in NYHA functional class IV preoperatively; one of these patients had culture positive for Staphylococcus aureus. Inhospital survival was 85.7%, one-year postoperative survival - 80.9%, and both five-year and ten-year survivals were 76.0%. The long-term survival was negatively influenced by recurrent infective endocarditis, heart failure, and age. Death occurred in 1 patient (11.1%) of the 9 patients who at the time of surgery were younger than 50 years and 4 patients (33.3%) of the 12 who were older than 50 years at the time of operation. The infection of aortic root is not common pathology; however, it is a complicated disease. Esophageal echocardiography is an informative method while diagnosing aortic root abscesses. The inhospital mortality is increased by the heart failure persisting after the operation and sepsis. The long-term survival is decreased by preoperative infective endocarditis of the prosthesis and heart failure. The mortality rate of patients older than 50 years is 3-fold higher than mortality rate of younger ones." }, { "id": "pubmed23n0863_12114", "title": "Complete atrioventricular block after isolated aortic valve replacement.", "score": 0.009615384615384616, "content": "Temporary atrioventricular (AV) conduction disturbances are a common complication following cardiac surgery, especially involving the aortic valve. Permanent complete AV block is a serious and rare complication. Its prevalence has been estimated at 3-6% of all patients undergoing aortic valve replacement. Identification of factors that affect the occurrence of complete AV block requiring permanent pacemaker implantation might help reduce the risk of this problem in the future. To evaluate clinical, anatomical and surgical factors that might affect occurrence of complete AV, resulting in the need for permanent pacemaker implantation. In our prospective study, we analysed clinical data of consecutive 159 patients operated due to isolated aortic valve disease between February 2011 and March 2012. Patients with a pacemaker implanted before that time were excluded from the study. The main indication for surgery was aortic stenosis (n = 114, 71.7%). Infectious endocarditis was an indication in 6 (3.8%) cases. Mean patient age was 65.3 ± 11.4 years, and the proportion of males to females was 56.6%/43.4%. Overall, 135 (84.9%) patients had sinus rhythm preoperatively. All operations were performed using median sternotomy, cardiopulmonary bypass, and hypothermia at 30-32°C. A biological prosthesis was implanted in 120 (70.4%) patients. Patients who needed an additional procedure such as another valve surgery, aortic surgery or coronary artery bypass grafting were excluded from the study. Permanent pacemaker implantation was required in 11 (6.9%) patients. The pacemaker was implanted after at least 7 days of complete AV block which was then considered permanent. Univariate analysis showed that permanent pacemaker implantation was associated with prolonged cardiopulmonary bypass time, prolonged aortic cross-clamp time, and the occurrence of electrolyte disturbances. Univariate logistic regression revealed that the need for permanent pacemaker implantation depended on 5 factors including prolonged cardiopulmonary bypass time, prolonged aortic cross-clamp time, larger size of the implanted valve prosthesis, endocarditis as the indication for surgery, and electrolyte disturbances. In both backward and forward stepwise multivariate regression models, two parameters, prolonged aortic cross-clamp time and the presence of electrolyte disturbances, correlated with the occurrence of complete AV block. Permanent complete AV block is a serious complication after aortic valve surgery. Of all analysed clinical, anatomical and surgical factors, prolonged cardiopulmonary bypass time, prolonged aortic cross-clamp time, larger size of the implanted valve prosthesis, endocarditis as the indication for surgery, and electrolyte disturbances were found to be statistically significant predictors of permanent pacemaker implantation." }, { "id": "pubmed23n0087_13814", "title": "[Endocarditis with Ionescu-Shiley's bioprosthesis. Long-term results].", "score": 0.009615384615384616, "content": "With the aim to attesting the ability of treated pericardial tissue to resist infection we analyzed the incidence of prosthetic valve endocarditis in 541 operative survivors with the Ionescu-Shiley (I-S) valve since January 1977. A total of 580 valves were available for the study, 21 (3.8%) sustained I-S endocarditis or 0.65% patients/annum. The mean age was 53.2 years; male/female ratio was 16/5. Native endocarditis was present in 20 cases (3.6%). There were 13 aortic endocarditis (2 in cases of multiple replacement) and eight mitral. The interval between insertion and endocarditis ranged from 2 weeks to 108 months (means 31); 8 cases were early I-S endocarditis (38%) and 13 late endocarditis (62%). The organisms isolated were: Staphylococcus (epidermidis, aureus) in 10 cases. Streptococcus (viridans, fecalis) in 7 cases, gram negative in three and no organism was cultured in 3 cases. The outcome was as follows: specific medical treatment in 4 cases (one early), valve re-replacement in 11 (four early) from whom eight survived, and 6 patients died with unspecific medical treatment. The total mortality rate 9/21 (43%), in early endocarditis 5/8 (62.5%) and in late endocarditis 5/13 (38%). Operative and necropsy findings in 12/21 showed always periprosthetic abscess but no leaflet perforations. The rate of I-S valve endocarditis compares favourably with other valve substitutes. Early re-replacement combined with adequate antibiotic treatment is mandatory according to our experience." }, { "id": "wiki20220301en333_2588", "title": "Adventist HealthCare White Oak Medical Center", "score": 0.009523809523809525, "content": "CT imaging Angiography Emergent and routine abdominal aortic aneurysm (AAA) stent graft Carotid stenting Arterial embolization Full spectrum of cardiac surgery Bypass Surgery Beating Heart Surgery Aortic Valve Surgery Mitral Valve Surgery Tricuspid Valve Surgery Thoracic Aortic Procedures Atrial Fibrillation (Maze) Surgery Endoscopic Vein Harvesting Cardiac Tumor Registry Full spectrum of vascular surgery Comprehensive electrophysiology service Catheter ablation Pacemaker and defibrillator implants Monitored Cardiac Rehabilitation Cardiac and Vascular Research through the Center for Cardiac and Vascular Research (CCVR) Percutaneous coronary intervention (PCI) Primary PCI- an early life-saving medical procedure for heart attack patients" }, { "id": "pubmed23n1124_15051", "title": "Rapid Evolution of an Aortic Endocarditis.", "score": 0.009523809523809525, "content": "Cardiac surgery is necessary in almost 50% of patients with endocarditis. Early surgery, i.e., the surgery performed during the first hospitalization, is required in the following cases: heart failure secondary to valve regurgitation; <iS. aureus</i, fungal organism, or other highly resistant organism infection; heart block, annular or aortic abscess, or destructive penetrating lesions; evidence of persistent infection as manifested by persistent bacteremia or fevers lasting &gt;5 days after onset of appropriate antimicrobial therapy. A 62-year-old man developed a fever (38 °C) 3 days after a transaortic electrophysiological study; blood cultures were positive for <iS. aureus</i, and were sensitive to vancomycin and ceftaroline. Antibiotic therapy was started, controlling the fever and the patient's infective and inflammatory profiles well; however, 3 days later, acute aortic regurgitation developed. At transesophageal echocardiography (TEE), a rare condition was revealed-vegetation was attached to the aortic wall, impeding correct aortic valve closure. Cardiac operation was carried out and the time for surgery was discussed; based on the patient's clinically stable condition, and on the infection, which was controlled well by antibiotics therapy, surgery was not performed in emergency circumstance (within 24-48 h)-rather, it was programmed during the hospitalization. A TEE surveillance was initiated, and after 7 days, TEE revealed a new picture, with images of an aortic abscess with small perforation in the right atrium, requiring emergency surgery, carried out 20 h later. In our case, the rapid evolution of the vegetation attached to the aortic wall suggested the following: (1) that the time for the surgery cannot be guided only by clinical procedure but must also be guided by imaging pictures; (2) that strictly TEE surveillance is mandatory in patients with aortic endocarditis not initially referred for emergency surgery." }, { "id": "pubmed23n0891_12550", "title": "A novel solution to prosthetic valve dehiscence after aortic valve surgery in Behçet's disease.", "score": 0.009433962264150943, "content": "Prosthetic valve dehiscence after aortic valve surgery in Behçet's disease patients is common. We aimed to validate the usefulness of our new technique 'subannular endomyocardial implantation of valve prosthesis' designed to prevent prosthetic valve dehiscence. Subannular endomyocardial implantation of valve prosthesis involves suturing the sewing cuff of the valve prosthesis in the endomyocardium below the aortic annulus, which is based on the idea that annular tissue should be excluded from the suture line in Behçet's disease patients. Medical records of 7 patients in whom the new technique was performed between 2002 and 2014 were reviewed. Five men and two women were included (median age, 44 years). Aortic root replacement was performed in 6 cases, and aortic valve replacement in 1. No operative mortality occurred. Postoperatively, complete atrioventricular block developed in 3 cases, and permanent pacemakers were implanted in 2. No reoperation was performed for prosthetic valve dehiscence during the median 7.8-year follow-up. One late death occurred due to sudden cardiac arrest 8.4 years after surgery. One additional permanent pacemaker was implanted for complete atrioventricular block, which developed at 4.2 years postoperatively. The last echocardiography (median, 6.7 years after surgery) revealed no paravalvular leakages. Subannular endomyocardial implantation of valve prosthesis seems useful for preventing prosthetic valve dehiscence after aortic valve surgery for Behçet's disease. It poses a risk of complete atrioventricular block, but considering the high reoperation rate and mortality due to prosthetic valve dehiscence after conventional aortic valve surgery, this risk seems reasonable." }, { "id": "pubmed23n0282_9581", "title": "[Prosthetic valve endocarditis after double valve replacement].", "score": 0.009433962264150943, "content": "This is a report of a patient who underwent re-AVR due to prosthetic valve endocarditis after double valve replacement (MVR, AVR). A 54-year-old female was admitted to other hospital on April 14, 1990, because of high fever, progressive anemia, and cardiomegaly. The patient was hospitalized to our department urgently with the diagnosis of prosthetic valve endocarditis. Arterial blood culture grew methicillin-resistant Staphylococcus epidermidis. Echocardiography showed a vegetation at the disc of the mechanical valve in the mitral position, but we could not find any vegetation or thrombus there at the reoperation, and the aortic mechanical valve seemed to be intact. Signs of inflammation continued to be positive after reoperation. On the 33rd hospital day, a diastolic murmur was heard, and emergency cardiac catheterization was done. Detachment of the prosthetic aortic valve and rupture of the sinus of Valsalva due to mycotic aneurysm, and the dissection of the aorta had occurred. We performed re-AVR and replacement of the ascending aorta. The patient died of multiple organ failure following drug-induced hepatic failure. It is suggestive that we missed the prosthetic aortic valve endocarditis during the reoperation. Our thoughts and introspections on the echocardiographic diagnosis of the prosthetic valve endocarditis after double valve replacement were discussed." }, { "id": "pubmed23n0898_971", "title": "Low permanent pacemaker rates following Lotus device implantation for transcatheter aortic valve replacement due to modified implantation protocol.", "score": 0.009259259259259259, "content": "Conduction disturbances requiring permanent pacemaker implantation following transcatheter aortic valve replacement (TAVR) are a common problem. Pacemaker implantation rates after TAVR appear to be higher compared to conventional aortic valve replacement. The aim of this study was to analyze whether a high annulus implantation conveys the benefit of a decreased rate of permanent pacemaker implantation while being safe and successful according to Valve Academic Research Consortium 2 (VARC2)-criteria. A total of 23 patients with symptomatic severe aortic valve stenosis, an aortic annulus of 19-27 mm and at high risk for surgery were treated with the Lotus valve. In all patients the valve was implanted in a high annulus position via femoral access. The primary device performance endpoint was VARC2-defined device success after 30 days and the primary safety endpoint was the need for permanent pacemaker implantation. The mean age was 73.23 ± 7.65 years, 46% were female, 38% were New York Heart Association class III/IV at baseline. Thirty-day follow-up data were available for all patients. The VARC2-defined device success rate after 30 days was 22/23 (96%). 2/21 (10%) patients required a newly implanted pacemaker due to 3rd degree atrioventricular block. 25% of the patients developed a new left bundle branch block after valvuloplasty or device implantation. 21 of the 23 patients (96%) had no other signs of conduction disturbances after 30 days. The approach of the modified implantation technique of Lotus TAVR device was safe and effective. The incidence of need for a permanent pacemaker following TAVR could be significantly reduced due to adopted implantation protocol." }, { "id": "pubmed23n0719_13610", "title": "[Pacemaker infection developed one month after the surgery for prosthetic valve endocarditis].", "score": 0.009259259259259259, "content": "A 57-year-old man underwent mitral valve replacement and tricuspid annuloplasty for mitral and tricuspid regurgitation. Pacemaker implantation was conducted because of postoperative sick sinus syndrome 2 months after the operation. One year later, the patient was readmitted to the hospital because of high fever. Echocardiography showed 2 vegetations of 10 mm in diameter attached to the mitral mechanical valve. No vegetations were detected on the tricuspid valve or the pacemaker leads. Mitral valve re-replacement was urgently performed under the diagnosis of prosthetic valve endocarditis caused by Staphylococcus aureus. One month after the reoperation, pacemaker infection developed in spite of suitable infection control by daily intravenous injection of sensitive antibiotics. We proceeded to place a temporary pacing wire and extracted the entire permanent pacing system. A new permanent pacemaker was implanted 5 days later. The patient was discharged on the 62th postoperative day without recurrence of infection." }, { "id": "pubmed23n1102_6320", "title": "Conduction delays after transcatheter aortic valve implantation with balloon-expandable prosthesis and high implantation technique.", "score": 0.009174311926605505, "content": "Performing transcatheter aortic valve implantation with high implantation technique, i.e. with an aorto-ventricular ratio &gt; 60/40, reduces the need of permanent pacemaker implantation. Valve calcification and prosthesis oversizing are predictors of permanent pacemaker implantation, but there are no available data on their role when transcatheter aortic valve implantation is performed with an aorto-ventricular ratio &gt; 60/40. The aim of this study was to evaluate the effect of leaflets/annulus calcification and prosthesis oversizing on the incidence of permanent pacemaker implantation after transcatheter aortic valve implantation with a high implantation technique. Transcatheter aortic valve implantation was performed in 48 patients implanting a balloon-expandable transcatheter heart valve with an aorto-ventricular ratio &gt; 60/40. Calcium burden was assessed by preprocedural multidetector computed tomography. An invasive electrophysiological study was performed before and after transcatheter aortic valve implantation. Five patients (10.4%) needed permanent pacemaker implantation. At univariate analysis, baseline right bundle branch block and postprocedural PR, QRS and His-ventricular interval elongation significantly predicted permanent pacemaker implantation (p &lt; 0.05). Receiver-operating characteristic curve analysis showed a correlation between transcatheter heart valve oversizing and permanent pacemaker implantation need, with the best cut-off being 17% (AUC = 0.72, p = 0.033). Linear regression analysis demonstrated that QRS complex elongation was related to total, left and non-coronary leaflet calcification (p &lt; 0.05). This study demonstrates that, when transcatheter aortic valve implantation is performed using a balloon-expandable transcatheter heart valve deployed with an aorto-ventricular ratio &gt; 60/40, the presence of leaflets/annulus calcification or the need to oversize the prosthesis correlate with the occurrence of pathological cardiac conduction delays." }, { "id": "pubmed23n0033_523", "title": "Immediate and long-term results of emergency aortic valve replacement in acute bacterial endocarditis.", "score": 0.009174311926605505, "content": "A surgically treated material comprising 18 patinets with heart failure from aortic insufficiency during acute endocarditis has been reviewed. At the time of operation the mean duration of heart failure was 3 weeks and duration of endocarditis 9 weeks. Blood culture was positive in half of the patients, 39% had predisposing valve disease, 14 (78%) had a preoperative heart catheterization. The peroperatively measured regurgitation averaged 55%. All 18 patients had an artifical valve implanted, and the mean observation time for 13 long-term survivors was 3 1/3 years. There were 3 postoperative and 2 late deaths. A long-term survival rate of 73% strongly supports early surgical treatment in patients with aortic insufficiency and heart failure during acute endocarditis." }, { "id": "wiki20220301en216_27080", "title": "Cardiothoracic anesthesiology", "score": 0.00909090909090909, "content": "Cardiac surgical training Fellows are trained to provide perioperative anesthetic management for patients with severe cardiopulmonary pathology. Some of the cardiac surgeries they train for include the following: coronary artery bypass surgery (CABG) both on cardiopulmonary bypass as well as on a beating heart, heart valve surgery, aortic reconstruction requiring deep hypothermic arrest, mechanical ventricular assist device (VAD) placement, thoracic aortic aneurysm repair, aortic dissection repair, heart transplants, lung transplants, heart/lung transplants, and adult congenital heart surgery. Adequate exposure and experience provided in the management of adult patients for cardiac pacemaker and automatic implantable cardiac defibrillator placement, surgical treatment of cardiac arrhythmias, and the complete gamut of invasive cardiologic (catheter-based) and electrophysiological procedures is expected as well." }, { "id": "pubmed23n0061_22548", "title": "[Active infective endocarditis complicated by paravalvular abscess. Review of 40 cases].", "score": 0.00909090909090909, "content": "We have performed a retrospective analysis of the clinical, echocardiographic, surgical and necropsy data in 40 patients affected by infective endocarditis complicated by paravalvular abscess. The abscess developed on prosthetic valve in 13 cases, and on native valve in 27. Aortic valve was the most affected (85%). The clinical course was considered to be acute in 52% of the patients. Fever persisted despite of adequate antibiotic therapy in 57%. In 90%, overt heart failure were present. Staphylococcus were the most frequent causative microorganism (S. aureus, 22.5%; S. epidermidis, 20%). Bundle branch or atrioventricular block were detected in 18 patients (sensibility, 45%; specificity, 88%). Bidimensional echocardiography, along with Doppler techniques when necessary, detected an abscess in 81% of patients (sensibility, 80%; specificity, 84%). Thirty patients were operated. Eight of them (26%) died, two intraoperatively. Ten patients were not operated and nine died (90%). The difference was significant (p less than 0.001). Only age and surgical treatment were related to early survival. Over the follow-up of the operated patients, five presented prosthetic dehiscence, but only two required a new operation 3 months after the first intervention, and none died. In conclusion, the detection of a paravalvular abscess complicating an infective endocarditis is an indication for surgical treatment. Both surgical mortality and postoperative prosthetic dehiscence are acceptable. Bidimensional echocardiography is the most reliable tool for the diagnosis of this complication." }, { "id": "pubmed23n0681_6198", "title": "Changes in atrioventricular conduction and predictors of pacemaker need after percutaneous implantation of the CoreValve®. Aortic valve prosthesis.", "score": 0.009009009009009009, "content": "Although changes in atrioventricular conduction frequently occur after percutaneous implantation of an aortic valve prosthesis, little is known about the mechanisms involved or how these changes progress. We investigated ECG abnormalities and predictors of pacemaker need after percutaneous implantation of the CoreValve® aortic valve prosthesis. Between April 2008 and October 2009, 65 patients with symptomatic severe aortic stenosis received a CoreValve® prosthesis. Clinical and ECG parameters were recorded and predictors of pacemaker need due to advanced atrioventricular block were investigated. The analysis excluded three patients because they had pacemakers and a fourth who died during the procedure. The patients' mean age was 79 ± 7.8 years and their logistic EuroSCORE was 20 ± 14%. Implantation was successful in 98.4%. After implantation, 47.5% had left bundle branch block and 21 patients (34.4%) required a permanent pacemaker. The need for a pacemaker was associated with a greater depth of prosthesis implantation in the left ventricular outflow tract (LVOT): 13 ± 2.5 mm vs. 8.8 ± 2.8 mm (P&lt; .001). Moreover, depth was the only predictor: odds ratio 1.9, 95% confidence interval 1.19-3.05 (P&lt; .007). A cutpoint of 11.1 mm for the prosthesis depth in the LVOT had a sensitivity of 81% and a specificity of 84.6% for predicting the need for a pacemaker. After CoreValve® aortic valve prosthesis implantation, a high percentage of patients needed a permanent pacemaker for advanced atrioventricular block. The only independent predictor was the depth of the prosthesis in the LVOT, which could serve as an early indicator of pacemaker need." }, { "id": "pubmed23n0083_12110", "title": "[Infective endocarditis of a valve prosthesis. Multicenter study (179 cases)].", "score": 0.009009009009009009, "content": "Over a 5-year period (1982-1986) 176 cases of infective endocarditis on prosthesis (IEP) were recorded in 40 cardiology departments. 65 p. 100 of the patients were male, and the mean age of the population was 51 years. Mechanical prostheses were involved in 57 p. 100 of the cases and bioprosthesis in 43 p. 100. There was a high proportion of initial indications for bacterial endocarditis (18 p. 100) and for reoperation on prosthesis (10 p. 100). IEP developed early in 40 cases and late in 139 cases; 19 (48 p. 100) of the early IEPs were staphylococcal, while 31 p. 100 of late IEPs were streptococcal (p less than 0.01). 143 patients were reoperated upon within less than 1 month in 41 p. 100 of the cases, with a pre-operative antibiotic therapy of less than 10 days in 39 p. 100. Reoperation was performed in stage IV or as an emergency in 45 p. 100 of the cases. Abscesses were three times more frequent with aortic prostheses than with mitral prostheses (58 p. 100 vs 20 p. 100, p less than 0.001). Vegetations were more frequent on mechanical prostheses than on bioprostheses (43 p. 100 vs 31 p. 100, NS). The operative mortality rate was 25 p. 100; the mortality rate of unoperated patients was even higher (31 p. 100). The survival rate in operated IEP was 51 p. 100 at 30 months, as against 46 p. 100 at 12 months in unoperated IEP.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0910_17787", "title": "Conduction Abnormalities and Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement Using the Repositionable LOTUS Device: The United Kingdom Experience.", "score": 0.008928571428571428, "content": "The authors report the incidence of pacemaker implantation up to hospital discharge and the factors influencing pacing rate following implantation of the LOTUS bioprosthesis (Boston Scientific, Natick, Massachusetts) in the United Kingdom. Transcatheter aortic valve replacement (TAVR) is associated with a significant need for permanent pacemaker implantation. Pacing rates vary according to the device used. The REPRISE II (Repositionable Percutaneous Replacement of Stenotic Aortic Valve Through Implantation of Lotus Valve System) trial reported a pacing rate of 29% at 30 days after implantation of the LOTUS device. Data were collected retrospectively on 228 patients who had the LOTUS device implanted between March 2013 and February 2015 across 10 centers in the United Kingdom. Twenty-seven patients (12%) had pacemakers implanted pre-procedure and were excluded from the analysis. Patients were aged 81.2 ± 7.7 years; 50.7% were male. The mean pre-procedural QRS duration was 101.7 ± 20.4 ms. More than one-half of the cohort (n = 111, 55%) developed new left bundle branch block (LBBB) following the procedure. Permanent pacemakers were implanted in 64 patients (32%) with a median time to insertion of 3.0 ± 3.4 days. Chief indications for pacing were atrioventricular (AV) block (n = 46, 72%), or LBBB with 1st degree AV block (n = 11, 17%). Amongst those who received a pacemaker following TAVR the pre-procedural electrocardiogram findings included: No conduction disturbance (n = 41, 64%); 1st degree AV block (n = 10, 16%); right bundle branch block (n = 6, 9%) and LBBB (n = 5, 8%). LBBB (but not permanent pacemaker) occurred more frequently in patients who had balloon aortic valvuloplasty before TAVR (odds ratio [OR]: 1.25; p = 0.03). Pre-procedural conduction abnormality (composite of 1st degree AV block, hemiblock, right bundle branch block, LBBB) was independently associated with the need for permanent pacemaker (OR: 2.54; p = 0.048). The absence of aortic valve calcification was also associated with a higher pacing rate (OR: 0.55; p = 0.031). Multivariate regression analysis did not show an independent association between depth of implant, valve oversizing, balloon post-dilatation, and the need for pacing post-procedure. Following implantation of the repositionable LOTUS valve, 55% of patients developed LBBB and 32% of patients required a pacemaker during their index hospital admission. Patients with pre-procedural conduction disturbance and non-calcified aortic valves were more likely to need pacing. No other anatomic features were identified with increased pacing requirement with the LOTUS device." }, { "id": "pubmed23n0103_4597", "title": "[Endocarditis on cardiac pacemaker endocavitary electrodes. Apropos of 7 cases].", "score": 0.008928571428571428, "content": "The authors report 7 cases of endocarditis on cardiac pacing catheters observed out of a total of 2 950 primary implantations and 1 600 pacemaker replacements. This is a rare condition (0.15%) but carries a poor prognosis as it usually occurs in elderly patients and demands aggressive management. The presence of multiple pacing catheters and surgical contamination due to manipulation of the pulse generator (reimplantation, pacemaker replacement) are predisposing factors. The infecting organism in these cases was a staphylococcus. One case of metastatic infection was also observed (acinetobacter). Ablation of the septic endocarditic material under effective, prolonged, double antibiotherapy is essential. Recently implanted electrodes were withdrawn by simple traction in 2 cases. This manoeuvre was attempted initially in all cases but stopped when chest pain or runs of ventricular extrasystoles occurred. Open heart explantation of pacing electrodes adherent to the ventricular apex was performed in 5 patients. Cardiopulmonary bypass without cardiac standstill enabled dissection of the fibrous rings surrounding the catheter after purging the blood from the atrial and ventricular cavities. In one patient, associated tricuspid valve endocarditis was found and valvular replacement was performed with a bioprosthesis. Endocardial pacing was replaced by epicardial pacing in patients with permanent AV block. The prognosis of this condition is poor; there were 2 deaths in this series of 7 patients." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": true, "char_ranges": [ [ 25, 135 ] ], "word_ranges": [ [ 5, 24 ] ], "text": "An asymptomatic myoma of this size that does not deform the endometrial cavity is not a problem for pregnancy." } }

{ "1": "Laparoscopic myomectomy.", "2": "Laparotomic myomectomy.", "3": "Myoma embolization by arterial catheterization.", "4": "Treatment with Gn-Rh analogues for three months before attempting pregnancy.", "5": "Attempting pregnancy without any previous treatment." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0537_4575", "title": "Uterine artery embolization as a treatment option for uterine myomas.", "score": 0.01668520578420467, "content": "Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of \"contemporaneous cohorts,\" which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options. The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas." }, { "id": "pubmed23n0537_4576", "title": "Myomas and assisted reproductive technologies: when and how to act?", "score": 0.016151866151866152, "content": "The effect of myomas on reproductive outcome has been the subject of many studies; however, a definitive answer is still missing. Therefore, the authors have tried to outline some guidelines for the management of women who have uterine myomas and desire to conceive. The location and size of the myomas are the two parameters that influence the success of a future pregnancy. Subserosal myomas seem to have little, if any,effect on reproductive outcome, especially if they are up to 5 to 7 cm in diameter. Intramural myomas that do not encroach upon the endometrium also can be considered to be relatively harmless to reproduction, if they are smaller than 4 to 5 cm in diameter. This is the ambiguous gray zone of the subject, and where research should be focused before a consensus can be established. Myomas that compress the uterine cavity with an intramural portion (submucous myoma type II) and submucous myomas significantly reduce pregnancy rates, and should be removed before assisted reproductive techniques are used. Hysteroscopic myomectomy is the gold standard for the treatment of submucous myomas. For other myomas, abdominal myomectomy, or laparoscopic myomectomy--when the experience of the surgeon and the facilities are sufficient--are the best alternatives. In most of the literature, the pregnancy rates were increased and the miscarriage rates were decreased after surgery with these two techniques. Other alternative treatment modalities, such as CUV, laparoscopic myolysis, or MRI-guided focused ultrasound, are to be monitored and evaluated thoroughly before they are applied as routine procedures." }, { "id": "pubmed23n1102_20141", "title": "Myoma Expulsion after Uterine Artery Embolization.", "score": 0.014609094535301157, "content": "Uterine leiomyomas are the most common benign pelvic tumors in women over 35 years and can be symptomatic or asymptomatic. Among the main treatment strategies, there are hormone therapy, hysterectomy, myomectomy, and uterine artery embolization (UAE), a recent and promising treatment for patients who wish to avoid hysterectomy. Ideal candidates for UAE are women with symptomatic uterine leiomyomas that present no desire for pregnancy, premenopausal and heavy menstrual bleeding, or dysmenorrhea caused by intramural fibroids. <iCase Presentation</i. A 36-year-old female diagnosed with leiomyomas and an extensive history of failed previous treatments who, in order to preserve her uterus, underwent UAE and had tumor expulsion 15 days after the procedure. The patient remained eight months in amenorrhea and, currently, presents normal hormone levels and irregular periods. UAE presents itself as a minimally invasive procedure and as an efficient alternative for those patients who wish to preserve their uteri and also improve their symptoms and quality of life." }, { "id": "pubmed23n0497_19442", "title": "[Ability to conceive and the course of pregnancy in women after laparoscopic myomectomy].", "score": 0.014329113924050632, "content": "The aim of the study was to assess fertility of patients after myomectomy. The study included a group of 32 patients, aged 22-41, who underwent laparoscopic myomectomy. Primary infertility was diagnosed in 23 women (71.8%), whereas secondary infertility in 9 women (28.2%). Indications for surgery were rapid growth of myoma during last year and intramural myoma &gt; 3 cm in diameter. The incision of the uterus and removal of myomas was made with harmonic scalpel. The average diameter of the largest myoma was 5.6 cm (range 3-11 cm). The number of myomas observed during operation ranged from 1 to 6. No conversion to laparotomy was performed. The average operation time was 85 min (range 60-185 min). After the operation 13 patients became pregnant, which constitutes 40.6%. Pregnancy ended with birth at term in 9 patients (28.1%), spontaneous abortion occurred in 4 patients (12.5%). Three-dimensional ultrasonography was performed after miscarriage and normal uterine cavity was observed. No obstetric complications were diagnosed in women who conceived. The main conclusions of the study are: 1. Uterine myomas constitute one of the significant causes of infertility and myomectomy using laparoscopy increases the chance of pregnancy. 2. Laparoscopy seems to be a promising and feasible method of myomectomy in women at reproductive age." }, { "id": "wiki20220301en050_67857", "title": "Uterine myomectomy", "score": 0.01409470277635837, "content": "Myomectomy during pregnancy Leiomyomata tend to grow during pregnancy but only the large ones causing endometrial cavity distortion could interfere with the growing pregnancy directly. Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a caesarean section to gain access to the baby. References Gynecological surgery" }, { "id": "pubmed23n0756_6658", "title": "[Uterine artery embolization for myomas treatment].", "score": 0.013899613899613899, "content": "Myoma treatment by uterine artery embolisation (UAE) using non-spherical PVA particles or calibrated tris-acryl microspheres&gt;500μm is effective in more than 90 % of cases in the short-term. In the long-term, menorrhagia, bulk-related symptoms and pelvic pain are significantly improved or eliminated in 75 % of cases at 5 to 7 years. At 6 months, uterine volume reduction and larger myoma volume reduction varies between 30 to 60 % and 50 to 80 % respectively. During hospital stay the complication rate is very low, less than 3 % mostly urinary infection and pain. Secondary hysterectomy for complication is less than 2 % at 3 months. Definitive amenorrhea is reported in less than 5 % of cases in women of more than 45-year of age. No significant impact of embolization on hormonal function has been reported in women less than 45 years with normal baseline function. UAE is not indicated for submucous myomas. Randomized studies comparing embolization to hysterectomy demonstrate that reinterventions are more frequently performed after embolization. Secondary hysterectomy is performed in 13 to 24 % of cases at 2 years and in up to 28 % of cases at 5 years. Hospital stay, duration of recovery and time off work are shorter after embolization compared to hysterectomy. Embolization is cheaper than hysterectomy at 12 and 24 months even taking into consideration the additional costs of imaging and reinterventions. UAE is a good alternative treatment in women with unique myoma of less than 10cm and multiple myomas around 15cm. This treatment should be proposed to women each time possible. Randomized studies comparing embolization to myomectomy demonstrate that in the short and mid-term there is no difference in terms of control of menorrhagia and bulk-related symptoms. Uterine volume reduction and quality of life were not different at 6 months. Periprocedural and 30-day complication rates are not different. At 6 months, the rate of complications is higher after myomectomy. Reinterventions are more frequent after embolization compared to myomectomy. Hospital stay, duration of recovery and time off work are shorter after embolization compared to myomectomy. UAE is less aggressive than myomectomy and should be proposed as a conservative alternative treatment. Embolization should be considered with caution in pregnancy-seeking women since there is still a lack of good quality data available in the specific group of patients. FSH level is more frequently elevated after embolization compared to myomectomy. Pregnancy rate and term pregnancy rate are higher after myomectomy compared to embolization. Spontaneous abortion is more frequent after embolization than after myomectomy. At this time, UAE is not indicated excepted in studies or in specific cases when the woman want a pregnancy. Embolization performed before myomectomy (preoperative or combined procedures) can be discussed for an individual patient but there is not enough data to support its routine use. " }, { "id": "pubmed23n0623_15545", "title": "[Management of menometrorrhagia in women with and without pregnancy intention: hierarchy of therapies].", "score": 0.013623407109322602, "content": "The first line of treatment recommended for women with idiopathic menorrhagia is pharmaceutical agents, i.e. levonorgestrel intra-uterine device, tranexamic acid, estroprogestatif pills, oral progestin and non-sterodial anti-inflammatory drugs. The second line of treatment is surgical, using endometrial curettage for women who desire pregnancy in the future. On the other hand, in women who no longer intend to get pregnant either endometrial ablation or hysterectomy can be used. The menorrhagia associated with endometrial polyps is treated through the hysteroscopic polypectomy, which result can be improved by the use of the levonorgestrel intra-uterine device or the endometrial ablation. The menorrhagia related to submucosal myomas is managed by hysteroscopic myomectomy, either as a first line of treatment or following the failure of the pharmaceutical management. The first line of treatment of interstitial myomas is represented by the medical management, followed by laparoscopic or abdominal myomectomy for women who still want to be pregnant, and by myomectomy or uterine arteries embolization for women who no longer desire pregnancy. Hysterectomy is the most efficient treatment of menorrhagia due to interstitial myomas, and may be proposed either as a third line of treatment for the myomectomy and embolization failures or as a second line of treatment for women who do not wish to conserve their uterus. Finally, the treatment for women with clinically or radiologically suspected adenomyosis is medical, followed by hysterectomy for women who desire no pregnancy." }, { "id": "pubmed23n0502_11451", "title": "[Embolization of uterine fibroids and infertility: is a clinical trial conceivable?].", "score": 0.013082349081364828, "content": "Uterine artery embolization is a recent technique intended for treating uterine fibroids, as an alternative to hysterectomy. The possible side effects putting at stake the prognosis of fertility after embolization are considered as a brake to its use for the treatment of infertility associated with myoma. Secondary hysterectomy and permanent amenorrhea are the two main risks. But they are not so frequent and can be prevented. To date, the experience in the field of fertility and pregnancy after arterial embolization for fibroids is quite limited. However, first results are encouraging and not very different from those observed after surgical myomectomy. A therapeutic trial using arterial embolization for the management of fibroids within a context of infertility can be devised in the presence of submucosal or intramural myomas responsible for metromenorrhagia and with no major infertility factors associated. It is likely that uterine artery embolization should provide results equivalent or superior to those of surgical myomectomy in case of numerous and intramural fibroids with no prevailing myoma. Arterial embolization could be also interesting in case of recurrent myoma after laparotomic myomectomy." }, { "id": "Gynecology_Novak_2288", "title": "Gynecology_Novak", "score": 0.012527069798434116, "content": "New appearance of fibroids is not more common following laparoscopic myomectomy when compared with abdominal myomectomy. Eighty-one women randomized to either laparoscopic or abdominal myomectomy were followed with transvaginal sonography every 6 months for at least 40 months (160). Fibroids larger than 1 cm were detected in 27% of women following laparoscopic myomectomy compared to 23% in the abdominal myomectomy group, and no woman in either group required any further intervention. Uterine artery embolization (UAE) is an effective treatment for selected women with uterine fibroids. The effects of UAE on early ovarian failure, fertility and pregnancy are unclear." }, { "id": "Surgery_Schwartz_11889", "title": "Surgery_Schwartz", "score": 0.012098335269066977, "content": "of uterine myomas.Menorrhagia resulting from leiomyomas can be severe at times, requiring hospitalization or transfusion. Examination typically reveals an enlarged and irregular uterus. Diagnosis is usually made by transvaginal ultrasonography. Other diagnos-tic modalities, including MRI, computed tomography (CT), and hysterosalpingogram or saline-infused hysterosalpingography, are especially useful in the cases of submucosal and intrauterine myomas. Management options of leiomyomas are tailored to the individual patient depending on her age and desire for fertil-ity and the size, location, and symptoms of the myomas. Con-servative management options include oral contraceptive pills (OCPs), medroxyprogesterone acetate, GnRH agonists, uterine artery embolization, myomectomy, and hysterectomy.32-34 Uter-ine artery embolization is contraindicated in patients planning future pregnancy and may result in acute degeneration of myo-mas requiring hospitalization for pain control. Myomectomy is" }, { "id": "pubmed23n0623_15542", "title": "[Methods and efficacy of medical and surgical treatment of non functional menorrhagia].", "score": 0.011815661815661816, "content": "To assess the efficacy of therapies in menorrhagia related to atypical endometrial hyperplasia, polyps, myoma, adenomyosis and arteriovenous malformation of the uterus. Medline and Cochrane contents were searched to June 2008. Atypical endometrial hyperplasia is classically treated by hysterectomy, but may temporarily regress under hormone therapy (progestins, Gn-RH agonists) in women of childbearing age. Hysteroscopic resection is the standard treatment for endometrial polyps. Recurrence of bleeding is reduced by combining it with endometrial ablation. Myoma-related menorrhagia can be treated by Gn-RH agonists for 3 months or levonorgestrel in utero (LNG-IUS). Hysteroscopic resection is the standard treatment of submucous myomas. Interstitial myomas can be treated by myomectomy, myolysis, uterine artery embolisation or occlusion, or hysterectomy. Laparoscopic myomectomy and uterine artery embolisation are effective, well tolerated, and the best researched. LNG-IUS is effective and well tolerated to treat adenomyosis-related menorrhagia. The effect of other conservative treatments of the uterus (endometrial ablation, uterine artery embolisation or occlusion) is limited, especially in case of deep and extensive adenomyosis. Uterine artery embolisation is the standard treatment for arteriovenous malformation. Numerous medical and technical innovations have been recently developed as conservative treatments for menorrhagia. However, hysterectomy remains the standard treatment of atypical endometrial hyperplasia and adenomyosis." }, { "id": "Gynecology_Novak_2209", "title": "Gynecology_Novak", "score": 0.011532680246721608, "content": "An inability to evaluate the ovaries on pelvic examination is not an indication for surgery. Myomectomy should be considered as a safe alternative to hysterectomy, even for those women who have large uterine fibroids and wish to retain their uterus. Submucous fibroids, sometimes associated with increased menstrual bleeding or infertility, often can be removed hysteroscopically. Routine ultrasound follow-up is sensitive, but may detect many clinically insignificant fibroids. Uterine artery embolization (UAE) is an effective treatment for selected women with uterine fibroids. The effects of UAE on early ovarian failure, fertility, and pregnancy are unclear." }, { "id": "Gynecology_Novak_2333", "title": "Gynecology_Novak", "score": 0.011243386243386243, "content": "142. Darwish AM, Ahmad AM, Mohammad AM. Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Hum Reprod 2004;19:2391–2394. 143. Murakami T, Hayasaka S, Terada Y, et al. Predicting outcome of one-step total hysteroscopic resection of sessile submucous myoma. J Minim Invasive Gynecol 2008;15:74–77. 144. Indman PD. Hysteroscopic treatment of submucous myomas. Clin Obstet Gynecol 2006;49:811–820. 145. Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic fluid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc 2000;7:167–168. 146. Murakami T, Tamura M, Ozawa Y, et al. Safe techniques in surgery for hysteroscopic myomectomy. J Obstet Gynaecol Res 2005;31:216– 223. 147. Indman PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstet Gynecol 1993;81:716–720. 148." }, { "id": "wiki20220301en050_67853", "title": "Uterine myomectomy", "score": 0.010877684407096171, "content": "Laparoscopy Using the laparoscopic approach the uterus is visualized and its fibroids located and removed. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm." }, { "id": "Gynecology_Novak_2334", "title": "Gynecology_Novak", "score": 0.010645635979030626, "content": "147. Indman PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstet Gynecol 1993;81:716–720. 148. Mints M, Radestad A, Rylander E. Follow up of hysteroscopic surgery for menorrhagia. Acta Obstet Gynecol Scand 1998;77:435– 438. 149. Glasser MH, Zimmerman JD. The HydroThermAblator system for management of menorrhagia in women with submucous myomas: 12-to 20-month follow-up. J Am Assoc Gynecol Laparosc 2003;10: 521–527. 150. Sabbah R, Desaulniers G. Use of the NovaSure impedance controlled endometrial ablation system in patients with intracavitary disease: 12month follow-up results of a prospective, single-arm clinical study. J Minim Invasive Gynecol 2006;13:467–471. 151. Malone L. Myomectomy: recurrence after removal of solitary and multiple myomas. Obstet Gynecol 1969;34:200–203. 152. Parker WH. Uterine myomas: management. Fertil Steril 2007;88:255–271. 153." }, { "id": "wiki20220301en050_67851", "title": "Uterine myomectomy", "score": 0.01038288397308679, "content": "Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. Indications The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction. The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion. Treatment options for uterine fibroids include observation or medical therapy, such a GnRH agonist, hysterectomy, uterine artery embolization, and high-intensity focused ultrasound ablation." }, { "id": "Surgery_Schwartz_11890", "title": "Surgery_Schwartz", "score": 0.010321209258384506, "content": "Uter-ine artery embolization is contraindicated in patients planning future pregnancy and may result in acute degeneration of myo-mas requiring hospitalization for pain control. Myomectomy is indicated in patients with infertility thought secondary to fibroids and for those with symptomatic fibroids who wish to preserve their reproductive capacity. Hysterectomy is the only definitive therapy. Treatment with GnRH agonists for 3 months prior to surgery may be administered in anemic patients, and it may allow them time to normalize their hematocrit, avoiding transfusions; GnRH also decreases blood loss at hysterectomy and shrinks the myomas by an average of 30%. The latter may make the preferred vaginal surgical approach more feasible.Endometrial Hyperplasia. Endometrial hyperplasia is caused by chronic unopposed hyperestrogenic state (relative absence of progesterone) and is characterized by proliferation of endo-metrial glands resulting in increased gland-to-stroma ratio. It can be" }, { "id": "Gynecology_Novak_2243", "title": "Gynecology_Novak", "score": 0.010298850574712644, "content": "After an exhaustive review of the medical literature published between 1975 and 2000, with evaluation of 637 relevant articles and careful study of 200 articles, the authors found no satisfactory answers to fundamental question about fibroid treatments (83). Women and their physicians need information on which to base decisions regarding possible treatments. This section summarizes the literature regarding the management of fibroids. Treatment options include observation, medical therapy, hysteroscopic myomectomy, laparoscopic myomectomy, hysterectomy, uterine artery embolization, and focused ultrasound." }, { "id": "Gynecology_Novak_2058", "title": "Gynecology_Novak", "score": 0.010000683807439825, "content": "The surgical options range from a variety of techniques for endometrial ablation or resection to hysterectomy to a variety of conservative surgical techniques for management of uterine leiomyoma, including hysteroscopy with resection of submucous leiomyomas, laparoscopic techniques of myomectomy, uterine artery embolization, and magnetic resonance–guided focused ultrasonography ablation (see Chapters 23 and 24) (143,189). The choice of procedure depends on the cause of the bleeding, the patient’s preferences, the physician’s experience and skills, the availability of newer technologies, and a careful assessment of risks versus benefits based on the patient’s medical condition, concomitant gynecologic symptoms or conditions, and desire for future fertility. The assessment of the relative advantages, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research. Various techniques of endometrial ablation were compared with the gold" }, { "id": "Gynecology_Novak_2330", "title": "Gynecology_Novak", "score": 0.009974804840774855, "content": "128. Parker WH, Rodi IA. Patient selection for laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1994;2:23–26. 129. Jin C, Hu Y, Chen X, et al. Laparoscopic versus open myomectomya meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2009;145:14–21. 130. Malzoni M, Rotond M, Perone C, et al. Fertility after laparoscopic myomectomy of large uterine myomas: operative technique and preliminary results. Eur J Gynaecol Oncol 2003;24:79–82. 131. Andrei B, Crovini G, Rosi A. Uterine myomas: pelviscopic treatment. Clin Exp Obstet Gynecol 1999;26:44–46. 132. Koh C, Janik G. Laparoscopic myomectomy: the current status. Curr Opin Obstet Gynecol 2003;15:295–301. 133. Agarwala N, Liu CY. Safe entry techniques during laparoscopy: left upper quadrant entry using the ninth intercostal space–a review of 918 procedures. J Minim Invasive Gynecol 2005;12:55–61. 134." }, { "id": "pubmed23n1134_808", "title": "Critical Steps to Performing a Successful Single-site Laparoscopic Myomectomy for Large Pedunculated Myoma during Pregnancy.", "score": 0.009900990099009901, "content": "To demonstrate tips and tricks for the successful use of single-site laparoscopic surgery for pedunculated myomectomy during pregnancy. Stepwise demonstration with narrated video footage. An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0010 with a symptomatic 12-cm degenerating pedunculated myoma refractory to conservative pain management. Recent literature has indicated that most laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be used in cases unresponsive to conservative management [1]. However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy have been sparse [2]. Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single-site surgery without any complications [3-6]. Using laparoscopy in myomectomy compared with laparotomy during pregnancy permits decreased postoperative pain, quicker recovery, and lowered risk of postoperative complications [5,7,8]. Single-site laparoscopic surgery also aids in improved patient cosmesis and can be used for the myoma removal. Literature has demonstrated that single-site laparoscopy is safe and feasible during all stages of pregnancy [3,4]. Nevertheless, this approach may be challenging for inexperienced surgeons owing to the lack of triangulation and crowding of instruments in single-site laparoscopy [5]. At 21 weeks and 3 days pregnancy, our patient underwent single-incision laparoscopic surgery myomectomy. A 2.5-cm skin incision was made at the umbilicus to the abdominal cavity, and a GelPOINT Mini was inserted. Through the laparoscope, we can observe that a 12-cm pedunculated myoma was protruding from the right uterine fundus on a 4-cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the myoma. Subsequently, an Endo Catch bag was placed around the myoma and brought up to the umbilical incision. Using a scalpel, bag-contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50 cc and the total operative time was 123 minutes. The extended operating time was caused by slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and she was discharged home on postoperative day 2. At 38 weeks, she successfully delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single-site entry technique uses the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through a 2.5-cm incision, the surgeon placed a suture in the myoma stalk because other hemostasis agents such as vasopressin are contraindicated in pregnancy. 3. Owing to difficulties related to single-site surgery, the surgeon should possess extensive expertise in single-site surgery. 4. Manipulation of the uterus should be minimized to reduce the disturbance of the pregnant uterus. 5. V-loc suture allows for faster and simplified uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5-mm accessory port can be placed. 7. During tissue extraction, gentle traction should be used to reduce provoking the pregnant uterus. 8. When transecting the myoma stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus. Single-incision laparoscopic surgery myomectomy for pedunculated myoma may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon, the patient may benefit from faster specimen removal and recovery." }, { "id": "pubmed23n0416_15708", "title": "[Management of uterine myomas in women of fertile age].", "score": 0.009900990099009901, "content": "Review of current knowledge about uterine fibroids management in young women. Analysis of possible diagnostic and therapeutic algorithms regarding fertility preserving. Review article. Department of Obstetrics and Gynecology, 1st Faculty of Medicine and the General Faculty Hospital, Charles University, Prague. Analysis of the facts in literature (texts in medical journals, monographies, textbooks, internet database Medline and Ovid) and authors' clinical experience. Alternatives of treatment of infertility in women with uterine fibroids have significantly enlarged in past 10 years. However none of the indicated methods is perfect. Expectation does not exclude the risk of growth of fibroids and abortion. The effect of pharmacological therapy is only temporary. Myomectomy is associated with the risk of surgical complications, fibroids' recurrence and uterine rupture in subsequent gestation. Although uterine artery embolisation (on an average) halves the fibroids volume, the long-term effect of the method on female fertility is still unknown. Nevertheless it seems convenient to advise the active approach to all women planning pregnancy and having significant (submucous or intramural) fibroid even before spontaneous or assisted conception. Most recent studies indicate significant improvement of reproduction outcomes after myomectomy, especially in young women with the absence of other factors of infertility. Only the results of randomized, controlled trials (that are still awaited) will inform us about comparison of the effects and risks of myomectomy and uterine artery embolization in management of infertility." }, { "id": "pubmed23n0968_18287", "title": "Port site parasitic leiomyoma after laparoscopic myomectomy: a case report and review of the literature.", "score": 0.00980392156862745, "content": "Uterine fibroids are the commonest benign gynecological tumors. Laparoscopic myomectomy is becoming increasingly popular as one of the surgical treatment options for symptomatic cases. Large tissues such as leiomyomas or even the uterus need to be morcellated in order to be retrieved from the abdominal cavity. Some of the morcellated fragments or small fibroids may be accidentally left in the abdominal cavity during the retrieval process. These may subsequently become implanted in the abdominal cavity, develop blood supply from the surrounding structures, and grow to form parasitic myomas with varied clinical presentation, depending on the location and size. A 47-year-old African woman presented to our hospital 6 years after laparoscopic myomectomy with a lower abdominal mass. Her work-up revealed an anterior abdominal wall mass consistent with uterine leiomyoma. She was scheduled for excision of the mass, which was subsequently histologically confirmed to be a uterine fibroid. Parasitic leiomyomas are a rare late complication of power morcellation following laparoscopic myomectomy or hysterectomy. Most patients present with an abdominal/pelvic mass and may need surgical excision to relieve the symptoms. Care should be taken during power morcellation to prevent excessive fragmentation of the tissues, some of which may become implanted and persist to form parasitic myomas. Moreover, effort should be made to retrieve all myoma fragments by carefully checking the abdominal cavity. Whenever possible, the morcellation should be done in a containment bag." }, { "id": "pubmed23n0619_19880", "title": "[New options in the diagnosis and management of uterine myoma].", "score": 0.00980392156862745, "content": "Myoma accounts for nearly 95% of all benign tumors of female genital organs and is the most common neoplasm of female genital tract. Along with thorough history and gynecologic examination, ultrasound study is of utmost importance in the diagnosis of myoma; magnetic resonance (MR) study may also be required in rare cases. A number of therapeutic options are available for the management of myoma, ranging from medicamentous therapy through operative procedures (e.g., total or supracervical hysterectomy or myoma enucleation) and novel non-operative procedures (e.g., embolization of uterine artery (EUA) and magnetic resonance guided focused ultrasound (MRgFUS). Discomforts caused by a myoma are an absolute indication for treatment. Therapeutic option to be chosen is determined by the number, size and location of myomas, and the patient's preferences. Therapeutic choice should rely on the patient's decision for or against treatment, sparing the uterus. An individualized treatment protocol should be tailored for each patient." }, { "id": "pubmed23n0514_10241", "title": "[Efficacy of general magnetotherapy in conservative therapy of uterine myoma in women of reproductive age].", "score": 0.009708737864077669, "content": "Sixty women of the reproductive age with uterine myoma were divided into two groups. Thirty patients of the study group received combined therapy plus general magnetotherapy (GMT). Patients of the control group received only combined treatment. Ultrasound investigation registered a reduction in the size of myoma nodes by 16.7% in the study group, while in the controls myoma size did not change (p &lt; 0.05). 1-year follow-up data for the study group demonstrated no cases of the myoma growth while 16.6% of the controls showed growth of myoma nodes, in 6.6% of them supravaginal myoma amputation was made for rapidly growing myoma." }, { "id": "pubmed23n0831_366", "title": "The management of uterine fibroids in women with otherwise unexplained infertility.", "score": 0.009615384615384616, "content": "To provide recommendations regarding the best management of fibroids in couples who present with infertility. Usual and novel treatment options for fibroids will be reviewed with emphasis on their applicability in women who wish to conceive. Management of fibroids in women wishing to conceive first involves documentation of the presence of the fibroid and determination of likelihood of the fibroid impacting on the ability to conceive. Treatment of fibroids in this instance is primarily surgical, but must be weighed against the evidence of surgical management improving clinical outcomes, and risks specific to surgical management and approach. The outcomes of primary concern are the improvement in pregnancy rates and outcomes with management of fibroids in women with infertility. Published literature was retrieved through searches of PubMed, MEDLINE, the Cochrane Library in November 2013 using appropriate controlled vocabulary (e.g., leiomyoma, infertility, uterine artery embolization, fertilization in vitro) and key words (e.g., fibroid, myomectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English and French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to November 2013. Grey (unpublished literature) was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The quality of evidence in this document was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). These recommendations are expected to allow adequate management of women with fibroids and infertility, maximizing their chances of pregnancy by minimizing risks introduced by unnecessary myomectomies. Reducing complications and eliminating unnecessary interventions are also expected to decrease costs to the health care system. Summary Statements 1. Subserosal fibroids do not appear to have an impact on fertility; the effect of intramural fibroids remains unclear. If intramural fibroids do have an impact on fertility, it appears to be small and to be even less significant when the endometrium is not involved. (II-3) 2. Because current medical therapy for fibroids is associated with suppression of ovulation, reduction of estrogen production, or disruption of the target action of estrogen or progesterone at the receptor level, and it has the potential to interfere in endometrial development and implantation, there is no role for medical therapy as a stand-alone treatment for fibroids in the infertile population. (III) 3. Preoperative assessment of submucosal fibroids is essential to the decision on the best approach for treatment. (III) 4. There is little evidence on the use of Foley catheters, estrogen, or intrauterine devices for the prevention of intrauterine adhesions following hysteroscopic myomectomy. (II-3) 5. In the infertile population, cumulative pregnancy rates by the laparoscopic and the minilaparotomy approaches are similar, but the laparoscopic approach is associated with a quicker recovery, less postoperative pain, and less febrile morbidity. (II-2) 6. There are lower pregnancy rates, higher miscarriage rates, and more adverse pregnancy outcomes following uterine artery embolization than after myomectomy. (II-3) Studies also suggest that uterine artery embolization is associated with loss of ovarian reserve, especially in older patients. (III) Recommendations 1. In women with infertility, an effort should be made to adequately evaluate and classify fibroids, particularly those impinging on the endometrial cavity, using transvaginal ultrasound, hysteroscopy, hysterosonography, or magnetic resonance imaging. (III-A) 2. Preoperative assessment of submucosal fibroids should include, in addition to an assessment of fibroid size and location within the uterine cavity, evaluation of the degree of invasion of the cavity and thickness of residual myometrium to the serosa. A combination of hysteroscopy and transvaginal ultrasound or hysterosonography are the modalities of choice. (III-B) 3. Submucosal fibroids are managed hysteroscopically. The fibroid size should be &lt; 5 cm, although larger fibroids have been managed hysteroscopically, but repeat procedures are often necessary. (III-B) 4. A hysterosalpingogram is not an appropriate exam to evaluate and classify fibroids. (III-D)  5. In women with otherwise unexplained infertility, submucosal fibroids should be removed in order to improve conception and pregnancy rates. (II-2A) 6. Removal of subserosal fibroids is not recommended. (III-D) 7. There is fair evidence to recommend against myomectomy in women with intramural fibroids (hysteroscopically confirmed intact endometrium) and otherwise unexplained infertility, regardless of their size. (II-2D) If the patient has no other options, the benefits of myomectomy should be weighed against the risks, and management of intramural fibroids should be individualized. (III-C) 8. If fibroids are removed abdominally, efforts should be made to use an anterior uterine incision to minimize the formation of postoperative adhesions. (II-2A) 9. Widespread use of the laparoscopic approach to myomectomy may be limited by the technical difficulty of this procedure. Patient selection should be individualized based on the number, size, and location of uterine fibroids and the skill of the surgeon. (III-A) 10. Women, fertile or infertile, seeking future pregnancy should not generally be offered uterine artery embolization as a treatment option for uterine fibroids. (II-3E)." }, { "id": "pubmed23n0324_11880", "title": "[Surgical treatment of uterine myoma: need for surgery and long-term results].", "score": 0.009615384615384616, "content": "We analysed the indications to myomectomy in females in reproductive age and estimated efficasy of this treatment. 112 patients aged 23-45 were analysed. Most common indication to this procedure were: menorrhagia--45.54%, myoma found at gynecological examination--21.43%, adnexal mass--20.54% and pelvic pain--15.18%. 54.46% patients were parous, 34.82% nulligravid and 10.72% had a history of spontaneous abortion. There was low percentage of intraoperation complications--2.67%, as well as postoperation complications--3.57%. More than 5 years follow-up revealed recurrent myoma in 14.28% females and in 6.25% hysterectomy was performed. Cervical polypus was found in 8.04%, endometrial hyperplasia in 2.68%. 18.75% patients had menorrhagia and 5.36% abdominal pain. Successful pregnancies have occurred in 42.11% infertile women prior to surgery but with patent fallopian tubes. Our study shows that myomectomy is safe and well accepted method of treatment for uterine myomas however always stands a risk of recurrents." }, { "id": "Surgery_Schwartz_12061", "title": "Surgery_Schwartz", "score": 0.009544027401170259, "content": "GY, Jung SE, Choi KH. Dif-fuse and focal adenomyosis: MR imaging findings. Radio-graphics. 1999;19:S161-S170. 32. Filicori M, Hall DA, Loughlin JS, Rivier J, Vale W, Crowley WF, Jr. A conservative approach to the management of uter-ine leiomyoma: pituitary desensitization by a luteinizing hormone-releasing hormone analogue. Am J Obstet Gynecol. 1983;147:726-727. 33. Matsuo H, Maruo T. GnRH analogues in the manage-ment of uterine leiomyoma (in Japanese). Nippon Rinsho. 2006;64(suppl 4):75-79.Brunicardi_Ch41_p1783-p1826.indd 182218/02/19 4:35 PM 1823GYNECOLOGYCHAPTER 41 34. Szabo E, Nagy E, Morvay Z, Palko A, Csernay L. Uterine artery embolization for the conservative management of leio-myoma (in Hungarian). Orv Hetil. 2001;142:675-680. 35. Mutter GL. Diagnosis of premalignant endometrial disease. J Clin Pathol. 2002;55:326-331. 36. Kurman RJ, Kaminski PF, Norris HJ. The behavior of endome-trial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer." }, { "id": "pubmed23n0823_15040", "title": "The management of uterine leiomyomas.", "score": 0.009523809523809525, "content": "The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities. The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider. Implementation of this guideline should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits. Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2013, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron defficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities. The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3) 2. The presence of uterine fibroids can lead to a variety of clinical challenges. (III) 3. Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III) 4. Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2) 5. Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2) 6. Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I) 7. Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III) 8. Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2) 9. Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3) 10. Newer focused energy delivery methods are promising but lack long-term data. (III) Recommendations 1. Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D) 2. Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B) 3. In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A) 4. Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A) 5. Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A) 6. When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B) 7. Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A) 8. Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A) 9. Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A) 10. In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B)." }, { "id": "pubmed23n0527_7153", "title": "[Embolization of uterine arteries during myoma treatment from the patient's point of view].", "score": 0.009523809523809525, "content": "To acquire information about the patient's follow-up evaluation of treating fibroids by uterine artery embolization (UAE). A retrospective multicenter clinical trial. Department of Obstetrics and Gynaecology, 1st Faculty of Medicine and the General Faculty Hospital, Charles University, Prague. 45 women who underwent the UAE due to uterine fibroids from 1999 to 2003 were asked to complete a questionnaire. The questionnaire included 26 questions asking how the women had been informed and what they had expected. Further questions were focused on the course of embolization itself, early post-procedural difficulties (post-embolization syndrome) and patient's overall evaluation of treatment in a longer term. Those women who had completed the questionnaire and had been ready to co-operate were thereafter examined and included in the follow-up monitoring and, if necessary, further treatment was recommended. Thirty one out of 45 patients from 26 to 48 years of age, who had been addressed (68.9%) answered the questionnaire. UAE was indicated 12 times (38.7%) on account of symptoms, 10 times (32.3%) because of sterility, 5 times (16.1%) as a preventive measure within the framework of family planning and 4 times (12.9%) for an asymptomatic but growing leiomyoma. Twenty seven (87.1%) women were also offered an alternative treatment, which they refused. As far as problems are concerned, 18 (58%) women described the course of treatment as corresponding with what they had expected, 5 times it was less painful, and 8 times it was worse than expected. The long-term results were considered as positive by 87.1% of responders, only 12.9% considered the treatment as failure. 5 in 11 women planning pregnancy became pregnant, 3 of them gave birth in term and 2 miscarried in the 1st trimester. From the point of view of the patients, the evaluated method proves highly successful, it is well tolerated and it involves a low risk of complications. It is not possible, at this point, however, to give an unequivocal answer to the question whether the method should also be routinely offered to women who are planning pregnancy." }, { "id": "article-30893_61", "title": "Uterine Fibroid Embolization -- Clinical Significance -- Trials and Guidelines for Treatment of Fibroids", "score": 0.009492461244425567, "content": "In one study, patients having intramural fibroids larger than 4 cm were randomized to UAE (n = 58) or to myomectomy (open or laparoscopic according to surgeon preference; n = 63) and followed for two years. This is the primary study used as the rationale for making myomectomy the first-line invasive therapy in women who still wish to conceive, as 50% of UAE versus 78% of myomectomy patients were able to conceive.  UAE in this study had an increased calculated relative risk compared to myomectomy for (1) inability to conceive and (2) miscarriage (95% CI of [1] 1.11 to 4.44 and of [2] 1.25 to 6.22).  However, Gupta (2014), included Mara's patients with others having undergone myomectomy in RCTs and deemed the evidence that myomectomy provides a fertility benefit over UAE to be \"low-quality evidence\" that \"should be regarded with extreme caution.\"  Another systematic review on myomectomy concluded that there is currently insufficient evidence that myomectomy improves fertility compared to UAE whether by the laparoscopic or open approach. [22]" }, { "id": "Gynecology_Novak_3938", "title": "Gynecology_Novak", "score": 0.009483998561668464, "content": "Proper patient selection for myomectomy, regardless of route, is extremely important, particularly because, by age 50, the prevalence of leiomyomas may be as high as 70% in whites and 80% in women of African ancestry (44). It is relatively easy to mistakenly ascribe symptoms to the presence of leiomyomas. Unless the myoma involves the endometrial cavity, it is unlikely to contribute to heavy menstrual bleeding or infertility; the impact of intramural myomas on infertility is not well understood (45). Leiomyomas that cause pressure are often large and may be located near vital vascular structures that may preclude the laparoscopic approach even in expert hands. Many women will do well with expectant or medical management or with procedural alternatives such as uterine artery embolization. The surgeon should freely select a laparotomic approach, either at the outset or during the procedure, if technical limitations put the patient at risk or otherwise compromise the potential relevant" } ] } } }

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{ "1": "Switch to major opioids.", "2": "Extra doses of opioids should be administered as necessary.", "3": "Corticoids should be added.", "4": "Switch to a major opioid and maintain NSAIDs.", "5": "The patient should be admitted for intravenous treatment with major opioid." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0881_4562", "title": "[Breast Cancer Patient with Bone Metastases Who Was Able to Return Home without Using Opioids after Administration of Strontium-89 Chloride].", "score": 0.01702158481819499, "content": "A 46-year-old woman underwent mastectomy for right inflammatory breast cancer.Three years later, she was diagnosed with multiple bone metastases and was treated with systemic chemotherapy and zoledronic acid.Six years after the mastectomy, she complained of severe sacral pain, and 40 Gy external radiotherapy was applied to the sacral metastases.Oxycodone was also administered, but dose escalation was difficult because of severe nausea and fatigue.A bone scan showed increased uptake of Tc99m in an area consistent with the painful regions, and an injection of 89SrCl2 was administered.Five weeks after the injection, her severe pain was relieved and she was able to discontinue the use of opioids completely.She successfully lived at home for 100 days without using opioids.In this case, radionuclide therapy with 89SrCl2 led to remarkable pain relief with an improvement in the quality of life of the patient. " }, { "id": "wiki20220301en522_29798", "title": "Opioid rotation", "score": 0.014498757249378625, "content": "Opioid rotation or opioid switching is the process of changing one opioid to another to improve pain control or reduce unwanted side effects. This technique was introduced in the 1990s to help manage severe chronic pain and improve the opioid response in cancer patients. In order to obtain adequate levels of pain relief, patients requiring chronic opioid therapy may require an increase in the original prescribed dose for a number of reasons, including increased pain or a worsening disease state. Over the course of long term treatment, an increase in dosage cannot be continued indefinitely as unwanted side effects of treatment often become intolerable once a certain dose is reached, even though the pain may still not be properly managed. One strategy used to address this is to switch the patient between different opioid drugs over time, usually every few months. Opioid rotation requires strict monitoring in patients with ongoing levels of high opioid doses for extended periods of time," }, { "id": "pubmed23n0730_3779", "title": "Cancer Pain Management and Bone Metastases: An Update for the Clinician.", "score": 0.012935729847494554, "content": "Breast cancer patients with bone metastases often suffer from cancer pain. In general, cancer pain treatment is far from being optimal for many patients. To date, morphine remains the gold standard as first-line therapy, but other pure μ agonists such as hydromorphone, fentanyl, or oxycodone can be considered. Transdermal opioids are an important option if the oral route is impossible. Due to its complex pharmacology, methadone should be restricted to patients with difficult pain syndromes. The availability of a fixed combination of oxycodone and naloxone is a promising development for the reduction of opioid induced constipation. Especially bone metastases often result in breakthrough pain episodes. Thus, the provision of an on-demand opioid (e.g., immediate-release morphine or rapid-onset fentanyl) in addition to the baseline (regular) opioid therapy (e.g., sustained-release morphine tablets) is mandatory. Recently, rapid onset fentanyls (buccal or nasal) have been strongly recommended for breakthrough cancer pain due to their fast onset and their shorter duration of action. If available, metamizole is an alternative non-steroid-anti-inflammatory-drug. The indication for bisphosphonates should always be checked early in the disease. In advanced cancer stages, glucocorticoids are an important treatment option. If bone metastases lead to neuropathic pain, coanalgetics (e.g., pregabalin) should be initiated. In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management. In diffuse bone pain radionuclids (such as samarium) can be beneficial. Invasive measures (e.g., neuroaxial blockage) are rarely necessary but are an important option if patients with cancer pain syndromes are refractory to pharmacologic management and radiotherapy as described above. Clinical guidelines agree that cancer pain management in incurable cancer is best provided as part of a multiprofessional palliative care approach and all other domains of suffering (psychosocial, spiritual, and existential) need to be carefully addressed («total pain»)." }, { "id": "wiki20220301en269_37542", "title": "Metastatic breast cancer", "score": 0.012800097991180794, "content": "Liver metastases. Typically, pain from liver metastases responds to chemotherapy and analgesia. However, in cases when chemotherapy is contraindicated or the liver metastases are refractory to chemotherapy (and pain medication fails to provide appropriate palliation of liver metastasis-related pain, radiotherapy should be considered; it may relieve pain and shrink the metastases, and perhaps extend survival in a subset of patients with a good response to radiotherapy. Brain metastases. Brain metastases occur in up to 10–15% of breast-cancer patients, and often (but not always) occur late in the disease. They require urgent treatment; brain metastases may progress rapidly, and can suddenly produce life-threatening complications such as increased intracranial pressure, herniation of the brain, and seizures. Radiotherapy is essential in the treatment of brain metastases from breast cancer, as it halts tumor progression quickly and can induce a response in the majority of patients." }, { "id": "pubmed23n0793_10115", "title": "Nonopioid drugs in the treatment of cancer pain.", "score": 0.012066744178738648, "content": "The WHO analgesic ladder for the treatment of cancer pain provides a three-step sequential approach for analgesic administration based on pain severity that has global applicability. Nonopioids were recommended for mild pain, with the addition of mild opioids for moderate pain and strong opioids for severe pain. Here, we review the evidence for the use of nonopioid analgesic agents in patients with cancer and describe the mode of action of the main drug classes. Evidence supports the use of anti-inflammatory drugs such as acetaminophen/paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) for mild cancer pain. Adding an NSAID to an opioid for stronger cancer pain is efficacious, but the risk of long-term adverse effects has not been quantified. There is limited evidence to support using acetaminophen with stronger opioids. Corticosteroids have a specific role in spinal cord compression and brain metastases, where improved analgesia is a secondary benefit. There is limited evidence for adding corticosteroids to stronger opioids when pain control is the primary objective. Systematic reviews suggest a role for antidepressant and anticonvulsant medications for neuropathic pain, but there are methodologic issues with the available studies. Bisphosphonates improve pain in patients with bony metastases in some tumor types. Denosumab may delay worsening of pain compared with bisphosphonates. Larger studies of longer duration are required to address outstanding questions concerning the use of nonopioid analgesia for stronger cancer pain." }, { "id": "pubmed23n1062_4526", "title": "Management of cancer pain with analgetic adjuvant and weak opioid in prostate cancer bone metastases: A case series.", "score": 0.012066365007541477, "content": "In cancer patients, cancer pain is the most common cancer complication. About 60-90% of patients with advanced stage cancer experience various levels of pain, and about 30% of patients have been suffering from persistent severe pain. Bones are the most frequent targets of metastases in patients with cancer such as breast, prostate, lung, kidney, and thyroid. In advanced prostate cancer, bone metastasis leads to bone pain, skeletal fracture, and increased mortality. At least 75% of patients with bone metastasis experience bone pain. We report three cases of cancer pain, treated with primary cancer from the prostate metastasis to the spine. All three patients had lower back pain that radiated to the left and right limbs, with mixed pain and bone pain, where early hospital admission shows the Numeric Rating Scale (NRS) pain scale 9-10. Treated with administration of adjuvant therapy (Gabapentin) and weak opioids (injections of Tramadol) as well as injections of Metylprednisolone (for 3 days), the patient's pain scale was evaluated, and the average NRS obtained on days 2-4 was 5-6. On day 5-8, treatment continued with Gabapentin and Tramadol injections, and the pain scale (NRS) decreased to 2-3. All patients on the 8-9<supth</sup day of treatment also received Biphosphonates to reduce pain, bone damage, fracture risk, and blood calcium levels. Patients can be discharged with an oral Gabapentin prescription only. A pain scale (NRS) reduction of &gt;50% is obtained from the initial pain scale in cancer pain patients treated using a combination of adjuvant therapy and weak opioids." }, { "id": "pubmed23n0490_14353", "title": "[Bisphosphonate as an adjuvant therapy for the pain of bone metastases, 3 cases].", "score": 0.011394765984729265, "content": "Pain from bone metastases limits mobility and may cause pathological fractures that can seriously impair the patient's quality of life. Conservative treatments such as orthopedic fixation, radiotherapy, and opioids sometimes fail to give satisfactory pain relief. Bisphosphonates have been reported to reduce the severity of pain from bone metastasis due to breast cancer, prostate cancer, and multiple myeloma. Recent clinical reports demonstrated the effectiveness of bisphosphonates in reducing pain from bone metastases in various malignancies. This study presents 3 cases of refractory pain from bone metastases due to thyroid, colorectal and hepatocellular carcinoma. Primary treatment included orthopedic fixation, radiotherapy, and/or parenteral opioids that failed to reduce bone pain. Bisphosphonate therapy was considered at the start of pain control treatment using opioids. All 3 cases showed gradual reduction in pain after i.v. pamidronate administration and allowed physicians to control further pain with opioids. In 1 case, the patient was successfully withdrawn from opioids. The role of bisphosphonates in painful bone metastases remains unclear. However, recent encouraging reports have indicated that bisphosphonate may become one of the adjuvant treatments available to control refractory bone pain from various malignancies." }, { "id": "wiki20220301en354_20184", "title": "Cancer pain", "score": 0.011193237330614673, "content": "The WHO guidelines recommend prompt oral administration of drugs when pain occurs, starting, if the person is not in severe pain, with non-opioid drugs such as paracetamol, dipyrone, non-steroidal anti-inflammatory drugs or COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, mild opioids such as codeine, dextropropoxyphene, dihydrocodeine or tramadol are added to the existing non-opioid regime. If this is or becomes insufficient, mild opioids are replaced by stronger opioids such as morphine, while continuing the non-opioid therapy, escalating opioid dose until the person is painless or the maximum possible relief without intolerable side effects has been achieved. If the initial presentation is severe cancer pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic. However, a 2017 Cochrane Review found that there is no" }, { "id": "pubmed23n0597_2545", "title": "[Not Available].", "score": 0.010928508189464364, "content": "Oral medication is the simplest way in treatment of chronic pain. For cancer pain oral analgesics are efficacious in more than 90% of the patients. When a causal therapy of pain (e.g. chemotherapy, operation) fails an analgesic ladder with oral analgesics is instituted. This ladder starts with a non-narcotic analgesic in a sufficient dose. The regular dose of acetylsalicylic acid or paracetamol is 4 g daily. When this dose does not work sufficiently, a weak opioid (e.g. dihydrocodeine) is given concomitantly at an individual dose. When the weak opioid fails, strong opioids are given (e.g. morphine). The drugs should be given by mouth whenever possible. The most important point is the regular application according to a time-schedule. This time-schedule is related to the action time of the drug. Patients with severe vomiting or dysphagia can receive a continuous subcutaneous infusion. These measures are based on recommendations of the WHO.The same medications can be employed in patients with chronic non-malignant pain, provided that all other conventional measures in pain treatment fail. However, many states of pain are not opioid-responsive. Pain related to the sympathetic nervous system is more responsive to antidepressants than to opioids or NSAID. Neuropathic pain as in trigeminal neuralgia responds to anticonvulsants. Pain from muscle spasm is better controlled by muscle relaxants than by analgesics. Bone pain is more sensitive to NSAID than to any other drug.In any state of pain the response to the different groups of drugs should be evaluated first. Then a stepwise pharmacological approach should be performed. In most cases pain can be treated effectively by oral drugs." }, { "id": "pubmed23n0824_24227", "title": "[A case of stage IV breast cancer with improved cancer pain using bevacizumab and paclitaxel].", "score": 0.010858050847457626, "content": "A 65-year-old woman with a right breast tumor and right arm pain was seen in our hospital. She was diagnosed with scirrhous carcinoma (Stage IV, hormone receptor-positive, and HER2-negative) with pleural effusion and metastasis to the lung, liver, bone, and multiple lymph nodes. Systemic chemotherapy with biweekly bevacizumab and weekly paclitaxel was administered, and an opioid (oxycodone 40 mg/day) was administered for pain control. At the end of the first course, the patient's pain was improved, and the opioid dose was reduced (oxycodone 20 mg/day). The patient had a partial response (PR) over 24 treatment courses (1 year 10 months), and good pain control was obtained. Bevacizumab and paclitaxel therapy successfully brought about a rapid and good response and improved the patient's quality of life as palliative chemo- therapy." }, { "id": "wiki20220301en221_10420", "title": "Pain ladder", "score": 0.009900990099009901, "content": "The WHO guidelines recommend prompt oral administration of drugs (\"by the mouth\") when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as paracetamol (acetaminophen) or aspirin, with or without \"adjuvants\" such as non-steroidal anti-inflammatory drugs (NSAIDs) including COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weak opioid such as codeine, dihydrocodeine or tramadol is added to the existing non-opioid regime. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such as morphine, diamorphine, fentanyl, buprenorphine, oxymorphone, oxycodone, or hydromorphone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be" }, { "id": "pubmed23n0046_5619", "title": "[Therapy for symptomatic pain in advanced breast cancer].", "score": 0.009900990099009901, "content": "From 1983-1989, 106 patients with breast cancer were treated in our pain management unit on 6767 treatment days. Pain was caused by bone metastasis in 73% of patients. Neuropathic pain was reported by 32% of the patients. In all but four of these patients, new tumour growth was diagnosed. Patients were treated according to WHO analgesic guidelines with non-opioids on 16% of the days, non-opioids in combination with weak opioids on 36% and with strong opioids on 38% (orally 90%, parenterally 4% of the days). Due to the prevalence of bone pain non-steroidal antiinflammatory drugs were given on 56% of the days. The high incidence of neuropathic pain led to frequent use of co-analgesics (antidepressants 17%, anticonvulsants 12%, steroids 12% of the days). Adjuvant therapy for symptoms other than pain was given on 86% of the days. Whilst 92% of patients reported more than moderate pain on admission, 45% obtained complete pain relief beginning from the first days of treatment. On 92% of the days, patients described their pain as moderate or less. Side effects were treated symptomatically and played a minor role in a reason to change therapy." }, { "id": "pubmed23n0398_15341", "title": "[Postoperative morphine excess or rational therapy? An exceptional case of applying the morphine equivalent].", "score": 0.00980392156862745, "content": "We report on a 51-year-old female with a 7 year history of breast cancer. In August 2000 surgical replacement of the 8th thoracic vertebra was performed. From November 2000 the patient developed progressive pain, due to additional spine metastases, leading to pain therapy (according to the patient record) as follows: MST 320 mg oral 4 times daily, Durogesic 100 micrograms/h transdermal, Sevredol 40 mg oral 3 times daily and Ibuprofen 800 mg oral 3 times daily. Due to the risk of spinal instability and persisting pain a thoracic spondylodesis from Th 4-L2 was performed. Parallel to arrival in the PACU the patient developed extremely intensive pain. Pain control was achieved by fractional injection of overall 660 mg morphine in the first 120 min. After interviewing the patient, opioid consumption surprisingly turned out to be 60% higher than presumed. Pain therapy was continued by infusion and PCA with morphine in a daily intravenous dosage of 600-800 mg. Consecutively the pain therapy was switched to oral morphine and co-analgesics and the patient was discharged home 14 days postoperatively. Some patients with chronic cancer pain are used to increased opioid dosages prior to planned surgery. In the perioperative setting these dosages have to be continued and adapted to current requirements, otherwise analgesic undersupply occurs. In our case report we describe a serious sequence of postoperative analgesic undersupply in an opioid consuming patient. The main principles of post-operative dosing and logistic pitfalls are illustrated." }, { "id": "pubmed23n0734_14257", "title": "[Management of bone metastases from breast cancer].", "score": 0.009714285714285713, "content": "Bone is the most common of breast cancer metastasis. Bone metastasis causes skeletal-related events(SREs), including pain, bone fractures, spinal cord compression, and hypercalcemia. SREs significantly impair patients' quality of life. The main purpose of treatment for bone metastasis is to prevent or delay SREs and to improve patients' quality of life. Accurate diagnosis of bone metastases is important in order to choose an appropriate treatment. Treatment of bone metastasis requires a multidisciplinary approach. Analgesic medication with NSAIDs and opioids is the first choice for pain control. In addition to bisphosphonate, the receptor activator of the nuclear factor κB ligand(RANKL)inhibitor, denosumab is a novel bone-targeting agent effective in preventing SREs. Prophylactic stabilization of impending fractures provides several advantages compared with fixation of an acute fracture, in terms of short hospitalization and a quick return to baseline. In general, radiation therapy is indicated for patients for whom surgery is suitable. Radiation therapy to palliate pain from bone metastasis can reduce the intake of analgesic medications. Local radiation therapy is indicated for a limited number of bone metastases, and systemic radionuclide therapy is appropriate for multiple lesions. In summary, treatment using these modalities for bone metastasis from breast cancer should be stratified, considering the symptoms, site of bone metastasis, and patients' life expectancy and performance status." }, { "id": "wiki20220301en035_29261", "title": "Strontium-89", "score": 0.009708737864077669, "content": "As such, intravenous or intracavity administration of 89Sr may be helpful in the palliation of painful bony metastases, as it allows for targeted radiation to metastatic lesions, inducing apoptosis of cells, membrane and protein damage. Subsequently, bone pain resulting from cytokine release at the site of lesions, bone-associated nerve compression and stretching of the periosteum may be reduced. Treatment with 89Sr has been particularly effective in patients with hormonally-resistant prostate cancer, often leading to a decreased requirement for opioid analgesics, an increase in time until further radiation, and a decrease in tumour markers. It is an artificial radioisotope which is used in treatment of bone cancer. In circumstances where cancer patients have widespread and painful bony metastases, the administration of 89Sr results in the delivery of beta particles directly to the area of bony problem, where calcium turnover is greatest." }, { "id": "pubmed23n0897_7586", "title": "[A Case of Recurrent Breast Cancer with Bone Metastasis Successfully Treated with Everolimus and Exemestane Therapy].", "score": 0.009708737864077669, "content": "We report a case of a patient treated with everolimus and exemestane combination therapy for bone metastasis after breast surgery.The patient, a 58-year-old woman, consulted our department for back pain in October 2014.S he was diagnosed with left breast cancer when she was 41 years old.She had received Bt+Ax for left breast cancer and administered tamoxifen for 5 years.We decided on everolimus and exemestane combination therapy after observing an abnormal uptake in the 7th to 8th thoracic vertebrae on a PET-CT scan.The pain was controlled using oxycodone and fentanyl orally disintegrating tablet with zoledronic acid.After receiving treatment, the patient experienced pruritus and a Grade 2 rash, but they were managed with antihistamine administration and the treatment was continued.Four months later, the abnormal uptake on the right thoracic vertebrae shrunk; the pain almost disappeared, and oxycodone and fentanyl orally disintegrating tablet were discontinued.Subsequently, exemestane was used alone.Six months later, the range of abnormal uptake on the thoracic vertebrae progressed, and the disease was evaluated as PD.Four months later, everolimus and exemestane combination therapy was resumed, and the abnormal uptake on the thoracic vertebrae almost disappeared as observed on a PET scan.The effectiveness of the treatment was evaluated as CR because other local recurrence and new metastases were not found. Everolimus might exhibit bone resorption inhibiting effects and bone protection effects, but the decision regarding the periods of suitable use and the effects of long-term continuation of treatment are controversial, and further discussion based on experience of increasing use is required." }, { "id": "pubmed23n0414_15520", "title": "[Delirium is certainly not an unavoidable complication of pain control in the terminal phase of life].", "score": 0.009615384615384616, "content": "In three terminal patients, a man aged 19 years who suffered from progressive osteosarcoma, a man aged 71 years with a small-cell pulmonary carcinoma, and a 68-year-old woman with cerebral metastases from a mammary carcinoma, delirium developed due to increased dosage of opioids for seemingly intractable pain (the first two patients) and dexamethasone (third patient). The delirium subsided after opioid rotation, administration of drugs for neuropathic pain, and treatment with an antipsychotic, respectively. This enhanced the patients' quality of terminal life and quality of dying. In terminal patients, analgesics-induced delirium must be considered, diagnosed and treated without delay." }, { "id": "wiki20220301en162_876", "title": "Vertebral compression fracture", "score": 0.009523809523809525, "content": "Diagnosis Compression fractures are usually diagnosed on spinal radiographs, where a wedge-shaped vertebra may be visible or there may be loss of height of the vertebra. In addition, bone density measurement may be performed to evaluate for osteoporosis. When a tumor is suspected as the underlying cause, or the fracture was caused by severe trauma, CT or MRI scans may be performed. Treatment Conservative treatment Back brace for support while the bone heals—either a Jewett brace for relatively stable and mild injuries, or a thoracic lumbar sacral orthosis (TLSO) for more severe ones. Opioids or non-steroidal anti-inflammatory drugs (NSAIDs) for pain. For osteoporotic patients, calcitonin may be helpful. Surgical Kyphoplasty and vertebroplasty are minimally invasive procedures that inject cement into the bone of the back that is fractured. However, the data examining the effectiveness of these procedures is mixed. References Further reading" }, { "id": "pubmed23n0525_12564", "title": "Controversies in pharmacotherapy of pain management.", "score": 0.009523809523809525, "content": "Since the establishment of the WHO three-step ladder for management of cancer pain, several controversies have arisen, which are partly due to new drug development, reformulations of older analgesics, and technological advancements. As a result, clinicians need clarification of several questions. Is morphine the opioid of choice for moderate to severe pain in cancer? Should combinations of opioids be used? When should spinal opioids be used to treat pain in cancer? What are the appropriate opioid doses for breakthrough pain? Should selective cyclo-oxygenase (COX) 2 inhibitors be used? What is the best tactic to treat neuropathic pain, and what first-line adjuvant analgesic should be used? And do bisphosphonates relieve bone pain in cancers other than breast cancer and myeloma? This review addresses these questions." }, { "id": "pubmed23n0327_16541", "title": "Radiation therapy in the management of symptomatic bone metastases: the effect of total dose and histology on pain relief and response duration.", "score": 0.009492685963274197, "content": "In order to better define variables and factors that may influence the pain response to radiation, and to look for a radiation regimen that can assure the highest percentage and the longest duration of pain relief, we performed a prospective, although not randomized, study on patients with bone metastases from various primary sites. From December 1988 to March 1994, 205 patients with a total of 255 solitary or multiple bone metastases from several primary tumors were treated in our radiotherapy center with palliative intent. Irradiation fields were treated with three main fractionation schedules: (1) Conventional fractionation: 40-46 Gy/20-23 fractions in 5-5.5 weeks; (2) Short course: 30-36 Gy/10-12 fractions in 2-2.3 weeks; (3) Fast course: 8-28 Gy/1-4 consecutive fractions. Pain intensity was self-assessed by patients using a visual analogic scale graduated from 0 (no pain) to 10 (the strongest pain one can experience). Analgesic requirement was assessed by using a five-point scale, scoring both analgesic strength and frequency (0 = no drug or occasional nonopioids; 1 = Nonopioids once daily; 2 = Nonopioids more than once daily; 3 = Mild opioids (oral codeine, pentazocine, etc.), once daily; 4 = Mild opioids more than once daily; 5 = Strong opioids (morphine, meperidine, etc.). Complete pain relief meant the achievement of a score &lt; or = 2 in the pain scale or 0 in the analgesic requirement scale. Partial pain relief indicated a score of 3 to 4 or of 1 to 2 on the former and latter scale, respectively. Total pain relief (complete + partial) was observed in 195 (76%) sites, in 158 of which (62%) a complete response was obtained. Metastases from NSC lung tumors appeared to be the least responsive among all primary tumors, with 46% complete pain relief in comparison to 65% and 83% complete relief in breast (p = 0.04) and in prostate metastases (p = 0.002), respectively. A significant difference in pain relief was detected among the several ranges of total dose delivered to the painful metastases, with 81%, 65%, and 46% complete relief rates in the 40-46 Gy, 30-36 Gy (p = 0.03), and 8-28 Gy (p = 0.0001) dose ranges respectively. A straight correlation between total dose and complete pain relief was confirmed by the curve calculated by the logistic model which shows that doses of 30 Gy or more are necessary to achieve complete pain relief in 70% or more of bone metastases. This correlation holds also for the duration of pain control, as shown by the actuarial analysis of time to pain progression. Multivariate analyses, with complete pain relief and time to pain progression as endpoints show a highly significant effect of radiation dose (p = 0.0007) and performance status (p = 0.003), with lower rates of complete pain relief and shorter time to pain progression observed after smaller radiation total doses or higher Eastern Cooperative Oncology Group (ECOG) scores. Although single-dose or short course irradiation is an attractive treatment in reducing the number of multiple visits to radiotherapy departments for patients with painful bone metastases, it is nevertheless clear that aggressive protracted treatments seem to offer significant advantages especially for patients in whom the expected life span is not short." }, { "id": "wiki20220301en008_45456", "title": "Chronic pain", "score": 0.009433962264150943, "content": "Chronic pain may originate in the body, or in the brain or spinal cord. It is often difficult to treat. Epidemiological studies have found that 8% - 11.2% of people in various countries have chronic widespread pain. Various non-opioid medicines are initially recommended to treat chronic pain, depending on whether the pain is due to tissue damage or is neuropathic. Psychological treatments including cognitive behavioral therapy and acceptance and commitment therapy may be effective for improving quality of life in those with chronic pain. Some people with chronic pain may benefit from opioid treatment while others can be harmed by it. People with non-cancer pain who have not been helped by non-opoid medicines might be recommended to try opioids if there is no history of substance use disorder and no current mental illness. If the chronic pain is not relieved, opioids should be discontinued." }, { "id": "pubmed23n0486_1609", "title": "The treatment of metastatic breast cancer in bone.", "score": 0.009433962264150943, "content": "The author report clinical experience with 212 cases of mammary cancer metastatic to bone, in 186 of which radiotherapy was given, and in 26 steroid hormone therapy. At least 70 per cent of patients with bone metastasis from breast cancer were relieved of pain by adequate roentgen therapy, the relief lasting for most of the survival time in many instances. About 25 per cent of patients had recalcification or reossification of bony lesions with roentgen therapy; while dramatic, this is not always an indication that relief of pain will continue or that survival time will be lengthened. If and when adequate radiotherapy has not been effective or cannot be administered (for example, in a patient with extremely widespread metastasis, or one residing at a considerable distance from radiotherapeutic service) steroid hormone therapy in adequate dosage is frequently beneficial. From 40 per cent to 75 per cent of patients with bone metastases from breast cancer are relieved of pain by steroid hormone therapy. In about 15 per cent of cases recalcification of the lesion occurs. Effective roentgen therapy may usually be given in a relatively brief period of time (one to two weeks). Effective steroid hormone therapy usually requires from 12 to 24 weeks. Complications of steroid hormone therapy are numerous. Some patients are made considerably worse by such therapy. These complications may only be controlled by reduction or discontinuation of the hormones. For this reason, it is recommended that irradiation always be used as the initial method of palliation." }, { "id": "pubmed23n0905_18201", "title": "Combined application of diclofenac and celecoxib with an opioid yields superior efficacy in metastatic bone cancer pain: a randomized controlled trial.", "score": 0.009357234740030706, "content": "Metastatic bone cancer pain is one of the most common clinical cancer pains and is caused by many factors. This study was conducted to explore the clinical efficacy of using two non-steroidal anti-inflammatory drugs (NSAIDs) along with an opioid in treating metastatic bone cancer pain. A total of 342 patients with a pain score of 7-10 on the visual analog scale (VAS) were recruited for 4 weeks of treatment and randomly assigned to three different groups-one group received two NSAIDs (diclofenac and celecoxib), one group received diclofenac, and one group received celecoxib. All patients received morphine sulfate 10 mg/12 h with a reduction of 50% or addition of 25% each time until the VAS score was &lt;5. The VAS score, remission rate (RR), breakthrough pain (BTP), morphine sulfate dose and side-effects among the three groups were compared. After 4 weeks of treatment, we found that using two NSAIDs along with an opioid could yield a significantly lower VAS score (p = 0.006), higher RR (p = 0.0002) and fewer incidences of BTP (p = 0.011), compared to the use of only one NSAID. Furthermore, using two NSAIDS could significantly decrease the consumption of morphine sulfate compared to using each NSAID in isolation (p = 0.0031 in week 1; p = 0.020 in week 2; p = 0.0012 in week 4). Additionally, using two NSAIDs could produce fewer incidences of dizziness (p = 0.002), constipation (p &lt; 0.0001) and drowsiness (p &lt; 0.0001). Although limited by the relatively small samples, these results indicate that using two NSAIDs along with an opioid in treating metastatic bone cancer pain was more effective and acceptable, which is worthy of further clinical application." }, { "id": "wiki20220301en354_20187", "title": "Cancer pain", "score": 0.009345794392523364, "content": "More than half of people with advanced cancer and pain will need strong opioids, and these in combination with non-opioid pain medicine can produce acceptable analgesia in 70–90 percent of cases. Morphine is effective in relieving cancer pain although oxycodone shows superior tolerability and anlgesic effect, though cost may limit its value in certain healthcare systems. Side effects of nausea and constipation are rarely severe enough to warrant stopping of treatment. Sedation and cognitive impairment usually occur with the initial dose or a significant increase in dosage of a strong opioid, but improve after a week or two of consistent dosage. Antiemetic and laxative treatment should be commenced concurrently with strong opioids, to counteract the usual nausea and constipation. Nausea normally resolves after two or three weeks of treatment but laxatives will need to be aggressively maintained. Buprenorphine is another opioid with some evidence of its efficacy but only low quality" }, { "id": "pubmed23n1003_12687", "title": "[Effectiveness of Strontium-89 for Neuropathic Pain Caused by Bone Metastases from Breast Cancer: A Case Report].", "score": 0.009345794392523364, "content": "The patient was a 47-year-old female with stage IV breast cancer and multiple bone metastases. She received various systemic therapies (hormone therapy and chemotherapy) and underwent mastectomy between 2013 and 2018; in the beginning of 2018, she started experiencing bone metastatic pain in the right hip joint and neural pain on the dorsal side of the left thigh. These symptoms worsened gradually, and nonsteroidal anti-inflammatory analgesics or narcotic analgesics were not effective for treating this pain. Strontium-89 (<sup89</supSr) treatment was administered in April 2018. The pain was relieved immediately after <sup89</supSr treatment. The patient's quality of life improved markedly. She spent her remaining life without using analgesic drugs, until she died in October 2018 due to exacerbation of the original disease. Although radiotherapy is believed to be less effective for neuropathic pain than for bone metastatic pain, it should be considered as a treatment option in patients with neuropathic pain." }, { "id": "wiki20220301en014_89114", "title": "Medication overuse headache", "score": 0.009259259259259259, "content": "Headache treatment Opioids and butalbital are sometimes inappropriately used as treatment for migraine and headache and should be avoided in favor of more effective, migraine-specific treatments. Opioid and butalbital use can worsen headaches and cause MOH. When a patient fails to respond to other treatment or migraine specific treatment is unavailable, then opioids may be used. Regular use of over-the-counter drugs (OTC) such as paracetamol and NSAIDs can also be a cause of MOH. OTC medication for headache should be limited to use for not more than two days weekly. Concurrent with MOH, overuse of acetaminophen (known as paracetamol in some countries) for treating headaches risks causing liver damage and NSAID overuse can cause gastrointestinal bleeding." }, { "id": "wiki20220301en131_193", "title": "Opioid-induced hyperalgesia", "score": 0.009174311926605505, "content": "One general treatment option is to gradually reduce or discontinue the dose of opioid to see if OIH is improved, although this could induce withdrawal symptoms that may initially increase pain. Opioid switching, also called opioid rotation, is the replacement of the current opioid with another pharmacological agent such as morphine or methadone. It was effective in some studies, but can increase sensitivity to pain, requiring higher doses of the opioid-sparing drug. Opioid rotation is a safe and effective alternative to completely stopping opioid therapy. Methadone is also believed to show some efficacy in OIH, presumably due to its weak NMDA antagonist activity. Ketamine, an NMDA antagonist, has been shown to prevent the extended use of opioid in post-operative hyperalgesia when it is infused in a small amount perioperatively along with the opioid but there are also studies that show ketamine being ineffective in modulating hyperalgesia." }, { "id": "pubmed23n1034_7551", "title": "Dexamethasone for the Prevention of a Pain Flare After Palliative Radiation Therapy for Painful Bone Metastases: The Multicenter Double-Blind Placebo-Controlled 3-Armed Randomized Dutch DEXA Study.", "score": 0.009174311926605505, "content": "After radiation therapy for painful bone metastases, up to 44% of patients report a pain flare (PF). Our study compared 2 dose schedules of dexamethasone versus placebo to prevent PF. This double-blind, randomized, placebo-controlled trial allocated patients with painful bone metastases from solid tumors randomly to receive 8 mg dexamethasone before radiation therapy followed by 3 daily doses (group A), 8 mg dexamethasone followed by 3 doses of placebo (group B), or 4 doses of placebo (group C). Patients reported worst pain scores, study medication side effects, and opioid intake before treatment and thereafter daily for 14 days and on day 28. PF was defined as at least a 2-point increase on a 0 to 10 pain scale with no decrease in opioid intake or a 25% or greater increase in opioid intake with no decrease in pain score, followed by a return to baseline or lower. The primary analysis was by intention to treat with patients who had missing data classified as having a PF. From January 2012 to April 2016, 295 patients were randomized. PF incidence was 38% for group A, 27% for group B, and 39% for group C (P = .07). Although patients in group B had the lowest PF incidence, a relatively high percentage did not return to baseline pain levels, indicating pain progression. The mean duration of PF was 2.1 days for group A, 4.5 days for group B, and 3.3 days for group C (P = .0567). Dexamethasone postponed PF occurrence; in group A 52% occurred on days 2 to 5 versus 73% in group B and 99% in group C (P = .02). Patients in group A reported lower mean pain scores on days 2 to 5 than those in group B or C (P &lt; .001). Side effects were similar. There was insufficient evidence that dexamethasone reduced the incidence of radiation-induced PF. However, dexamethasone postponed the occurrence of PF and led to lower mean pain scores on days 2 to 5." }, { "id": "wiki20220301en131_194", "title": "Opioid-induced hyperalgesia", "score": 0.00909090909090909, "content": "The use of an NSAID, especially some COX-2 inhibitors, or acetaminophen either as monotherapy or combination therapy is also suggested as a possible treatment option. Research needs It can be difficult to apply research into OIH to average patients, because some research focused on people taking very high doses or in methadone rehabilitation programs. Opioid-induced hyperalgesia has also been criticized as overdiagnosed among chronic pain patients, due to poor differential practice in distinguishing it from the much more common phenomenon of opioid tolerance. The misdiagnosis of common opioid tolerance (OT) as opioid-induced hyperalgesia (OIH) can be problematic as the clinical actions suggested by each condition can be contrary to each other. Patients misdiagnosed with OIH may have their opioid dose mistakenly decreased (in the attempt to counter OIH) at times when it is actually appropriate for their dose to be increased or rotated (as a counter to opioid tolerance)." }, { "id": "pubmed23n0607_5267", "title": "Opioids for metastatic bone pain.", "score": 0.00909090909090909, "content": "Metastatic bone pain is characteristic of cancer pain. Satisfactory analgesic effects are achieved in more than 70% of patients with cancer pain who receive a combination of nonsteroidal anti-inflammatory drugs and opioids, according to the WHO therapeutic guidelines. Morphine, oxycodone, and fentanyl are commonly administered opioids. We found that the mean dose of oxycodone to achieve analgesic effects was 55 mg, and at doses of &lt;or=80 mg satisfactory analgesia was achieved in 80% of our patients. Palliative radiation was performed in 6 patients, resulting in pain relief in 4 and therefore the dose of opioids could be reduced. Bone metastasis should not be considered as the terminal stage, and decisions on the administration of drugs, in combination with radiation or orthopedic therapy, should be made at an early stage. Alleviation of pain and allowing a better quality of patient survival time, even if not for long, should be attempted." }, { "id": "pubmed23n0285_10509", "title": "Strontium chloride Sr 89 for treating pain from metastatic bone disease.", "score": 0.009065934065934067, "content": "The role of strontium chloride Sr 89 in the palliative treatment of pain associated with metastatic bone disease is reviewed. Conventional therapies to relieve metastatic bone pain include nonopioid and opioid analgesics, hormonal therapy, external-beam irradiation, and chemotherapy. Limitations in the long-term safety and effectiveness of these treatments have increased interest in using systemic radioactive isotopes for palliation of pain. Strontium chloride Sr 89 is a relatively new bone-seeking radiopharmaceutical that has FDA-approved labeling for use in relieving pain associated with skeletal metastases. An analogue of calcium, strontium chloride Sr 89 is rapidly cleared from the blood after i.v. injection. The agent selectively irradiates metastatic sites while generally sparing normal soft-bone tissue. In clinical studies, a majority of patients with prostate or breast cancer obtained substantial relief from bone pain after receiving strontium chloride Sr 89 alone or in combination with external-beam irradiation. Adverse effects tend to be mild, but patients should be monitored for possible hematologic toxicity. Patients should discontinue any calcium-containing products before receiving the agent. The typical dose is 4 mCi (148 MBq) administered by slow i.v. push over one to two minutes; doses can be repeated at three-month intervals. Pain relief usually begins in 10-20 days and lasts up to six months. Radiation safety measures are necessary in handling strontium chloride Sr 89 and the wastes of patients. Strontium chloride Sr 89 is costly, but preliminary analysis indicates that it may reduce management expenditures overall.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en020_61867", "title": "Opioid", "score": 0.009009009009009009, "content": "Clinical studies have consistently associated medical and recreational opioid use with hypogonadism (low sex hormone levels) in different sexes. The effect is dose-dependent. Most studies suggest that the majority (perhaps as much as 90%) of chronic opioid users suffer from hypogonadism. Opioids can also interfere with menstruation in women by limiting the production of luteinizing hormone (LH). Opioid-induced hypogonadism likely causes the strong association of opioid use with osteoporosis and bone fracture, due to deficiency in estradiol. It also may increase pain and thereby interfere with the intended clinical effect of opioid treatment. Opioid-induced hypogonadism is likely caused by their agonism of opioid receptors in the hypothalamus and the pituitary gland. One study found that the depressed testosterone levels of heroin addicts returned to normal within one month of abstinence, suggesting that the effect is readily reversible and is not permanent. , the effect of low-dose or" } ] } } }

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{ "1": "The risk of a new molar gestation in a future pregnancy is 50%.", "2": "She should not become pregnant until she has undergone periodic controls and has spent one year with negative BHCG levels.", "3": "Subsequent controls are not necessary if the evacuation of the trophoblastic tissue was complete.", "4": "It is necessary to carry out periodic controls since 40% of the cases will develop a gestational trophoblastic neoplasia.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en036_29141", "title": "Gestational trophoblastic disease", "score": 0.018521679754182313, "content": "In the past, it was seen as important not to get pregnant straight away after a GTD. Specialists recommended a waiting period of 6 months after the hCG levels become normal. Recently, this standpoint has been questioned. New medical data suggest that a significantly shorter waiting period after the hCG levels become normal is reasonable for approximately 97% of the patients with hydatidiform mole. Risk of a repeat GTD The risk of a repeat GTD is approximately 1 in 100, compared with approximately 1 in 1000 risk in the general population. Especially women whose hCG levels remain significantly elevated are at risk of developing a repeat GTD. Persistent trophoblastic disease The term «persistent trophoblastic disease» (PTD) is used when after treatment of a molar pregnancy, some molar tissue is left behind and again starts growing into a tumour. Although PTD can spread within the body like a malignant cancer, the overall cure rate is nearly 100%." }, { "id": "pubmed23n0403_4413", "title": "[Gestational trophoblastic tumors and recent clinical information].", "score": 0.017324133793310333, "content": "Recent clinical advances in the field of gestational trophoblastic diseases are described. WHO modified its risk factor scoring system. This change was proposed to combine both the basic FIGO anatomic staging with the modified WHO risk factor scoring system. Patients who score as low-risk are treated with single agent chemotherapy, such as methotrexate (MTX), and patients refractory to MTX are treated with a combination chemotherapy, EMA/CO. Patients who score as high-risk are treated with EMA/CO, and patients refractory to the first line chemotherapy may be successfully treated with EP/EMA. Recent epidemiological data showed that women with complete hydatidiform moles could anticipate normal reproduction in the future. Studies found that pregnancies after treatment of molar pregnancy resulted in 69% full-term, live births; 8% premature deliveries; 1% ectopic pregnancies, and 0.5% stillbirths. First-trimester spontaneous abortions occurred in 17% of pregnancies, and major and minor malformations were detected in 0.4% of infants. Patients with hydatidiform mole were at increased risk of developing molar pregnancy in subsequent conceptions. After having one molar pregnancy, the risk of having molar disease in a future gestation was about 1%. The risk of persistent gestational trophoblastic tumors was increased by long-term oral contraceptive use before conception. In a large, multicenter, case-control study, the risk was shown to be increased in women who had ever used oral contraceptives, but was highest for women taking oral contraceptives during the cycle in which they became pregnant. Partial hydatidiform moles were never previously proven to transform into choriocarcinoma; however, a recent study with molecular techniques clearly showed that partial moles could transform into choriocarcinoma. All patients with suspected partial moles should be reviewed centrally and require hCG follow-up." }, { "id": "pubmed23n0482_23918", "title": "Placental site trophoblastic tumor arising from antecedent molar pregnancy.", "score": 0.017046278833599306, "content": "Placental site trophoblastic tumor (PSTT) is a rare form of gestational trophoblastic disease. Little is known about its pathogenesis and natural history. This report describes two cases that arose in patients with documented complete hydatidiform moles and summarizes the antecedent prenatal histories of PSTTs based on a detailed Medline literature analysis. A 28-year-old, G(2)P(2) female had a live, 12-week gestation fetus and a coexisting molar pregnancy. Her hCG levels dropped promptly from 1.5 million to 23,273 IU/ml after termination, but rose shortly thereafter together with the onset of recurrent vaginal bleeding. Curettage revealed persistent mole. Persistently elevated hCG led to hysterectomy disclosing a fundal PSTT. The second case was that of a 48-year-old, G(2) woman who presented with symptoms of preeclampsia, hyperthyroidism, and elevated hCG. Curettage yielded a complete hydatidiform mole. Although the hCG level decreased for a short period, it soon increased despite treatment with methotrexate. A second curettage revealed a PSTT. A Medline literature analysis of PSTT, which consists almost entirely of individual cases and several small series, disclosed that PSTT is preceded in 61% of cases by normal term pregnancy, 12% molar pregnancy, 9% spontaneous abortion, 8% therapeutic abortion, and 3% with ectopic pregnancy, stillbirths or preterm delivery. No information is known in 7%. This report describes two additional cases of PSTT preceded by complete molar pregnancy. PSTT is a well recognized, but uncommon form of gestational trophoblastic disease. Although little is known about its pathogenesis, it is preceded not uncommonly by an abnormal pregnancy, including a molar pregnancy." }, { "id": "pubmed23n0208_14120", "title": "[Studies on the viability of trophoblast after termination of various kinds of pregnancies (author's transl)].", "score": 0.016394496592516395, "content": "Although normal value of hCG (LH level) does not necessarily indicate eradication of viable trophoblast, its confirmation has been demonstrated as a clinically useful guide for the probable prevention of choriocarcinoma after hydatidiform mole by Takeuchi et al. Choriocarcinoma preceded by other pregnancies than hydatidiform mole which has the highest risk for choriocarcinoma has drawn more attention than before in connection with the decrease of postmolar choriocarcinoma. So that I have studied the regression rate of urinary gonadotropin (hCG) after the termination of various kinds of pregnancies. In 2,433 cases of induced abortion, 695 cases of spontaneous abortion, 1,724 cases of term delivery and 43 cases of hydatidiform mole, their urinary hCG were determined to the level of physiological range of LH. The rate of hCG regression was in the order of term delivery, spontaneous abortion, induced abortion and hydatidiform mole. The younger was the gestational age of trophoblast, the slower was the regression of hCG. At one month after the termination of pregnancy, 80.1%, 11%, 0.3%, 8% and 4.1%, and at two month 55.8%, 1.6%, 0.5%, 4% and 0.5% for hydatidiform mole, induced abortion of less than 12 week of gestation, spontaneous abortion of less than 12 week of gestation, spontaneous abortion of between 13 and 20 week of gestation respectively still showed abnormal hCG value. One percent of induced abortion at 5 month, 4% of spontaneous abortion at 3 month, 0.3% of term delivery at 4 month still maintained abnormal titer. No malignant sequelae in patients under the investigation have ever been observed in the follow up period between 3 and 8 years." }, { "id": "pubmed23n0105_13561", "title": "Increased frequency of complete hydatidiform mole in women with repeated abortion.", "score": 0.015027886800247883, "content": "The association between spontaneous abortion and gestational trophoblastic disease (GTD) has been investigated in a study based on 93 women with 2 consecutive (repeated) spontaneous abortions and 82 control subjects who delivered normal babies. Nine molar pregnancies were observed among 7 of the 93 cases of repeated abortion while no control reported previous GTD. This difference was statistically significant and was not explained by allowance for age and number of pregnancies between cases and controls (chi 2(1) = 4.20; P = 0.04). When the observed number (9) of hydatidiform mole in the 385 pregnancies of the women with repeated abortion was compared with the expected one (0.28) based on the regional frequency data, the estimated relative risk was 32.1 with a 95% confidence interval from 13.9 to 63.3. The present findings confirm the association between GTD and spontaneous abortion and indicate that the risk is larger in women with repeated abortions." }, { "id": "pubmed23n0256_1552", "title": "Persistence of gestational trophoblastic disease for longer than 1 year following evacuation of hydatidiform mole.", "score": 0.014803921568627452, "content": "A spontaneous fall in the radioimmunoassay for the beta subunit of hCG to less than 2 mIU/mL documents regression of hydatidiform mole following evacuation of a molar pregnancy. Continued negative hCG levels for the year after evacuation indicates the absence of risk for persistent gestational trophoblastic disease. This report describes an unusual case of recurrent nonmetastatic gestational trophoblastic disease 16 months after initial evacuation. A 29-year-old woman presented at 19 weeks' gestation with severe preeclampsia and vaginal bleeding. Pelvic ultrasonography demonstrated a molar pregnancy. Pathology following uterine evacuation confirmed a hydatidiform mole. Serial hCG levels fell progressively to less than 2 mIU/mL over the following 25 weeks. She remained compliant with oral contraceptive pills despite having no sexual activity. Sixteen months after uterine evacuation, recurrence of gestational trophoblastic disease was documented by a rising beta-hCG, negative pelvic ultrasound, normal liver function tests, and normal computed tomography of the head. Endometrial curettage showed no chorionic villi or molar tissue. She was treated with five courses of actinomycin D and has remained disease-free for the following 5 years. This late recurrence of gestational trophoblastic disease suggests that those with a molar pregnancy may benefit from surveillance beyond 1 year after uterine evacuation." }, { "id": "pubmed23n0512_9094", "title": "Persistent gestational trophoblastic disease is rarely, if ever, derived from non-molar first-trimester miscarriage.", "score": 0.0147525978571044, "content": "Traditional epidemiologic data suggest that persistent gestational trophoblastic disease (pGTD), may follow, and be derived from, either molar pregnancy, non-molar term pregnancy or first-trimester non-molar miscarriage. We examined a database of cases of possible or probable hydatidiform moles and proven pGTD derived from the Regional Trophoblastic Disease Unit, Charing Cross Hospital, London. There were 424 cases (6%), in whom the initial registered diagnosis was that of PHM or CHM but central histopathological review diagnosed a definite non-molar hydropic abortion (HA). In eight of the 424 (2%), although the histology of the most recent index pregnancy was that of non-molar miscarriage, there was a previous history of pregnancy affected by hydatidiform mole; two of these developed subsequent pGTD. Of a further 86 cases referred for a histopathological opinion prior to registration which demonstrated definite non-molar HA, none developed pGTD (zero of 510 (0%, 95% CI 0-0.7%)). During the same period there were 352 cases with pGTD requiring chemotherapy. In 31 cases, the only known pregnancy was the preceding apparent non-molar HA. However, of these, there were only three cases in whom the preceding histological products of conception had been centrally reviewed and were suggestive of non-molar pregnancy. However, in all three of these cases, the specimens were inadequate for definite exclusion of molar pregnancy. In one case in whom no material was available for review, molecular genetic analysis using restriction fragment length polymorphisms was carried out, and the choriocarcinoma was genetically derived from a previous molar pregnancy rather than the preceding HA. There were therefore no cases identified on the database of the trophoblastic disease unit of pGTD requiring treatment in whom the trophoblastic tumour could be genetically proven to have arisen from the preceding first trimester non-molar HA. We suggest that the risk of pGTD developing from a histologically confirmed non-molar HA is less than 1 in 50,000 and that the majority of pGTD cases previously reported to have been caused by a non-molar miscarriage probably represent disease due to an unrecognised early molar pregnancy." }, { "id": "article-22233_9", "title": "Gestational Trophoblastic Disease -- Epidemiology", "score": 0.014561050513607964, "content": "Risk factors for molar pregnancy include extremes of age, ethnicity, and a prior history of a HM, suggesting a genetic etiology. The risk of a complete mole is higher for women older than 35 years and younger than 21 years and 7.5 times higher for women older than 40 years. The risk of repeat molar pregnancy in women with a history of molar pregnancy is approximately 1% which is 10 to 20 times the risk in the general population. [1] Interestingly, a history of prior spontaneous abortion has been reported to confer a 2- to 3-fold increased risk of molar pregnancy compared to women without a history of spontaneous abortion. [3] Following 2 molar gestations, the risk of having a third mole is > 10%. [7] It is also important to note that malignant transformation such as choriocarcinoma or placental-site trophoblastic tumor can occur following any pregnancy." }, { "id": "wiki20220301en036_29144", "title": "Gestational trophoblastic disease", "score": 0.014150943396226415, "content": "However, the incidence of rare diseases (such as GTD) is difficult to measure, because epidemiologic data on rare diseases is limited. Not all cases will be reported, and some cases will not be recognised. In addition, in GTD, this is especially difficult, because one would need to know all gestational events in the total population. Yet, it seems very likely that the estimated number of births that occur at home or outside of a hospital has been inflated in some reports. Terminology Gestational trophoblastic disease (GTD) may also be called gestational trophoblastic tumour (GTT). Hydatidiform mole (one type of GTD) may also be called molar pregnancy. Persistent disease; persistent GTD: If there is any evidence of persistence of GTD, usually defined as persistent elevation of beta hCG (see «Diagnosis» below), the condition may also be referred to as gestational trophoblastic neoplasia (GTN). See also Trophoblastic neoplasms References External links" }, { "id": "pubmed23n0525_17277", "title": "Postevacuation hCG levels and risk of gestational trophoblastic neoplasia in women with complete molar pregnancy.", "score": 0.013946869070208728, "content": "Women diagnosed with complete hydatidiform molar pregnancy are at 15% to 28% risk of developing persistent gestational trophoblastic neoplasia (GTN) requiring further management with chemotherapy. Our objective was to develop human chorionic gonadotropin (hCG) criteria that establish a patient's risk of developing persistent GTN or achieving remission from their baseline risk within a few weeks of molar evacuation. We used a database from the New England Trophoblastic Disease Center to analyze hCG levels from 1,029 women with complete molar pregnancies. We conducted a retrospective cohort study using data from 1973 to 2001. Women whose hCG level declined below 50 mIU/mL during their follow-up were found to be at no more than 1.1% risk for developing persistent GTN, irrespective of when this level was reached. Women whose hCG levels was below 200 mIU/mL in the fourth week after evacuation (59.8% of all women), or below 100 mIU/mL in the sixth week after evacuation (65.8% of all women), had a risk of persistence below 9%. hCG levels above 2,000 mIU/mL in the fourth week after evacuation (13.3% of women) were associated with a 63.8% risk of developing persistent disease. These data may allow clinicians to evaluate the risk of persistence that their patients with complete molar pregnancy have based on early hCG results after molar evacuation. In the fourth week after molar evacuation, 59.8% of women may be counseled that their risk of developing persistent GTN is substantially reduced from their baseline, whereas 13.3% of women may be warned that their risk of developing persistent GTN is greater than 50%. II-2." }, { "id": "wiki20220301en036_29137", "title": "Gestational trophoblastic disease", "score": 0.013816701316701317, "content": "The use of a reliable contraception method is very important during the entire follow up period, as patients are strongly advised against pregnancy at that time. If a reliable contraception method is not used during the follow-up, it could be initially unclear to clinicians as to whether a rising hCG level is caused by the patient becoming pregnant again, or by the continued presence of GTD. In women who have a malignant form of GTD, hCG concentrations stay the same (plateau) or they rise. Persistent elevation of serum hCG levels after a non molar pregnancy (i.e., normal pregnancy [term pregnancy], or preterm pregnancy, or ectopic pregnancy [pregnancy taking place in the wrong place, usually in the fallopian tube], or abortion) always indicate persistent GTD (very frequently due to choriocarcinoma or placental site trophoblastic tumour), but this is not common, because treatment mostly is successful." }, { "id": "wiki20220301en036_29129", "title": "Gestational trophoblastic disease", "score": 0.01371976647206005, "content": "All five closely related tumours develop in the placenta. All five tumours arise from trophoblastic cells. The trophoblast is the membrane that forms the wall of the blastocyst in the early development of the fetus. In a normal pregnancy, trophoblastic cells aid the implantation of the fertilised egg into the uterine wall. But in GTD, they develop into tumour cells. Cause Two main risk factors increase the likelihood for the development of GTD: 1) The woman being under 20 years of age, or over 35 years of age, and 2) previous GTD. Although molar pregnancies affect women of all ages, women under 16 and over 45 years of age have an increased risk of developing a molar pregnancy.Being from Asia/of Asian ethnicity is an important risk factor. Hydatidiform moles are abnormal conceptions with excessive placental development. Conception takes place, but placental tissue grows very fast, rather than supporting the growth of a fetus." }, { "id": "wiki20220301en036_29140", "title": "Gestational trophoblastic disease", "score": 0.013623407109322602, "content": "In this scoring system, women with a score of 7 or greater are considered at high risk. It is very important for malignant forms of GTD to be discovered in time. In Western countries, women with molar pregnancies are followed carefully; for instance, in the UK, all women who have had a molar pregnancy are registered at the National Trophoblastic Screening Centre. There are efforts in this direction in the developing countries too, and there have been improvements in these countries in the early detection of choriocarcinoma, thereby significantly reducing the mortality rate also in developing countries. Becoming pregnant again Most women with GTD can become pregnant again and can have children again. The risk of a further molar pregnancy is low. More than 98% of women who become pregnant following a molar pregnancy will not have a further hydatidiform mole or be at increased risk of complications." }, { "id": "wiki20220301en073_24425", "title": "Trophoblastic neoplasm", "score": 0.013615795968737146, "content": "Management of GTN requires pathology review, treatment options and monitoring of hCG. Therefore, it can be treated with curettage, hysterectomy and single agent or multi agent chemotherapy. Although this group of diseases are highly susceptible to chemotherapy, prognosis depends on the type of GTN and whether the tumor has spread to other areas of the body. Cause and Risk factors The exact cause of gestational trophoblastic neoplasia (GTN) is unknown. GTN often arises after molar pregnancies but can also occur after any gestation including miscarriages and term pregnancies. Although risk factors may impact on the development of the tumor, most do not directly cause of disease. According to the some studies, the risk of complete molar pregnancy is highest in women over age 35 and younger than 20. The risk is even higher for women over age 45. Signs and Symptoms The symptoms of GTN will vary from person to person. People with the same disease may not have all the symptoms listed." }, { "id": "pubmed23n0798_17361", "title": "[Reservation of fertility for seventeen patients with placental site trophoblastic tumor].", "score": 0.013401655498620418, "content": "To approach the efficiency and feasibility of preserving the fertility for patients with placental site trophoblastic tumor (PSTT). Totally 2 086 cases of gestational trophoblastic neoplasm (GTN) patients registered in Peking Union Medical College Hospital between 1998 and 2013. Fifty-seven of them were PSTT patients, 40 cases of which suffered hysterectomy, the rest 17 PSTT patients who preserved their fertility were analyzed retrospectively. The computerized database of clinical and pathological reports was reviewed in this cohort. The clinical manifestation of PSTT was not specific compared to other types of GTN. The average age of the 17 patients was 29.5 years old (range 22-39 years). The most common antecedent pregnancy was term birth (8 cases), the others were spontaneous abortion in 4 case, artificial abortion in 3 cases and molar pregnancy in 2 cases. The baseline serum β-hCG was slightly elevated and 12 patients (12/15) were less than 1 000 U/L. In this cohort, nine of the patients were in stage I, while the other eight cases were in stage III . The patients suffered conservative surgery, including dilation and curettage of uterus in 7 cases, open abdomen uterine lesion excision in 4 cases, laparoscopic uterine lesion excision in 3 cases, hysteroscopic uterine lesion excision in 1 case, and pulmonary lobectomy in 2 cases. Two of the patients didn't received chemotherapy, while the other 15 cases suffered combination chemotherapy. Compared with 40 patients who suffered hysterectomy during the same interval, fertility preservation group did not result in poor outcomes or high risk of relapse rate. Six subsequent pregnancies happened after the therapy, two of them were during their second-trimester, while four patients had healthy babies by vaginal delivery in two and cesarean section in two. The scar of the uterus was fairly well during the cesarean sections. Reservation of fertility therapy could be considered in highly-selected patients for young women who strongly desired to preserve their fertility and with localized lesion. Exactitude follow-up after therapy should be recommended. Contraception should also be recommended for at least one year after the chemotherapy. Vaginal delivery could be an option for the future pregnancies." }, { "id": "pubmed23n0501_5170", "title": "Low risk of relapse after achieving undetectable HCG levels in women with complete molar pregnancy.", "score": 0.013012650068487631, "content": "Complete hydatidiform molar pregnancies occur in approximately 1 of 1,000 conceptions. After uterine evacuation of the trophoblastic tissue, women are followed up with serial serum human chorionic gonadotropin (hCG) measurements. Patients are considered to have attained remission when their hCG level spontaneously declines to an undetectable level and remains there during a 6-month follow-up period. This standard effectively detects all disease recurrence; however, it is resource intensive, delays child bearing, and is subject to significant noncompliance. Our objective was to determine the risk of disease recurrence after hCG spontaneously declines to undetectable levels. We used a database from the New England Trophoblastic Disease Center to analyze hCG levels in patients with complete molar pregnancies. Among 1,029 women with complete molar pregnancy and complete data, 15% developed persistent gestational trophoblastic neoplasia. The rate of persistent neoplasm among those whose hCG level fell spontaneously to undetectable levels was 0.2% (2/876, 95% confidence interval 0-0.8%). No women developed persistent gestational trophoblastic neoplasia after their hCG level fell to undetectable levels using an assay with a sensitivity of 5 mIU/mL (n = 82, 95% confidence interval 0-4.5%). Based on our experience with women with complete hydatidiform molar pregnancies whose hCG values spontaneously fell to undetectable levels after molar evacuation, we conclude that the risk of recurrent neoplasm after hCG levels fall to less than 5 mIU/mL approaches zero." }, { "id": "pubmed23n0789_5549", "title": "Gestational trophoblastic neoplasia: A 6 year retrospective study.", "score": 0.012932468396540253, "content": "To study the clinical presentations of gestational trophoblastic neoplasia and its response to chemotherapy. This is a retrospective study of 28 women of gestational trophoblastic neoplasia evaluated over a period of 6 years from January 2004 to December 2009. Patients were evaluated on the basis of their age, number of deliveries, history of abortion or molar pregnancy, and the treatment received. All patients were scored on the basis of WHO scoring system. Patients with low risk (score &lt;/=6) received single agent chemotherapy with methotrexate or actinomycin D. Patients with high risk (score &gt;/=7) received multiple agent chemotherapy with EMACO regimen. After completion of chemotherapy patients were followed for a minimum of 2 years. The response to treatment was evaluated during follow-up by clinical examination, beta hCG levels and imaging as and when required. Out of 28 women only 27 could be evaluated, because 1 patient was lost to follow-up. Out of 27 patients, 18 patients (66.67%) achieved complete remission with the first-line chemotherapy and additional 25.92% (7/27) achieved complete remission with second line chemotherapy resulting in complete remission of 92.5% (25/27). Gestational trophoblastic neoplasia is curable if patient is properly evaluated and scored. It shows good response to chemotherapy." }, { "id": "wiki20220301en303_13536", "title": "Placental site trophoblastic tumor", "score": 0.01189910643592354, "content": "Placental site trophoblastic tumor is a form of gestational trophoblastic disease, which is thought to arise from intermediate trophoblast. It may secrete human placental lactogen (human chorionic somatomammotropin), and result in a false-positive pregnancy test. Placental site trophoblastic tumor is a monophasic neoplasm of the implantation site intermediate trophoblast, and usually a benign lesion, which comprises less than 2% of all gestational trophoblastic proliferations. Preceding conditions include molar pregnancy (5%). Compared to choriocarcinoma or invasive mole, hemorrhage is less conspicuous and serum β-HCG level is low, making early diagnosis difficult. Immunohistochemistry: Often stains with hPL, keratin, Mel-CAM, EGFR. Treatment Because chemotherapy is ineffective; the patient should undergo hysterectomy. Prognosis 10–20% of cases metastasize leading to death. References External links Health issues in pregnancy Germ cell neoplasia" }, { "id": "pubmed23n0511_9522", "title": "Gestational trophoblastic disease: is intensive follow up essential in all women?", "score": 0.011230110159118727, "content": "To determine the timescale of the registration process for gestational trophoblastic disease and its impact on hCG level at registration and subsequent need for chemotherapy. A prospective observational study using a standardised protocol for registration, assessment and treatment for molar pregnancy. A supra-regional tertiary referral centre for gestational trophoblastic disease. A total of 2046 consecutive women registered between January 1994 and December 1998 with a diagnosis of molar pregnancy. Data at and after registration, collected prospectively on a computerised database, were statistically analysed (by multiple logistic regression and ANOVA). Relationship between length of time to and hCG value at registration; also the subsequent need for chemotherapy. A total of 2046 women with a diagnosis of molar pregnancy were registered in the study period. The mean time interval between first evacuation and registration at the referral centre was 47 days (median 37, range 0-594). One hundred and five out of 2046 (5.1%) women needed chemotherapy. Sixty-three precent of the women (1296 out of 2046) had a normal level of urinary hCG (less than 40 IU/24 hours) at the time of registration and only one (0.08%) needed chemotherapy. Binary logistic regression analysis showed a statistically significant relationship between time to registration, hCG value, histology, pretreatment risk score and decision to administer chemotherapy. Women with gestational trophoblastic disease who were registered late were significantly more likely to have normal levels of hCG and were less likely to need chemotherapy. A less intensive follow up may be justified in women with gestational trophoblastic disease who are registered with a normal hCG level." }, { "id": "wiki20220301en032_59230", "title": "Molar pregnancy", "score": 0.01117089969866552, "content": "Etymology The etymology is derived from hydatisia (Greek \"a drop of water\"), referring to the watery contents of the cysts, and mole (from Latin mola = millstone/false conception). The term, however, comes from the similar appearance of the cyst to a hydatid cyst in an Echinococcosis. See also Gestational trophoblastic disease References External links Humpath #3186 (Pathology images) Clinically reviewed molar pregnancy and choriocarcinoma information for patients from Cancer Research UK MyMolarPregnancy.com: Resource for those diagnosed with molar pregnancy. Links, personal stories, and support groups. Germ cell neoplasia Pregnancy with abortive outcome" }, { "id": "pubmed23n0834_2417", "title": "Postmolar gestational trophoblastic neoplasia: beyond the traditional risk factors.", "score": 0.010950516617114598, "content": "To investigate the slope of linear regression of postevacuation serum hCG as an independent risk factor for postmolar gestational trophoblastic neoplasia (GTN). Multicenter retrospective cohort study. Academic referral health care centers. All subjects with confirmed hydatidiform mole and at least four measurements of β-hCG titer. None. Type and magnitude of the relationship between the slope of linear regression of β-hCG as a new risk factor and GTN using Bayesian logistic regression with penalized log-likelihood estimation. Among the high-risk and low-risk molar pregnancy cases, 11 (18.6%) and 19 cases (13.3%) had GTN, respectively. No significant relationship was found between the components of a high-risk pregnancy and GTN. The β-hCG return slope was higher in the spontaneous cure group. However, the initial level of this hormone in the first measurement was higher in the GTN group compared with in the spontaneous recovery group. The average time for diagnosing GTN in the high-risk molar pregnancy group was 2 weeks less than that of the low-risk molar pregnancy group. In addition to slope of linear regression of β-hCG (odds ratio [OR], 12.74, confidence interval [CI], 5.42-29.2), abortion history (OR, 2.53; 95% CI, 1.27-5.04) and large uterine height for gestational age (OR, 1.26; CI, 1.04-1.54) had the maximum effects on GTN outcome, respectively. The slope of linear regression of β-hCG was introduced as an independent risk factor, which could be used for clinical decision making based on records of β-hCG titer and subsequent prevention program." }, { "id": "pubmed23n1013_18140", "title": "Gestational Trophoblastic Neoplasia After Human Chorionic Gonadotropin Normalization Following Molar Pregnancy: A Systematic Review and Meta-analysis.", "score": 0.010831064664383362, "content": "To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG) levels to guide evidence-based follow-up recommendations. MEDLINE, EMBASE, Web of Science, POPLINE, Cochrane, and ClinicalTrials.gov were searched from inception to November 2018, using the intersection of \"gestational trophoblastic disease,\" \"molar pregnancy,\" and \"human chorionic gonadotropin\" themes. Search results were screened to identify cohort studies of molar pregnancy reporting gestational trophoblastic neoplasia development, with at least 6 months of intended normal hCG follow-up. Two reviewers independently identified articles for inclusion. Data were extracted using a standardized form. For meta-analysis, cumulative incidence of gestational trophoblastic neoplasia, with CIs by the Agresti-Coull method, and pooled risk ratios (RRs) comparing complete and partial mole were calculated. Among the 19 eligible studies that reported adequate data for inclusion in the primary meta-analysis, we found low incidence of gestational trophoblastic neoplasia after normal hCG level following both complete mole (64/18,357, 0.35%, 95% CI 0.27-0.45%), and partial mole (5/14,864, 0.03%, 95% CI 0.01-0.08%). There was a significantly higher risk of gestational trophoblastic neoplasia after complete compared with partial molar pregnancy (RR 4.72, 95% CI 1.81-12.3, P=.002). Among gestational trophoblastic neoplasia cases after normal hCG level following complete mole, 89.6% occurred when the time from evacuation to normalization was 56 days or longer, and 60.7% were diagnosed beyond the commonly recommended 6-month surveillance interval. Sensitivity analyses, including those limiting to studies at low risk of bias, did not significantly affect results. We found an overall incidence of gestational trophoblastic neoplasia of 15.7% for complete mole (1,354/8,611, 95% CI 15.0-16.5%) and 3.95% for partial mole (221/5,593, 95% CI 3.47-4.50%). Gestational trophoblastic neoplasia development after normal hCG level following molar pregnancy is rare. Recommendations for frequency and duration of hCG follow-up can be minimized to lessen burden on patients and informed by the type of molar pregnancy and time interval from uterine evacuation to hCG normalization. PROSPERO, CRD42019116414." }, { "id": "Obstentrics_Williams_2678", "title": "Obstentrics_Williams", "score": 0.010667814772292384, "content": "his is the most common type of trophoblastic neoplasm to follow a term pregnancy or a miscarriage, and only a third of TABLE 20-4. International Federation of Gynecology and Obstetrics (FIGO) Staging and Diagnostic Scoring System for Gestational Trophoblastic Neoplasia Age (years) <40 :::40 Antecedent pregnancy Mole Abortion Term <103 largest tumor size (including uterus) <3 cm 3-4 cm :::5 cm Site of metastases Spleen, kidney GI Liver, brain Number of metastases Previous failed chemotherapy drugs :::2 aAdapted by FIGO. blow risk = WHO score of 0 to 6; high risk = WHO score ofs:::7. J-hCG = beta human chorionic gonadotropin; GI = gastrointestinal; GTN = gestational trophoblastic neoplasia. Adapted with permission from FIGO Committee on Gynecologic Oncology: Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia, Int J Gynaecol Obstet 2009 Apr;l 05(1 )j3-4. 4-6 7-12 >12 103 to 104 104 to 105 :::105" }, { "id": "wiki20220301en036_29127", "title": "Gestational trophoblastic disease", "score": 0.010119940029985008, "content": "Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours. These tumours are rare, and they appear when cells in the womb start to proliferate uncontrollably. The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy. There are several different types of GTD. Hydatidiform moles are benign in most cases, but sometimes may develop into invasive moles, or, in rare cases, into choriocarcinoma, which is likely to spread quickly, but which is very sensitive to chemotherapy, and has a very good prognosis. Gestational trophoblasts are of particular interest to cell biologists because, like cancer, these cells invade tissue (the uterus), but unlike cancer, they sometimes \"know\" when to stop." }, { "id": "pubmed23n0402_13285", "title": "Gestational trophoblastic disease.", "score": 0.010109498344792463, "content": "To provide standards for the diagnosis and treatment of patients with hydatidiform mole and gestational trophoblastic tumours (GTT). Prognostic factors useful for treatment decisions in GTT are defined with patients classified as low-, medium-, and high-risk groups. Improved mortality and morbidity. Evidence was gathered using Medline for relevant studies and articles from 1980 to 2001 with specific reference to diagnosis, treatment options, and outcomes. The quality of evidence of Recommendations has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. 1. Suction curettage is the preferred method of evacuation of the hydatidiform mole (III-C). Post-operative surveillance with hCG assays is essential (II-3B). 2. Low-risk patients with both non-metastatic and metastatic disease should be treated with single-agent chemotherapy, either methotrexate or dactinomycin (II-3B). 3. Medium-risk patients should usually be treated with multi-agent chemotherapy, either MAC or EMA (III-C); single-agent chemotherapy may also be used (III-C). 4. High-risk patients should be treated with multi-agent chemotherapy EMA/CO, with selective use of surgery and radiotherapy (II-3B). Salvage chemotherapy with EP/EMA and surgery should be employed in resistant disease (III-C). 5. Placental site trophoblastic tumour that is non-metastatic should be treated with hysterectomy (III-C). Metastatic disease should be treated with chemotherapy, most commonly EMA/CO (III-C).6. Women should be advised to avoid pregnancy until hCG levels have been normal for six months following evacuation of a molar pregnancy and for one year following chemotherapy for gestational trophoblastic tumour. The combined oral contraceptive pill is safe for use by women with GTT (III-C). These guidelines have been reviewed and approved by the Policy and Practice Guidelines Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC), the Gynaecologic Oncologists of Canada (GOC), the Society of Canadian Colposcopists (SCC), and by Executive and Council of the SOGC. The Society of Obstetricians and Gynaecologists of Canada." }, { "id": "wiki20220301en036_29136", "title": "Gestational trophoblastic disease", "score": 0.009852973447443493, "content": "Women who undergo chemotherapy are advised not to conceive for one year after completion of treatment. These women also are likely to have an earlier menopause. It has been estimated by the Royal College of Obstetricians and Gynaecologists that the age at menopause for women who receive single agent chemotherapy is advanced by 1 year, and by 3 years for women who receive multi agent chemotherapy. Follow up Follow up is necessary in all women with gestational trophoblastic disease, because of the possibility of persistent disease, or because of the risk of developing malignant uterine invasion or malignant metastatic disease even after treatment in some women with certain risk factors." }, { "id": "pubmed23n0367_11187", "title": "[Gestational trophoblastic disease: the epidemiological analysis of 342 cases].", "score": 0.00980392156862745, "content": "Between 1987-1996 dates were collected to assess frequency and risk factors for gestational trophoblastic disease in a case-control study of 342 women with trophoblastic tumors and 342 pregnant women admitted for deliveries or spontaneous abortion to University Hospitals in Poznan, Poland. Were analyzed the age of women obstetric history, place of live and repeat appearance of hydatidiform mole. The risk of trophoblastic disease increased with increase in maternal age and above third pregnancy. The risk independent of living in town or in the country. The second and more incident of hydatidiform mole was associated with greater risk of malignant sequele. The study of the pregnancy of gestational trophoblastic disease was led in Great Poland in the support on the date from all pathologic centres in this region and public demographic office. The frequently of hydatidiform mole was between 1987-1996 2.32 per 100,000 women, and 0.76 for 1000 live birth (1 HM for 1315 live birth). The frequently of choriocarcinoma was 0.08 per 100,000 women (and 0.38 per 10,000 live birth (1 CHA per 26,315 live birth)." }, { "id": "pubmed23n0834_6601", "title": "PP120. Hydatidiform mole as a cause of eclampsia in the first trimester: A case report.", "score": 0.009708737864077669, "content": "The occurrence of preeclampsia before the 20th week of gestation is rare and it has been associated with hydatidiform molar pregnancy. We describe a case of first trimester eclampsia which occurred in a patient with hydatidiform mole. Case report. A 16-year-old woman came to emergency service for abdominal pain and vaginal bleeding. She had been suffering of vomiting after meals and complaining for abdominal mass for 2months, without consulting her physician. The last reported period was 1month before; the patient told her periods were regular and the only disease she reported was chronic HBV hepatitis. Vital parameters were all normal. Urine pregnancy test resulted always negative. The gynecological exam reported an increased uterus and a little bleeding, so serum bhCG was performed because of the exam findings and resulted 110,5317UI/L. The transvaginal ultrasound showed images consistent with gestational trophoblastic disease. Computed tomography (CT) scan revealed the presence of an uterine mass and three lung nodules, reported as possibly metastatic. A few days later, the patient underwent dilation and curettage (D&amp;C). Second grade hydatiform mole was diagnosed by histology. After D&amp;C, the serum bhCG was 202,511UI/L. The day after, the patient presented bilateral acute blindness, followed by incoming general seizures, concurrent hypertension and tachycardia. Intravenous diazepam, levetiracetam and mannitol controlled the seizures, but the conscious state of the patient remained critical. Temperature reached 40°C, with concurrent leukocytosis. Then, a lumbar puncture was performed but it resulted negative for inflammatory/infective processes. A head CT was performed the same day and showed a posterior reversible encephalopathy syndrome (PRES). Intravenous methylprednisolone was started. Long term therapy with methylprednisolone and levetiracetam was effective and the patient's status improved and stabilized. A subsequent chemotherapy with EMA/CO regimen (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine/oncovine) was performed for six cycles, until serum bhCG resulted negative and the abdomen/pelvis ultrasound, head NMR and chest X-ray resulted normal. Preeclampsia and eclampsia are regarded as common causes of PRES, which is considered to be the result of vasogenic brain edema. Clinical and imaging findings are usually reversible. Early diagnosis and elimination of possible causes are important in order to avoid permanent visual or brain injury. Imaging (especially MRI) should be carried out in eclamptic patients with visual disturbance in order to exclude other causes of blindness. Molar pregnancy is a rare but important cause of eclampsia, and it has always to be considered in case of early manifestations." }, { "id": "wiki20220301en036_29133", "title": "Gestational trophoblastic disease", "score": 0.009680601800468615, "content": "Differential diagnosis These are not GTD, and they are not tumours Exaggerated placental site Placental site nodule Both are composed of intermediate trophoblast, but their morphological features and clinical presentation can differ significantly. Exaggerated placental site is a benign, non cancerous lesion with an increased number of implantation site intermediate trophoblastic cells that infiltrate the endometrium and the underlying myometrium. An exaggerated placental site may occur with normal pregnancy, or after an abortion. No specific treatment or follow up is necessary. Placental site nodules are lesions of chorionic type intermediate trophoblast, usually small. 40 to 50% of placental site nodules are found in the cervix. They almost always are incidental findings after a surgical procedure. No specific treatment or follow up is necessary. Treatment Treatment is always necessary." }, { "id": "Obstentrics_Williams_2689", "title": "Obstentrics_Williams", "score": 0.009648080625998607, "content": "Cormano ], Mackay G, Holschneider C: Gestational trophoblastic disease diagnosis delayed by the hook efect. Obstet GynecoIo126(4):811, 2015 Dantas PRS, Maesd. I, Filho ]R, et al: Does hormonal contraception during molar pregnancy follow-up influence the risk and clinical aggressiveness of gestational trophoblastic neoplasia after controlling for risk factors? Gynecol Oncol September 16, 2017 [Epub ahead of print] Davis MR, Howitt BE, Quade B], et al: Epithelioid trophoblastic tumor: a single institution case series at the New England Trophoblastic Disease Center. Gynecol Oncol 137(3):456,o20o15 Delmis ], Pfeifer 0, Ivanisecvic M, et al: Sudden death from trophoblastic embolism in pregnancy. Euro] Obstet Gynecol Reprod Bioi 92:225, 2000 de Medeiros SF, Norman RJ: Human chorionic gonadotrophin protein core and sugar branches heterogeneity: basic and clinical insights. Hum Reprod Update 15(1):69,o2009" }, { "id": "pubmed23n0552_19433", "title": "Estrogen and progesterone receptors and telomerase enzyme immunohistochemical detection in gestational trophoblastic tumors.", "score": 0.009615384615384616, "content": "The purpose of this study is to evaluate the immunohistochemical detection of telomerase enzyme and estrogen receptor (ER) and progesterone receptor (PGR) in gestational trophoblastic neoplasia (GTN) and its clinical significance. Formalin-fixed paraffin blocks for 30 patients (24 with molar pregnancy, 3 with choriocarcinoma, and 3 with placental site trophoblastic tumor) as cases and six products of conception samples from patients with incomplete abortion as controls were included in the study. Immunohistochemical detection of the telomerase catalytic protein and ER and PGR was carried out using streptavidin-biotin-peroxidase method. All control tissues were negative for telomerase and ER expression, while five of six were PGR positive. Significant positive telomerase expression was detected in all gestational trophoblastic tumors (three of six partial moles, 12 of 18 complete moles, three of three choriocarcinomas, and two of three placental site trophoblastic tumors). Nine of 24 molar pregnancies were followed by GTN. Molar pregnancies followed by GTN were associated with higher serum beta-hCG (human chorionic gonadotrophic hormone), larger uterine size for gestational age, negative ER expression, negative PGR expression, and positive telomerase expression. All patients with molar pregnancy with negative telomerase expression (9 of 24) showed spontaneous regression after evacuation. Positive telomerase expression and its immunohistochemical detection are associated with the development of GTN. Negative telomerase expression is highly predictive of postmolar spontaneous regression. Patients with molar pregnancies with negative telomerase expression can be saved the long-term follow-up. ER and PGR expression do not show a significantly different pattern in molar tissues, while negative expression is associated with developing GTN. Cautions on the use of postmolar hormonal contraception may be unjustified." }, { "id": "pubmed23n0383_12290", "title": "Pregnancy outcomes of patients who conceived within 1 year after chemotherapy for gestational trophoblastic tumor: a clinical report of 22 patients.", "score": 0.009615384615384616, "content": "The aim of this study was to explore the risk of pregnancy of patients who conceived within 1 year after successful chemotherapy for gestational trophoblastic tumor (GTT). From 1966 to 1996, 22 patients who conceived within 1 year after chemotherapy were followed up and analyzed retrospectively. Among 22 patients, 9 had term deliveries and 1 had a premature birth, 6 had induced abortion at the patient's request, and 6 had therapeutic abortion because of various indications such as repeated hydatidiform mole (1 case), intrauterine death (1 case), inevitable abortion (1 case), and threatened abortion (3 cases). The fetal loss rate was 27.1% (6/22). The incidence rate of gestational trophoblastic disease (GTD) was 9.1% (2/22). The incidence rate of GTT was 4.5% (1/22). The average interval between completion of chemotherapy and pregnancy was 10.25 months in the group of term pregnancies and 5.86 months in that of fetal loss (P &lt; 0.05), indicating that the longer the interval, the lesser the risk of GTD. The results suggest that contraception for 1 year is necessary in patients with GTT after successful chemotherapy. However, in the case of a patient who conceives within 1 year, it is not necessary to terminate pregnancy, but the pregnancy must be carefully watched." } ] } } }

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{ "1": "A lues serology since it is most likely a Treponema pallidum infection.", "2": "A gynecological examination to rule out ovarian cancer.", "3": "By the clinical characteristics it seems to be normal lymph nodes and complementary explorations should not be done.", "4": "A Paul-Bunell test should be performed to rule out infectious mononucleosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en154_45003", "title": "Genital ulcer", "score": 0.018957771787960466, "content": "Overview A genital ulcer may be located on the vulva, penis, perianal region, or anus. Globally, the incidence of genital ulcers is estimated to be approximately 20 million cases annually. The most likely cause of a genital ulcer varies depending on the characteristics of a population and location. The most common cause of genital ulcers in the United States is herpes simplex infections, with syphilis the second most common cause, and chancroid the third. These common causes of genital ulcer disease (HSV-1, HSV-2 and treponema pallidum) can all be efficiently transmitted through oral sex. Important signs associated with genital ulcers that may assist in the diagnosis of the cause of the genital ulcer may include the presence of tender or non-tender enlarged lymph nodes in the groin area, a painful or non-painful genital ulcer, or the presence of vesicular lesions, which are small, painful, elevated blisters." }, { "id": "wiki20220301en042_58337", "title": "Inguinal lymph nodes", "score": 0.017778128950695322, "content": "Clinical significance The presence of swollen inguinal lymph nodes is an important clinical sign because lymphadenopathy (swelling) may indicate an infection, or spread as a metastasis from cancers, such as anal cancer and vulvar cancer. Inguinal lymph nodes may normally be up to 2 cm. The cut-off value for normal sized inguinal nodes is up to 10 mm. Additional images References Lymphatic organ anatomy" }, { "id": "wiki20220301en393_31405", "title": "Inguinal lymphadenopathy", "score": 0.017713490099009903, "content": "Inguinal lymphadenopathy causes swollen lymph nodes in the groin area. It can be a symptom of infective or neoplastic processes. Infective aetiologies include Tuberculosis, HIV, non-specific or reactive lymphadenopathy to recent lower limb infection or groin infections. Another notable infectious cause is Lymphogranuloma venereum, which is a sexually transmitted infection of the lymphatic system. Neoplastic aetiologies include lymphoma, leukaemia and metastatic disease from primary tumours in the lower limb, external genitalia or perianal region and melanoma. References Further reading Inflammations Diseases of veins, lymphatic vessels and lymph nodes" }, { "id": "wiki20220301en012_95894", "title": "Lymphogranuloma venereum", "score": 0.014514462809917356, "content": "The secondary stage most often occurs 10–30 days later, but can present up to six months later. The infection spreads to the lymph nodes through lymphatic drainage pathways. The most frequent presenting clinical manifestation of LGV among males whose primary exposure was genital is unilateral (in two-thirds of cases) lymphadenitis and lymphangitis, often with tender inguinal and/or femoral lymphadenopathy because of the drainage pathway for their likely infected areas. Lymphangitis of the dorsal penis may also occur and resembles a string or cord. If the route was anal sex, the infected person may experience lymphadenitis and lymphangitis noted above. They may instead develop proctitis, inflammation limited to the rectum (the distal 10–12 cm) that may be associated with anorectal pain, tenesmus, and rectal discharge, or proctocolitis, inflammation of the colonic mucosa extending to 12 cm above the anus and associated with symptoms of proctitis plus diarrhea or abdominal cramps." }, { "id": "InternalMed_Harrison_10857", "title": "InternalMed_Harrison", "score": 0.012903993102012904, "content": "Diagnosis Although most genital ulcerations cannot be diagnosed confidently on clinical grounds alone, clinical findings (Table 163-7) FIGURE 163-5 Chancroid: multiple, painful, punched-out ulcers with undermined borders on the labia occurring after autoinoculation. Sexually Transmitted Infections: Overview and Clinical Approach FIGURE 163-6 Genital herpes. A relatively mild, superficial ulcer is typically seen in episodic outbreaks. (Courtesy of Michael Remington, University of Washington Virology Research Clinic.) FIGURE 163-7 Lymphogranuloma venereum (LGV): striking ten-der lymphadenopathy occurring at the femoral and inguinal lymph nodes, separated by a groove made by Poupart’s ligament. This “sign-of-the-groove” is not considered specific for LGV; for example, lym-phomas may present with this sign. InITIAL MAnAgEMEnT of gEnITAL oR PERIAnAL uLCER" }, { "id": "pubmed23n0999_2351", "title": "[A chancre instead of cancer].", "score": 0.012523663899810689, "content": "Syphilis (lues) is a sexually transmitted infection caused by the spirochete Treponema pallidum. In adolescents, the diagnosis of primary syphilis can be made promptly by taking a sexual medical history and inspecting the glans penis. A 17-year-old male was referred to the paediatric oncology centre for additional diagnostics due to inguinal lymphadenopathy, with a strong suspicion of a malignant lymphoma. None of the physicians took a sexual medical history or investigated the glans penis, as a result of which essential information was lacking. The combination of inguinal lymphadenopathy and the ultrasound findings for the inguinal region made the physicians only consider a malignancy. However, it actually concerned a reactive lymphadenopathy associated with primary syphilis. This case demonstrates that a full medical history and thorough physical examination can prevent the need for costly and invasive diagnostics." }, { "id": "article-32329_33", "title": "Anatomy, Abdomen and Pelvis: Female External Genitalia -- Clinical Significance -- Sexually Transmitted Infections", "score": 0.012023460410557185, "content": "Treponema pallidum : Syphilis infections result from Treponema pallidum . This infection usually manifests as a painless chancre in the primary stage. If the disease is left untreated, it will progress to the secondary stage. In the secondary stage, it manifests as fever, widespread maculopapular skin rashes involving the palms and soles,  widespread lymphadenopathy (epitrochlear node is pathognomic), and genital lesions similar to genital warts (condylomata lata- has a rounder surface when compared with condylomata acuminata). If there is still no treatment during the secondary stage, the infection will progress into the tertiary stage. The tertiary stage causes necrotic lesions called Gummas, neurological symptoms such as tabes dorsalis, Argyll Robertson pupils, and general paresis, cardiac symptoms such as aortitis. The treatment of syphilis is with the use of penicillin." }, { "id": "Gynecology_Novak_2917", "title": "Gynecology_Novak", "score": 0.011982570806100218, "content": "Several clinical presentations are highly suggestive of specific diagnoses: 1. A painless and minimally tender ulcer, not accompanied by inguinal lymphadenopathy, is likely to be syphilis, especially if the ulcer is indurated. A nontreponemal rapid plasma reagin (RPR) test, or venereal disease research laboratory (VDRL) test, and a confirmatory treponemal test—fluorescent treponemal antibody absorption (FTA ABS) or microhemagglutinin–T. pallidum (MHA TP)—should be used to diagnose syphilis presumptively. Some laboratories screen samples with treponemal enzyme immunoassay (EIA) tests, the results of which should be confirmed with nontreponemal tests. The results of nontreponemal tests usually correlate with disease activity and should be reported quantitatively. 2." }, { "id": "article-23529_0", "title": "Anatomy, Abdomen and Pelvis: Inguinal Lymph Node -- Introduction", "score": 0.010770340970593541, "content": "The inguinal lymph node can be subdivided into the superficial and deep lymph nodes and collectively drains the anal canal(below the pectinate line), the skin below the umbilicus, lower extremity, scrotum, vulva, glans penis, and clitoris. The lymph node's primary function is to filter for harmful substances as lymphatic fluids travel through its cortex, paracortex, and medulla. Clinical signs of inguinal lymphadenopathy can help to clue physicians in possible diagnoses of sexually transmitted diseases such as syphilis, chancroid, and lymphogranuloma venereum. The lymph node can also serve to assist in the diagnosis of cancer." }, { "id": "article-23529_10", "title": "Anatomy, Abdomen and Pelvis: Inguinal Lymph Node -- Clinical Significance -- Lymphadenopathy", "score": 0.010652680652680654, "content": "Syphilis is a bacterial infection caused by the spirochete Treponema pallidum. Clinical presentation of secondary syphilis can present with diffuse lymphadenopathy along with fever, skin rashes, and condylomata lata. [7] Chancroid" }, { "id": "article-28956_50", "title": "Sexually Transmitted Infections -- History and Physical -- Granuloma Inguinale", "score": 0.010634061789988991, "content": "Females and males: Signs and symptoms: Patients will present with highly vascularized lesions over the genitals and perineum that tend to be painless. [37] [38] It can cause severe scarring. Physical Exam: Typical findings include ulcer-like lesions that are beefy red, consistent with high vascularization that bleeds easily with manipulation. Subcutaneous granulomas may be present, but lymphadenopathy is uncommon. The lesions tend to be relatively large and irregular. It is often found to be associated with secondary infections. Four main lesions can be seen on examination: 1. Ulcerovegetative: large painless ulcer on the patient's physical exam. 2. Nodular: soft and erythematous that tend to ulcerate throughout the infectious process. 3. Cicatricial: dry ulcerations that tend to transition into plaques. 4. Hypertrophic: lesions are thick and painless. [37] [39]" }, { "id": "article-23529_8", "title": "Anatomy, Abdomen and Pelvis: Inguinal Lymph Node -- Clinical Significance -- Lymphadenopathy", "score": 0.01052548274770497, "content": "Swollen lymph nodes usually indicate infection from bacteria or viruses. Swollen inguinal lymph nodes could indicate an infection of areas of the lower body. One of the more concerning causes of inguinal lymphadenopathy is sexually transmitted infections. Sexually transmitted infections that commonly presents with inguinal lymphadenopathy are lymphogranuloma venereum, secondary syphilis, and chancroid caused by Chlamydia trachomatis (L1-L3), Treponema pallidum , and Haemophilus ducreyi , respectively. Lymphogranuloma venereum" }, { "id": "wiki20220301en013_140385", "title": "Yaws", "score": 0.00980392156862745, "content": "Serological tests cannot distinguish yaws from the closely related syphilis; no test distinguishing yaws from syphilis is widely available. The two genomes differ by about 0.2%. PCR and DNA sequencing can distinguish the two. There are also no common blood tests which distinguish among the four treponematoses: syphilis (Treponema pallidum pallidum), yaws (Treponema pallidum pertenue), bejel (Treponema pallidum endemicum), and pinta (Treponema carateum). Haemophilus ducreyi infections can cause skin conditions that mimic primary yaws. People infected with Haemophilus ducreyi lesions may or may not also have latent yaws, and thus may or may not test positive on serological tests. This was discovered in the mid 2010s. It seems that a recently diverged strain of Haemophilus ducreyi has evolved from being a sexually transmitted infection to being a skin ulcer pathogen that looks like yaws. Yaws has been reported in nonendemic countries." }, { "id": "InternalMed_Harrison_4570", "title": "InternalMed_Harrison", "score": 0.009734428122393996, "content": "node is an enlarged left supraclavicular node infiltrated with metastatic cancer from a gastrointestinal primary. Metastases to supraclavicular nodes also occur from lung, breast, testis, or ovarian cancers. Tuberculosis, sarcoidosis, and toxoplasmosis are nonneoplastic causes of supraclavicular adenopathy. Axillary adenopathy is usually due to injuries or localized infections of the ipsilateral upper extremity. Malignant causes include melanoma or lymphoma and, in women, breast cancer. Inguinal lymphadenopathy is usually secondary to infections or trauma of the lower extremities and may accompany sexually transmitted diseases such as lymphogranuloma venereum, primary syphilis, genital herpes, or chancroid. These nodes may also be involved by lymphomas and metastatic cancer from primary lesions of the rectum, genitalia, or lower extremities (melanoma)." }, { "id": "wiki20220301en302_4978", "title": "Cervical lymphadenopathy", "score": 0.009708737864077669, "content": "Cervical lymphadenopathy is a sign or a symptom, not a diagnosis. The causes are varied, and may be inflammatory, degenerative, or neoplastic. In adults, healthy lymph nodes can be palpable (able to be felt), in the axilla, neck and groin. In children up to the age of 12 cervical nodes up to 1 cm in size may be palpable and this may not signify any disease. If nodes heal by resolution or scarring after being inflamed, they may remain palpable thereafter. In children, most palpable cervical lymphadenopathy is reactive or infective. In individuals over the age of 50, metastatic enlargement from cancers (most commonly squamous cell carcinomas) of the aerodigestive tract should be considered. Classification Cervical lymphadenopathy can be thought of as local where only the cervical lymph nodes are affected, or general where all the lymph nodes of the body are affected. Causes" }, { "id": "InternalMed_Harrison_10874", "title": "InternalMed_Harrison", "score": 0.009708737864077669, "content": "adenopathy that is sometimes mistaken for malignancy; syphilis, LGV, HSV infection, and chancroid involving the anus can produce inguinal adenopathy because anal lymphatics drain to inguinal lymph nodes." }, { "id": "pubmed23n0954_11063", "title": "Unusual Manifestations of Secondary Syphilis: Case Presentations.", "score": 0.009615384615384616, "content": "Dear Editor, Syphilis is an infection caused by Treponema pallidum. Without treatment, it goes through the following stages: primary, secondary, latent, and tertiary (1). The clinical picture of secondary syphilis is very variable (2,3). We present two rare cases of secondary syphilis, one with nodular lesions initially considered to be lymphoma and second with periostitis, which was initially interpreted as an osteoma. To date, only 15 cases with nodular lesions and 10 cases with periostitis in secondary syphilis have been reported in the literature. The first patient was a 59 year old man who presented in a private practice with nodular lesions on the face and axillary and inguinal folds (Figure 1, a, b). The initial diagnostic consideration was lymphoma. A biopsy specimen was taken, and the histopathological features revealed epidermal hyperplasia with papillomatosis, minimal spongiosis with many neutrophils and with a marked inflammatory infiltrate in dermis, consisting of lymphocytes, plasma cells, and neutrophils; the diagnosis of interfaced dermatitis was established (Figure 1, d, e). After one month, the patient presented to our clinic with numerous nodular lesions, some of them painful, located on the trunk and intertriginous folds, including the intergluteal cleft - the lesions in this area being suggestive of condylomata lata (Figure 1, c). The diagnosis of secondary syphilis was taken into consideration, and screening serum tests were performed and found reactive: a Venereal Diseases Research Laboratory (VDRL) titer of 1:64 and Treponema pallidum Hemaglutination Assay (TPHA) titer of 1:80. Hepatitis and anti-human immunodeficiency virus (HIV) antibodies serology was negative. The biopsy was repeated and showed the same histopathological changes. In addition, Warthin-Starry staining was performed, revealing the presence of some spiral micro-organisms in the dermis corresponding to Treponema pallidum (Figure 1, f). A diagnosis of secondary syphilis was established, and the patient was treated with benzathine penicillin G 2.4 million units by intramuscular injection once a week for 2 consecutive weeks. The skin lesions regressed within 1 month, and serological tests showed a VDRL titer of 1:8 3 months after treatment. The second patient was a homosexual male, 35 years old, diagnosed with HIV infection, stage B2. He presented with bone pain in the calves and forearms, with insidious onset. He also presented with an associated erythematous maculo-papular rash on the trunk and limbs and generalized lymphadenopathy (Figure 2, a, b). The tibial crest and radius were sensitive to palpation. A right leg radiography was performed, raising suspicion of osteoid osteoma. The CT scan excluded the diagnosis of osteoma; taking into account the epidemiological context, the diagnosis of syphilis was suspected. The diagnosis was confirmed by leg ultrasound examination (2D US) which showed thickening of the compact tibial bone associated with subperiosteal destructive and proliferative changes (Figure 2, c, d) and by serology for syphilis: the VDRL titer was 1:32 and the TPHA titer was 1:80. The patient was treated with benzathine penicillin 2.4 million units, once a week, for 2 consecutive weeks, with clinical improvement. Syphilis continues to be a serious public health problem worldwide, even if it is a controllable disease due to diagnostic tests and effective and accessible treatment. According to the World Health Organization in 2008, the estimated number of new cases of sexually transmitted diseases in adults with syphilis is 10.6 million cases (4). The cases presented in this paper were characterized by unusual manifestations, requiring good collaboration between the dermatologist and other specialties. In the first case, the diagnosis of secondary syphilis was confirmed by positive serological, clinical, and histopathological findings. The main differential diagnosis of nodular syphilis includes lymphoma, sarcoidosis, Kaposi's sarcoma, atypical mycobacteriosis, deep fungal infections, leprosy, tuberculosis, leishmaniasis, and lymphomatoid papulosis (5). Another important differential diagnosis is between secondary and tertiary syphilis, especially when ulcerating nodules are present. Tertiary syphilis is characterized by unilateral, deep ulcerating nodules with necrotizing granulomas (6). Bone involvement during syphilis is mainly represented by polyarthritis, synovitis, osteitis, and periostitis (7,8). Syphilitic periostitis is characterized by localized or diffuse pain, particularly during the night, which is relieved by movement. The skull, the shoulder girdle, and the long bones are the most common sites of involvement (9). In conclusion, we presented two different cases of secondary syphilis that contribute to the clinical experience of rare cases presented in the literature, raising the awareness of dermatologists and other specialists about less specific clinical aspects of syphilis." }, { "id": "article-28956_53", "title": "Sexually Transmitted Infections -- History and Physical -- Lymphogranuloma venereum (LGV)", "score": 0.009615384615384616, "content": "Females and males: Signs and symptoms: Patients will present with painful lymphadenopathy localized to the inguinal area. Patients may note the initial presentation of a pustule that gradually progresses to large painful ulceration. [41] Men tend to present with early or acute stages, while women typically present much later. [19] Physical Exam: Lymphogranuloma venereum presents with two stages: Primary phase is a small painless papule/pustule that will ulcerate and can be visualized throughout the affected genital area. During the secondary phase, patients present with unilateral lymphadenopathy that is fluctuant with palpation or may be suppurative in a presentation known as buboes. [38] Buboes tend to rupture in the acute phase and progress to a thickened mass. [42]" }, { "id": "InternalMed_Harrison_4562", "title": "InternalMed_Harrison", "score": 0.009574110708820126, "content": "Lymphadenopathy may be an incidental finding in patients being examined for various reasons, or it may be a presenting sign or symptom of the patient’s illness. The physician must eventually decide whether the lymphadenopathy is a normal finding or one that requires further study, up to and including biopsy. Soft, flat, submandibular nodes (<1 cm) are often palpable in healthy children and young adults; healthy adults may have palpable inguinal nodes of up to 2 cm, which are considered normal. Further evaluation of these normal nodes is not warranted. In contrast, if the physician believes the node(s) to be abnormal, then pursuit of a more precise diagnosis is needed. APPROACH TO THE PATIENT:" }, { "id": "article-28956_39", "title": "Sexually Transmitted Infections -- History and Physical -- Chancroid", "score": 0.00955787720493603, "content": "Females and males: Signs and symptoms: Often occurs in the 20 to 30-year-old age group, frequently among sex workers and their clients. The areas most often affected include the distal portion of the penis in men, while in women, the vagina, labia, and perianal regions are involved. The most significant symptom is the extremely high pain level noted when the lesion reaches the ulcerative stage. [6] Physical Exam: The lesion starts as a reddish papule which rapidly progresses to a pustule followed by an extremely painful ulcer. The ulcer sometimes called a \"soft chancre,\" will have soft and irregular margins with a friable base and a grayish-yellowish exudate. It tends to bleed easily. The ulcers are typically 1 cm to 2 cm in diameter and usually resolve spontaneously within three months, even if left untreated. Close to half of the affected individuals will develop regional lymphadenopathy, which may be tender. A minority (about 25%) of these patients will progress to infected bulla or abscesses, which can rupture and become superinfected leading to significant tissue destruction and damage to the genitalia. It is estimated that 10% of affected individuals will also have syphilis or genital herpes as well." }, { "id": "InternalMed_Harrison_9486", "title": "InternalMed_Harrison", "score": 0.009544270585774855, "content": "Approach to the Patient with an Infectious Disease regions (e.g., popliteal, inguinal, epitrochlear, axillary, multiple cervical regions), with notation of the location, size (normal, <1 cm), presence or absence of tenderness, and consistency (soft, firm, or shotty) and of whether the nodes are matted (i.e., connected and moving together). Of note, palpable epitrochlear nodes are always pathologic. Of patients presenting with lymphadenopathy, 75% have localized findings, and the remaining 25% have generalized lymphadenopathy (i.e., that involving more than one anatomic region). Localized lymphadenopathy in the head and neck region is found in 55% of patients, inguinal lymphadenopathy in 14%, and axillary lymphadenopathy in 5%. Determining whether the patient has generalized versus localized lymphadenopathy can help narrow the differential diagnosis, as various infections present differently." }, { "id": "wiki20220301en032_60070", "title": "Lymphadenopathy", "score": 0.009523809523809525, "content": "Lymph node enlargement is recognized as a common sign of infectious, autoimmune, or malignant disease. Examples may include: Reactive: acute infection (e.g., bacterial, or viral), or chronic infections (tuberculous lymphadenitis, cat-scratch disease). The most distinctive sign of bubonic plague is extreme swelling of one or more lymph nodes that bulge out of the skin as \"buboes.\" The buboes often become necrotic and may even rupture. Infectious mononucleosis is an acute viral infection usually caused by Epstein-Barr virus and may be characterized by a marked enlargement of the cervical lymph nodes. It is also a sign of cutaneous anthrax and Human African trypanosomiasis Toxoplasmosis, a parasitic disease, gives a generalized lymphadenopathy (Piringer-Kuchinka lymphadenopathy). Plasma cell variant of Castleman's disease - associated with HHV-8 infection and HIV infection" }, { "id": "pubmed23n0900_17463", "title": "Scrotal lymphangioma circumscriptum.", "score": 0.009433962264150943, "content": "Lymphangioma circumscriptum (LC) is anuncommon, benign, cutaneous disorder thatinvolves lymphatic dilatation to cause vesicularand papular lesions on the trunk, extremities, andanogenital areas. It may be a diagnostic challengewhen appearing in the anogenital region andoften is misdiagnosed and mistreated as infectiousetiologies, which include molluscum contagiosumand condylomata accuminata. We report a healthy40-year-old man with a six-month history of aneruption of multiple, asymptomatic, scrotal papulesthat were diagnosed as lymphangiomas. Awarenessof scrotal LC in adult men without prior disease orsymptoms is necessary for proper diagnosis andavoidance of unnecessary treatment." }, { "id": "wiki20220301en071_45148", "title": "Sézary disease", "score": 0.009345794392523364, "content": "Generalized erythroderma– redness of the skin Lymphadenopathy – swollen, enlarged lymph nodes Atypical T-cells – malignant lymphocytes known as \"Sézary cells\" seen in the peripheral blood with typical cerebriform nuclei (brain-shaped, convoluted nuclei) Hepatosplenomegaly– enlarged liver and spleen Palmoplantar keratoderma – thickening of the palms of the hands, and soles of the feet Diagnosis Those who have Sézary disease often present with skin lesions that do not heal with normal medication. A blood test generally reveals any change in the levels of lymphocytes in the blood, which is often associated with a cutaneous T-cell lymphoma. Finally, a biopsy of a skin lesion can be performed to rule out any other causes." }, { "id": "InternalMed_Harrison_12283", "title": "InternalMed_Harrison", "score": 0.009345794392523364, "content": "The presentation of chancroid does not usually include all of the typical clinical features and is sometimes atypical. Multiple ulcers can coalesce to form giant ulcers. Ulcers can appear and then resolve, with inguinal adenitis (Fig. 182-2) and suppuration following 1–3 weeks later; this clinical picture can be confused with that of lymphogranuloma venereum (Chap. 213). Multiple small ulcers can resemble folliculitis. Other differential diagnostic considerations include the various infections causing genital ulceration, such as primary syphilis, secondary syphilis (condyloma latum), genital herpes, and donovanosis. In rare cases, chancroid lesions become secondarily infected with bacteria; the result is extensive inflammation. FIGURE 182-2 Chancroid with characteristic penile ulcers and associated left inguinal adenitis (bubo)." }, { "id": "pubmed23n0805_14300", "title": "Primary syphilis of the oropharynx: an unusual location of a chancre.", "score": 0.009259259259259259, "content": "A 33-year-old man presented with a two-week history of an asymptomatic ulcer of the oropharynx and submandibular lymph nodes swelling. Laboratory examinations were normal, but serological tests revealed positivity for rapid plasma reagin, Treponema pallidum haemagglutination assay and anti-T. pallidum IgM antibodies. Since the patient denied any homosexual relationship, a biopsy of the lesion was performed, which confirmed primary syphilis. The patient received an intramuscular injection of Benzathine Penicillin G (2.4 MU) with complete resolution of the lesion. Extragenital chancres occur in at least 5% of patients with primary syphilis, and the oral mucosa is the most frequent location as a consequence of orogenital/oroanal contact with an infectious lesion. Because of their transient nature, these oral ulcerations are often underestimated by the patient or by any unsuspecting clinician. Health professionals should consider the recent sexual history of their patients and should be prepared to recognise oral and systemic manifestations of sexually transmitted infections. " }, { "id": "wiki20220301en017_7708", "title": "Chancroid", "score": 0.009259259259259259, "content": "About half of infected men have only a single ulcer. Women frequently have four or more ulcers, with fewer symptoms. The ulcers are typically confined to the genital region most of the time. The initial ulcer may be mistaken as a \"hard\" chancre, the typical sore of primary syphilis, as opposed to the \"soft chancre\" of chancroid. Approximately one-third of the infected individuals will develop enlargements of the inguinal lymph nodes, the nodes located in the fold between the leg and the lower abdomen. Half of those who develop swelling of the inguinal lymph nodes will progress to a point where the nodes rupture through the skin, producing draining abscesses. The swollen lymph nodes and abscesses are often referred to as buboes." }, { "id": "pubmed23n0668_207", "title": "Oropharyngeal lesions and cervical lymphadenopathy: syphilis is a differential diagnosis that is still relevant.", "score": 0.009174311926605505, "content": "Syphilis (lues), a chronic infectious disease caused by Treponema pallidum, has been increasing in incidence during the last few years. Therefore, while clinically it is often not suspected, syphilis is increasingly becoming a differential diagnosis in routine pathology. To report our experience with five cases of cervical lymphadenopathy and/or oropharyngeal lesions, clinically thought to be lymphomas, lymph node metastases or carcinoma, in which we made the mostly clinically unsuspected diagnosis of syphilis. Fine needle aspiration of enlarged cervical lymph nodes was evaluated by cytology and flow cytometry (fluorescence-activated cell sorting analysis), and biopsies were examined by using histology. In addition, all materials were also subjected to immunostaining, silver staining and molecular (PCR) testing. Fine needle aspiration cytology revealed follicular hyperplasia in two cases and granulomatous lymphadenitis in one case. In three patients, concomitant biopsy of co-existing oropharyngeal lesions revealed histological findings compatible with syphilis. T pallidum was detected in all cytological and histological samples by immunohistochemistry/immunocytochemistry and PCR. Subsequently, a diagnosis of syphilis was confirmed clinically and by serology. Syphilitic lymphadenitis is still a relevant differential diagnosis of cervical lymphadenopathy, and it is clinically often not suspected. Co-existing oropharyngeal lesions should alert the physician to this differential diagnosis; and lesions with compatible morphology should be tested with immunohistochemistry and immunocytochemistry and/or molecular analysis to confirm the diagnosis of syphilis." }, { "id": "wiki20220301en067_61541", "title": "Sexual health clinic", "score": 0.009174311926605505, "content": "In a private room or space, the patient will partially undress. The clinician may inspect the patient's: Throat and lymph nodes of the neck for inflammation Pubic hair for lice Lymph nodes of the groin for swelling Genitals, anus, and surrounding areas for sores and warts The clinician may swab the patient's: Throat to test for gonorrhea and possibly chlamydia Cheek, inside, to diagnose HIV Sores of the genitals, anus, and surrounding areas to test for herpes Urethra to test for gonorrhea and possibly chlamydia Vagina to test for chlamydia and possibly gonorrhea Cervix to test for cervical intraepithelial neoplasia (a Pap test) Rectum to test for gonorrhea and possibly chlamydia The clinician may take small blood samples by pricking a finger or from a vein to test for HIV, syphilis, and possibly herpes and hepatitis C." }, { "id": "pubmed23n0693_21371", "title": "Disseminated lupus vulgaris.", "score": 0.00909090909090909, "content": "A 28-year-old woman presented with reddish raised, shiny lesions over the face and ears present for the past 3 years. Four years ago, she developed in her left axilla a nodule that became fluctuant and tender, which ruptured to discharge seropurulent material. It subsided after the patient had received antibiotics for 6 months, leaving puckered scarring. There was no history of antituberculous treatment. After 1 year, she developed papulonodular lesions on her face, nose, and ears. There was now a history of malaise, fever, dry cough, and anorexia and weight loss for the past 2 months. The patient was fully vaccinated in childhood, including against varicella infection. The general physical examination revealed lymphadenopathy involving cervical, axillary, and inguinal lymph nodes 0.5 x 0.5 cm to 1 x 1.5 cm, firm in consistency, and nontender. They were discrete except in the left axilla where multiple matted lymph nodes were present with overlying scarring and a papule. Her systemic examination was normal. Cutaneous examination showed a shiny erythematous plaque 3x2 cm with central atrophy and scarring on the face (Figure). It was comprised of multiple shiny nontender soft papules arranged in annular configuration. Similar discrete papules and nodules with adherent fine scaling were seen bilaterally on the alar prominence of the nose, lower lip, and post-auricular area. On diascopy, apple jelly nodules were seen. The hemogram, liver function tests, and renal function tests were normal, except for an elevated erythrocyte sedimentation rate. The Mantoux test showed erythema and an induration of 20 x 20 cm. A posteroanterior view on the chest x-ray showed fibrotic changes suggestive of pulmonary tuberculosis. Ultrasonography of the abdomen and pelvis showed no tubercular foci. Human immunodeficiency virus serology by enzyme-linked immunosorbent assay with 3 different kits was nonreactive. Histopathology from a nodule showed a focally thinned-out epidermis with follicular plugging and multiple epithelioid cell granulomas, rimmed by lymphocytes in the deeper portion of the dermis, mainly peri-appendageal. Stain for acid-fast bacteria was negative. Cultures from the skin lesions were negative. The patient was diagnosed as having lupus vulgaris with multiple lesions of varying morphology at different sites with pulmonary tuberculosis and healed lymph node involvement." }, { "id": "pubmed23n0366_8796", "title": "[Peripheral lymphadenopathy in childhood--recommendations for diagnostic evaluation].", "score": 0.009009009009009009, "content": "Enlargement of peripheral lymph nodes most commonly caused by a local inflammatory process is frequently seen in childhood. The aim of the present study was to analyze the most common causes of peripheral lymphadenopathy and to develop a simple algorithm for the primary diagnostic evaluation of peripheral lymph node enlargement in this age group. Between April and September 1999 87 unselected children (median age: 5 1/2 years) with peripheral lymphadenopathy were referred to the Department of Pediatrics, University of Graz, for further investigation. EBV infection was diagnosed in 20 (23.0%) children. 19 (21.8%) patients had acute bacterial lymphadenitis. In 21 (24.1%) patients lymph node enlargement was classified as \"post/parainfectious (viral)\". Four patients each had toxoplasmosis and cat scratch disease. In 11 (12.6%) patients neither physical nor laboratory examinations revealed pathologic results. Among the remaining 8 children sarcoidosis and Hodgkin disease was diagnosed in one patient each. Small, soft, mobile, nontender, cervical, axillary or inguinal lymph nodes do not require further investigations. In case of enlarged, tender lymph nodes with overlying skin erythema and fever diagnostic evaluation should include complete blood count, erythrocyte sedimentation rate and/or c-reactive protein level, supplemented by appropriate antibody testing (EBV, CMV, Toxoplasma gondii, Bartonella henselae). Firm, enlarged, painless lymph nodes which are matted together and fixed to the skin or underlying tissues necessitate a more detailed diagnostic evaluation in order to exclude malignant or granulomatous diseases. Our study demonstrated that primary diagnostic evaluation of childhood peripheral lymphadenopathy is mainly based on clinical grounds. In most cases a small number of additionally performed laboratory tests allow to correctly identify the cause of the peripheral lymph node enlargement." }, { "id": "Gynecology_Novak_2919", "title": "Gynecology_Novak", "score": 0.009009009009009009, "content": "3. One to three extremely painful ulcers, accompanied by tender inguinal lymphadenopathy, are unlikely to be anything except chancroid. This is especially true if the adenopathy is fluctuant. 4. An inguinal bubo accompanied by one or several ulcers is most likely chancroid. If no ulcer is present, the most likely diagnosis is LGV. Recommended regimens for the treatment of chancroid include azithromycin, 1 g orally in a single dose; ceftriaxone, 250 mg intramuscularly in a single dose; ciprofloxacin, 500 mg orally twice a day for 3 days; or erythromycin base, 500 mg orally four times daily for 7 days. Patients should be reexamined 3 to 7 days after initiation of therapy to ensure the gradual resolution of the genital ulcer, which can be expected to heal within 2 weeks unless it is unusually large." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 201, 334 ] ], "word_ranges": [ [ 28, 50 ] ], "text": "In osteoporosis, one of the main risks associated with increased fracture risk is low adherence to treatment, so answer 1 is correct." }, "2": { "exist": true, "char_ranges": [ [ 335, 520 ] ], "word_ranges": [ [ 50, 80 ] ], "text": "Answer 2 is found in the SER guidelines, which confirm that some studies conclude that bone remodeling markers can be useful for early monitoring of adherence and response to treatment." }, "3": { "exist": true, "char_ranges": [ [ 831, 1114 ] ], "word_ranges": [ [ 127, 164 ] ], "text": "Patients on pharmacological treatment for OP should use calcium and vitamin D supplements because practically all clinical trials that have demonstrated efficacy of antiosteoporotic drugs routinely include calcium supplements and cholecalciferol (vitamin D3), but not in monotherapy." }, "4": { "exist": true, "char_ranges": [ [ 521, 770 ] ], "word_ranges": [ [ 80, 117 ] ], "text": "Answer 4 is correct because again in the SER 2019 guidelines they quote: \"The current scientific evidence allows us to affirm that neither increasing dietary calcium nor taking calcium supplements alone protects against the appearance of fractures\"." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Low adherence to treatment is associated with an increased risk of fracture.", "2": "Bone remodeling markers may be useful for early monitoring of response to treatment.", "3": "Vitamin D monotherapy is effective in reducing such fractures in non-institutionalized elderly.", "4": "Increasing dietary calcium or taking calcium supplements alone does not protect against the occurrence of fractures.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0298_13589", "title": "Prevention of hip fractures by correcting calcium and vitamin D insufficiencies in elderly people.", "score": 0.018442971273159952, "content": "For a 50-year old caucasian woman today, the risk of a hip fracture over her remaining lifetime is about 17%. Tomorrow the situation will clearly be worse because the continual increase in life expectancy will cause a 3-fold rise in worldwide fracture incidence over the next 60 years, particularly in women, but also in men. In addition, a secular increase in the incidence of hip fractures in individuals of the same age has been noted in both sexes by several investigators, and the cost of hip fractures is expected to dramatically increase in the next decades. Consequently, preventive strategies are urgently required. A great deal has been learned in recent years about the risk factors for hip fracture, the pathophysiology of this fracture, and the prediction of fracture risk, particularly through bone mass measurements on the hip and biochemical evaluations of parathyroid and vitamin D status. The two main determinants of hip fractures are falls and bone loss leading to an intrinsic femoral fragility. A substantial femoral bone loss continues throughout the old age, with a continuous and exponential increase in the risk of hip fracture, and any reduction or arrest of this loss will induce an important reduction in the incidence of hip fractures. A preventive effect on the risk of hip fracture may be partly achieved by using long term estrogen replacement therapy after menopause, but also by using vitamin D and calcium supplements for a late prevention in elderly people. Vitamin D insufficiency and deficit in calcium intake are very common in elderly people living either in institutions or at home, particularly in Europe where dairy products are not fortified with vitamin D. The cumulative response to this deficit in calcium intake and low vitamin D status is a negative calcium balance which stimulates parathyroid hormone secretion. In 300 residents of nursing homes, we recently found a significant negative correlation between serum 25 OHD and log serum PTH after age-adjustment. In addition, in 446 elderly women living at home in 5 French cities and selected from the voting lists, we also found an age-adjusted relationship between serum 25 OHD and PTH concentrations. This senile secondary hyperparathyroidism is one of the determinants of femoral bone loss and can be reversed by calcium and vitamin D supplements. We have shown in a 3-year controlled prospective study that the daily use of these supplements (1.2 g of calcium and 800 IU of vitamin D3) given in a large population of 3270 elderly ambulatory women living in nursing homes reduced of 23% (intention-to-treat analysis) the number of hip fractures and other non vertebral fractures. In parallel, serum perathyroid hormone concentration was reduced of 28% and low serum 25-hydroxyvitamin D concentration returned to normal values. After 18 months of treatment the bone density of the total proximal femoral region had increased 2.7% the vitamin D3-calcium group and decreased 4.6% in the placebo group (p &lt; 0.001). This prevention is safe and can be recommended in people living in institutions. It could be also useful in other elderly subjects particularly at risk because of a low calcium intake, an absence of solar exposure and a previous history of falls. From the data of our study we assessed the economic consequences in terms of medical cost of this prevention. In case of treatment of all women living in nursing homes in France, this would saved FF 150000000 per year, the economic balance of prevention becoming positive as soon as the age of the beginning of the prevention reaches 73.5 years. It is now possible to partly stop bone loss in elderly people and it is never too late to prevent hip fractures with calcium and vitamin D supplements." }, { "id": "pubmed23n0655_3344", "title": "Efficacy of vitamin D3 supplementation in preventing fractures in elderly women: a meta-analysis.", "score": 0.016662057522123894, "content": "The efficacy of vitamin D(3) in preventing fractures and falls has been explored in a number of clinical trials. However, recent evidence revealed new questions about the adequate doses of vitamin D(3) supplementation and its efficacy in fracture prevention independent of calcium supplements for various types of fractures. To conduct a meta-analysis to estimate the effectiveness of 800 IU daily vitamin D(3) supplementation for increasing bone mineral density (BMD) and preventing fractures in postmenopausal women. Medline and EMBASE were searched for controlled trials comparing the effectiveness of cholecalciferol (vitamin D(3)) against placebo with or without background calcium supplementation in the treatment of postmenopausal women. Eight controlled trials evaluating the effect of vitamin D(3) supplementation with or without calcium were assessed. Of 12 658 women included in a Bayesian meta-analysis, 6089 received vitamin D(3) (with or without calcium) and 6569 received placebo (with or without calcium). Compared to placebo, vitamin D(3) with calcium supplementation showed beneficial effects on the incidence of non-vertebral (odds ratio [OR] 0.77, 95% credibility limit [CL] 0.6-0.93) and hip (OR 0.70, 95% CL 0.53-0.90) fractures, while the effects on non-vertebral-non-hip fractures (OR 0.84, 95% CL 0.67-1.04) % point increase) were associated with more uncertainty. Vitamin D(3) supplementation showed a 70% probability of being a better treatment than placebo for the prevention of non-vertebral fractures, hip fractures, and non-vertebral, non-hip fractures. Compared to calcium supplementation, vitamin D(3) plus calcium reduced non-vertebral fractures (OR 0.68, 95% CL 0.43-1.01) and non-vertebral, non-hip fractures (OR 0.64, 95% CL 0.38-0.99), but did not reduce hip fractures (OR 1.03, 95% CL 0.39-2.25). Key limitations to this analysis include a small number of studies and heterogeneity in the study populations. This meta-analysis supports the use of vitamin D3 of 800 IU daily to reduce the incidence of osteoporotic non-vertebral, hip, and non-vertebral-non-hip fractures in elderly women. Vitamin D(3) with calcium appears to achieve benefits above those attained with calcium supplementation alone for non-vertebral and non-vertebral-non-hip fractures." }, { "id": "pubmed23n0275_4712", "title": "Prevention of hip fractures.", "score": 0.016387959866220735, "content": "For a 50-year old Caucasian woman today, the risk of a hip fracture over her remaining life-time is about 17%. Tomorrow the situation will clearly be worse because the continuous increase in life expectancy will cause a three-fold increase in worldwide fracture incidence over the next 60 years. Through diagnostic bone mass measurements at the hip and assessment of biochemical parameters, a great deal has been learned in recent years about reduction of hip fracture risk. Preventive strategies are based on prevention of falls, use of hip protectors, and prevention of bone fragility. The latter includes the optimization of peak bone mass during childhood, postmenopausal estrogen replacement therapy, and also late prevention consisting in reversing senile secondary hyperparathyroidism, which plays an important role in the decrease of skeletal strength. This secondary hyperparathyroidism, which results from both vitamin D insufficiency and low calcium intake, is preventable with vitamin D3 and calcium supplements. They have recently been shown capable of providing effective prevention of hip fractures in elderly women living in nursing homes, with a reduction of about 25% in the number of hip fractures noted in a 3-year controlled study in 3,270 women (intention-to-treat analysis). In conclusion, it is never too early to reduce the risk of osteoporosis and never too late to prevent hip fractures." }, { "id": "pubmed23n0671_592", "title": "Reducing fracture risk with calcium and vitamin D.", "score": 0.01628327733264409, "content": "Studies of vitamin D and calcium for fracture prevention have produced inconsistent results, as a result of different vitamin D status and calcium intake at baseline, different doses and poor to adequate compliance. This study tries to define the types of patients, both at risk of osteoporosis and with established disease, who may benefit from calcium and vitamin D supplementation. The importance of adequate compliance in these individuals is also discussed. Calcium and vitamin D therapy has been recommended for older persons, either frail and institutionalized or independent, with key risk factors including decreased bone mineral density (BMD), osteoporotic fractures, increased bone remodelling as a result of secondary hyperparathyroidism and increased propensity to falls. In addition, treatment of osteoporosis with a bisphosphonate was less effective in patients with vitamin D deficiency. Calcium and vitamin D supplementation is a key component of prevention and treatment of osteoporosis unless calcium intake and vitamin D status are optimal. For primary disease prevention, supplementation should be targeted to those with dietary insufficiencies. Several serum 25-hydroxyvitamin D (25(OH)D) cut-offs have been proposed to define vitamin D insufficiency (as opposed to adequate vitamin D status), ranging from 30 to 100 nmol/l. Based on the relationship between serum 25(OH)D, BMD, bone turnover, lower extremity function and falls, we suggest that 50 nmol/l is the appropriate serum 25(OH)D threshold to define vitamin D insufficiency. Supplementation should therefore generally aim to increase 25(OH)D levels within the 50-75 nmol/l range. This level can be achieved with a dose of 800 IU/day vitamin D, the dose that was used in successful fracture prevention studies to date; a randomized clinical trial assessing whether higher vitamin D doses achieve a greater reduction of fracture incidence would be of considerable interest. As calcium balance is not only affected by vitamin D status but also by calcium intake, recommendations for adequate calcium intake should also be met. The findings of community-based clinical trials with vitamin D and calcium supplementation in which compliance was moderate or less have often been negative, whereas studies in institutionalized patients in whom medication administration was supervised ensuring adequate compliance demonstrated significant benefits." }, { "id": "pubmed23n0396_7604", "title": "Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study.", "score": 0.0162569649295313, "content": "Vitamin D insufficiency and low calcium intake contribute to increase parathyroid function and bone fragility in elderly people. Calcium and vitamin D supplements can reverse secondary hyperparathyroidism thus preventing hip fractures, as proved by Decalyos I. Decalyos II is a 2-year, multicenter, randomized, double-masked, placebo-controlled confirmatory study. The intention-to-treat population consisted of 583 ambulatory institutionalized women (mean age 85.2 years, SD = 7.1) randomized to the calcium-vitamin D3 fixed combination group (n = 199); the calcium plus vitamin D3 separate combination group (n = 190) and the placebo group (n = 194). Fixed and separate combination groups received the same daily amount of calcium (1200 mg) and vitamin D3 (800 IU), which had similar pharmacodynamic effects. Both types of calcium-vitamin D3 regimens increased serum 25-hydroxyvitamin D and decreased serum intact parathyroid hormone to a similar extent, with levels returning within the normal range after 6 months. In a subgroup of 114 patients, femoral neck bone mineral density (BMD) decreased in the placebo group (mean = -2.36% per year, SD = 4.92), while remaining unchanged in women treated with calcium-vitamin D3 (mean = 0.29% per year, SD = 8.63). The difference between the two groups was 2.65% (95% CI = -0.44, 5.75%) with a trend in favor of the active treatment group. No significant difference between groups was found for changes in distal radius BMD and quantitative ultrasonic parameters at the os calcis. The relative risk (RR) of HF in the placebo group compared with the active treatment group was 1.69 (95% CI = 0.96, 3.0), which is similar to that found in Decalyos I (RR = 1.7; 95% CI = 1.0, 2.8). Thus, these data are in agreement with those of Decalyos I and indicate that calcium and vitamin D3 in combination reverse senile secondary hyperparathyroidism and reduce both hip bone loss and the risk of hip fracture in elderly institutionalized women." }, { "id": "pubmed23n0567_4693", "title": "Where do we stand on vitamin D?", "score": 0.01620224435758416, "content": "A meta-analysis of primary prevention high-quality trials published in 2005 found that oral cholecalciferol (D3) in a daily dose of 700-800 IU or intermittently 100,000 IU every 4 months with or without calcium, should reduce both hip and non-vertebral fracture risk significantly compared to placebo. Trials that administered 400 IU vitamin D did not achieve fracture efficacy. Notably, there was a significant association between higher achieved 25-hydroxyvitamin D levels (25(OH)D) in the treatment groups and fracture efficacy: The minimal mean level where fracture efficacy was observed was 74 nmol/l (25(OH)D). Epidemiological data for bone density and lower extremity strength support this threshold, and high-quality trials that used 700 to 800 IU D3 suggested fall risk reduction by 35 to 65% in institutionalized and community-dwelling older individuals. However, since the 2005 meta-analysis, benefits of vitamin D on fracture and fall reduction have been questioned by results from several recent trials. This review proposes that the interpretation of these recent trials is hindered by different doses of vitamin D, different types of supplemental vitamin D (D3 or ergocalciferol D2), low adherence, concurrent use of supplements outside the study protocol, open study design, short follow-up, and/or different patient risk profiles including primary and secondary fracture prevention. In most recent trials, low adherence, the use of the relatively less potent D2, or a too low dose of D3 (400 IU) may have prohibited a shift of (25(OH)D) levels in the treatment groups to the desirable range of at least 75 nmol/l. In summary, from recent trials, two lesson may be learned: (1) Adherence less than 60% is insufficient to achieve fracture efficacy with daily 800 IU D3 plus calcium, (2) D2 in any application or any previously studied dose may not reduce fractures in institutionalized or community-dwelling older individuals." }, { "id": "pubmed23n0667_6165", "title": "Treatment for osteoporosis in Australian residential aged care facilities: consensus recommendations for fracture prevention.", "score": 0.015027612574341546, "content": "Older people living in residential aged care facilities (RACFs) are at considerably higher risk of suffering fractures than older people living in the community. When admitted to RACFs, patients should be assessed for fracture risk to ensure early implementation of effective fracture prevention measures. Routine or regular determination of calcium and phosphate serum levels in institutionalised older people is not indicated. Opinion is divided about the value of routine measurements of serum concentrations of 25-hydroxyvitamin D, parathyroid hormone and bone turnover markers. The non-pharmacological approach to fracture prevention includes multifactorial programs of falls prevention and the use of hip protectors. Vitamin D supplementation is recommended for all patients in RACFs. Dietary calcium intake should be optimised (1200-1500 mg per day is recommended) and supplementation offered to those with inadequate intake. The decision to prescribe calcium supplements should be guided by patients' tolerance, whether or not they have a history of kidney stones, and emerging data about its cardiovascular safety. Bisphosphonates are the first-choice pharmacological agents for fracture prevention in older persons at high risk. Intravenous administration is as efficient as oral and has the significant advantage of better adherence. Use of strontium ranelate has not been tested on people in RACFs, but evidence in the \"old-old\" (those aged 75 years and older) suggests it could be a therapeutic option for fracture prevention in this setting. In general, teriparatide should not be considered as a first-line treatment for fracture prevention, particularly for people in RACFs." }, { "id": "pubmed23n0644_7970", "title": "Strategies for treatment to prevent fragility fractures in postmenopausal women.", "score": 0.014611613876319759, "content": "The objective of treatment of osteoporosis is to decrease the risk of fractures in patients at high risk for a first or subsequent fracture. The efficacy of treatment will depend on the efficiency and level of implementation of clinical case finding to select patients at risk, the results of additional investigations, the efficacy, tolerance and safety of medical intervention and the adherence to treatment during follow-up. Each of these steps is critical in treatment in daily practice. Failure to consider one or another step can result in suboptimal fracture prevention or overtreatment. The aim of case finding is to identify patients for treatment, who have disease characteristics of patients in whom fracture prevention has been demonstrated in randomised controlled trials (RCTs). These include patients with a low-trauma hip or vertebral fracture, with a low bone mineral density (BMD) or with a high risk of fracture based on the presence of clinical risk factors (CRFs) for osteoporosis and fractures such as included in the FRAX case-finding algorithm, with or without BMD. Case finding starts clinically, with systematic or opportunistic doctor- and/or patient-driven evaluation for the presence of CRFs, but its implementation is low. Further investigations aim to assess the risk of fracture(s) and to have baseline measurements for the subsequent monitoring of treatment, to exclude diseases that mimic osteoporosis, to identify the cause of osteoporosis and contributory factors and to select the most appropriate treatment. Medical intervention consists of providing information about osteoporosis to the patient, lifestyle advice, optimalisation of calcium intake and vitamin D status, fall prevention to reduce fall risk, correction of reversible contributors to secondary osteoporosis and a wide array of drugs for prevention of a first or subsequent vertebral, hip and non-vertebral, non-hip fracture. Drug treatment is based on manipulation of bone remodelling by inhibiting bone resorption (bisphosphonates, selective oestrogen-receptor modulator (SERMs), calcitonin), stimulating bone formation (parathyroid hormone) or mixed effects (strontium ranelate). Follow-up allows to check tolerance and safety, to optimise adherence and to decide about adequacy of response, duration and switching of therapy." }, { "id": "wiki20220301en001_33041", "title": "Osteoporosis", "score": 0.014391077531930203, "content": "Studies of the benefits of supplementation with calcium and vitamin D are conflicting, possibly because most studies did not have people with low dietary intakes. A 2018 review by the USPSTF found low-quality evidence that the routine use of calcium and vitamin D supplements (or both supplements together) did not reduce the risk of having an osteoporotic fracture in male and female adults living in the community who had no known history of vitamin D deficiency, osteoporosis, or a fracture. The USPSTF does not recommend low dose supplementation (less than 1 g of calcium and 400 IU of vitamin D) in postmenopausal women as there does not appear to be a difference in fracture risk. A 2015 review found little data that supplementation of calcium decreases the risk of fractures. While some meta-analyses have found a benefit of vitamin D supplements combined with calcium for fractures, they did not find a benefit of vitamin D supplements (800 IU/day or less) alone. While supplementation does" }, { "id": "wiki20220301en289_2170", "title": "Vitamin D", "score": 0.014248816185966424, "content": "Bone health In general, no good evidence supports the commonly held belief that vitamin D supplements can help prevent osteoporosis. Its general use for prevention of this disease in those without vitamin D deficiency is thus likely not needed. For older people with osteoporosis, taking vitamin D with calcium may help prevent hip fractures, but it also slightly increases the risk of stomach and kidney problems. A study found that supplementation with 800 IU or more daily, in those older than 65 years was \"somewhat favorable in the prevention of hip fracture and non-vertebral fracture\". The effect is small or none for people living independently. Low serum vitamin D levels have been associated with falls, and low bone mineral density. Taking extra vitamin D, however, does not appear to change the risk." }, { "id": "pubmed23n0540_22200", "title": "Addressing the musculoskeletal components of fracture risk with calcium and vitamin D: a review of the evidence.", "score": 0.013823857302118173, "content": "Osteoporotic fractures are an extremely common and serious health problem in the elderly. This article presents the rationale for calcium and vitamin D supplementation in the prevention and treatment of osteoporotic fractures and reviews the literature evidence on the efficacy of this strategy. Two musculoskeletal risk factors are implicated in osteoporotic fractures in the elderly: the loss of bone mass due to secondary hyperparathyroidism and the increased propensity to falls. Calcium and vitamin D reverse secondary hyperparathyroidism with resultant beneficial effects on bone mineral density (BMD). Additionally, calcium and vitamin D supplementation significantly improves body sway and lower extremity strength, reducing the risk of falls. The effects of combined calcium and vitamin D on parathyroid function and BMD provide a strong rationale for the use of this therapy in the prevention and treatment of osteoporosis and osteoporotic fractures. There is general agreement that, in patients with documented osteoporosis, calcium and vitamin D supplementation should be an integral component of the management strategy, along with antiresorptive or anabolic treatment. Frail elderly individuals constitute another major target population for calcium and vitamin D because evidence from randomized studies in institutionalized elderly subjects demonstrates that these supplements reduce osteoporotic fracture risk, particularly in the presence of dietary deficiencies. However, the results of trials in community-dwelling subjects have been equivocal. Within the primary-care setting, further research is required to establish appropriate target subgroups for calcium and vitamin D supplementation; overall, the data are consistent with a benefit individuals with insufficient calcium and/or vitamin D, although patients with documented osteoporosis will derive further benefit in terms of fracture prevention from the addition of an antiresorptive agent." }, { "id": "pubmed23n0913_22610", "title": "The use of cholecalciferol in patients with hip fracture.", "score": 0.013636363636363637, "content": "Major osteoporotic fractures are steadily increasing due to population aging. Programs of secondary prevention against refracture are essential to decrease morbidity and mortality and the cost for individuals and the society. Vitamin D supplementation and optimization of calcium intake are of a pivotal importance to start specific osteoporosis treatment and for its safety and efficacy. Cholecalciferol is the most widely employed drug for vitamin D supplementation. Aim of this study was to assess the trends in the use of vitamin D supplements containing cholecalciferol in the population of hip fracture patients older than 65 years, resident in the region of Tuscany (Italy) in the years 2011-2015 and to describe vitamin D status in a subgroup of this individuals directly referred to a bone clinic for further evaluation after hip osteoporotic fracture. Data were retrieved from the electronic anonymous regional administrative database administered by the Region of Tuscany (Italy) in the years 2011-2015 within the T.A.R.Ge.T. project (Trattamento Appropriato delle Rifratture Geriatriche in Toscana, i.e., \"Appropriate treatment of geriatric refractures in Tuscany\"), a program endorsed by the region itself. Data pertaining to cholecalciferol prescriptions and hospital discharge codes were retrieved and appropriately crossed to get data on the use of cholecalciferol supplements in patients before and after a hip fracture. A retrospective analysis was carried out in a subgroup of subjects (n 254) appropriately referred to the local fracture liaison service after the major osteoporotic fracture and vitamin D status in terms of serum 25(OH) vitamin D levels was assessed. The majority of subjects experiencing a hip fracture (98.2% and 88.3% in 2011 and 2015, respectively) did not receive vitamin D supplements at the time of the fracture event. Although a trend in increase in prescriptions for cholecalciferol supplements could be observed in the years of the study, the percentage of treated individuals remained low even after the fracture, since only 30-35% of subjects receives cholecalciferol supplements at one year after the fracture. Cholecalciferol remained the most prescribed drug in this population, while a substantial decrease of cholecalciferol in association with calcium salts was observed. The use of high doses of cholecalciferol has decreased in this population, while diminished the use of the drops has been accompanied by an increase in prescriptions of single monthly dose supplements. The correction of vitamin D inadequacy is preliminary to any treatment for osteoporosis and together with calcium may reduce fracture risk by itself. The prescription of vitamin D supplements is low in patients before and after a hip fracture in a Mediterranean region and despite the overall increase in vitamin use and abuse in the general population. Proper educational programs and active fracture liaison services are needed in order to bridge this gap." }, { "id": "pubmed23n0575_244", "title": "Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis.", "score": 0.01355110475282149, "content": "Whether calcium supplementation can reduce osteoporotic fractures is uncertain. We did a meta-analysis to include all the randomised trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss. We identified 29 randomised trials (n=63 897) using electronic databases, supplemented by a hand-search of reference lists, review articles, and conference abstracts. All randomised trials that recruited people aged 50 years or older were eligible. The main outcomes were fractures of all types and percentage change of bone-mineral density from baseline. Data were pooled by use of a random-effect model. In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types (risk ratio 0.88, 95% CI 0.83-0.95; p=0.0004). In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0.54% (0.35-0.73; p&lt;0.0001) at the hip and 1.19% (0.76-1.61%; p&lt;0.0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p&lt;0.0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0.80 vs 0.94; p=0.006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0.84 vs 0.87; p=0.03). Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation)." }, { "id": "wiki20220301en286_22362", "title": "Canadian health claims for food", "score": 0.013507873268829445, "content": "Research supporting the claim There is a significant body of evidence which establishes that high calcium intakes augment bone gain during growth, retards age-related bone loss, and reduces osteoporotic fracture risk. A meta-analysis study in 2007 assessed whether calcium supplementation can reduce osteoporotic fractures. The meta-analysis included all the randomized trials in which calcium, or calcium in combination with vitamin D, was used to prevent fracture and osteoporotic bone loss." }, { "id": "pubmed23n0359_17457", "title": "Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women.", "score": 0.013401655498620418, "content": "Long-term vitamin D and calcium supplementation is effective in reducing nonvertebral fractures in elderly people. Increased bone fragility caused by secondary hyperparathyroidism (sHPT) and impaired balance are known risk factors for hip fractures. The hypothesis is that short-term therapy with calcium and vitamin D may improve body sway as well as sHPT more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D (cholecalciferol) and calcium on body sway and biochemical measures of bone metabolism were measured. The sample consisted of 148 women (mean [+/-SD] age, 74 +/- 1 years) with a 25-hydroxycholecalciferol level below 50 nmol/liter. They received either 1200 mg of calcium plus 800 IU of vitamin D or 1200 mg of calcium per day. We measured intact parathyroid hormone (PTH), markers of bone turnover, and body sway before and after treatment. Falls and fractures among the participants were followed over a 1-year period. Compared with calcium mono, supplementation with vitamin D and calcium resulted in an increase in serum 25-hydroxyvitamin D of 72% (p &lt; 0.0001), a decrease in the serum PTH of 18% ( p = 0.0432), and a decrease in body sway of 9% (p = 0.0435). The mean number of falls per subject during a 1-year follow-up period was 0.45 for the calcium mono group and 0.24 for the calcium and vitamin D group (p = 0.0346). Short-term supplementation with vitamin D and calcium improves sHPT and body sway and therefore may prevent falls and subsequent nonvertebral fractures in elderly women." }, { "id": "wiki20220301en028_33474", "title": "Bone fracture", "score": 0.013196267133275007, "content": "Other A Cochrane review of low-intensity pulsed ultrasound to speed healing in newly broken bones found insufficient evidence to justify routine use. Other reviews have found tentative evidence of benefit. It may be an alternative to surgery for established nonunions. Vitamin D supplements combined with additional calcium marginally reduces the risk of hip fractures and other types of fracture in older adults; however, vitamin D supplementation alone did not reduce the risk of fractures. Children" }, { "id": "wiki20220301en038_11967", "title": "Women's Health Initiative", "score": 0.013107369664746713, "content": "CaD component findings Among the intervention cohort, a small but significant improvement in hip bone density was observed, although a significant reduction in hip fractures was not observed. However, subgroup analysis revealed a possible benefit to older women in terms of a reduced risk of hip fractures, attributable to calcium plus vitamin D supplementation. It was also found that the intervention did not have an effect on the incidence of colorectal cancer, possibly owing to the long latency associated with colorectal cancers. Calcium plus vitamin D was not found to affect the incidence of breast cancer. Finally, an increased risk of kidney stones was observed among those taking calcium plus vitamin D." }, { "id": "wiki20220301en159_33147", "title": "Senile osteoporosis", "score": 0.013071895424836603, "content": "Calcium and vitamin D3 intake from diet or supplementation are crucial in the ethiopathogenesis of this disease; therefore, the effective treatments should consist of non pharmacological methods (such as a modified diet with more calcium 1000–1500 mg/day and vitamin D3 intake of 600-800 IU/day, exercising, smoking cessation, and alcohol restriction), fall prevention, and individually chosen pharmacological intervention (antiresorptive agent like bisphosphonate or estrogen replacement therapy in women). Given bone fracture (hip, vertebrae, and colles) is a devastating complication of osteoporosis, vitamin D3 combined with calcium are used as primary prevention, along with alendronate, residronate, strontium and zoledronic acid which have proven efficacy in primary and secondary hip fracture prevention. The Institute of Medicine recommends a daily allowance of 800 IU of Vitamin D for people 70 and over, to get to a level of serum 25-hydroxyvitamin D (25OHD) of at least 20 ng/ml (50" }, { "id": "pubmed23n0624_21250", "title": "Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials.", "score": 0.013056189675197245, "content": "Antifracture efficacy with supplemental vitamin D has been questioned by recent trials. We performed a meta-analysis on the efficacy of oral supplemental vitamin D in preventing nonvertebral and hip fractures among older individuals (&gt; or =65 years). We included 12 double-blind randomized controlled trials (RCTs) for nonvertebral fractures (n = 42 279) and 8 RCTs for hip fractures (n = 40 886) comparing oral vitamin D, with or without calcium, with calcium or placebo. To incorporate adherence to treatment, we multiplied the dose by the percentage of adherence to estimate the mean received dose (dose x adherence) for each trial. The pooled relative risk (RR) was 0.86 (95% confidence interval [CI], 0.77-0.96) for prevention of nonvertebral fractures and 0.91 (95% CI, 0.78-1.05) for the prevention of hip fractures, but with significant heterogeneity for both end points. Including all trials, antifracture efficacy increased significantly with a higher dose and higher achieved blood 25-hydroxyvitamin D levels for both end points. Consistently, pooling trials with a higher received dose of more than 400 IU/d resolved heterogeneity. For the higher dose, the pooled RR was 0.80 (95% CI, 0.72-0.89; n = 33 265 subjects from 9 trials) for nonvertebral fractures and 0.82 (95% CI, 0.69-0.97; n = 31 872 subjects from 5 trials) for hip fractures. The higher dose reduced nonvertebral fractures in community-dwelling individuals (-29%) and institutionalized older individuals (-15%), and its effect was independent of additional calcium supplementation. Nonvertebral fracture prevention with vitamin D is dose dependent, and a higher dose should reduce fractures by at least 20% for individuals aged 65 years or older." }, { "id": "wiki20220301en509_6723", "title": "Calcium supplement", "score": 0.013043478260869565, "content": "Health effects Bone health In healthy people, calcium supplementation is not necessary for maintaining bone mineral density, and carries risks that outweigh any benefits. Calcium intake is not significantly associated with hip fracture risk in either men or women. The U.S. Preventive Service Task Force recommends against a daily supplement of calcium or vitamin D. Although a slight increase in bone mineral density occurred in healthy children from calcium supplementation, using additional dietary calcium is not justified, according to a 2006 review. Cardiovascular impact There is good evidence that 1,000 mg to 1,500 mg of daily calcium supplementation can effect a modest reduction in blood pressure in adults who do not have a blood pressure condition." }, { "id": "pubmed23n0913_22460", "title": "Pharmacological treatment of osteoporosis in the oldest old.", "score": 0.013002220876236623, "content": "The incidence of osteoporotic fractures increases with age. Consequently, the global prevalence of osteoporotic fractures will increase with the aging of the population. In old age, osteoporosis is associated with a substantial burden in terms of morbidity and mortality. Nevertheless, osteoporosis in old age continues to be underdiagnosed and undertreated. This may, at least partly, be explained by the fact that evidence of the antifracture efficacy of osteoporosis treatments comes mainly from randomized controlled trials in postmenopausal women with a mean age of 70-75 years. However, in the last years, subgroup analyses of these landmark trials have been published investigating the efficacy and safety of osteoporosis treatment in the very elderly. Based on this evidence, this narrative review discusses the pharmacological management of osteoporosis in the oldest old (≥80 years). Because of the high prevalence of calcium and/or vitamin D deficiency in old age, these supplements are essential in the management of osteoporosis in the elderly people. Adding antiresorptive or anabolic treatments or combinations, thereof, reduces the risk of vertebral fractures even more, at least in the elderly with documented osteoporosis. The reduction of hip fracture risk by antiresorptive treatments is less convincing, which may be explained by insufficient statistical power in some subanalyses and/or a higher impact of nonskeletal risk factors in the occurrence of hip fractures. Compared with younger individuals, a larger absolute risk reduction is observed in the elderly because of the higher baseline fracture risk. Therefore, the elderly will benefit more of treatment. In addition, current osteoporosis therapies also appear to be safe in the elderly. Although more research is required to further clarify the effect of osteoporosis drugs in the elderly, especially with respect to hip fractures, there is currently sufficient evidence to initiate appropriate treatment in the elderly with osteoporosis and osteoporotic fractures." }, { "id": "wiki20220301en396_2959", "title": "Eldecalcitol", "score": 0.012987426388667834, "content": "The new analogs of vitamin D, such as eldecalcitol, are observed to have stronger effects in preventing bone loss, fractures, and falls in comparison to calcitriol. Eldecalcitol is even more effective than its counterpart alfacalcidol, another vitamin D analog. Studies have shown eldecalcitol is more effective than alfacalcidol in preventing vertebral and wrist fractures, and even falls, with osteoporotic patients with vitamin D insufficiencies. Eldecalcitol is also more effective at preventing fractures than vitamin D and calcium supplements. Eldecalcitol increases calcium absorption for vitamin D deficient patients, and therefore could be used for osteoporosis treatment for all age groups." }, { "id": "wiki20220301en004_137076", "title": "Dietary supplement", "score": 0.012976593295426797, "content": "\"Adequate calcium as part of a healthful diet, along with physical activity, may reduce the risk of osteoporosis in later life.\" \"Adequate calcium and vitamin D throughout life, as part of a well-balanced diet, may reduce the risk of osteoporosis.\" \"Adequate calcium and vitamin D as part of a healthful diet, along with physical activity, may reduce the risk of osteoporosis in later life.\" In the same year, the European Food Safety Authority also approved a dietary supplement health claim for calcium and vitamin D and the reduction of the risk of osteoporotic fractures by reducing bone loss." }, { "id": "pubmed23n0044_15714", "title": "Vitamin D3 and calcium to prevent hip fractures in elderly women.", "score": 0.012490450725744843, "content": "Hypovitaminosis D and a low calcium intake contribute to increased parathyroid function in elderly persons. Calcium and vitamin D supplements reduce this secondary hyperparathyroidism, but whether such supplements reduce the risk of hip fractures among elderly people is not known. We studied the effects of supplementation with vitamin D3 (cholecalciferol) and calcium on the frequency of hip fractures and other nonvertebral fractures, identified radiologically, in 3270 healthy ambulatory women (mean [+/- SD] age, 84 +/- 6 years). Each day for 18 months, 1634 women received tricalcium phosphate (containing 1.2 g of elemental calcium) and 20 micrograms (800 IU) of vitamin D3, and 1636 women received a double placebo. We measured serial serum parathyroid hormone and 25-hydroxyvitamin D (25(OH)D) concentrations in 142 women and determined the femoral bone mineral density at base line and after 18 months in 56 women. Among the women who completed the 18-month study, the number of hip fractures was 43 percent lower (P = 0.043) and the total number of nonvertebral fractures was 32 percent lower (P = 0.015) among the women treated with vitamin D3 and calcium than among those who received placebo. The results of analyses according to active treatment and according to intention to treat were similar. In the vitamin D3-calcium group, the mean serum parathyroid hormone concentration had decreased by 44 percent from the base-line value at 18 months (P &lt; 0.001) and the serum 25(OH)D concentration had increased by 162 percent over the base-line value (P &lt; 0.001). The bone density of the proximal femur increased 2.7 percent in the vitamin D3-calcium group and decreased 4.6 percent in the placebo group (P &lt; 0.001). Supplementation with vitamin D3 and calcium reduces the risk of hip fractures and other nonvertebral fractures among elderly women." }, { "id": "pubmed23n0715_18836", "title": "Prevention of fractures in older people with calcium and vitamin D.", "score": 0.012100745743633037, "content": "The greatest cause of fracture in older people is osteoporosis which contributes to increased morbidity and mortality in older people. A number of meta-analyses have been performed assessing the effectiveness of calcium supplementation alone, vitamin D supplementation alone and the combined therapy on bone loss and fracture reduction in older people. The results of these meta-analyses indicate that vitamin D supplementation alone is unlikely to reduce fracture risk, calcium supplementation alone has a modest effect in reducing total fracture risk, but compliance with calcium supplements is poor in the long term. The combination of calcium supplementation with vitamin D supplementation, particularly in those at risk of marginal and low vitamin D status reduces total fractures, including hip fractures. Therefore older people would be recommended to consume adequate dietary calcium (&gt;1100 mg/day) together with maintaining adequate vitamin D status (&gt;60 nmol/L 25(OH)D) to reduce risk of fracture. It is a challenge to consume sufficient dietary calcium from dietary sources, but the increasing range of calcium fortified foods could assist in increasing the dietary calcium intake of older people. In addition to the usual dairy based food sources, vitamin D supplements are likely to be required for older people with reduced mobility and access to sunlight." }, { "id": "pubmed23n0541_7815", "title": "Effects of calcium supplementation on clinical fracture and bone structure: results of a 5-year, double-blind, placebo-controlled trial in elderly women.", "score": 0.012019914651493598, "content": "Increased dietary calcium intake has been proposed as a population-based public health intervention to prevent osteoporotic fractures. We have examined whether calcium supplementation decreases clinical fracture risk in elderly women and its mechanism of action. Five-year, double-blind, placebo-controlled study of 1460 women recruited from the population and older than 70 years (mean age, 75 years) who were randomized to receive calcium carbonate, 600 mg twice per day, or identical placebo. The primary end points included clinical incident osteoporotic fractures, vertebral deformity, and adverse events ascertained in 5 years. Bone structure was also measured using dual x-ray absorptiometry of the hip and whole body, quantitative ultrasonography of the heel, and peripheral quantitative computed tomography of the distal radius. Among our patients, 16.1% sustained 1 or more clinical osteoporotic fractures. In the intention-to-treat analysis, calcium supplementation did not significantly reduce fracture risk (hazard ratio, 0.87; 95% confidence interval, 0.67-1.12). However, 830 patients (56.8%) who took 80% or more of their tablets (calcium or placebo) per year had reduced fracture incidence in the calcium compared with the placebo groups (10.2% vs 15.4%; hazard ratio, 0.66; 95% confidence interval, 0.45-0.97). Calcium-treated patients had improved quantitative ultrasonography findings of the heel, femoral neck and whole-body dual x-ray absorptiometry data, and bone strength compared with placebo-treated patients. Of the 92 000 adverse events recorded, constipation was the only event increased by the treatment (calcium group, 13.4%; placebo group, 9.1%). Supplementation with calcium carbonate tablets supplying 1200 mg/d is ineffective as a public health intervention in preventing clinical fractures in the ambulatory elderly population owing to poor long-term compliance, but it is effective in those patients who are compliant." }, { "id": "pubmed23n0364_20168", "title": "Effect of calcium or 25OH vitamin D3 dietary supplementation on bone loss at the hip in men and women over the age of 60.", "score": 0.011829498794238415, "content": "Dietary supplements that prevent bone loss at the hip and that can be applied safely in the elderly are likely to reduce hip fractures. A daily dietary supplement of 750 mg calcium or 15 microg 25OH vitamin D3 on bone loss at the hip and other sites, bone turnover and calcium-regulating hormones were studied over 4 yr in elderly volunteers using a randomized, double-blind, placebo-controlled trial. Bone mineral density (BMD) was measured by dual x-ray absorptiometry and bone structure by radiographs. Calcium biochemistry and bone turnover markers were measured in blood and urine. The 316 women entering the trial had a mean age of 73.7 yr and the 122 men of 75.9 yr. Baseline median calcium intake was 546 mg/day, and median serum 25OH vitamin D3 was 59 nmol/L. On placebo, loss of BMD at total hip was 2% and femoral medulla expansion was 3% over 4 yr. Calcium reduced bone loss, secondary hyperparathyroidism, and bone turnover. 25OH vitamin D3 was intermediate between placebo and calcium. Fracture rates and drop-out rates were similar among groups, and there were no serious adverse events with either supplement. A calcium supplement of 750 mg/day prevents loss of BMD, reduces femoral medullary expansion, secondary hyperparathyroidism, and high bone turnover. A supplement of 15 microg/day 25OH vitamin D3 is less effective, and because its effects are seen only at low calcium intakes, suggests that its beneficial effect is to reverse calcium insufficiency." }, { "id": "pubmed23n0480_21551", "title": "A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: The Nottingham Neck of Femur (NONOF) Study.", "score": 0.011777155731549123, "content": "survivors of hip fracture are at 5- to 10-fold risk of a second hip fracture. There is little consensus about secondary prevention. Many are given calcium and vitamin D, but the evidence supporting this is circumstantial. to compare the effects of different calcium and vitamin D supplementation regimens on bone biochemical markers, bone mineral density and rate of falls in elderly women post-hip fracture. randomised controlled trial. orthogeriatric rehabilitation ward. 150 previously independent elderly women, recruited following surgery for hip fracture, were assigned to receive a single injection of 300,000 units of vitamin D(2), injected vitamin D(2) plus 1 g/day oral calcium, 800 units/day oral vitamin D(3) plus 1 g/day calcium, or no treatment. Follow-up was one year, with measurement of 25-hydroxyvitamin D, parathyroid hormone, bone mineral density, and falls. mean 25-hydroxyvitamin D increased and mean parathyroid hormone was suppressed in all the actively treated groups, more so in the group receiving combined oral vitamin D and calcium. Twenty per cent of participants injected with vitamin D were deficient in 25-hydroxyvitamin D a year later. Bone mineral density showed small but statistically significant differences of up to 4.6% between actively treated groups and placebo. Relative risk of falling in the groups supplemented with vitamin D was 0.48 (95% CI 0.26-0.90) compared with controls. Vitamin D supplementation, either orally or with injected vitamin D, suppresses parathyroid hormone, increases bone mineral density and reduces falls. Effects may be more marked with calcium co-supplementation. The 300,000 units of injected vitamin D may not last a whole year." }, { "id": "wiki20220301en396_2957", "title": "Eldecalcitol", "score": 0.011644591611479028, "content": "Treatment for Osteoporosis Eldecalcitol can be used for the treatment of hypocalcaemia or osteoporosis. Calcium absorption increases with the presence of eldecalcitol by the body, occurring in the intestines, which is useful for those who have low calcium levels. Eldecalcitol is more often used due to its effects to treat osteoporosis. In the aging population, the bone matrix becomes weakened through untreated osteoporosis. This leads to an increased risk of severe fractures that include spinal and hip fractures in addition to vertebral and wrist fractures. This creates a burden on the health care system due to a decline in the quality of life for the individuals that suffer from this condition. Some risk factors leading to the predisposition of developing osteoporosis are previous incidents of bone fractures and a reduction in bone mineral density. These factors expectantly increase as age increases." }, { "id": "wiki20220301en038_11966", "title": "Women's Health Initiative", "score": 0.011277619441635255, "content": "Calcium/vitamin D The calcium/vitamin D (CaD) trial component was designed to test the hypothesis that women taking a combination of calcium and vitamin D will experience a reduced risk of hip and other fractures, as well as breast and colorectal cancer. Women participating in this intervention were randomly assigned to receive a regimen of 1000 mg calcium in combination with 400 International Units (IU) of vitamin D (n = 18176) or a placebo (n = 18106), and were followed for an average of 7 years, with monitoring for bone density, fractures, and pathologically confirmed cancers as the measures of outcomes. Women in the CaD trial were already participating in the HT trial, the DM trial, or both. In addition to the global exclusion criteria, component-specific exclusion criteria hypercalcemia, renal calculi, corticosteroid use, and calcitriol use." }, { "id": "pubmed23n0613_15488", "title": "[Update on treatment of postmenopausal osteoporosis].", "score": 0.011253358621779674, "content": "The most frequent sites of osteoporotic fractures are the vertebrae, the hip, the forearm and the proximal humerus. Drugs that inhibit bone resorption constitute the mainstay for the treatment of postmenopausal osteoporosis. A recent meta-analysis indicates that vitamin D can reduce the risk of hip fractures only if calcium supplements are also administered. The effect of hormone replacement therapy on the risk of non vertebral fractures is less clear than on vertebral fractures. Raloxifene (a SERM) reduces the rate of vertebral fractures and of breast cancer, but it does not protect against hip fracture. Bisphosphonates are the most commonly used compounds to treat postmenopausal osteoporosis. The level of evidence for currently used bisphosphonates (alendronate, ibandronate, risedronate, zoledronate) to reduce vertebral fracture rate is maximal. Results of controlled clinical trials indicate a reduction in the risk of vertebral fractures of 40-50% and of 20-40% for non vertebral fractures, including hip fractures. However, their relative efficacy on hip fractures has been less well studied and remains more controversial. Long-term compliance of bisphosphonate therapy is improved by intermittent schemes. The most recent developpements concern the intravenous administration of ibandronate and even more of zoledronate (yearly infusions). The reduction in the rate of vertebral and hip fractures has been demonstrated in the main zoledronate trial and a prolongation of survival has been shown in the study including patients with a recent hip fracture. Whereas hyperparathyroidism is a cause of bone loss, the intermittent administration of parathyroid hormone or of its 1-34 fragment (teriparatide) exerts anabolic effects on the skeleton. The treatment is demanding and costly (daily sc injections during 18 months), requires some monitoring (serum and urinary calcium) but the results, at least for vertebral fractures, are quite favorable. Strontium ranelate is a less powerful stimulator of bone formation but it also reduces bone resorption. Its daily administration for 3 years reduces the risk of vertebral fractures and, to a lesser extent, of non vertebral fractures. Lastly, denosumab is a high affinity antibody against RANK Ligand that specifically blocks the formation and the activity of osteoclasts. The efficacy of this promising compound will soon be known." }, { "id": "wiki20220301en286_22363", "title": "Canadian health claims for food", "score": 0.01040453451354919, "content": "In total, 63 897 individuals were analysed, most of whom were women (n=58 785 [92%]) with a mean age of 67.8 years (SD 9.7). In trials that reported fracture as an outcome (17 trials, n=52 625), treatment was associated with a 12% risk reduction in fractures of all types. In trials that reported bone-mineral density as an outcome (23 trials, n=41 419), the treatment was associated with a reduced rate of bone loss of 0.54% (0.35–0.73; p<0.0001) at the hip and 1.19% (0.76–1.61%; p<0.0001) in the spine. The fracture risk reduction was significantly greater (24%) in trials in which the compliance rate was high (p<0.0001). The treatment effect was better with calcium doses of 1200 mg or more than with doses less than 1200 mg (0.80 vs 0.94; p=0.006), and with vitamin D doses of 800 IU or more than with doses less than 800 IU (0·84 vs 0·87; p=0·03)." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 12, 160 ] ], "word_ranges": [ [ 1, 24 ] ], "text": "the clinical picture described is of diabetic neuropathy. Of the drugs proposed, the first choice would be a dual antidepressant such as duloxetine." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Ibuprofen.", "2": "Oxycodone.", "3": "Duloxetine.", "4": "Paracetamol.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1063_8703", "title": "Treatment-induced diabetes neuropathy: description of singular clinical signs to reach a prompt diagnosis.", "score": 0.019704911667637354, "content": "A 23-year-old woman diagnosed with type 1 diabetes mellitus in 2011 came to our outpatient office because of an inability to walk correctly. She was under a basal bolus insulin regimen. In the summer of 2016, she experienced a rapid improvement in her glycaemic control. A few weeks later, she started to complain of a severe burning pain in the soles of her feet (pain score 10/10). Neither macrovascular nor microvascular complications were detected. The patient was forced to walk barefoot due to an intense pain using shoes or socks and used to soak her feet in water for several hours daily. She also developed severe intolerance to environmental heat, both indoors and outdoors. A diagnosis of treatment-induced diabetic neuropathy was made. The patient was admitted to a general ward to start pain therapy. After a 6-month course of different neuropathic pain drugs, the patient was able to walk autonomously again." }, { "id": "pubmed23n0905_18789", "title": "When the Treatment Becomes the Problem.", "score": 0.017679127725856697, "content": "A 47-year-old white male with a 5-year history of type 2 diabetes mellitus presented to clinic with uncontrolled hyperglycemia, weight loss, and body aches that impeded his ability to work and sleep. He had initially controlled his diabetes successfully with weight loss and exercise. However, in the previous 6 months he had noticed unintentional weight loss. He was evaluated at another clinic where he was prescribed sitagliptin/metformin (Janumet) for his uncontrolled hyperglycemia. After 6 weeks his blood glucose had not significantly improved, and an endocrinologist prescribed insulin glargine (Lantus) and insulin aspart (NovoLog). About 3 days later he developed migratory joint pains and myalgias. After some weeks his insulin regimen was changed to insulin detemir (Levemir), and his myalgia symptoms briefly improved but then worsened. He experienced tingling of his feet that caused increasing difficulty sleeping. His review of systems was remarkable for fatigue, weight loss, polydipsia, polyphagia, polyuria, myalgias and arthralgias, numbness and tingling of both feet, and difficulty sleeping." }, { "id": "pubmed23n0682_23865", "title": "Evidence-based interventional pain medicine according to clinical diagnoses. 18. Painful diabetic polyneuropathy.", "score": 0.016560678325384208, "content": "In the industrialized world, polyneuropathy induced by diabetes mellitus (DM) is one of the most prevalent forms of neuropathy. Diabetic neuropathy can result from a direct toxic effect of glucose on nerve cells. Additionally, the damage of the nerve structures (central and peripheral) is accompanied by a microvascular dysfunction, which damages the vasa nervorum. More than 80% of the patients with DM-induced polyneuropathy have a distal and symmetric presentation. The initial symptoms are: signs of diminished sensation, burning feet, which may occur particularly during the night and worsen when touched, and tingling sensation in the feet. Attacks of shooting pain may also occur. Proper control of DM is mandatory. Based on the recently published National Institute for Health and Clinical Excellence guidelines, treatment of painful diabetic neuropathy should start with duloxetine or amitriptyline if duloxetine is contraindicated. If pain relief is inadequate, monotherapy with amitriptyline or pregabalin, or combination therapy with amitriptyline and pregabalin should be considered. If pain relief is still insufficient, tramadol instead of or in combination with a second-line agent should be considered. In patients who are unable to take oral medication, topical lidocaine can be considered for localized pain. There are currently four studies showing that spinal cord stimulation can potentially provide pain alleviation for the longer term in patients with painful diabetic polyneuropathy. Complications are mainly implant related, though infections also occur. The available evidence (2 C+) justifies spinal cord stimulation to be considered, preferably study related." }, { "id": "pubmed23n0702_7029", "title": "Painful diabetic neuropathy: diagnosis and management.", "score": 0.014608952287260207, "content": "The prevalence of painful diabetic peripheral neuropathy (PDN) is about 20% in patients with type 2 diabetes and 5% in those with type 1. Patients should be systematically questioned concerning suggestive symptoms, as they are not usually volunteers. As PDN is due to small-fibre injury, the 10 g monofilament pressure test as well as the standard electrophysiological procedures may be normal. Diagnosis is based on clinical findings: type of pain (burning discomfort, electric shock-like sensation, aching coldness in the lower limbs); time of occurrence (mostly at rest and at night); and abnormal sensations (such as tingling or numbness). The DN4 questionnaire is an easy-to-use validated diagnostic tool. Three classes of drugs are of equal value in treating PDN: tricyclic antidepressants; anticonvulsants; and selective serotonin-reuptake inhibitors. These compounds may be prescribed as first-line therapy following pain assessment using a visual analogue scale. If the initial drug at its maximum tolerated dose does not lead to a decrease in pain of at least 30%, another drug class should be prescribed; if the pain is decreased by 30% but remains greater than 3/10, a drug from a different class may be given in association." }, { "id": "wiki20220301en023_25278", "title": "Peripheral neuropathy", "score": 0.012192048390145548, "content": "Most types of polyneuropathy progress fairly slowly, over months or years, but rapidly progressive polyneuropathy also occurs. It is important to recognize that at one time it was thought that many of the cases of small fiber peripheral neuropathy with typical symptoms of tingling, pain, and loss of sensation in the feet and hands were due to glucose intolerance before a diagnosis of diabetes or pre-diabetes. However, in August 2015, the Mayo Clinic published a scientific study in the Journal of the Neurological Sciences showing \"no significant increase in...symptoms...in the prediabetes group\", and stated that \"A search for alternate neuropathy causes is needed in patients with prediabetes.\" The treatment of polyneuropathies is aimed firstly at eliminating or controlling the cause, secondly at maintaining muscle strength and physical function, and thirdly at controlling symptoms such as neuropathic pain." }, { "id": "InternalMed_Harrison_28034", "title": "InternalMed_Harrison", "score": 0.012117531378333045, "content": "Polyneuropathy/Mononeuropathy The most common form of diabetic neuropathy is distal symmetric polyneuropathy. It most frequently presents with distal sensory loss and pain, but up to 50% of patients do not have symptoms of neuropathy. Hyperesthesia, paresthesia, and dysesthesia also may occur. Any combination of these symptoms may develop as neuropathy progresses. Symptoms may include a sensation of numbness, tingling, sharpness, or burning that begins in the feet and spreads proximally. Neuropathic pain develops in some of these individuals, occasionally preceded by improvement in their glycemic control. Pain typically involves the lower extremities, is usually present at rest, and worsens at night. Both an acute (lasting <12 months) and a chronic form of painful diabetic neuropathy have been described. The acute form is sometimes treatment-related, occurring in the context of improved glycemic control. As diabetic neuropathy progresses, the pain subsides and eventually disappears," }, { "id": "pubmed23n1145_8415", "title": "Top 20 Research Studies of 2021 for Primary Care Physicians.", "score": 0.011591387404889105, "content": "This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. Among patients in this age group with type 2 diabetes treated with medication, an A1C level of less than 7% is associated with increased risk of hospitalization for hypoglycemia, especially when using a sulfonylurea or insulin. For patients with chronic low back pain, exercise, nonsteroidal anti-inflammatory drugs, duloxetine, and opioids were shown to be more effective than control in achieving a 30% reduction in pain, but self-discontinuation of duloxetine and opioids was common. There is no clinically important difference between muscle relaxants and placebo in the treatment of nonspecific low back pain. In patients with chronic pain, low- to moderate-quality evidence supports exercise, yoga, massage, and mindfulness-based stress reduction. For acute musculoskeletal pain, acetaminophen, 1,000 mg, plus ibuprofen, 400 mg, without an opioid is a good option. Regarding screening for colorectal cancer, trial evidence supports performing fecal immunochemical testing every other year. For chronic constipation, evidence supports polyethylene glycol, senna, fiber supplements, magnesium-based products, and fruit-based products. The following abdominal symptoms carry a greater than 3% risk of cancer or inflammatory bowel disease: dysphagia or change in bowel habits in men; rectal bleeding in women; and abdominal pain, change in bowel habits, or dyspepsia in men and women older than 60 years. For secondary prevention in those with established arteriosclerotic cardiovascular disease, 81 mg of aspirin daily appears to be effective. The Framingham Risk Score and the Pooled Cohort Equations both overestimate the risk of cardiovascular events. Over 12 years, no association between egg consumption and cardiovascular events was demonstrated. Gabapentin, pregabalin, duloxetine, and venlafaxine provide clinically meaningful improvements in chronic neuropathic pain. In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic." }, { "id": "pubmed23n0998_22168", "title": "A comparative double-blind randomized study on the effectiveness of Duloxetine and Gabapentin on painful diabetic peripheral polyneuropathy.", "score": 0.010560044580663137, "content": "<bBackground:</b The most common cause of polyneuropathy is diabetes mellitus. Neuropathic pain is seen in 26% of diabetic population. Therapeutic techniques for this disease can become challenging. <bMethod:</b This study was a prospective comparative double-blind randomized study which was conducted during an eight-week period. Totally, 104 painful diabetic peripheral polyneuropathy (PDPP) patients who had a minimum Visual Analog Scale (VAS) of 40 millimeters, received no pain-controlling medication, and had no other severe disease at its final stage were randomly assigned to two groups (n=52) through the four block method. One group received Duloxetine and the other received Gabapentin. The effectiveness was measured through primary effectiveness (VAS scale) and secondary effectiveness (Sleep Interference Score, and Clinical Global Impression of Change (CGIC)). Medication compliance was assessed by enumerating the number of patients who refused treatment because of side effects. The Fisher's exact T-test and ANOVA were used for data analysis. This study was approved by the Ethics Committee of Jundishapur, University of Medical sciences Ahvaz, Iran, under reference number: IR.AJUMS.REC.1395.78. In addition, this study was registered and approved in the Iranian Registry of Clinical Trials (IRCT ID: IRCT20161023030455N2) (http://irct.ir/). <bResults:</b VAS, Sleep Interference Score, and CGIC were significantly improved (P&lt;0.05) through time in both groups, [For GBP: VAS<supBaseline</sup=64±20.03, VAS<supweek1</sup=55.32±18.76, VAS<supweek4</sup=44.68±15.82, VAS<supweek8</sup=39.43±14.32; For DLX: VAS<supBase-line</sup=62±21.18, VAS<supweek1</sup=58.76±20.37, VAS<supweek4</sup=45.84±16.21, VAS<supweek8</sup=36.78±15.62] while a significant difference between the two groups was not observed (P&lt;0.05). However, such significant improvements were not observed in the Duloxetine group at the end of the first week (P=674). Improvement in Sleep Interference Score and CGIC were similar to the results for the VAS scale. Side effects in the Duloxetine group (n=2) compared to the Gabapentin group (n=9) were significantly less (P&lt;0.001). As a result, medication acceptance in the Duloxetine group (n=47) was significantly better than the Gabapentin (n=41) group (P&lt;0.001). <bConclusion:</b Both Duloxetine and Gabapentin are effective for the treatment of PDPP. On the one hand, Gabapentin shows the effect earlier while has more side effects. Conversely, Duloxetine has better medication compliance. <bTrial registration:</b The method of this study was approved by the Ethics Committee of Jundishapur University of Medical Sciences, Ahvaz, Iran, under reference number: IR.AJUMS.REC.1395.78. In addition, this study was registered and approved in the Iranian Registry of Clinical Trials (IRCT ID: IRCT20161023030455N2) (http://irct.ir/)." }, { "id": "pubmed23n0946_25816", "title": "Top 20 Research Studies of 2017 for Primary Care Physicians.", "score": 0.009900990099009901, "content": "Based on systematic surveillance of more than 110 medical journals, 247 studies met criteria as POEMs (patient-oriented evidence that matters) in 2017. Members of the Canadian Medical Association identified 20 of these POEMs as most relevant to practice. This article reviews the clinical questions and bottom-line answers from these studies. Blood pressure should be measured after a period of rest, using a bare arm, and orthostatic blood pressure is more predictive when measured after one minute of standing rather than three minutes. Intensive blood pressure lowering results in cardiovascular benefits but also renal harms in high-risk patients with an average age of 68 years. The initiation of a statin for primary prevention does not reduce cardiovascular events in adults 65 years or older. Sterile gloves do not reduce the risk of infection for common outpatient skin procedures, and the preferred approach to managing onychomycosis is empiric oral terbinafine. Routine home glucose monitoring is not needed in patients with type 2 diabetes mellitus, and trying to achieve an A1C target level of 6.0% rather than 7.0% to 7.9% does not improve outcomes and may be harmful. Fasting blood glucose and A1C levels have limited accuracy for identifying glucose intolerance, and patients 65 years and older with thyroid-stimulating hormone levels between 4.6 and 10.0 mIU per mL should be rechecked before considering treatment. Gabapentin and pregabalin are not effective for acute or chronic low back pain, even in patients with sciatica. Physical therapy does not provide any additional benefit over usual care in patients with acute ankle sprain, and corticosteroid injections for knee osteoarthritis are ineffective and may damage cartilage. A two-question screening test can rule out depression in older adults; a large U.S. trial continued to find no benefit to prostate cancer screening; and clinicians need to be thoughtful about how they discuss recommendations to stop screening for cancer in older patients. Finally, ibuprofen, naproxen, and celecoxib have similar risks of adverse events, and continuous positive airway pressure in patients with obstructive sleep apnea does not reduce the risk of cardiovascular events." }, { "id": "InternalMed_Harrison_15296", "title": "InternalMed_Harrison", "score": 0.0098467067625055, "content": "evidence of peripheral nerve disease. Presenting symptoms are usually painful burning sensations in the feet and lower extremities. Findings on examination include a stocking-type sensory loss to pinprick, temperature, and touch sensation and a loss of ankle reflexes. Motor changes are mild and are usually limited to weakness of the intrinsic foot muscles. Response of this condition to antiretrovirals has been variable, perhaps because antiretrovirals are responsible for the problem in some instances. When due to dideoxynucleoside therapy, patients with lower extremity peripheral neuropathy may complain of a sensation that they are walking on ice. Other entities in the differential diagnosis of peripheral neuropathy include diabetes mellitus, vitamin B12 deficiency, and side effects from metronidazole or dapsone. For distal symmetric polyneuropathy that fails to resolve following the discontinuation of dideoxynucleosides, therapy is symptomatic; gabapentin, carbamazepine, tricyclics," }, { "id": "pubmed23n0882_2379", "title": "Small Fiber Neuropathy in Children: Two Case Reports Illustrating the Importance of Recognition.", "score": 0.009708737864077669, "content": "Small fiber neuropathy (SFN) is a debilitating condition that often leads to pain and autonomic dysfunction. In the last few decades, SFN has been gaining more attention, particularly in adults. However, literature about SFN in children remains limited. The present article reports the cases of 2 adolescent girls diagnosed with SFN. The first patient (14 years of age) complained about painful itch and tingling in her legs, as well as dysautonomia symptoms for years. She also reported a red/purple-type discoloration of her legs aggravated by warmth and standing, compatible with erythromelalgia. The diagnosis of SFN was confirmed by a reduced intraepidermal nerve fiber density (IENFD) in skin biopsy sample. No underlying conditions were found. Symptomatic neuropathic pain treatment was started with moderate effect. The second patient (16 years of age) developed painful sensations in both feet and hands 6 weeks after an ICU admission for diabetic ketoacidosis, which included dysautonomia symptoms. She also exhibited some signs of erythromelalgia. The patient was diagnosed with predominant SFN (abnormal IENFD and quantitative sensory testing) as well as minor large nerve fiber involvement. Treatment with duloxetine, combined with a rehabilitation program, resulted in a marked improvement in her daily functioning. Although the SFN diagnosis in these 2 cases could be established according to the definition of SFN used in adults, additional diagnostic tools are needed that may be more appropriate for children. Additional information about the course of SFN in children may result in better treatment options." }, { "id": "pubmed23n1085_14176", "title": "Treatment-induced diabetes neuropathy: reminder of an important clinical lesson.", "score": 0.009708737864077669, "content": "Treatment-induced neuropathy of diabetes (TIND) is an acute, painful and rare complication of intensive glycaemic control in diabetes. We present a case of a 32-year-old man with sudden onset of severe lower limb pain. It worsened progressively and was refractory to analgesic and muscle relaxant therapies. It became so severe that the patient was impossible to stand, causing a marked impact on his daily life. He had a history of type 1 diabetes, diagnosed 3 years ago, and an episode of deep vein thrombosis of the left leg, 4 years ago. While completing an extensive workup, various analgesic adjustments were made, with no improvement. After careful revision of his medical data, a significant reduction of his A1C 6 months before the appearance of symptoms was noticed. A diagnosis of TIND was made. The patient was treated with amitriptyline and showed noticeable improvement after the first month." }, { "id": "pubmed23n0800_14851", "title": "Breathlessness with pulmonary metastases: a multimodal approach.", "score": 0.009615384615384616, "content": "Case Study  Sarah is a 58-year-old breast cancer survivor, social worker, and health-care administrator at a long-term care facility. She lives with her husband and enjoys gardening and reading. She has two grown children and three grandchildren who live approximately 180 miles away. SECOND CANCER DIAGNOSIS  One morning while showering, Sarah detected a painless quarter-sized lump on her inner thigh. While she thought it was unusual, she felt it would probably go away. One month later, she felt the lump again; she thought that it had grown, so she scheduled a visit with her primary care physician. A CT scan revealed a 6.2-cm soft-tissue mass in the left groin. She was referred to an oncologic surgeon and underwent an excision of the groin mass. Pathology revealed a grade 3 malignant melanoma. She was later tested and found to have BRAF-negative status. Following her recovery from surgery, Sarah was further evaluated with an MRI scan of the brain, which was negative, and a PET scan, which revealed two nodules in the left lung. As Sarah had attended a cancer support group during her breast cancer treatment in the past, she decided to go back to the group when she learned of her melanoma diagnosis. While the treatment options for her lung lesions included interleukin-2, ipilimumab (Yervoy), temozolomide, dacarbazine, a clinical trial, or radiosurgery, Sarah's oncologist felt that ipilimumab or radiosurgery would be the best course of action. She shared with her support group that she was ambivalent about this decision, as she had experienced profound fatigue and nausea with chemotherapy during her past treatment for breast cancer. She eventually opted to undergo stereotactic radiosurgery. DISEASE RECURRENCE  After the radiosurgery, Sarah was followed every 2 months. She complained of shortness of breath about 2 weeks prior to each follow-up visit. Each time her chest x-ray was normal, and she eventually believed that her breathlessness was anxiety-related. Unfortunately, Sarah's 1-year follow-up exam revealed a 2 cm × 3 cm mass in her left lung, for which she had a surgical wedge resection. Her complaints of shortness of breath increased following the surgery and occurred most often with anxiety, heat, and gardening activities, especially when she needed to bend over. Sarah also complained of a burning \"pins and needles\" sensation at the surgical chest wall site that was bothersome and would wake her up at night. Sarah met with the nurse practitioner in the symptom management clinic to discuss her concerns. Upon physical examination, observable signs of breathlessness were lacking, and oxygen saturation remained stable at 94%, but Sarah rated her breathlessness as 7 on the 0 to 10 Borg scale. The nurse practitioner prescribed duloxetine to help manage the surgical site neuropathic pain and to assist with anxiety, which in turn could possibly improve Sarah's breathlessness. Several nonpharmacologic modalities for breathlessness were also recommended: using a fan directed toward her face, working in the garden in the early morning when the weather is cooler, gardening in containers that are at eye level to avoid the need to bend down, and performing relaxation exercises with pursed lip breathing to relieve anxiety-provoked breathlessness. One month later, Sarah reported relief of her anxiety; she stated that the fan directed toward her face helped most when she started to feel \"air hungry.\" She rated her breathlessness at 4/10 on the Borg scale. SECOND RECURRENCE: MULTIPLE PULMONARY NODULES  Sarah's chest x-rays remained clear for 6 months, but she developed a chronic cough shortly before the 9-month exam. An x-ray revealed several bilateral lung lesions and growth in the area of the previously resected lung nodule. Systemic therapy was recommended, and she underwent two cycles of ipilimumab. Sarah's cough and breathlessness worsened, she developed colitis, and she decided to stop therapy after the third cycle. In addition, her coughing spells triggered bronchospasms that resulted in severe anxiety, panic attacks, and air hunger. She rated her breathlessness at 10/10 on the Borg scale during these episodes. She found communication difficult due to the cough and began to isolate herself. She continued to attend the support group weekly but had difficulty participating in conversation due to her cough. Sarah was seen in the symptom management clinic every 2 weeks or more often as needed. No acute distress was present at the beginning of each visit, but when Sarah began to talk about her symptoms and fear of dying, her shortness of breath and anxiety increased. The symptom management nurse practitioner treated the suspected underlying cause of the breathlessness and prescribed oral lorazepam (0.5 to 1 mg every 6 hours) for anxiety and codeine cough syrup for the cough. Opioids were initiated for chest wall pain and to control the breathlessness. Controlled-release oxycodone was started at 10 mg every 12 hours with a breakthrough pain (BTP) dose of 5 mg every 2 hours as needed for breathlessness or pain. Sarah noted improvement in her symptoms and reported a Borg scale rating of 5/10. Oxygen therapy was attempted, but subjective improvement in Sarah's breathlessness was lacking. END OF LIFE  Sarah's disease progressed to the liver, and she began experiencing more notable signs of breathlessness: nasal flaring, tachycardia, and restlessness. Opioid doses were titrated over the course of 3 months to oxycodone (40 mg every 12 hours) with a BTP dose of 10 to 15 mg every 2 hours as needed, but her breathlessness caused significant distress, which she rated 8/10. The oxycodone was rotated to IV morphine continuous infusion with patient-controlled analgesia (PCA) that was delivered through her implantable port. This combination allowed Sarah to depress the PCA as needed and achieve immediate control of her dyspneic episodes. Oral lorazepam was also continued as needed. Sarah's daughter moved home to take care of her mother, and hospice became involved for end-of-life care. As Sarah became less responsive, nurses maintained doses of morphine for control of pain and breathlessness and used a respiratory distress observation scale to assess for breathlessness since Sarah could no longer self-report. A bolus PCA dose of morphine was administered by Sarah's daughter if her mother appeared to be in distress. Sarah died peacefully in her home without signs of distress. " }, { "id": "pubmed23n0560_14348", "title": "Randomized study of tramadol/acetaminophen versus placebo in painful diabetic peripheral neuropathy.", "score": 0.009615384615384616, "content": "To examine the efficacy and safety of tramadol/acetaminophen (APAP) for the management of painful diabetic peripheral neuropathy (DPN). Adults with painful DPN involving the lower extremities received 37.5 mg tramadol/325 mg APAP or placebo, up to 1-2 tablets four times daily, for 66 days. Subjects rated average daily pain and sleep interference from 0 ('none') to 10 ('pain as bad as you can imagine' or 'complete interference') every night. Baseline values were recorded for 7 days before starting study medication. The primary endpoint was change in mean of average daily pain scores from baseline to final week. Secondary efficacy outcomes included pain intensity, sleep interference, quality of life, mood, and global impression of change. Potential study limitations included permission to use serotonin reuptake inhibitors concomitantly (except venlafaxine or duloxetine) and the lack of a tramadol-alone or APAP-alone control group. A total of 160 subjects received tramadol/APAP and 153 received placebo. Tramadol/APAP reduced average daily pain significantly compared to placebo from baseline to the final week (-2.71 vs. -1.83, p = 0.001). Tramadol/APAP was associated with significantly greater improvement than placebo (p &lt; or = 0.05) for all measures of pain intensity, sleep interference, and global impression, as well as several measures of quality of life and mood. The only adverse event reported by &gt; 10% of subjects in either the tramadol/APAP or placebo group was nausea (11.9% and 3.3%, respectively). Adverse events resulted in early study discontinuation for 8.1% and 6.5% of subjects in the tramadol/APAP and placebo groups, respectively. Tramadol/APAP was more effective than placebo and was well tolerated in the management of painful DPN." }, { "id": "wiki20220301en508_19443", "title": "Oxycodone/ibuprofen", "score": 0.009523809523809525, "content": "Oxycodone/ibuprofen (INNs, trade name Combunox) is an oral combination drug formulation of the opioid analgesic oxycodone and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen that is used in the treatment of chronic and acute pain. This particular drug is supplied in a fixed dose combination tablet which contains Oxycodone Hydrochloride, USP 5 mg with Ibuprofen, USP 400 mg. Adverse effects See also Oxycodone/paracetamol Oxycodone/aspirin Hydrocodone/ibuprofen References External links Combination analgesics" }, { "id": "pubmed23n0698_22311", "title": "Clinical Approach to the Treatment of Painful Diabetic Neuropathy.", "score": 0.009523809523809525, "content": "Painful neuropathy is a common and often progressive complication of diabetes. Patients frequently report symptoms of tingling, burning, lancinating pain, hyperesthesia and allodynia. The natural history of the disease may vary from intermittent mild symptoms to severe chronic daily pain; the latter is often associated with diminished quality of life. There are a variety of pharmaceutical agents from different medicinal categories available for the symptomatic treatment of painful diabetic neuropathy, however selecting an agent is often challenging given the breadth of choices and lack of consistent guidelines. As a result, many patients remain untreated or undertreated.This article presents a practical clinical approach to the treatment of pain in diabetic neuropathy. Recommendations for first, second and third line medications are based on specific evidence for the treatment of painful diabetic neuropathy as well as safety, tolerability, drug interactions and cost. Additional topics of discussion include breakthrough pain, opioid use and topical therapies. This review does not comprehensively discuss all possible treatments for painful neuropathy, but provides a systematic approach designed to guide clinicians in tailoring therapies to the individual patient." }, { "id": "pubmed23n1025_4535", "title": "Midthoracic Punctate Midline Myelotomy for Treatment of Chronic, Intractable, Nonmalignant, Abdominal Visceral Pain: 2-Dimensional Operative Video.", "score": 0.009433962264150943, "content": "Punctate midline myelotomy (PMM) is a surgical procedure that damages the ascending fibers of the postsynaptic dorsal column (PSDC) pathway to interrupt visceral pain transmission.1-3 It can offer relief to patients with chronic visceral pain conditions that are refractory to other treatments. Here, we present a surgical video of midthoracic PMM in a patient with chronic, intractable, nonmalignant visceral abdominal pain that failed over a decade of medical treatment. We choose T7-8 as the level for laminectomy in patients with pelvic or lower abdominal pain, because the postsynaptic pain fibers transmitting visceral pain sensation from the lower abdominal organs will invariably be caudal to this level. The patient developed immediate and complete relief of her visceral pain after the procedure, which was sustained through the 11-wk follow-up period to date and was able to be weaned off narcotics. Postoperatively, she remained full strength and had no impairment of light touch or proprioception of her lower extremities. Detailed physical examination showed a reduced vibratory sensation on the glabrous skin of her great toes. Regarding patient-reported sensory changes (not detected on physical examination), she reported some numbness on the insides of her feet that had resolved by 11-wk follow-up. She also reported some numbness of the vulva, but not of the vagina. However, by 11-wk follow-up, she reported this had resolved and she had normal sexual function. The only persistent sensation at 11-wk follow-up was slight tingling in her toes that was not bothersome to her.4 The patient presented in the following video consented to both the surgical procedure and the publication of her clinical history and operative video." }, { "id": "pubmed23n1147_8042", "title": "[Primary hyperparathyroidism of chance, a case study].", "score": 0.009433962264150943, "content": "The authors are reporting here a documented case of hyperparathyroidism leading to hypercalcemia diagnosed spontaneously. A 75-year old female patient with has been treated since 3-4 years with metformin and ramipiril fortype 2 diabetes and high blood pressure, respectively. She was seen in our endocrinology outpatient visit for tingling in the arms associated with cervical pain with increasing intensity over the last six months. The patient's mother was diabetic and her father had high blood pressure. The diagnostic of primary hyperparathyroidism, resulting from a diffuse hyperplasia of the parathyroid gland, was retained after medical, biological, chirurgical and anatomo-pathological investigations. The blood level of PTH1-84 was 916.60pg/ml Normal value=15-68.3pg/ml. Diffuse poly-arthralgia in the neck and the lower limbs may not always be due to arthrosis in elderlies. Further investigation such as the dosage of blood level of calcium and PTH are required." }, { "id": "pubmed23n0809_19565", "title": "Clinical and nerve conduction study correlation in patients of diabetic neuropathy.", "score": 0.009259259259259259, "content": "1) To study types of neuropathy in Type 2 diabetes. 2) To correlate clinical features of peripheral neuropathy with nerve conduction study in Type 2 diabetes. A total of 50 diabetics, whose onset of diabetes after the age of 30 years were studied from Dr. D. Y. Patil hospital and research centre. Type 2 Diabetes mellitus with symptom suggestive of peripheral neuropathy were studied and included. Chronic alcoholic, peripheral neuropathy due to any other known cause were excluded. METHOD OF COLLECTION OF DATA: History of symptoms like paraesthesia like tingling sensation, burning feet, hyperaesthesia, foot ulcer, history of weakness and gait abnormality was noted. Complete central nervous system examination was performed to look for signs such as diminished ankle jerk, diminished power. Sensory examination for loss of light touch, superficial pain, temperature sense, vibration and joint position was done. Nerve conduction studies were performed using Clarity Octopus NCV/EMG machine. Written and informed consent from patient were taken. 1) 46 patients i.e. 92% presented with complaints of tingling sensation and 32 patients i.e. 64% had burning feet. 2) 29 patients i.e. 58% have diminished ankle jerk, 29 patients i.e. 58% have diminished or loss of vibration sense, in 21 patients i.e. 42% patients have diminished light touch and 20 patients i.e. 40% patients have loss of joint position senses. 3) NCV performed on 50 patients of diabetic neuropathy out of which all patients i.e. 100% had involvement of lower limb and only 24 patients i.e. 48% had involvement of upper limb also. 4) Involvement of tibial and sural nerve is more common i.e. 86% and 82% respectively. 5) 42 patients i.e. 84% found to have distal symmetrical polyneuropathy, 2 patients i.e. 4% had isolated tibial nerve involvement, 4 patients i.e. 8% had pure sensory sural nerve involvement, and only 1 patient each of isolated medial and plantar nerve involvement. Distal symmetrical polyneuropathy is most common form of diabetic neuropathy. Involvement of tibial and sural nerve is more common in diabetic neuropathy." }, { "id": "pubmed23n0502_8150", "title": "[Diabetic Neuropathy. Diagnosis and Treatment in the Physician's Office].", "score": 0.009259259259259259, "content": "The most common form of diabetic neuropathy is the distal symmetrical sensorimotor variety. It is all the more likely to develop, the longer diabetes mellitus has been clinically manifest. Clinical signs of this neuropathy include the loss of the Achilles tendon reflex, sensory disorders beginning distally, distal muscle paresis and such signs of autonomic nerve involvement as erectile disorders, disordered bladder emptying, diaphoretic disorders or orthostatic hypotension. The diagnostic work-up should also include a number of laboratory investigations to exclude other causes of neuropathy. The basis of treatment is the earliest detection of diabetes mellitus and the establishment of normoglycemia. The individual manifestations are treated symptomatically. For the treatment of pain, it may become necessary to apply opioids if antidepressants and anticonvulsants fail to prove effective." }, { "id": "wiki20220301en003_199458", "title": "Paracetamol", "score": 0.009174311926605505, "content": "Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior to ibuprofen in that respect, and the benefits of its use for fever are unclear. Paracetamol may relieve pain in acute mild migraine but only slightly in episodic tension headache. However, the aspirin/paracetamol/caffeine combination helps with both conditions where the pain is mild and is recommended as a first-line treatment for them. Paracetamol is effective for post-surgical pain, but it is inferior to ibuprofen. The paracetamol/ibuprofen combination provides further increase in potency and is superior to either drug alone. The pain relief paracetamol provides in osteoarthritis is small and clinically insignificant. The evidence in its favor for the use in low back pain, cancer pain and neuropathic pain is insufficient." }, { "id": "pubmed23n0355_18473", "title": "[Night headache: report of 2 cases].", "score": 0.009174311926605505, "content": "The pathogenesis of hypnic headache is still unknown. Some authors supposed that the genesis of hypnic disorder is a decrease of melatonin secretion. It is a rare, moderately severe headache that occurs in middle-aged or elderly patients and affects both sexes. It appears exclusively during sleep and often with alarm clock regularity. The attack lasts from two to 6 hours, it may be unilateral or diffuse, pulsating or boring, without autonomic system features. Case 1. A 49 year old man reported the history of two week nocturnal headache that awakened him every night from sleep. The headache lasted two hours. There were no autonomic system features. Case 2. A 52 year old man suffered from nocturnal headaches for 6 weeks. The pain occurred between 2 and 5 almost every night and woke the patient. He suffered from diabetes mellitus too. Both patients were treated with flunarizine with good results." }, { "id": "pubmed23n0805_21378", "title": "Hand and foot syndrome secondary to capecitabine.", "score": 0.00909090909090909, "content": "A 55-year-old woman on treatment with capecitabine and paclitaxel for breast carcinoma presented with history of a tingling sensation in her hands and feet with a progressive burning sensation. She also noted discomfort, minimal pain and stiffness while holding objects. On examination, there was patchy hyperpigmentation of both the palms and soles, and the dorsa of hands and feet. This was accompanied by a thickening of the skin more over the knuckles and toes. In addition there was a moist desquamation around the toes and over the palmar creases and a bluish discoloration of the lunulae of both thumbnails. She was diagnosed with hand and foot syndrome and started on pyridoxine and emollients. The finding of keratoderma noted in our patient is not seen commonly in hand and foot syndrome. " }, { "id": "pubmed23n0792_13619", "title": "[Chronic pain in the diabetic patient: a quali-quantitative observational study].", "score": 0.00909090909090909, "content": "The purpose of this study is to evaluate the prevalence and characteristics of pain in subjects affected by Diabetes Mellitus (DM), to assess approach and therapeutically valid outcomes as well as the knowledge of the Law n. 38/15/03/2010 of the Italian Government (\"Dispositions to guarantee the access to the Palliative Cares and Pain Therapy\"). We have enrolled 462 patients affected by DM [242 (52.4%) males, 209 (42.5%) females; while in 11 (5.1%) cases the gender has not been specified], with characteristics as follows: 62 patients (13.4%) affected by T1DM (37 males and 25 females) e 400 patients (86.6%) affected by T2DM (224 males e 176 females). The average age was of 65.2 years old (range 20-91). All the patients have been presented with an original questionnaires based on 10 questions. 221 subjects (48%) have claimed to have experienced pain; 60% within the females, 38% within the males (p&lt;0.001). 31% of these are to be included among the patients with T1DM, 50.5% among those with T2DM (p&lt;0.01). The presence of chronic pain has been acknowledged by 162 subjects (35%). As per chronic pain, this has been described as articular pain by 128 patients (80%), while 63 (38%) located the pain through the spine and 29 (18%) throughout the muscles. Chronic pain was described as moderate by 73 subjects (45%), intense by 59 (36%), feeble by 15 (9%), utterly intense by 5 (3%), moderate/intense by 1 (1%). The drugs for treating the chronic pain used by the patients have been enlisted as follows: FANS (41%), paracetamol (30%), glucocorticoids (3%), weak opioids (2%); 27% of subjects have received no therapy. As for the Law 38/2010, only 8% have said they have had news of it. The data gathered in this study have drawn attention on the fact that the presence of pain is higher in female gender, with a prevalence of 60% compared to the 38% of the male gender. It has been observed no relation with the age range, in particular no proportional increase level of pain has been observed, although the higher peak of prevalence has been experienced in the age range between 70-79, both for pain in general and for chronic pain. Speaking about efficacy of the treatment, almost 50% of the subjects have received no improvement from the therapy." }, { "id": "pubmed23n0787_7073", "title": "[Opioid combination of transdermal fentanyl and oral oxycodone for pain in a patient with giant-cell tumor of the sacrum].", "score": 0.009009009009009009, "content": "We describe successful pain control in a patient suffering from severe pain, using an opioid combination of transdermal fentanyl and oral oxycodone. A woman in her 40s with a giant-cell tumor of the sacrum suffered from refractory 4-5/5 pain on the Wong-Baker faces pain rating scale in her sacrum, feet and legs. Despite administration of fentanyl (2,520 microg day(-1)), she could not sleep in the supine position due to pain and dysesthesia. We gradually changed her medication from transdermal fentanyl to oral oxycodone. However, the patient complained of constant drowsiness after the complete switch to oral oxycodone (120 mg x day(-1)). Hence, we reduced the oral oxycodone dose and began a combination of transdermal fentanyl and oral oxycodone in addition to increasing doses of pregabalin. With the combination of transdermal fentanyl (25 microg x hr(-1)) and oral oxycodone (60 mg x day(-1)) her pain decreased to 1-3/5 on the faces pain rating scale. Our experience suggests that an opioid combination may provide favorable pain control in patients with severe pain, while minimizing the side effects of each drug." }, { "id": "pubmed23n0945_6153", "title": "Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy.", "score": 0.009009009009009009, "content": "Diabetic peripheral neuropathy (DPN) is the commonest cause of neuropathy worldwide, and its prevalence increases with the duration of diabetes. It affects approximately half of patients with diabetes. DPN is symmetric and predominantly sensory, starting distally and gradually spreading proximally in a glove-and-stocking distribution. It causes substantial morbidity and is associated with increased mortality. The unrelenting nature of pain in this condition can negatively affect a patient's sleep, mood, and functionality and result in a poor quality of life. The purpose of this review was to critically review the current literature on the diagnosis and treatment of DPN, with a focus on the treatment of neuropathic pain in DPN. A comprehensive literature review was undertaken, incorporating article searches in electronic databases (EMBASE, PubMed, OVID) and reference lists of relevant articles with the authors' expertise in DPN. This review considers seminal and novel research in epidemiology; diagnosis, especially in relation to novel surrogate end points; and the treatment of neuropathic pain in DPN. We also consider potential new pharmacotherapies for painful DPN. DPN is often misdiagnosed and inadequately treated. Other than improving glycemic control, there is no licensed pathogenetic treatment for diabetic neuropathy. Management of painful DPN remains challenging due to difficulties in personalizing therapy and ascertaining the best dosing strategy, choice of initial pharmacotherapy, consideration of combination therapy, and deciding on defining treatment for poor analgesic responders. Duloxetine and pregabalin remain first-line therapy for neuropathic pain in DPN in all 5 of the major published guidelines by the American Association of Clinical Endocrinologists, American Academy of Neurology, European Federation of Neurological Societies, National Institute of Clinical Excellence (United Kingdom), and the American Diabetes Association, and their use has been approved by the US Food and Drug Administration. Clinical recognition of DPN is imperative for allowing timely symptom management to reduce the morbidity associated with this condition." }, { "id": "pubmed23n0324_4304", "title": "[Abdominal migraine in adults].", "score": 0.008928571428571428, "content": "A case of a 35-year-old woman with abdominal migraine is presented. For four years she had been suffering from abdominal pains occurring only at night, always between 1 and 3 a.m. The patient always woke with abdominal pains and nausea. Each time she had diarrhoea and vomited and found that this gave her relief from the pain. Sometimes she lost consciousness for 1-2 minutes. After the attack she felt very weak, her legs and feet became numb and she found it difficult to get to sleep. The attacks and the fainting fits increased in frequency until she had several a month. Numerous gastrological examinations did not reveal any deviations from the normal. At the anti- epileptic consulting unit, abdominal epilepsy was excluded (no abnormalities were found in the eeg and CT examinations of the cranium). As a child she had paroxysmal abdominal pains. When the patient was 10 years old, she had an attack lasting one week and though the pain was severe on the left side, appendectomy was performed. Her mother suffers from migraine with very severe head pains. The patient was referred to our consulting unit where she was treated with Pizotifen in doses of 0.5 mg morning and noon and 1 mg in the evening for three months during which time she had no attacks. A few weeks after discontinuing this treatment, the nocturnal attacks again occurred though the pains were not so severe. She was then prescribed Nitrendipine, 5 mg nightly, and the attacks ceased. However, the patient said that she had felt better when taking Pizotifen." }, { "id": "pubmed23n0420_22665", "title": "Tender neck in a diabetic patient.", "score": 0.008928571428571428, "content": "A 45-year-old Indian patient with a history of type 2 diabetes mellitus presented with history of pain in the left side of the neck associated with sore throat of one month duration. The diagnosis of subacute granulomatous thyroiditis (de Quervains thyroiditis) was made which was confirmed radiologically by depressed radioactive iodine uptake. The patient showed marked clinical response and improvement within 24 hours on anti-inflammatory drugs and corticosteroid." }, { "id": "pubmed23n0051_18175", "title": "Infection in the diabetic foot.", "score": 0.008849557522123894, "content": "A 56-year-old woman presented with a chronic infection of her right first toe. The woman had a 15-year history of diabetes mellitus and had been insulin dependent for the past five years. Her toe had been injured one month earlier when hit by a frozen chicken that fell out of the freezer. The accident caused a bruise and a small cut. Serous to purulent drainage then developed. When she presented, the toe was reddened and draining. Physical examination showed a nonobese woman with no fever or other evidence of systemic infection. The wound showed no evidence of necrotizing fasciitis. Peripheral pulses were 2+ and capillary refill was slow. Sensation in both feet was decreased. The transcutaneous oxygen tension in the feet was reduced at 20 mm Hg. Relevant laboratory findings included a serum glucose of 250 and creatinine of 1.5. X-rays of the foot were compatible with diffuse osteomyelitis of the distal phalanx of the great toe. Technetium and indium scans were positive, with increased uptake localized to the area of x-ray changes (Figure 1). The patient was admitted to the hospital." }, { "id": "pubmed23n0898_8440", "title": "Complaints of Upper Extremity Numbness and Tingling Relieved With Dry Needling of the Teres Minor and Infraspinatus: A Case Report.", "score": 0.008771929824561403, "content": "Study Design Case report. Background Abnormal sensation, such as numbness or tingling, is traditionally thought to originate from neural compression. There is limited evidence to support reports of abnormal sensation arising from a trigger point. Case Description The patient was a 60-year-old woman with a primary complaint of right shoulder pain and secondary complaints of neck pain and right upper extremity numbness. Cervical spine neurological examination was unremarkable, and manual examination did not reproduce the patient's arm numbness or tingling symptoms. Compression of a trigger point in the infraspinatus and teres minor reproduced the patient's primary complaint of shoulder pain. The initial intervention included dry needling, which reproduced her upper extremity numbness. Subsequent treatment included manual therapy and exercise. Outcomes The patient was seen for a total of 3 visits, including the evaluation. Dry needling was utilized in 2 of her 3 visits. At discharge, she reported complete resolution of pain and altered sensation. Additionally, her scores on the Neck Disability Index, numeric pain-rating scale, and global rating of change exceeded the minimal clinically important difference. These outcomes were maintained at 2- and 12-month follow-up phone calls. Discussion This case report described the examination and use of dry needling in a case where the diagnosis was unclear. Clinicians may consider trigger point referral when examining patients with reports of abnormal sensation, especially when a more common cause cannot be identified. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2017;47(4):287-292. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7055." }, { "id": "pubmed23n0261_14927", "title": "Application of OpSite film: a new and effective treatment of painful diabetic neuropathy.", "score": 0.008771929824561403, "content": "The aim of the study was to assess the effect of application of OpSite dressings on the pain and quality of life in 33 patients with chronic diabetic neuropathy. The effect of OpSite was compared with no treatment. After a run-in period of 2 weeks, OpSite was applied to one of the painful legs for 4 weeks. This was followed by another period of 4 weeks when OpSite was switched to the opposite leg. Pain was assessed by visual analogue scale and the primary analysis variable was within patient difference in pain between OpSite leg and no treatment leg at week 4 corrected for baseline. Secondary variables were paracetamol pill ingestion and the quality of life dimensions, sleep, mobility, contact discomfort, appetite, and mood. Changes in these variables from baseline to weeks 4 and 8 were analysed. There was a significantly greater reduction in pain in the OpSite treated limbs than the control limbs (p &lt; 0.001). By week 4 paracetamol intake also declined significantly (p = 0.034) and patients experienced a significant improvement in contact discomfort, sleep, mood, appetite, and mobility (p &lt; 0.002 for all 5 variables). OpSite appeared to alleviate the pain associated with diabetic painful neuropathy and thus improved patients' quality of life." }, { "id": "pubmed23n1040_19306", "title": "Multiple extremity necrosis in fatal calciphylaxis: Case report.", "score": 0.008695652173913044, "content": "The clinical impact of vascular calcification is well established in the context of cardiovascular morbidity and mortality, but other clinical syndromes, such as calciphylaxis, although less frequent, have a significant impact on chronic kidney disease. Case report of a 27-year-old woman, who had complained of bilateral pain in her toes for 3 days, with the presence of small necrotic areas in the referred sites. She had a history of type 1 diabetes (25 years ago), with chronic kidney disease, on peritoneal dialysis, in addition to rheumatoid arthritis. She was admitted to the hospital, which preceded the current condition, due to exacerbation of rheumatoid arthritis, evolving with intracardiac thrombus due to venous catheter complications, when she started using warfarin. Ischemia progressed to her feet, causing the need for bilateral amputations. Her chirodactyls were also affected. Thrombophilia, vasculitis, endocarditis or other embolic sources were investigated and discarded. Her pathology report evidenced skin necrosis and superficial soft parts with recent arterial thrombosis, and Monckeberg's medial calcification. We started treatment with bisphosphonate and sodium thiosulfate, conversion to hemodialysis and replacement of warfarin with unfractionated heparin. Despite all the therapy, the patient died after four months of evolution. Calciphylaxis is a rare microvasculature calcification syndrome that results in severe ischemic injuries. It has pathogenesis related to the mineral and bone disorder of chronic kidney disease combined with the imbalance between promoters and inhibitors of vascular calcification, with particular importance to vitamin K antagonism. The preventive strategy is fundamental, since the therapy is complex with poorly validated effectiveness." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 130 ] ], "word_ranges": [ [ 0, 21 ] ], "text": "Digoxin is useful as a symptomatic treatment (it is a positive inotropic) in heart failure, although it does not improve survival." }, "2": { "exist": true, "char_ranges": [ [ 131, 267 ] ], "word_ranges": [ [ 21, 41 ] ], "text": "Carvedilol is a very well tolerated aß-blocker (due to its anti-a1 effect) that is associated with symptomatic and survival improvement." }, "3": { "exist": true, "char_ranges": [ [ 268, 374 ] ], "word_ranges": [ [ 41, 56 ] ], "text": "Acenocoumarol (Sintrom) would be indicated in this patient with chronic AF to avoid thromboembolic events." }, "4": { "exist": true, "char_ranges": [ [ 375, 602 ] ], "word_ranges": [ [ 56, 86 ] ], "text": "Enalapril and ACE inhibitors in general, by inhibiting the renin-angiotensin-aldosterone axis, suppress part of the neurohormonal effects that occur in heart failure; they improve survival in patients with systolic dysfunction." }, "5": { "exist": true, "char_ranges": [ [ 603, 750 ] ], "word_ranges": [ [ 86, 107 ] ], "text": "Ibuprofen and NSAIDs in general are contraindicated in patients with heart failure because they inhibit prostaglandin synthesis at the renal level," } }

{ "1": "Digoxin.", "2": "Carvedilol.", "3": "Acenocoumarol.", "4": "Enalapril.", "5": "Ibuprofen." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0308_20701", "title": "[The effects of mid- and long-term administration (3-4 years) of carvedilol in patients with idiopathic dilated cardiomyopathy].", "score": 0.01871774687308668, "content": "Carvedilol has been shown to determine a significant improvement in left ventricular function, symptoms, clinical course and prognosis of patients with chronic heart failure. However, these results were obtained in medium-term studies of &lt; 1 year duration. We report the results obtained with long-term (3-4 years) carvedilol administration to 40 patients with idiopathic dilated cardiomyopathy who were initially recruited in a 4-month double-blind placebo-controlled trial. In the initial 4-month double-blind trial, 20 patients were randomized to placebo and 20 to carvedilol treatment. All patients, except one who was not on ACE-inhibitors, were on digoxin, furosemide and ACE-inhibitors. Carvedilol or placebo doses were progressively titrated, at weekly intervals, up to the maximal doses of 25 mg bid. After the initial 4-month double-blind phase, all patients were followed long term. Mean follow-up duration was 52 +/- 12 months (range 48-61). Among the 20 patients initially randomized to carvedilol administration, 4 died (3 for cardiac and 1 for extracardiac causes) and 2 underwent heart transplant. Among the 20 patients initially randomized to placebo, 5 died for cardiac causes, 3 underwent heart transplant and 4 were started on carvedilol because of progressive heart failure during the initial 4 months of the study. The remaining 8 patients, who were kept on digoxin, furosemide and ACE-inhibitors, were used as control group. Each patient underwent an assessment of clinical conditions (NYHA functional classification and Minnesota Living with Heart Failure questionnaire), equilibrium radionuclide ventriculography, and maximal cardiopulmonary bicycle exercise testing. Exams were performed before treatment, after 4 and 12 months, and at the end of the follow-up period. No significant difference between the carvedilol and control group was present at baseline. Compared with baseline, patients in the control group presented a significant increase in left ventricular end-diastolic volume after long-term follow-up (from 126 +/- 62 to 138 +/- 43 and 158 +/- 52 ml/m2 after 12 and 48 months, respectively). No significant difference, compared to baseline values, was noted. Patients on carvedilol presented a persistent improvement in left ventricular function. This was shown by the progressive increment in left ventricular ejection fraction from 22 +/- 6 to 34 +/- 11, 37 +/- 11 and 37 +/- 13%, after 4, 12 and 48 months, respectively (p &lt; 0.001) with a concomitant reduction in left ventricular end-diastolic volume from 147 +/- 54 to 101 +/- 44 ml/m2 at the end of the follow-up (p &lt; 0.05). NYHA functional class remained significantly improved, in comparison with baseline (2.6 +/- 0.5 to 1.9 +/- 0.3, 1.9 +/- 0.8 and 2.0 +/- 1.0 after 4, 12 and 48 months, respectively; p &lt; 0.01). Maximal functional capacity, assessed as peak VO2 was not significantly changed after 4 months (from 15.2 +/- 3.6 to 16.4 +/- 4.0 ml/kg/min) and showed a tendency towards a further improvement after 12 months and at the end of the follow-up (17.3 +/- 5.6 and 17.2 +/- 5.3 ml/kg/min, respectively). These results show that the favorable effects of carvedilol administration on left ventricular function and clinical symptoms are maintained also after long-term treatment." }, { "id": "pubmed23n1106_10549", "title": "[Arrhythmogenic right ventricular cardiomyopathy associated with arrhythmia-induced cardiomyopathy: A case report].", "score": 0.017427884615384616, "content": "Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a kind of inherited cardio-myopathy, which is characterized by fibro-fatty replacement of right ventricular myocardium, leading to ventricular arrhythmia. However, rapid atrial arrhythmias are also common, including atrial fibrillation, atrial flutter and atrial tachycardia. Long term rapid atrial arrhythmia can lead to further deterioration of cardiac function. This case is a 51-year-old male. He was admitted to Department of Cardiology, Peking University Third Hospital with palpitation and fatigue after exercise. Electrocardiogram showed incessant atrial tachycardia. Echocardiography revealed dilation of all his four chambers, especially the right ventricle, with the left ventricular ejection fraction of 40% and the right ventricular hypokinesis. Cardiac magnetic resonance imaging found that the right ventricle was significantly enlarged, and the right ventricular aneurysm had formed; the right ventricular ejection fraction was as low as 8%, and the left ventricular ejection fraction was 35%. The patients met the diagnostic criteria of ARVC, and both left and right ventricles were involved. His physical activities were restricted, and metoprolol, digoxin, spironolactone and ramipril were given. Rivaroxaban was also given because atrial tachycardia could cause left atrial thrombosis and embolism. His atrial tachycardia converted spontaneously to normal sinus rhythm after these treatments. Since the patient had severe right ventricular dysfunction, frequent premature ventricular beats and non-sustained ventricular tachycardia on Holter monitoring, indicating a high risk of sudden death, implantable cardioverter defibrillator (ICD) was implanted. After discharge from hospital, physical activity restriction and the above medicines were continued. As rapid atrial arrhythmia could lead to inappropriate ICD shocks, amiodarone was added to prevent the recurrence of atrial tachycardia, and also control ventricular arrhythmia. After 6 months, echocardiography was repeated and showed that the left ventricle diameter was reduced significantly, and the left ventricular ejection fraction increased to 60%, while the size of right ventricle and right atrium decreased slightly. According to the clinical manifestations and outcomes, he was diagnosed with ARVC associated with arrhythmia induced cardiomyopathy. According to the results of his cardiac magnetic resonance imaging, the patient had left ventricular involvement caused by ARVC, and the persistent atrial tachycardia led to left ventricular systolic dysfunction." }, { "id": "pubmed23n0381_4950", "title": "Beneficial effect of carvedilol on heart rate response to exercise in digitalised patients with heart failure in atrial fibrillation due to idiopathic dilated cardiomyopathy.", "score": 0.01548758227778085, "content": "Fourteen digitalised patients diagnosed with heart failure (NYHA Functional class II) with idiopathic dilated cardiomyopathy in chronic established atrial fibrillation were administered carvedilol in addition to their anti-heart failure medications in an attempt to improve their heart rate control. Fourteen matched patients who did not receive carvedilol acted as control subjects. Patients treated with carvedilol showed significantly reduced resting heart rates (10-36%), maximal heart rates on exercise (5-20%) and an increased exercise time (2-30%) on treadmill stress tests (all P=0.001). Ventricular ectopic activity was also diminished. This was associated with symptomatic improvement in effort intolerance and palpitations. NYHA functional class, left ventricular dimensions and ejection fractions did not improve during the study period of 3 months. Thus, addition of carvedilol to digoxin had a beneficial effect on exercise tolerance in patients with idiopathic dilated cardiomyopathy in atrial fibrillation by virtue of an improved heart rate control both at rest and on exercise. Carvedilol was well tolerated despite impaired myocardial function." }, { "id": "pubmed23n0754_15408", "title": "ECG of the month. Irregular rhythm in a 25-year-old man with three prior cardiac operations. Coarse atrial fibrillation with a rapid ventricular response, left anterior fascicular block, left ventricular hypertrophy with repolarization abnormality.", "score": 0.014654282765737874, "content": "The patient underwent closure of an atrial septal defect at age 3, had a leaking \"mitral\" valve repaired at age 9, and at age 13 had a \"mitral\" valve replacement. He began taking warfarin sodium at that time and remained symptom-free until 10 days before his initial visit here when he presented to another hospital with dyspnea and palpitations. Treatment there consisted of lisinopril 10 mg qd, carvedilol 6.25 mg bid, aldactone 25 mg qd, furosemide 40 mg qd, digoxin 0.25 mg qd, and a continuation of warfarin sodium 7.5 mg qd. An echocardiogram showed a left ventricular ejection fraction of 20%. After diuresis, he was referred to our cardiology clinic. On his initial visit here, his heart rate was an irregular 120 beats/min, his blood pressure was 106/77 mmHg, and closing and opening snaps of a normally functioning mechanical mitral valvular prosthesis were heard. He was obese (height, 5' 9\"; weight, 272 lbs). An electrocardiogram was recorded (Figure 1)." }, { "id": "pubmed23n0371_468", "title": "The management of heart failure--an overview.", "score": 0.013546798029556651, "content": "National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given \"risk reduction\", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies." }, { "id": "pubmed23n0505_21749", "title": "Effects of carvedilol on ventriculo-arterial coupling in patients with heart failure.", "score": 0.012828947368421053, "content": "Ventriculo-arterial coupling, defined as the ratio of the effective afterload (Ea) to contractility (Ees), reflects the mechano-energetic performance of the heart and is increased in chronic heart failure (CHF); the aim of treatment is to reduce its value. We studied the effect of carvedilol on the Ea/Ees ratio in patients with CHF treated with ACE-inhibitors, diuretics, and digoxin. Between November 1999 and October 2001, 36 consecutive ambulatory patients (aged 31 to 76 years) with stable CHF and idiopathic or hypertensive cardiomyopathy, in sinus rhythm and with a left ventricular ejection fraction &lt; or = 40%, were started on carvedilol and the dose was increased to the maximum tolerated. Ees was calculated as the left ventricular systolic pressure--taken as the systolic arterial pressure measured using the cuff manometer simultaneously with two-dimensional echocardiographic recordings--divided by the left ventricular end-systolic volume. Ea was measured as the ratio of the left ventricular systolic pressure to the stroke volume. All patients were investigated prospectively after 6 and 12 months of treatment. Out of 36 patients, 4 did not tolerate the drug and were dropped out. At 6.35 +/- 1 months, the daily dosage of carvedilol was 49.7 +/- 21 mg. The NYHA functional class improved from 1.52 +/- 0.67 to 1.29 +/- 0.53 (p = 0.017), the heart rate markedly diminished from 73.6 +/- 13.3 to 60.8 +/- 10.8 b/min (p &lt; 0.001) and so did Ea (3.35 +/- 0.91 to 2.84 +/- 0.93, p = 0.001). Peripheral resistances and Ees did not change. Therefore, the decrease in the Ea/Ees ratio (2.61 +/- 0.78 vs 2.19 +/- 0.89, p = 0.004) and the related increase in left ventricular ejection fraction (28.8 +/- 5.68 vs 33.3 +/- 7.5%, p &lt; 0.001) were due to the decrease in Ea, while Ees did not vary significantly. Moreover, the Ea reduction was related linearly to the decrease in heart rate (r = 0.46, p = 0.001). There was no change in diuretic or ACE-inhibitor dosing during carvedilol titration. At 14.7 +/- 2 months of follow-up, no further variation occurred, short of a trend toward a slight increase in Ees (1.38 +/- 0.49 to 1.58 +/- 0.65, p = 0.07). Carvedilol, added to the conventional therapy of CHF, improves left ventricular performance and reduces the Ea/Ees ratio by decreasing Ea, mainly through a reduction in heart rate. This effect is already evident at 6 months and persists later on, while only after 12 months does Ees tend to increase slightly." }, { "id": "Pharmacology_Katzung_1326", "title": "Pharmacology_Katzung", "score": 0.010617260699656293, "content": "Enalapril Generic, Vasotec, Vasotec I.V. Fosinopril Generic, Monopril Lisinopril Generic, Prinivil, Zestril Quinapril Generic, Accupril Ramipril Generic, Altace Trandolapril Generic, Mavik Eprosartan Generic, Teveten Irbesartan Generic, Avapro Losartan Generic, Cozaar Telmisartan Generic, Micardis Bisoprolol Generic, Zebeta Carvedilol Generic, Coreg Metoprolol Generic, Lopressor, Toprol XL Eplerenone Generic, Inspra Isosorbide dinitrate Generic, Isordil Milrinone Generic, Primacor Ahmed A et al: Effectiveness of digoxin in reducing one-year mortality in chronic heart failure in the Digitalis Investigation Group trial. Am J Cardiol 2009;103:82. Borlaug BA, Colucci WS: Treatment and prognosis of heart failure with preserved ejection fraction. UpToDate, 2016. http://www.UpToDate.com. Bourge RC et al: Digoxin reduces 30-day all-cause hospital admission in older patients with chronic systolic heart failure. Am J Med 2013;126:701." }, { "id": "pubmed23n0479_20908", "title": "Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?", "score": 0.010263157894736842, "content": "This study examined the relative merits of digoxin, carvedilol, and their combination for the management of patients with atrial fibrillation (AF) and heart failure (HF). In patients with AF and HF, both digoxin and beta-blockers reduce the ventricular rate, and both may improve symptoms, but only beta-blockers have been shown to improve prognosis. If combined therapy is not superior to beta-blockers alone, treatment of patients with HF and AF could be simplified by stopping digoxin. We enrolled 47 patients (29 males; mean age 68 years) with persistent AF and HF (mean left ventricular ejection fraction [LVEF] 24%) in a randomized, double-blinded, placebo-controlled study. In the first phase of the study, digoxin was compared with the combination of digoxin and carvedilol (four months). In the second phase, digoxin was withdrawn in a double-blinded manner in the carvedilol-treated arm, thus allowing a comparison between digoxin and carvedilol (six months). Investigations were undertaken at baseline and at the end of each phase. Compared with digoxin alone, combination therapy lowered the ventricular rate on 24-h ambulatory electrocardiographic monitoring (p &lt; 0.0001) and during submaximal exercise (p &lt; 0.05), whereas LVEF (p &lt; 0.05) and symptom score (p &lt; 0.05) improved. In phase 2, there was no significant difference between digoxin alone and carvedilol alone in any variable. The mean ventricular rate rose and LVEF fell when patients switched from combination therapy to carvedilol alone. Six-minute walk distance was not significantly influenced by any therapy. The combination of carvedilol and digoxin appears generally superior to either carvedilol or digoxin alone in the management of AF in patients with HF." }, { "id": "article-26694_21", "title": "Paroxysmal Atrial Fibrillation -- Treatment / Management -- Rate Control", "score": 0.010103051121438673, "content": "Rate control is the preferred strategy for all asymptomatic AF patients. Guidelines on target heart rate in patients selected for rate control are lacking. A previously conducted randomized trial (RACE II) to assess heart rate goal in patients with AF showed no outcome difference between lenient and strict heart rate control; however, sufficient evidence to assess the impact on all-cause mortality was lacking. Physicians usually attempt to control heart rate control with agents such as beta-blockers (metoprolol, esmolol, propranolol), nondihydropyridine calcium-channel blockers (verapamil, diltiazem), or digoxin. All 3 classes of drugs are given intravenously (IV) for acute rate control and can be switched to oral therapy for chronic management. In patients with chronic heart failure with reduced ejection fraction, carvedilol therapy has shown significant improvement in left ventricular ejection fraction. Due to the negative inotropic properties of calcium channel blockers, physicians do not use these not preferred in such patients. Digoxin is usually reserved for patients who do not achieve rate control with beta-blockers or calcium channel blockers alone. Amiodarone can be used as second-line therapy when treatment with other agents has failed. [23] In patients refractory to medical therapy, AV node ablation with a permanent pacemaker placement can effectively control and regularize ventricular heart rate. Low doses of magnesium have shown synergistic effects on rate control. [24]" }, { "id": "pubmed23n0620_23588", "title": "Management of atrial fibrillation in the elderly.", "score": 0.009900990099009901, "content": "Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to slow immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in older patients, ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiar-rhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily." }, { "id": "wiki20220301en031_48107", "title": "Peripartum cardiomyopathy", "score": 0.00980392156862745, "content": "Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that is defined as a deterioration in cardiac function presenting typically between the last month of pregnancy and up to six months postpartum. As with other forms of dilated cardiomyopathy, PPCM involves systolic dysfunction of the heart with a decrease of the left ventricular ejection fraction (EF) with associated congestive heart failure and an increased risk of atrial and ventricular arrhythmias, thromboembolism (blockage of a blood vessel by a blood clot), and even sudden cardiac death. In essence, the heart muscle cannot contract forcefully enough to pump adequate amounts of blood for the needs of the body's vital organs. PPCM is a diagnosis of exclusion, wherein patients have no prior history of heart disease and there are no other known possible causes of heart failure. Echocardiogram is used to both diagnose and monitor the effectiveness of treatment for PPCM." }, { "id": "pubmed23n0397_8310", "title": "Management of the older person with atrial fibrillation.", "score": 0.00980392156862745, "content": "Atrial fibrillation (AF) is associated with a higher incidence of mortality, stroke, and coronary events than is sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, verapamil, or diltiazem may be given to slow immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and with symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds that are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and should be continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in older persons, ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Digoxin should not be used to treat patients with paroxysmal AF. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should receive 325 mg of aspirin daily." }, { "id": "pubmed23n0392_19644", "title": "[Effect of long-term treatment with enalapril, losartan and their combination on the quality of life of patients with congestive heart failure].", "score": 0.009708737864077669, "content": "To study the effect a combination of enalapril and losartan on life quality in patients with congestive heart failure (HF). One hundred and eighty six patients with NYHA functional classes II to IV HF were examined. The study inclusion criteria were as follows: a left ventricular (LV) end-diastolic volume of &gt; 160 ml, a LV ejection fraction of &lt; 35%, sinus rhythm, a cardiothoracic index of &gt; 0.55, no history data on prior treatment with an angiotensin-converting enzyme inhibitor (ACEI) and/or an AT1-antagonist, a patient's written free-will consent to participate in the study. The exclusion criteria were as follows: pacemaker migration, an artificial pacemaker, high-degree block, atrial fibrillation, cerebral circulatory disorders. All the patients were divided into 4 groups and received basic therapy with cardicet, 60-120 mg/day, aspirin, 250 mg/day, furosemide, 80-440 mg/week, and digoxin, 0.25-0.5 mg/day. Group 1 comprised 60 patients who refused therapy with ACEI and/or AT1-antagonist despite that they had indications for their use and they had been convinced many times. In Group 2 (n = 82) enalapril, an ACEI, was added to the basic therapy. Its initial dose of 2.5 mg/day was given once and slowly incremented to the therapeutical one (10-20 mg/day). Group 3 patients (n = 56) on the basic therapy were additionally treated with the AT1-antagonist losartan in a daily dose of 25-50 mg. They were started on 12.5 mg a day. In group 4 the basic therapy was added by a combination of enalapril and losartan in the same doses. The follow-up was 48 weeks. The efficiency of the treatments was controlled by the personal questionnaires SF-36, Life with Heart Failure, by evaluating the magnitude of clinical HF manifestations and by estimating the total life quality inxed. The data were analyzed by assuming that all the patients received the treatments. As compared with the conventional therapy and the use of each drug alone, a combination of the ACEI enalapril and the AT1-antagonist losartan promotes a more significant increase in the satisfaction of the patients with their vital activity, in the critical rate of their self-assessment of the \"internal picture\" of disease, and leads to a greater improvement of the quality of their life as a whole. The ICAE-AT1-antagonist combination exerts a positive impact on life quality in patients with heart failure." }, { "id": "pubmed23n0906_1992", "title": "Atrial Fibrillation: The New Epidemic of the Ageing World.", "score": 0.009615384615384616, "content": "The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases. AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily." }, { "id": "pubmed23n0372_275", "title": "Beneficial effects of pentoxifylline in patients with idiopathic dilated cardiomyopathy treated with angiotensin-converting enzyme inhibitors and carvedilol: results of a randomized study.", "score": 0.009523809523809525, "content": "We previously reported beneficial effects of pentoxifylline, a xanthine-derived agent known to inhibit the production of tumor necrosis factor-alpha, in patients with idiopathic dilated cardiomyopathy treated with diuretics, digoxin, and ACE inhibitors. Since then, 3 large clinical trials showed important clinical benefits of beta-blockers in this population. Therefore, we designed the present study to establish whether in patients with heart failure already receiving treatment with ACE inhibitors and beta-blockers, the addition of pentoxifylline would have an additive beneficial effect. In a single-center, prospective, double-blind, randomized, placebo-controlled study, 39 patients with idiopathic dilated cardiomyopathy were randomized to pentoxifylline 400 mg TID (n=20) or placebo (n=19) if they had a left ventricular ejection fraction &lt;40% after 3 months of therapy with digoxin, ACE inhibitors, and carvedilol. Primary end points were New York Heart Association functional class, exercise tolerance, and left ventricular function. Patients were followed up for 6 months. Five patients died (3 in the placebo group). Patients treated with pentoxifylline had a significant improvement in functional class compared with the placebo group (P:=0.01), with an increment in exercise time from 9.5+/-5 to 12.3+/-6 minutes (P:=0.1). Left ventricular ejection fraction improved from 24+/-9% to 31+/-13%, P:=0.03, in the treatment group. In patients with idiopathic dilated cardiomyopathy, the addition of pentoxifylline to treatment with digoxin, ACE inhibitors, and carvedilol is associated with a significant improvement in symptoms and left ventricular function." }, { "id": "pubmed23n0273_6468", "title": "Optimal management of older patients with atrial fibrillation.", "score": 0.009523809523809525, "content": "Long term oral warfarin should be administered to elderly patients with atrial fibrillation who are at high risk for developing thromboembolic stroke and who have no contraindications to anticoagulant therapy. Oral aspirin (acetylsalicylic acid) 325mg daily may be given to elderly patients with chronic atrial fibrillation who have contraindications to anticoagulant therapy or who are not at high risk for developing thromboembolic stroke. Management of atrial fibrillation includes treatment of the underlying disease and precipitating factors. If patients have paroxysmal atrial fibrillation with a very rapid ventricular rate associated with hypotension, severe left ventricular failure or chest pain due to myocardial ischaemia, immediate direct-current cardioversion should be performed. Intravenous verapamil, diltiazem or a beta-blocker should be used for immediate slowing of a very rapid ventricular rate associated with atrial fibrillation. If a rapid ventricular rate associated with atrial fibrillation persists at rest or during exercise despite digoxin, then oral verapamil, diltiazem or a beta-blocker should be added. Low dosages of oral amiodarone (200 to 400 mg/day) may be used in selected patients with symptomatic life-threatening atrial fibrillation refractory to other therapy. No medication which depresses atrioventricular conduction should be given to patients with atrial fibrillation and a slow ventricular rate. Cardioversion should not be performed in asymptomatic elderly patients with chronic atrial fibrillation. This author would use a beta-blocker for control of ventricular arrhythmias and following conversion of atrial fibrillation to sinus rhythm. Should atrial fibrillation recur, beta-blockers have the additional advantage of slowing the ventricular rate." }, { "id": "wiki20220301en063_19538", "title": "Valvular heart disease", "score": 0.009433962264150943, "content": "Mitral regurgitation Surgery is recommended for chronic severe mitral regurgitation in symptomatic patients with left ventricular ejection fraction (LVEF) of greater than 30%, and asymptomatic patients with LVEF of 30-60% or left ventricular end diastolic volume (LVEDV) > 40%. Surgical repair of the leaflets is preferred to mitral valve replacement as long as the repair is feasible. Mitral regurgitation may be treated medically with vasodilators, diuretics, digoxin, antiarrhythmics, and chronic anticoagulation. Mild to moderate mitral regurgitation should be followed with echocardiography and cardiac stress test every 1–3 years. Severe mitral regurgitation should be followed with echocardiography every 3–6 months." }, { "id": "pubmed23n0328_12245", "title": "[Drugs prescribed for chronic heart failure. Current data on their effectiveness].", "score": 0.009433962264150943, "content": "VARIABLE EFFICACY: Prognosis in patients with chronic heart failure remains poor. Certain drugs can lower mortality and improve quality of life. DRUGS WITH PROVEN EFFICACY: Converting enzyme inhibitors (CEI) have proven efficacy and should be used in all stages of heart failure outside contraindications. High-dose regimens are recommended when tolerated. Certain beta-blockers have also been added to the list of effective drugs for heart failure. Positive data have been reported for metroprolol, bisoprolol and carvedilol. Improved function has been demonstrated only with carvedilol allowing a clear reduction in mortality; it is currently indicated in combination with CEI and diuretics for patients with symptomatic heart failure. DRUGS WITH INSUFFICIENTLY PROVEN EFFICACY: Certain drugs which have been used for many years can improve heart function but data clearly proving lower mortality are lacking. These include diuretics and nitrate derivatives for symptomatic patients and digitalics which are useful not only for patients with complete arrhythmia due to atrial fibrillation but also for symptomatic patients with sinus rhythm. According to preliminary studies, aldosterone antagonists appear to have a positive effect on mortality due to heart failure. DRUGS WITH LIMITED INDICATIONS: Other drugs have been found to have no effect on mortality. Amiodarone, amlodipine and felodipine can thus be used for patients with associated diseases. Finally anticoagulant therapy should be reserved for patients with atrial fibrillation or a history of thromboembolism." }, { "id": "pubmed23n0053_11080", "title": "Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy.", "score": 0.009345794392523364, "content": "Ten patients aged 22 to 80 years (median 57) with severe left ventricular (LV) dysfunction and atrial fibrillation (AF) with rapid ventricular response were evaluated after therapy. Because most patients were unaware of their arrhythmia, duration was usually unknown. All patients had heart failure symptoms; 9 presented with New York Heart Association class III or IV disability, and 1 with class II disability. Initial LV ejection fraction ranged from 12 to 30% (median 25). No patient had symptomatic coronary artery disease (4 underwent angiography). Myocarditis and infiltrative processes were excluded by biopsy in 5 patients. All patients were considered initially to have idiopathic dilated cardiomyopathy with secondary AF. Ventricular rate was controlled in all patients, with sinus rhythm restored in 5. At follow-up (median 30 months, range 3 to 56), all patients were asymptomatic. LV ejection fraction after treatment ranged from 40 to 64% (median 52). It is concluded that in some patients initially considered to have idiopathic dilated cardiomyopathy, AF with rapid ventricular response may be the primary cause rather than the consequence of severe LV dysfunction. LV dysfunction may be completely reversible with ventricular rate control." }, { "id": "pubmed23n0506_20517", "title": "[Pharmacotherapy of chronic heart failure in clinical practice].", "score": 0.009345794392523364, "content": "Chronic heart failure affects between 1-5% of the population and rise steeply with age. Most patients with chronic heart failure should be routinely managed with a combination of 4 types of drugs: a diuretic, an angiotensin converting enzyme inhibitors (ACE-I), beta-blocker and usually digitalis. Diuretics are essential for symptomatic treatment when fluid overload is present, and should always be administrated in combination with ACE-I if possible. ACE-I improves survival and symptoms and reduces hospitalization in patients with moderate to severe ventricular systolic dysfunction, and in the absence of fluid retention should be given first. Angiotensin II receptor antagonist could be considered in patients who not tolerate ACE-I. beta-blocking agents are recommended for treatment of patients with stable, mild, moderate and severe heart failure unless there is a contraindication. Bisoprolol, metoprolol and carvedilol have been associated with reduction in total mortality, cardiovascular mortality and sudden death. Cardiac glycosides are indicated in atrial fibrillation and any degree of symptomatic heart failure in order slow ventricular rate. Indications for antiarrhythmic drug therapy include atrial fibrillation, non-sustained or sustained ventricular tachycardia. Oral anticoagulation reduces the risk of stroke in patients with atrial fibrillation, and there is a lack of evidence to support the use of antithrombotic therapy in patients in sinus rhythm." }, { "id": "pubmed23n0265_9695", "title": "Effects of short- and long-term carvedilol administration on rest and exercise hemodynamic variables, exercise capacity and clinical conditions in patients with idiopathic dilated cardiomyopathy.", "score": 0.009259259259259259, "content": "The study evaluated the effects of short- and long-term administration of carvedilol in patients with idiopathic dilated cardiomyopathy. Carvedilol is a beta-adrenergic blocking agent with vasodilator activity that might be well tolerated in patients with heart failure. Forty patients with idiopathic dilated cardiomyopathy treated with digoxin, furosemide and angiotensin-converting enzyme inhibitors were randomized in a double-blind manner to receive either placebo or carvedilol. Right heart hemodynamic variables were evaluated up to 8 h after short-term drug administration and, on the next day, during cardiopulmonary exercise testing before and 3 h after drug ingestion. Placebo or carvedilol was added to standard therapy, starting with a dose of 6.25 mg twice a day with weekly increments up to the maximum of 25 mg twice a day. Patients were reevaluated after 4 months by cardiopulmonary exercise testing and measurement of right heart hemodynamic variables 12 h after last drug ingestion and 3 h after drug readministration. Left ventricular ejection fraction and volume, measured by equilibrium radionuclide ventriculography, quality of life and submaximal exercise duration were assessed before and after long-term therapy. Compared with placebo, carvedilol produced a short-term reduction in heart rate and pulmonary artery and pulmonary wedge pressures and, after long-term administration, increased both rest and peak exercise cardiac, stroke volume and stroke work indexes, with a further reduction in right atrial, pulmonary artery and pulmonary wedge pressures. Long-term carvedilol administration also improved rest left ventricular ejection fraction (from 20 +/- 7% to 30 +/- 12%, p &lt; 0.001), submaximal exercise capacity, quality of life and New York Heart Association functional class. No baseline variable was predictive of the response to therapy. Short-term carvedilol administration reduces heart rate and mean pulmonary artery and pulmonary wedge pressures, whereas it improves both long-term rest and exercise left ventricular systolic function, reduces heart failure symptoms and improves submaximal exercise tolerance in patients with idiopathic cardiomyopathy." }, { "id": "pubmed23n0375_10801", "title": "Left ventricular diastolic heart failure with normal left ventricular systolic function in older persons.", "score": 0.009259259259259259, "content": "Underlying causes and precipitating causes of congestive heart failure (CHF) should be treated when possible. Older persons with CHF and normal left ventricular (LV) ejection fraction should have maintenance of sinus rhythm, treatment of hypertension and myocardial ischemia, slowing of the ventricular rate below 90 beats/minute, and reduction of salt overload. First-line drug treatment in the management of these persons is the use of loop diuretics combined with beta blockers as tolerated. Angiotensin-converting enzyme (ACE) inhibitors should be administered if CHF persists despite diuretics and beta blockers. If persons are unable to tolerate ACE inhibitors because of cough, rash, or altered taste sensation, angiotensin II type 1 receptor antagonists should be given. If CHF persists despite diuretics, beta blockers, and ACE inhibitors or the person is unable to tolerate beta blockers, ACE inhibitors, and angiotensin II type 1 receptor antagonists, isosorbide dinitrate plus hydralazine should be administered. Calcium channel blockers should be used if CHF persists despite administration of diuretics and the person is unable to tolerate beta blockers, ACE inhibitors, angiotensin II type 1 receptor antagonists, and isosorbide dinitrate plus hydralazine. Digoxin, beta blockers, verapamil, and diltiazem may be used to slow a rapid ventricular rate in persons with supraventricular tachyarrhythmias. Digoxin should not be used in persons with CHF in sinus rhythm with normal LV ejection fraction." }, { "id": "wiki20220301en000_119255", "title": "Digitalis", "score": 0.00919746173945502, "content": "under current regulations by the Food and Drug Administration on the basis of prospective, randomized study and clinical trials. It was also approved for the control of ventricular response rate for patients with atrial fibrillation. American College of Cardiology/American Heart Association guidelines recommend digoxin for symptomatic chronic heart failure for patients with reduced systolic function, preservation of systolic function, and/or rate control for atrial fibrillation with a rapid ventricular response. Heart Failure Society of America guidelines for heart failure provide similar recommendations. Despite its relatively recent approval by the Food and Drug Administration and the guideline recommendations, the therapeutic use of digoxin is declining in patients with heart failure—likely the result of several factors. The main factor is the more recent introduction of several drugs shown in randomised controlled studies to improve outcomes in heart failure. Safety concerns" }, { "id": "wiki20220301en023_12078", "title": "Arrhythmogenic cardiomyopathy", "score": 0.009174311926605505, "content": "Minor criteria Right ventricular dysfunction Mild global RV dilatation and/or reduced ejection fraction with normal LV. Mild segmental dilatation of the RV Regional RV hypokinesis Tissue characterization Electrocardiographical abnormalities Late potentials on signal averaged EKG. Ventricular tachycardia with a left bundle branch block (LBBB) morphology, with inferior or unknown axis Frequent PVCs (> 500 PVCs / 24 hours) Management The goal of management of ACM is to decrease the incidence of sudden cardiac death. This raises a clinical dilemma: How to prophylactically treat the asymptomatic patient who was diagnosed during family screening." }, { "id": "pubmed23n0417_6924", "title": "Pharmacologic therapy for patients with chronic heart failure and reduced systolic function: review of trials and practical considerations.", "score": 0.009174311926605505, "content": "Heart failure (HF) is a complex clinical syndrome resulting from any structural or functional cardiac disorder impairing the ability of the ventricles to fill with or eject blood. The approach to pharmacologic treatment has become a combined preventive and symptomatic management strategy. Ideally, treatment should be initiated in patients at risk, preventing disease progression. In patients who have progressed to symptomatic left ventricular dysfunction, certain therapies have been demonstrated to improve survival, decrease hospitalizations, and reduce symptoms. The mainstay therapies are angiotensin-converting enzyme (ACE) inhibitors and beta-blockers (bisoprolol, carvedilol, and metoprolol XL/CR), with diuretics to control fluid balance. In patients who cannot tolerate ACE inhibitors because of angioedema or severe cough, valsartan can be substituted. Valsartan should not be added in patients already taking an ACE inhibitor and a beta-blocker. Spironolactone is recommended in patients who have New York Heart Association (NYHA) class III to IV symptoms despite maximal therapies with ACE inhibitors, beta-blockers, diuretics, and digoxin. Low-dose digoxin, yielding a serum concentration &lt;1 ng/mL can be added to improve symptoms and, possibly, mortality. The combination of hydralazine and isosorbide dinitrate might be useful in patients (especially in African Americans) who cannot tolerate ACE inhibitors or valsartan because of hypotension or renal dysfunction. Calcium antagonists, with the exception of amlodipine, oral or intravenous inotropes, and vasodilators, should be avoided in HF with reduced systolic function. Amiodarone should be used only if patients have a history of sudden death, or a history of ventricular fibrillation or sustained ventricular tachycardia, and should be used in conjunction with an implantable defibrillator [corrected]. Finally, anticoagulation is recommended only in patients who have concomitant atrial fibrillation or a previous history of cerebral or systemic emboli." }, { "id": "wiki20220301en012_66475", "title": "Heart failure", "score": 0.00909090909090909, "content": "Anemia is an independent factor in mortality in people with chronic heart failure. Treatment of anemia significantly improves quality of life for those with heart failure, often with a reduction in severity of the NYHA classification, and also improves mortality rates. The European Society of Cardiology guideline in 2016 recommend screening for iron-deficiency anemia and treating with intravenous iron if deficiency is found. The decision to anticoagulate people with HF, typically with left ventricular ejection fractions <35% is debated, but generally, people with coexisting atrial fibrillation, a prior embolic event, or conditions that increase the risk of an embolic event such as amyloidosis, left ventricular noncompaction, familial dilated cardiomyopathy, or a thromboembolic event in a first-degree relative." }, { "id": "pubmed23n0395_18245", "title": "Atrial fibrillation.", "score": 0.00909090909090909, "content": "The prevalence and incidence of atrial fibrillation increase with age. Atrial fibrillation is associated with a higher incidence of coronary events, stroke, and mortality than sinus rhythm. A fast ventricular rate associated with atrial fibrillation may cause tachycardia-related cardiomyopathy. Management of atrial fibrillation includes treatment of underlying causes and precipitating factors. Immediate direct-current cardioversion should be performed in persons with atrial fibrillation associated with acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta-blockers, verapamil, or diltiazem may be used to immediately slow a fast ventricular rate associated with atrial fibrillation. An oral beta-blocker, verapamil, or diltiazem should be given to persons with atrial fibrillation if a rapid ventricular rate occurs a rest or during exercise despite digoxin. Amiodarone may be used in selected persons with symptomatic life-threatening atrial fibrillation refractory to other drug therapy. Nondrug therapies should be performed in persons with symptomatic atrial fibrillation in whom a rapid ventricular rate cannot be slowed by drug therapy. Paroxysmal atrial fibrillation associated with the tachycardia-bradycardia syndrome should be managed with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in persons with atrial fibrillation in whom symptoms such as dizziness or syncope associated with non-drug-induced ventricular pauses longer than 3 seconds develop. Elective direct-current cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than medical cardioversion in converting atrial fibrillation to sinus rhythm. Unless transesophageal echocardiography shows no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective direct-current or drug cardioversion of atrial fibrillation and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer the treatment strategy of ventricular rate control plus warfarin rather than to maintain sinus rhythm with antiarrhythmic drugs, especially in older patients. Digoxin should not be used in persons with paroxysmal atrial fibrillation. Patients with chronic or paroxysmal atrial fibrillation who are at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio (INR) of 2.0 to 3.0. Persons with atrial fibrillation who are at low risk for stroke or who have contraindications to warfarin should receive 325 mg aspirin daily." }, { "id": "wiki20220301en084_6362", "title": "List of dog diseases", "score": 0.009009009009009009, "content": "Dilated cardiomyopathy (DCM) is a disease of heart muscle resulting in decreased myocardial contractility. The left ventricle compensates for this disease by growing larger (eccentric or volume overload hypertrophy; AKA dilation). The left atrial is also dilated when the disease is severe. It is seen in large/giant dog breeds such as Boxers, Great Danes, and Doberman Pinschers. It is usually idiopathic, but can also be caused by taurine deficiency in American Cocker Spaniels or doxorubicin use. A mutation in the gene that encodes for pyruvate dehydrogenase kinase 4 is associated with DCM in Doberman Pinschers in the USA. Dilated cardiomyopathy usually ultimately results in congestive heart failure. Atrial fibrillation is common in giant breed dogs with DCM. Doberman Pinschers more commonly have ventricular arrhythmias (e.g., premature ventricular complexes; ventricular tachycardia) that predispose them to sudden death (i.e., ventricular fibrillation)." }, { "id": "wiki20220301en023_18140", "title": "Dilated cardiomyopathy", "score": 0.008928571428571428, "content": "Diagnosis Generalized enlargement of the heart is seen upon normal chest X-ray. Pleural effusion may also be noticed, which is due to pulmonary venous hypertension. The electrocardiogram often shows sinus tachycardia or atrial fibrillation, ventricular arrhythmias, left atrial enlargement, and sometimes intraventricular conduction defects and low voltage. When left bundle-branch block (LBBB) is accompanied by right axis deviation (RAD), the rare combination is considered to be highly suggestive of dilated or congestive cardiomyopathy. Echocardiogram shows left ventricular dilatation with normal or thinned walls and reduced ejection fraction. Cardiac catheterization and coronary angiography are often performed to exclude ischemic heart disease." }, { "id": "pubmed23n0073_12134", "title": "[The therapy of chronic heart failure].", "score": 0.008928571428571428, "content": "A rational therapy of the chronic cardiac insufficiency should be performed according to a certain scheme, in which case the knowledge of the basic disease is necessary for the causal treatment. Apart from the general measures the medicamentous therapy is of particular significance. Hereby up to now the digitalis glycosides remained the remedy of primary choice. They are without doubt indicated in the latent and manifest cardiac insufficiency, consequently from the transition of the NYHA stage II into stage III, in tachycardiac disturbances of rhythm also without cardiac insufficiency in form of auricular fibrillation and auricular flutter as well as in the paroxysmal supraventricular tachycardia. Prophylactic, preoperative applications of glycosides and such ones which are performed only for reasons of age are not justified. Also a maintenance therapy is in most cases no more necessary after removal of the cause of the cardiac insufficiency. - Diuretics are to be used in an insufficiency which continues existing despite application of glycosides. Their application must be performed as protracted as possible. - The therapies with vasodilators, such as prazosin, hydralazine and nitrates, which were performed during the last years, showed, indeed, initial success, but no long-term effect. Another fact it is, however, with the angiotensin-converting enzyme (ACE) inhibitors captopril and enalapril, which are to be regarded as second grade medicaments in combination with glycosides and diuretics. Whether or not they will supersede the glycosides, is at present still an open question. Other positively inotropic medicaments which in comparison to the glycosides show a larger therapeutic breadth are still being developed.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en074_48185", "title": "Tachycardia-induced cardiomyopathy", "score": 0.008849557522123894, "content": "Diagnosis There are no specific diagnostic criteria for TIC, and it can be difficult to diagnose for a number of reasons. First, in patients presenting with both tachycardia and cardiomyopathy, it can be difficult to distinguish which is the causative agent. Additionally, it can occur in patients with or without underlying structural heart disease. Previously normal left ventricular ejection fraction or left ventricular systolic dysfunction out of proportion to a patient’s underlying cardiac disease can be important clues to possible TIC. The diagnosis of TIC is made after excluding other causes of cardiomyopathy and observing resolution of the left ventricular systolic dysfunction with treatment of the tachycardia." }, { "id": "pubmed23n0477_12568", "title": "[Atrial fibrillation].", "score": 0.008849557522123894, "content": "Atrial fibrilation is the most frequent arrhythmia, the occurrence increasing with age and associated diseases. The incidence at the age below 60 years is markedly lower than one per cent, whereas in persons above 80 years of age it exceeds six per cent. The occurrence in patients with heart failure is from 10% (NYHA II) up to 50% (NYHA IV). Atrial fibrillation is classified into that observed for the first time and permanent, respectively, while transient forms include paroxyzmal and persistent atrial fibrillation. The diagnosis is based on ECG recording, while echocardiography is most significant. The therapy includes two basic questions--anticoagulant or anti-aggregation treatment and the control of rhythm or frequency. The anticoagulant therapy should be introduced in all patients, where contraindications are not present, being necessary before every cardioversion, provided atrial fibrillation lasts more than two days. In patients without any heart disease and with a physiological echocardiogram it is possible to administer only anti-aggregation treatment. Cardioversion (the control of rhythm) is recommended to all symptomatic patients, in other cases and especially in older persons the control of frequency is safer and of more advantage. Electrical cardioversion is more effective that a pharmacological treatment, the sinus rhythm is preferably controlled by dofetilid, ibutilid, propafenon and amiodaron. For the control of heart rate beta-blockers, diltiazem, verapamil and digitalis are recommended." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 300, 456 ] ], "word_ranges": [ [ 50, 75 ] ], "text": "Parvovirus B19 is the cause of erythema infectiosum or \"fifth disease\", whose characteristic rash is on the cheeks, giving the appearance of a slapped face." }, "2": { "exist": true, "char_ranges": [ [ 92, 299 ] ], "word_ranges": [ [ 14, 50 ] ], "text": "By the picture of high fever of several days that suddenly subsides with the appearance of a rash, we have a sudden exanthem, caused by Herpes virus type 6 (remember the mnemonic rule of \"sudden Hexanthem\")." }, "3": { "exist": true, "char_ranges": [ [ 457, 635 ] ], "word_ranges": [ [ 75, 101 ] ], "text": "Coxackie A16 causes herpangina and also boca-mano-pie disease, which presents an initially macular rash, which does not respect palms or soles and evolves into bursting vesicles." }, "4": { "exist": true, "char_ranges": [ [ 636, 792 ] ], "word_ranges": [ [ 101, 123 ] ], "text": "Finally, EBV infection produces a mononucleosis syndrome with high fever lasting several days, with pharyngeal erythema and grayish exudates on the tonsils." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Parvovirus B19.", "2": "Herpes virus type 6.", "3": "Coxackie A16 virus.", "4": "Primoinfection by Epstein-Barr virus.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0407_10432", "title": "Spontaneous resolution of hemophagocytic syndrome associated with acute parvovirus B19 infection and concomitant Epstein-Barr virus reactivation in an otherwise healthy adult.", "score": 0.014083210603829159, "content": "Reported here is the case of a patient who spontaneously recovered from hemophagocytic syndrome associated with acute B19 infection and concomitant Epstein-Barr virus reactivation. The previously healthy 37-year-old-man was hospitalized after 10 days of high fever, arthralgia and arthritis and was determined to have hemophagocytic syndrome. Immunoglobulin (Ig) M antibodies to Epstein-Barr virus (EBV) capsid antigen, early antigen and parvovirus B19 (B19) were found. B19 DNA and low-level EBV DNA were detected in bone marrow, serum and peripheral blood mononuclear cells. The patient recovered spontaneously without any treatment. Two months later anti-B19 IgG antibodies were detected, while at 9-month follow-up, anti-B19 IgM antibodies were no longer detectable and B19 DNA had disappeared from serum. To the best of our knowledge, this is the first report of spontaneous resolution of hemophagocytic syndrome associated with acute B19 infection and concomitant EBV reactivation in an otherwise healthy adult." }, { "id": "wiki20220301en257_8960", "title": "Herpesviral encephalitis", "score": 0.012730649412892404, "content": "Earlier treatment (within 48 hours of symptom onset) improves the chances of a good recovery. Rarely, treated individuals can have relapse of infection weeks to months later. There is evidence that aberrant inflammation triggered by herpes simplex can result in granulomatous inflammation in the brain, which responds to steroids. While the herpes virus can be spread, encephalitis itself is not infectious. Other viruses can cause similar symptoms of encephalitis, though usually milder (Herpesvirus 6, varicella zoster virus, Epstein-Barr, cytomegalovirus, coxsackievirus, etc.). References External links Herpes Viral encephalitis Pediatrics Herpes simplex virus-associated diseases" }, { "id": "InternalMed_Harrison_15515", "title": "InternalMed_Harrison", "score": 0.011842556107589516, "content": "Hand-foot-and-moUtH disease (Fig. 228-1) After an incubation period of 4–6 days, patients with hand-foot-and-mouth disease present with fever, anorexia, and malaise; these manifestations are followed by the development of sore throat and vesicles (see Fig. 25e-23) on the buccal mucosa and often on the tongue and then by the appearance of tender vesicular lesions on the dorsum of the hands, sometimes with involvement of the palms. The vesicles may form bullae and quickly ulcerate. About one-third of patients also have lesions on the palate, uvula, or tonsillar pillars, and one-third have a rash on the feet (including the soles) or on the buttocks. The disease is highly infectious, with attack rates of close to 100% among young children. The lesions usually resolve in 1 week. Most cases are due to coxsackievirus A16 or enterovirus 71." }, { "id": "InternalMed_Harrison_4115", "title": "InternalMed_Harrison", "score": 0.011753264795776604, "content": "PART 2 Cardinal Manifestations and Presentation of Diseases CAuSES of ExAnTHEMS I. Morbilliform A. Drugs B. Viral 1. 2. 3. Erythema infectiosum (erythema of cheeks; reticulated on extremities) 4. Epstein-Barr virus, echovirus, coxsackievirus, CMV, adenovirus, HHV-6/ HHV-7a, dengue virus, and West Nile virus infections 5. C. Bacterial 1. 2. 3. 4. 5. D. Acute graft-versus-host disease E. Kawasaki disease II. A. B. C. D. Early staphylococcal scalded-skin syndrome aPrimary infection in infants and reactivation in the setting of immunosuppression. Abbreviations: CMV, cytomegalovirus; HHV, human herpesvirus; HIV, human immunodeficiency virus." }, { "id": "pubmed23n0706_12075", "title": "Etiologies of rash and fever illnesses in Campinas, Brazil.", "score": 0.01164874551971326, "content": "Few population-based studies of infectious etiologies of fever-rash illnesses have been conducted. This study reports on enhanced febrile-rash illness surveillance in Campinas, Brazil, a setting of low measles and rubella virus transmission. Cases of febrile-rash illnesses in individuals aged &lt;40 years that occurred during the period 1 May 2003-30 May 2004 were reported. Blood samples were collected for laboratory diagnostic confirmation, which included testing for adenovirus, dengue virus, Epstein-Barr virus (EBV), enterovirus, human herpes virus 6 (HHV6), measles virus, parvovirus-B19, Rickettsia rickettsii, rubella virus, and group A streptococci (GAS) infections. Notification rates were compared with the prestudy period. A total of 1248 cases were notified, of which 519 (42%) had laboratory diagnosis. Of these, HHV-6 (312 cases), EBV (66 cases), parvovirus (30 cases), rubella virus (30 cases), and GAS (30 cases) were the most frequent causes of infection. Only 10 rubella cases met the rubella clinical case definition currently in use. Notification rates were higher during the study than in the prestudy period (181 vs 52.3 cases per 100,000 population aged &lt;40 years). Stimulating a passive surveillance system enhanced its sensitivity and resulted in additional rubella cases detected. In settings with rubella elimination goals, rubella testing may be considered for all cases of febrile-rash illness, regardless of suspected clinical diagnosis." }, { "id": "wiki20220301en503_18576", "title": "Eosinophilic myocarditis", "score": 0.011494755244755244, "content": "The DRESS syndrome is a severe immunological drug reaction. It differs from other drug reactions in that it: a) is caused by a particular set of drugs; b) typically occurs after a delay of 2 to 8 weeks following intake of an offending drug; c) presents with a specific set of signs and symptoms (i.e. modest or extreme elevations in blood eosinophil and atypical lymphocyte counts; acute onset of a skin rash; lymphadenopathy; fever; neuralgia; and involvement of at least one internal organ such as the liver, lung, or heart; d) develops in individuals with particular genetic predispositions; and e) involves reactivation of latent viruses, most commonly human herpesvirus 6 or more rarely human herpes virus 5 (i.e. human cytomegalovirus), human herpesvirus 7, and human herpesvirus 4 (i.e. Epstein–Barr virus). These viruses usually become dormant after infecting humans but under special circumstances, such as drug intake, are reactivated and may contribute to serious diseases such as the" }, { "id": "wiki20220301en055_19611", "title": "Eastern equine encephalitis", "score": 0.011364522417153996, "content": "Signs and symptoms The incubation period for Eastern equine encephalitis virus (EEEV) disease ranges from 4 to 10 days. The illness can progress either systematically or encephalitically, depending on the person's age. Encephalitic disease involves swelling of the brain and can be asymptomatic, while the systemic illness occurs very abruptly. Those with the systemic illness usually recover within 1–2 weeks. While the encephalitis is more common among infants, in adults and children, it usually manifests after experiencing the systemic illness. Symptoms include high fever, muscle pain, altered mental status, headache, meningeal irritation, photophobia, and seizures, which occur 3–10 days after the bite of an infected mosquito. Due to the virus's effect on the brain, patients who survive can be left with mental and physical impairments, such as personality disorders, paralysis, seizures, and intellectual impairment. Cause Virus" }, { "id": "wiki20220301en088_4970", "title": "Human herpesvirus 6", "score": 0.011083451872925556, "content": "HHV-6 has also been demonstrated to transactivate Epstein–Barr virus. Epidemiology Age Humans acquire the virus at an early age, some as early as less than one month of age. HHV-6 primary infections account for up to 20% of infant emergency room visits for fever in the United States and are associated with several more severe complications, such as encephalitis, lymphadenopathy, myocarditis and myelosuppression. The prevalence of the virus in the body increases with age (rates of infection are highest among infant between 6 and 12 months old) and it is hypothesized that this is due to the loss of maternal antibodies in a child that protect him or her from infections." }, { "id": "pubmed23n0771_11997", "title": "Cephalhematoma and petechial rashes associated with acute parvovirus B19 infection: a case report.", "score": 0.01097926139514251, "content": "Parvovirus B19 can cause petechial rashes in the acute phase of illness as well as erythema infectiosum (fifth disease) during convalescence. This petechial rash is often called \"gloves and socks\" syndrome because of the typical distribution of the eruption. However, involvement of other sites (e.g., intertriginous area) and generalized involvement have been recently recognized. We report here a patient with parvovirus-associated petechiae and cephalhematoma. The patient was a previously healthy 10-year-old boy. There was a family history of fatal bleeding; his sister died of intracranial bleeding with an uncertain cause at the age of 5 months. The patient was admitted to our hospital because of sudden onset of cephalhematoma associated with fever. He reported that he had no recent head trauma but that he massaged his scalp on the day before admission. On admission, his temperature was 38.8°C; otherwise, he was in a stable condition. Besides cephalhematoma, petechial rashes were present on his trunk and limbs. The initial laboratory tests were essentially normal, including platelet count and coagulation tests. Expanded laboratory tests were repeated to explore the etiology of his skin hemorrhage, all of which indicated that hematological disorders were unlikely. His symptoms subsided spontaneously over the next few days and he was discharged uneventfully. Anti-parvovirus IgM titer was elevated during hospitalization and typical erythema infectiosum was seen approximately 1 week after discharge. During 6 months follow-up, he remained stable without recurrence of a hemorrhagic episode. Finally, we concluded that his cephalhematoma was responsible for acute parvoviral infection. This is believed to be the first report describing a possible association between parvovirus B19 infection and cephalhematoma. Parvovirus B19 infection should be considered in the differential diagnosis of children who present with unexplained hemorrhage such as cephalhematoma or petechiae." }, { "id": "wiki20220301en087_3062", "title": "Eczema herpeticum", "score": 0.010862842121540126, "content": "Eczema herpeticum is a rare but severe disseminated infection that generally occurs at sites of skin damage produced by, for example, atopic dermatitis, burns, long-term usage of topical steroids or eczema. It is also known as Kaposi varicelliform eruption, Pustulosis varioliformis acute and Kaposi-Juliusberg dermatitis. Some sources reserve the term \"eczema herpeticum\" when the cause is due to human herpes simplex virus, and the term \"Kaposi varicelliform eruption\" to describe the general presentation without specifying the virus. This condition is most commonly caused by herpes simplex virus type 1 or 2, but may also be caused by coxsackievirus A16, or vaccinia virus. It appears as numerous umbilicated vesicles superimposed on healing atopic dermatitis. it is often accompanied by fever and lymphadenopathy. Eczema herpeticum can be life-threatening in babies." }, { "id": "wiki20220301en268_11771", "title": "Eruptive pseudoangiomatosis", "score": 0.010720601237842617, "content": "Eruptive pseudoangiomatosis is a cutaneous condition characterized by the sudden appearance of 2- to 4-mm blanchable red papules. It can appear in children or adults.The papules appear similar to hemangiomas Viruses found in patients include Echovirus 25 and 32, coxsackie B, Epstein-Barr virus, and cytomegalovirus. See also Boston exanthem disease Skin lesion References Virus-related cutaneous conditions" }, { "id": "wiki20220301en023_21706", "title": "Viral hepatitis", "score": 0.009900990099009901, "content": "Other viruses The virus first known to cause hepatitis was the yellow fever virus, a mosquito-borne flavivirus. Other viruses than can cause hepatitis include: Adenoviruses Arenaviruses: Guanarito virus, Junín virus, Lassa fever virus, Lujo virus, Machupo virus, and Sabiá virus Bunyaviruses: Crimean–Congo hemorrhagic fever virus, Dobrava virus, Hantaan virus, Puumala virus, Rift Valley fever virus, and Seoul virus Coronavirus: severe acute respiratory syndrome virus Erythrovirus: Parvovirus B19 Filoviruses: Ebola virus and Marburg virus Flaviviruses: dengue, Kyasanur Forest disease virus, Omsk hemorrhagic fever virus, and yellow fever virus Herpesviruses: cytomegalovirus, Epstein–Barr virus, varicella-zoster virus, human herpesvirus 6, human herpesvirus 7, and human herpesvirus 8 Orthomyxoviruses: influenza Picornaviruses: echovirus Reovirus: Colorado tick fever virus, reovirus 3" }, { "id": "pubmed23n0055_12762", "title": "[The blood picture in exanthema subitum (Zahorsky)/ critical 3-day fever-exanthema in young children].", "score": 0.009900990099009901, "content": "Exanthema subitum was described in 1910 by John Zahorsky/USA; in 1986 and 1988 the human herpesvirus 6 (HHV 6) was discovered as the causative agent of the disease and serologic tests were established for diagnostics (specific IgM and IgG antibodies). Up to this time the diagnosis was based on the typical clinical course: the prodromal febrile stage (3 days) followed by the onset of a (more or less characteristic) rash closely connected with the normalisation of the body temperature. Usually a typical white blood cell count was described for diagnostics on the first day of exanthema: leukocytopenia with eosino- and granulocytopenia associated with consequent lymphocytosis. We analysed the hematologic data for children with a serologically documented HHV6 infection including exanthema (group 1: n = 9), without exanthema (group 2: n = 11) or with a serologically unexplained febrile rash (group 3: n = 13). In children with exanthematous HHV6 infection (exanthema subitum) granulocytopenia and a decreased thrombocyte count (mean values) is the rule. But the total white blood cell count and the mean values for eosinophils did not differ between the groups studied." }, { "id": "pubmed23n0973_9586", "title": "Scarlet fever associated with hepatitis in pediatrics. A case report.", "score": 0.00980392156862745, "content": "Scarlet fever is a common illness in pediatrics caused by group A beta-hemolytic strep tococcus (GABHS), which usually occurs after an episode of pharyngitis, and has an overall excellent prognosis. Hepatitis secondary to scarlet fever is a rare complication described in adults and even less frequently in children. Our objective was to describe a case of hepatitis secondary to scarlet fever in a pediatric patient. A 12-year-old male with scarlet fever presented with a 4-day history of jaundice, dark urine, and decreased appetite. Laboratory tests revealed elevated liver enzy mes and total and direct bilirubin levels, and negative studies for hepatitis A, B and C, Epstein Barr virus, parvovirus B19, adenovirus, cytomegalovirus, human herpes virus-6, and herpes simplex virus 1 and 2. Abdominal ultrasound examination was normal. The pathogenesis of scarlet fever associated hepatitis remains unclear. Streptococcal pyrogenic exotoxin mediated cellular injury via cytokine production has been proposed as a possible mechanism of hepatotoxicity in GABHS infections. Hepatitis secondary to scarlet fever remains a rare but benign entity, with complete recovery expected over weeks to months." }, { "id": "pubmed23n0044_4404", "title": "[3-day fever: agreement between clinical diagnosis and seroconversion of type 6 human herpesvirus (HHV-6)].", "score": 0.00980392156862745, "content": "The aim of this study was to investigate the correlation between clinical diagnosis of exanthema subitum and seroconversion of herpes virus type 6 (HHV-6). 90 children with fever of unknown origin were investigated by 11 pediatricians in the Canton of Zürich, Switzerland, between October 1989 and June 1990. Antibodies against HHV-6 were determined at the first consultation and 2-3 weeks later. History and clinical findings were investigated and the clinical probability of the diagnosis exanthema subitum was estimated. 82 of the 90 children could be evaluated. 33 of them already had HHV-6 antibodies in their first blood sample although their history was negative concerning exanthema subitum. In 24 children exanthema subitum was proven by seroconversion. The clinical diagnosis was much more reliable at the second consultation compared to the first one. The clinical course of the disease was highly variable. Duration of fever differed widely and in some children the exanthema was atypical or even absent." }, { "id": "wiki20220301en018_104809", "title": "Herpes virus", "score": 0.009708737864077669, "content": "Herpes virus may refer to: Any member of the large family of DNA viruses known as Herpesviridae Human herpesviruses, nine types of herpesviruses that can cause diseases in humans Herpes simplex virus 1 and 2, responsible for herpes simplex infections Human alphaherpesvirus 3, also called varicella-zoster virus, responsible for chickenpox and shingles Human gammaherpesvirus 4, or Epstein–Barr virus, one of the most common viruses which can cause various diseases Human betaherpesvirus 5 Roseolovirus, a genus that includes three human herpesviruses: Human herpesvirus 6, the collective name for Human betaherpesvirus 6A and Human betaherpesvirus 6B Human betaherpesvirus 7 Human gammaherpesvirus 8, or Kaposi's sarcoma-associated herpesvirus" }, { "id": "pubmed23n0500_12593", "title": "[Viral exanthem].", "score": 0.009708737864077669, "content": "The most frequent cause of exanthematous diseases are viral infections, which provoke skin alterations either directly or via the reaction of the immune system. In many distinct parainfectious clinical pictures, several viruses from quite different groups are able to produce a specific exanthem. Dominant pathogens for exanthematous diseases include non-polio enteroviruses, respiratory viruses, Epstein-Barr virus, HHV-6 and HHV-7 viruses as well as parvovirus B19. In many cases exanthemata present with maculate or maculopapular features in disseminated distribution. Some exanthematous diseases exhibit typical predilection sites. In addition to the clinical picture, diagnosis is based on the patient's history, observation of the patient's general condition, awareness of the season in the year, and physical examination. In uncertain cases and for scientific studies, blood analysis, smear tests, and histological investigation confirm the diagnosis. Knowledge of exanthematous disease, which usually run harmless course, is essential for differentiation of life-threatening disorders. This article presents exanthematous viral diseases depending on age at primary manifestation." }, { "id": "article-23023_12", "title": "Herpes Virus Type 6 -- History and Physical", "score": 0.009690521844910415, "content": "HHV-6B is the causative agent in exanthema subitum (also known as roseola infantum), a childhood disease characterized by high fever and a mild skin rash, and accounts for up to 10 to 17% of acute febrile Emergency department visits in children up to 36 months of age. [9] Primary HHV-6 infection accounts for over 36% of all cases of acute fever in children between 12 and 15 months old and is almost exclusively caused by HHV-6B, not HHV-6A. [9] [8] [10]" }, { "id": "pubmed23n0343_15449", "title": "[Round Table: Urticaria in relation to infections].", "score": 0.009523809523809525, "content": "1) To study the clinical and analytic features of infectious disease associated to urticaria in children. 2) To look into the probable etiology of the infectious disease. 3) To determine atopic predisposition and previous urticarial episodes and to rule out the involvement of antibiotics. Transversal and observational study. Pediatric Allergy Outpatient Clinic of a tertiary Hospital. Forty-four children, aged 1 to 12 years with acute urticaria associated to clinically infectious or febrile illness attending an Emergency Pediatric Department. Symptoms evaluation and physical examination in the seventh first days and follow over 3-6 weeks by the same physician. Clinical features of urticaria (duration, angioedema associated); Clinic diagnosis of illness infectious (acute respiratory infection, gastroenteritis, febrile syndrome); white blood cells count, C-reactive protein, aminotransferases (AST, ALT), L-Y-glutamyl transferase; viral culture and antigen detection: enterovirus (EV), adenovirus, respiratory syncytial virus (RSV), parainfluenza 1, 2 and 3, influenza A y B and cytomegalovirus (CMV); serological assay: CMV, enterovirus, mycoplasma pneumoniae, Epstein-Barr, parvovirus B19. 22 children (50%) are between 1-2 years old. 40 patients (90,9%) had symptoms of respiratory tract infection and only four patients had a pneumonia. The other 4 children had a gastroenteritis. The analytic was suggestive of viral infection in 35 (79.5%) and unknown on seven patients. In 20 children (45.4%) was identified a probable infection. The viral detection was positive in 3 patients: CMV, herpes simplex 1 and influenza A. Twenty microbiological findings for seventeen patients was found by serological criterion of probable infection: enterovirus (10); parvovirus B19 (4); Epstein-Barr (3) y mycoplasma (3). Evidence of a double serologic infection was found in three patients. In comparison with a serological control group encountered that acute urticaria during a infectious disease is significantly associated (p = 0.0054) to high titer to enterovirus by complement-fixation. The urticaria was associated with angioedema in 38.6% and 9 children (20.4%) related an previous similar episode. Twenty-one (47.7%) had been treated with antibiotics before development the urticaria. All patients was given the suspected antibiotic and no patient developed any adverse reaction. The clinically infectious associated to urticarial rash in children, usually is a viral respiratory infections. Is more frequent at infant. In spite of antibiotic therapy is often related to development the urticaria, the subsequent challenge with the same antibiotic is good tolerated." }, { "id": "pubmed23n0321_16927", "title": "[Parvovirus B19 primo-infection and cold agglutinins].", "score": 0.009523809523809525, "content": "Parvovirus B19 infection is frequent. Primary infection leads to diverse skin manifestations including the recently described gloves-and-socks papulopurpura. A patient presented with a papulopurpuric eruption on the nose, hands, feet and perineum with cheilitis and high-grade fever. Parvovirus B19 serology showed characteristic IgG on the 15th day after the initial eruption demonstrating the seroconversion. Cold agglutinins were positive during the eruption and negative after regression. The gloves-and-socks papulopurpura syndrome was initially described in 1990. Since that time 20 cases have been reported. In 7 cases, primary parvovirus B19 infection was proven and viral infections were suspected in the others (measles, coxsackie B6, hepatitis B, Epstein-Barr virus). Our case evidenced here to undescribed skin manifestations and the development of cold agglutinins. The presence of cold agglutinins at eruption could explain the acral localizations observed in this syndrome." }, { "id": "wiki20220301en249_18863", "title": "Systemic vasculitis", "score": 0.009433962264150943, "content": "Vasculitis secondary to viral infection. Usually due to hepatitis B and C, human immunodeficiency virus, cytomegalovirus, Epstein–Barr virus, and parvovirus B19. Signs and symptoms Patients usually present with systemic symptoms with single or multiorgan dysfunction. Common (and nonspecific) complaints include fatigue, weakness, fever, joint pains, abdominal pain, hypertension, chronic kidney disease, and neurologic dysfunction. The following symptoms should raise a strong suspicion of a vasculitis:" }, { "id": "pubmed23n0044_19292", "title": "[Infections with herpesvirus 6--really only \"exanthema subitum\"? Part 1: More frequent disease pictures].", "score": 0.009433962264150943, "content": "The human herpes virus 6 (HHV6) is the causal agent of exanthem subitum (rose rash of infants). In addition, however, a wide range of other clinical manifestations are possible, the more common of these include: Untypical exanthem or uncharacteristic rash (with and without fever), acute respiratory disease (ARD) acute gastroenteritis and febrile convulsions (with and without exanthem). More uncommon, and in part unknown, clinical manifestations associated with HHV6 infection are discussed in Part 2 of this paper. In common with other herpes viruses, HHV6 also tends to show persistence and intermittent or chronic shedding in the normal population, making the unusually early infection of children (seroconversion in the first year of life in up to 80% of all children) understandable. This means that HHV6 infections manifesting in close temporal association with recommended vaccinations may be misinterpreted as complications of the vaccination. Today, the situation can be clarified by employing special virological-serological laboratory tests, which are available throughout the country." }, { "id": "wiki20220301en251_31484", "title": "Acute cerebellar ataxia of childhood", "score": 0.009345794392523364, "content": "Acute cerebellar ataxia of childhood is a childhood condition characterized by an unsteady gait, most likely secondary to an autoimmune response to infection, drug induced or paraneoplastic. Most common virus causing acute cerebellar ataxia are Chickenpox virus and Epstein Barr Virus, leading to a childhood form of post viral cerebellar ataxia. It is a diagnosis of exclusion. Signs and symptoms Acute cerebellar ataxia usually follows 2–3 weeks after an infection. Onset is abrupt. Vomiting may be present at the onset but fever and nuchal rigidity characteristically are absent. Horizontal nystagmus is present is approximately 50% of cases. Truncal ataxia with deterioration of gait Slurred speech and nystagmus Afebrile Cause Possible causes of acute cerebellar ataxia include varicella infection, as well as infection with influenza, Epstein-Barr virus, Coxsackie virus, Echo virus or mycoplasma." }, { "id": "pubmed23n0044_21143", "title": "[The relationship of clinical manifestations and age distribution in enterovirus infections--viral isolation and seroepidemiology in Aichi Prefecture].", "score": 0.009345794392523364, "content": "We studied the epidemiology of enterovirus infection in Aichi Prefecture from 1985 to 1989. We examined the age distribution of aseptic meningitis patients (AM) and exanthematous disease patients (Ex) and a seroepidemiological study of echovirus type 7 (E7), E9, E18 and group A coxsackievirus type 9 (CA9), was performed. The results is as follows: 1) E7, E9, E18 and CA9 were isolated from AM and Ex but E6, E11 and group B Coxsackie viruses (CB) were isolated in fewer cases from Ex. 2) The AM was consistently increased from June to August. Whereas the Ex was seen in all seasons but a slight increase was noted between June to July, and enteroviruses (EV) isolation was increased in this season. 3) The AM occurred in 0 year olds and 4 year olds whereas the Ex was seen in 0 to 1 years. EV was mainly isolated from 0-1 year olds. 4) The relationship of clinical manifestations and age was very clear in E9 and E18, a higher proportion of children at 1 years or under were those of the Ex and most children of the latter part of 4 years were those of the AM. The Ex had the same results with E7 and CA9 but AM was increased in 0 years and 4 year olds. 5) We studied the age distributions of neutralizing antibodies against E7, E9, E18 and CA9. The positive rate of neutralizing antibody after prevalence rose between 2-5 years of age. There were few patients among the 2 to 3 year olds but the neutralizing antibody was raised in this age. I considered that reason the enteroviruses infected mainly the 2 to 6 year olds showing no clinical symptoms where as some of the 3 year olds had aseptic meningitis and some under 1 year had symptoms of exanthematous diseases." }, { "id": "pubmed23n0535_17926", "title": "Acute necrotizing encephalopathy associated with human herpesvirus-6 infection.", "score": 0.009259259259259259, "content": "An extremely rare case of acute necrotizing encephalopathy caused by human herpesvirus-6 variant type B infection is reported. The patient, a 14-month-old previously healthy female, presented with high fever and generalized tonic convulsion followed by rapid deterioration of consciousness. On the second day of the illness, the protein level of the cerebrospinal fluid increased without pleocytosis. On the third day, magnetic resonance images demonstrated symmetric, abnormal signal intensity lesions in the bilateral thalamus, cerebellum, and brainstem. On the fourth day, characteristic maculopapular rash of exanthema subitum appeared on the trunk. Human herpesvirus-6 deoxyribonucleic acid was detected by the polymerase chain reaction in the serum, and immunoglobulin G and immunoglobulin M of serum human herpesvirus-6 were positive. On the twelfth day of illness, the patient died as a result of severe brain damage. Acute necrotizing encephalopathy should be included in the differential diagnosis when examining infants and young children with fulminating consciousness disturbance and intractable convulsion. In addition, as a causative virus, human herpesvirus-6 has to be considered at the pre-eruptive stage of exanthema subitum. Magnetic resonance images are useful because they reveal the characteristic distribution of lesions specific to acute necrotizing encephalopathy." }, { "id": "pubmed23n0370_11128", "title": "[Macrophage activation syndrome in primary human herpes virus-6 infection: a rare condition after liver transplantation in infants].", "score": 0.009174311926605505, "content": "Human herpes virus-6 primary infection generally occurs during the first three years of childhood and is generally asymptomatic. The virus has been identified as the causal agent of exanthemum subitum in children or mononucleosis-like disease in adults, and may also cause several disorders in immunocompromised patients. We report a clinical case of acute rejection observed 29 days after orthotopic liver transplantation in a 22-month-old child associated with acute hepatitis and a hemophagocytic syndrome on day 38. Human herpes virus-6 primary infection was identified based on several virological tests: seroconversion, detection of viral DNA in bone marrow and peripheral blood after polymerase chain reaction, and detection of viral replication in peripheral blood. Tests for Epstein-Barr virus, cytomegalovirus or Parvovirus B19 infections were negative. After treatment by ganciclovir (Cymévan(R)), clinical status improved." }, { "id": "pubmed23n0252_7727", "title": "[Clinical manifestations of infectious erythema in adults].", "score": 0.009174311926605505, "content": "The infectious erythema is usually childhood disease associated with rash and caused by parvovirus B19. At the beginning of 1993., at the Clinic for infectious and tropical diseases of the Military Medical Academy 36 patients were treated for this disease, the average age 21 years. The prodromal phase of illness lasted approximately 2.9 days, the elevated temperature 5.2 days, and 17 patients had temperature above 39 degrees C. The rash was usually maculo-papullous and lasted about 6 days. Four patients had the recurrence of rash. The polyarthralgia appeared for short in six patients and in one patient lasted longer than 4 months. The mild anemia during infectious erythema was observed in 18 patients. IgM antiparvo B19 antibodies were proven in serum in 91.7%, and IgG antibodies in 58.3% of patients." }, { "id": "pubmed23n0985_25692", "title": "[THE FEATURES OF THE COURSE OF INFECTIOUS MONONUKLEOSIS OF DIFFERENT ETIOLOGY IN CHILDREN].", "score": 0.00909090909090909, "content": "Aim - to study the effect of different pathogens (EBV, CMV, HHV-6, and MIXT) on the severity of clinical-paraclinical manifestations of infectious mononucleosis in children. The clinical and laboratory study performed for 410 children aged from 10 months up to 12 years with infectious mononucleosis. The association of herpes viruses, mainly EBV, CMV and HHV type 6, takes part in the formation of the clinical picture of IM in (52,9%) of cases. The sole participation of EBV in the development of IM was observed only in (34,1%), CMV (9,02%) and HHV-6 in (3,17%) patients. The etiology of infectious mononucleosis in children affects the acuity, severity, and intensity of the clinical and paraclinical signs of the disease. Infectious mononucleosis VEB etiology is manifested by acute onset (79,5%), intoxication (70,5%), subfebrile and febrile fever up to 7 days (61,03%), lacunar tonsillitis (85,8%), hepatomegaly ( 88,2%), splenomegaly (63,8%), mostly moderate (81,7%) with lymphocytosis (62,9%) and monocytosis (20,5%). For CMV mononucleosis - acute onset (89,9%), severe course (29,8%), febrile and high fever for up to 7 (56,7%) or more days, neutrophilic leukocytosis (73,55) with atypical mononuclear cells (64,7%) and anemia (29,7%). Severe (33,3%), with prolonged high fever (50%), exanthema syndrome (33,3%), pharyngitis without tonsillitis (66,7%), leukocytosis (66,7%) with accelerated ESR (66,7%) and monocytosis (33,3%) are characteristic of HHV-6 infection. For MIXT - acute onset (78,3%), intoxication (79,7%), lacunar tonsillitis (92,9%), hepatomegaly (84,1%) and splenomegaly (67%), low-grade and febrile fever from 3- x (27,1%) up to 7 days (35,05%), lymphocytosis (55,3%) with neutropenia (57,4%), atypical mononuclear cells (48,2%) and hypochromic anemia (17,29 %)." }, { "id": "wiki20220301en005_4065", "title": "Infectious mononucleosis", "score": 0.009075475589826583, "content": "Incubation period The exact length of time between infection and symptoms is unclear. A review of the literature made an estimate of 33–49 days. In adolescents and young adults, symptoms are thought to appear around 4–6 weeks after initial infection. Onset is often gradual, though it can be abrupt. The main symptoms may be preceded by 1–2 weeks of fatigue, feeling unwell and body aches. Cause Epstein–Barr virus About 90% of cases of infectious mononucleosis are caused by the Epstein–Barr virus, a member of the Herpesviridae family of DNA viruses. It is one of the most commonly found viruses throughout the world. Contrary to common belief, the Epstein–Barr virus is not highly contagious. It can only be contracted through direct contact with an infected person's saliva, such as through kissing or sharing toothbrushes. About 95% of the population has been exposed to this virus by the age of 40, but only 15–20% of teenagers and about 40% of exposed adults actually become infected." }, { "id": "wiki20220301en065_58852", "title": "Vertically transmitted infection", "score": 0.009009009009009009, "content": "T – toxoplasmosis from Toxoplasma gondii O – other infections (see below) R – rubella C – cytomegalovirus H – herpes simplex virus-2 or neonatal herpes simplex Other infections include: Parvovirus B19 Coxsackievirus Chickenpox (caused by varicella zoster virus) Chlamydia HIV Human T-lymphotropic virus Syphilis Zika fever, caused by Zika virus, can cause microcephaly and other brain defects in the child. Hepatitis B may also be classified as a vertically transmitted infection. The hepatitis B virus is large and does not cross the placenta. Hence, it cannot infect the fetus unless breaks in the maternal-fetal barrier have occurred, but such breaks can occur in bleeding during childbirth or amniocentesis." }, { "id": "pubmed23n0310_7710", "title": "[Febrile eruptions and herpesviruses].", "score": 0.009009009009009009, "content": "There are 2 types of febrile skin eruptions due to herpesviruses: rashes (human herpesvirus 6 and 7. Epstein-Barr virus and cytomegalovirus), and vesicular eruptions (varicella and herpes zoster, primary and recurrent herpetic infections). Clinical diagnosis is often easy, based on the features of the eruption: characteristic sudden exanthem, clinical signs of infectious mononucleosis, or early vesicular trunk lesions characteristic of varicella or herpes. However, it must be stressed that exanthematic viroses can be highly variable. In some cases, and based on the background on which these eruptions occur, laboratory investigations will be necessary, according to the suspected virus." }, { "id": "pubmed23n0970_3421", "title": "Severe atypical hand-foot-and-mouth disease in adults due to coxsackievirus A6: Clinical presentation and phylogenesis of CV-A6 strains.", "score": 0.008928571428571428, "content": "Typically, hand-foot-and-mouth disease (HFMD) is a mild childhood illness associated with coxsackievirus (CV)-A16, CV-A6, enterovirus (EV)-A71. To identify the viral agents associated with severe cases of atypical HFMD in Italy. Epidemiologically unrelated cases of severe atypical HFMD admitted to the Emergency Room (ER) of IRCCS San Martino IST (Genoa, Italy) in 2014-2016 were investigated. Serologic screening for viral positivity was performed against exanthem-inducing agents. Ten cases with serology indicative of recent EV infection were selected. Molecular assays were used to detect viral genomes in blood [EVs, Parvovirus B19 (PVB19), herpesviruses (CMV; EBV, HHV-6, -7, -8)]. CV-A6 was detected in 10 cases of severe atypical HFMD. Two cases were also infected with PVB19. Herpesviruses were not detected. Phylogenetic analysis mapped the CV-A6 strains into a single cluster related to two recent isolates from a German and an Asian child. Fever, systemic symptoms, severe vasculitis-like rash, and enanthem were predominant at presentation. Spontaneous recovery occurred in 1-3 weeks. CV-A6 is emerging as a frequent cause of severe atypical HFMD in Italian adults. This viral agent is disseminating worldwide. Dermatologists must identify the manifold alterations caused by EVs and understand the diagnostic power of current virology methods." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 606, 682 ] ], "word_ranges": [ [ 94, 107 ] ], "text": "Answer 1, a malformation is typical of young patients, rare in older people." }, "2": { "exist": true, "char_ranges": [ [ 299, 444 ] ], "word_ranges": [ [ 46, 67 ] ], "text": "the most frequent localizations are: putamen, thalamus, pons and cerebellum. Therefore, most of the time these are deep hemorrhages (CTO Manual)." }, "3": { "exist": true, "char_ranges": [ [ 956, 1049 ] ], "word_ranges": [ [ 156, 174 ] ], "text": "Answer 3 does not seem correct since vasculitis is a rare entity and more so in older people." }, "4": { "exist": true, "char_ranges": [ [ 769, 955 ] ], "word_ranges": [ [ 120, 156 ] ], "text": "Answer 4, a brain tumor, does not seem likely since the mass is not seen on CT, and as in the previous case, it is more difficult not to find such a lesion after contrast administration." }, "5": { "exist": true, "char_ranges": [ [ 0, 230 ] ], "word_ranges": [ [ 0, 34 ] ], "text": "Amyloid angiopathy is the most common cause of spontaneous non-hypertensive hemorrhage in elderly patients, and is usually lobar in location (as in the case). They often appear in association with Alzheimer's disease (CTO Manual)." } }

{ "1": "Arteriovenous malformation masked by acute hematoma.", "2": "Chronic arterial hypertension.", "3": "Isolated vasculitis of the nervous system.", "4": "Brain tumor.", "5": "Cerebral amyloid angiopathy (congophilic angiopathy)." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0113_1458", "title": "[A case report of simultaneous multiple intracerebral hematomas].", "score": 0.0196078431372549, "content": "A case of multiple spontaneous intracerebral hematomas is presented. A 67-year-old man with 7 years history of hypertension had sudden clumsiness in his right hand and an hour later dysarthria appeared. A CT scan taken 3 hours after the onset revealed two well demarcated high density areas in the left putamen and in the parietal subcortex. A diagnosis of multiple intracerebral hematomas was made. On neurological examination he was midly stuporous (13 points of Glasgow Coma Scale). Dysarthria, right hemiparesis and right extensor plantar response were seen. CT scan of 6 hours later disclosed the same findings as the previous study. He recovered well and neurologically free in a few days. On the following CT scans both hematomas were isodense 2 weeks later, and ring-like enhancement effect was noted. CT scan showed normal appearance 7 weeks later. On MRI using 0.5 T unit t-1 and t-2 weighted spin echo images of these hematomas also showed the similar chronological changes. The history, these CT and MRI studies suggest that two hematomas of this case occurred almost simultaneously in one cerebral hemisphere. No causative factors such as blood dyscrasias, AVM, angioma, septicemia, malignancies or sinus thrombosis was identified. We consider that a hypertensive intracerebral hematoma of the putamen was followed by the parietal intracerebral hematoma within a few hours, although amyloid angiopathy was not completely excluded because no cerebral biopsy of the lesion was performed." }, { "id": "pubmed23n0120_12079", "title": "[Cerebral amyloid angiopathy complicated by multiple cerebral infarcts and intracerebral hemorrhages: case report].", "score": 0.019232547387887194, "content": "Recently, cerebral amyloid angiopathy is stressed as an unusual and infrequent cause of cerebral infarct or intracerebral hemorrhage. This report described a case of cerebral amyloid angiopathy complicated by multiple cerebral infarcts and multiple intracerebral hemorrhages. This 70-year-old man was admitted to our hospital on November 10, 1984 for evaluation of the gradual onset of dysarthria. Examination showed only slight dysarthria. There was no history of hypertension or dementia. A computed tomography (CT) showed enlarged ventricles with cortical atrophy and multiple low-density lesions, deep in the left frontal, left parietal, right parietal lobes, and in the both basal ganglias. The patient discharged from the hospital with only slight dysarthria. On November 20, 1984, he was admitted to our hospital again, because he was found unresponsive on the floor. He was somnolent but arousable. Examination showed disorientation, impairment of recent memory and impairment of calculation, A CT scan demonstrated three small intracerebral hemorrhages in the left frontal, right parietal lobes and left basal ganglia. On the fifth hospital day he deteriorated acutely, becoming semicomatose and hemiparetic on the right side. A repeated CT scan showed two new intracerebral hemorrhages in the left frontal lobe. Cerebral angiograms showed only minimal changes due to the occupying lesions in the above mentioned area. The hematomas was evacuated via left fronto-parietal craniotomy. The specimens removed with hematoma (stained with hematoxylin-eosin, Congo red and thioflavin T) showed extensive amyloid angiopathy. Postoperatively he made a good recovery, although he had residual mental dysfunctions. He expired by pneumonia on March 30, 1985.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0580_22509", "title": "A restricted subarachnoid hemorrhage in the cortical sulcus in cerebral amyloid angiopathy: could it be a warning sign?", "score": 0.0180238694487294, "content": "Cerebral amyloid angiopathy is a well-known disease that is predominantly recognized in elderly people and repeatedly causes large subcortical hemorrhages. These hemorrhages may be derived from vessel wall weakness because of Abeta depositions in the wall of the cortical and leptomeningeal arteries. Although vessel ruptures in CAA have been thought to occur in cortical arteries, it was recently demonstrated that the primary hemorrhage occurs in the subarachnoid space, particularly the cerebral sulci, as a result of multiple ruptures of meningeal arteries in some cases of subcortical hematoma caused by CAA. Case patient 1 was a 74-year-old woman who presented with epileptic seizure. A restricted SAH in the right frontal lobe was observed on MRI. Thirty-three days later, left hemiparesis occurred suddenly and a huge subcortical hematoma was observed in the right frontal lobe on CT. The hematoma was removed, and the patient was pathologically diagnosed with amyloid angiopathy. Case patient 2 was a 73-year-old man who presented with epileptic seizure. A restricted SAH in the right frontal lobe was observed on MRI. Twenty days later, left hemiparesis occurred suddenly and a huge subcortical hematoma was observed in the right frontoparietal area on CT. Hematoma removal was performed on both patients, and they were diagnosed pathologically with amyloid angiopathy. We report on the cases of 2 patients with CAA who presented with epileptic seizure and were found to have a restricted subarachnoid hematoma in the cerebral sulcus on MRI before their subcortical hemorrhages occurred. Both cases were diagnosed pathologically. This demonstrated that vessel ruptures in CAA can occur in the subarachnoid space, particularly the cerebral sulci, as a result of ruptures of meningeal arteries. A restricted SAH on CT/MRI could be a warning sign of a huge subcortical hemorrhage in CAA." }, { "id": "pubmed23n0057_22816", "title": "Lobar intracerebral hemorrhage. A clinical, radiographic, and pathological study of 29 consecutive operated cases with negative angiography.", "score": 0.017980970811159493, "content": "The authors operated consecutively on 50 patients with lobar intracerebral hemorrhage during a prospectively designed study period from January, 1986, to March, 1990. They investigated the correlations between the underlying causes and the clinicoradiographic features in 29 patients who showed no angiographic vascular abnormalities, in order to elucidate the operative indication for such cases. Patients with ruptured saccular aneurysm or trauma were not included in this study. There were 15 males and 14 females, ranging in age from 7 to 76 years (mean 52.4 years). Histological diagnoses of the surgical specimens were as follows: vascular malformation in nine cases (arteriovenous malformation (AVM) in six and cavernous malformation in three), microaneurysm in 11, cerebral amyloid angiopathy in six, and brain tumor in two; in the remaining case the cause was not verified histologically. The underlying cause was determined in 96.5% of cases. The mean patient age was lowest in the cavernous malformation group (27.0 years), followed by the AVM (45.8 years), microaneurysm (59.8 years), and cerebral amyloid angiopathy (70.0 years) groups. Four patients with vascular malformation (three AVM's and one cavernous malformation) had previous episodes of bleeding at the same site, whereas none of those with microaneurysms or cerebral amyloid angiopathy had such episodes. On computerized tomography (CT) scans, the round to oval hematoma was related to the presence of an AVM or cavernous malformation in contrast to microaneurysms and cerebral amyloid angiopathy. Upon infusion of contrast material, variable enhancement was seen in five (two AVM's and three cavernous malformations) of the nine vascular malformations while no enhancement was noted in any patient with microaneurysm or cerebral amyloid angiopathy at the acute stage. Subarachnoid extension of the hematoma was associated with cerebral amyloid angiopathy significantly more frequently than with AVM's (p less than 0.05) and microaneurysms (p less than 0.01). The results suggest that clinicoradiographic pictures in cases with negative angiography are quite different among the three major pathological categories; namely, vascular malformation (AVM and cavernous malformation), microaneurysm, and cerebral amyloid angiopathy. It is suggested that the underlying etiology of a given lobar intracerebral hemorrhage with negative angiography may be predicted by a combination of patient age, history of previous bleeding at the same site, hematoma shape, and subarachnoid extension of the hematoma on CT scans. Based upon these findings, the authors discuss operative indications for such cases." }, { "id": "pubmed23n0567_21957", "title": "[A case of primary subarachnoid hemorrhage due to cerebral amyloid angiopathy].", "score": 0.017786561264822136, "content": "A 77-year-old man who was suffering from an intracerebral hemorrhage of the left subcortex without hypertension was admitted to our hospital. The only neurological symptom was right arm monoparesis. Brain MRI demonstrated a subarachnoid hemorrhage (SAH) in the left frontal lobe. On the day of admission, conventional cerebral angiography revealed no abnormalities in brain arteries. His symptom was disappeared immediately after admission. He was discharged without neurological deficit on day 25. However, he was rehospitalized in our hospital on the same day because he experienced a right subcortical hemorrhage. The neurological symptoms were consciousness disturbance, aphasia and right hemiparesis. Brain CT disclosed a subcortical hemorrhage in the left temporal lobe. CT stereo-guided drainage was performed. Then, we examined tissue removed from the brain's surface. Histologically, beta-amyloid protein was deposited on the walls of the meningeal and cortical vessels, and it replaced all the layers of those walls. Therefore, a diagnosis of cerebral amyloid angiopathy (CAA) was made. His condition gradually improved, but CT showed an asymptomatic ICH in the right parietal lobe on day 36. On day 47, he had a symptomatic ICH in the left caudate nuclei and right frontal lobe. He died on day 66 because of pneumonia. Intracranial hemorrhages due to CAA have been reported and the majority of the lesions have been lober hemorrhage. To the best of our knowledge, few reports have been published regarding primary SAH caused by CAA. The cause of SAH should be considered as CAA when SAH appears without hypertension or in elderly patients." }, { "id": "pubmed23n0757_25359", "title": "[Case report of a \"probable\" cerebral amyloid angiopathy].", "score": 0.017158294392523366, "content": "Sixty-two year old man was admitted to the department of neurosurgery after stroke episode. CT-scan revealed non-traumatic, non-hypertensive intracerebral hemorrhage in the left temporal lobe; cerebral amyloid angiopathy was suspected. Initially, according to Boston criteria, intracerebral hematoma was interpreted as a result of a \"probable\" cerebral amyloid angiopathy. Surgical evacuation of the hematoma lead to the partial recourse of speech and cognitive deficit. Four weeks after stroke onset and 3 weeks after surgery CT was performed, which revealed intracerebral hematoma in the right parietal lobe; this fact let to diagnose \"probable\" cerebral amyloid angiopathy. The second hematoma was evacuated, and surgical treatment together with medical therapy improved patient's quality of life. Treatment strategy for the intracerebral hematomas resulting from cerebral amyloid angiopathy has not been justified yet, which requires further investigations." }, { "id": "pubmed23n1126_11375", "title": "Repeated recurrent intracerebral hemorrhage may be involved in cerebral amyloid angiopathy-related inflammation: An autopsy case.", "score": 0.01676094699350513, "content": "We report an autopsy case of repeated recurrent intracerebral hemorrhage (ICH) diagnosed as having cerebral amyloid angiopathy-related inflammation (CAA-ri) in a 65-year-old woman. She had no history of hypertension or other risk factors for stroke. She had a history of lobar ICH in the right parietal lobe 30 months prior. Follow-up magnetic resonance imaging (MRI) performed 29 months after the initial ICH revealed superficial siderosis in the left frontal lobe. She initially presented with severe headache and dysarthria. An initial computed tomography (CT) revealed a subarachnoid hemorrhage on the left frontal lobe. One hour later, an epileptic seizure occurred, and another CT performed at the time revealed lobar ICH in the frontal lobe. Emergency surgical hematoma evacuation was performed. The cortical artery was removed from the surgical specimen. Hematoxylin and eosin (HE) staining revealed lymphocytic perivascular cuffs, and immunohistochemical staining revealed abundant amyloid-β (Aβ) deposits. The patient was diagnosed as having CAA-ri. On the next day, and 19, 46, 55, 78, 79, and 85 days after admission, ICH recurred. We did not administer immunosuppressive drugs, such as high-dose corticosteroids or cyclophosphamide, because of the patient's condition. Following the last ICH, the patient died on the 90th day after symptom onset. An autopsy was performed. Histologically, abundant Aβ deposits were observed within the leptomeningeal and cortical arteries. Further dense-cored amyloid plaques were observed in the cortical samples. Our findings that ICH occurred initially three times in the left hemispheres and later five times in the right hemispheres were considered immune-mediated effects on vascular function. Further, superficial hemosiderosis in the left frontal lobe occurred before the first three ICH events, and hyperintensity of the white matter on MRI was identified in the right parietal lobe, a typical finding of CAA-ri. We hypothesize that the inflammatory process in CAA-ri may be related to recurrent ICH." }, { "id": "pubmed23n0714_12220", "title": "Inflammatory cerebral amyloid angiopathy: the overlap of perivascular (PAN-like) with vasculitic (Aβ-related angiitis) form: an autopsy case.", "score": 0.015467583264193435, "content": "Beside advanced age, cerebral amyloid angiopathy (CAA) and hypertension (HTA) are the two most important risk factors for haemorrhagic stroke. Inflammatory changes of amyloid-laden vessels have been reported only in rare sporadic CAA cases. We present the case of a 78-year-old woman with a history of hypertension, dementia and haemorrhagic stroke of the right frontal lobe 2 years before admission. She was admitted with recurrence of symptoms of transient aphasia and central, right-side facial paresis that occurred an hour before her arrival at the hospital. In the admission unit, she was only slightly confused, with no other neurological deficits. An urgent CT scan revealed a recent haemorrhagic stroke in the left frontal lobe. In an hour her condition suddenly deteriorated. After a generalized seizure she presented with right-side hemiparesis with signs of uncal herniation and remained unconscious. A control CT scan showed a large haemorrhagic expansion that comprised the whole left brain hemisphere with 2 cm midline shift. She died about 10 hours after the onset of symptoms. At autopsy chronic inflammation of the thyroid gland, bronchopneumonia, fibrous and fatty heart degeneration and kidney haemorrhagic infarcts were documented. Amyloid deposition and systemic immune disorders in the inner organs were not demonstrated. In neuropathological examination we diagnosed inflammatory form of CAA with coexistence (the overlap) of two, perivascular and vascular, subtypes of CAA-related inflammation." }, { "id": "pubmed23n0222_2569", "title": "[Four cases of cerebral venous angioma--with special reference to its surgical indication and CT diagnosis].", "score": 0.01531986531986532, "content": "Four cases of venous angioma, one cerebral and three in the cerebellum, are reported. Case 1. A 50-year-old woman who had a sudden attack of headache and disorientation was admitted to the Mitsui Memorial Hospital. Neurological examination revealed slight disorientation, mild motor aphasis and right hemiparesis. Plain CT scan on admission showed a left frontal hematoma. Left cerebral angiomas demonstrated a caput-Medusae-like lesion which consisted of numerous small veins and drained into one single enlarged vein. Enhanced CT scan taken 12 days after the attack demonstrated a linear enhancement next ot the hematoma. Left frontal craniotomy was performed, and the hematoma was evacuated. In the next step, coagulation and resection of the major part of the angioma was attempted. However, this caused significant swelling of the adjacent brain and the angioma had to be resected totally including intervening normal cerebral tissue. Postoperatively, the patient became worse with significant hemiparesis and severe motor aphasia. After intensive rehabilitation treatment, she recovered gradually and was discharged on foot with moderate speech disturbances. Histological examination revealed a typical venous angioma with hyalinization of vessel wall. Case 2. A 55-year-old woman with a 9 year history of vertigo and headache was admitted to our hospital because of sudden onset of numbness in her right lower limb. Enhanced CT scan revealed a small nodular high density lesion and an old hematoma in the right cerebellar hemisphere. Vertebral angiograms demonstrated a single abnormal vein with some small veins in the right cerebellum. Right suboccipital craniectomy was performed and the blood clot was removed. The abnormal veins were electro-coagulated. The postoperative course was uneventful and the patient was discharged with no neurological deficit. Case 3. A 31-year-old man was admitted to our department with 9 month history of nausea and vertigo attack. Enhanced CT scan demonstrated a large nodular high density lesion in the left cerebellar hemisphere. Vertebral angiograms showed a typical caput-Medusae-like venous angioma. The patient had no evidence of hemorrhage and was discharged without surgery. Case 4. A 36-year-old man who had two attacks of nausea and headache was admitted to the Mitsui Memorial Hospital. Enhanced CT scan showed a linear high density lesion in the right cerebellar hemisphere. Vertebral angiograms disclosed a typical venous angioma in the right cerebellum. This patient also had no attack of bleeding and was discharged without operation.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0073_14064", "title": "[Three cases of cryptic arteriovenous malformation in basal ganglia manifested by putaminal hemorrhage].", "score": 0.015101043748612035, "content": "Three cases of histologically proven cryptic arteriovenous (AV) malformation of the basal ganglia are reported. Seventeen cases of patients showing putaminal hemorrhage in the CT scan underwent craniotomy for evacuation of a hematoma between January 1986 and December 1988. The preoperative diagnosis was hypertensive putaminal hemorrhage. In all three cases a network of abnormal vessels around the internal capsule was detected at surgery. Case 1: A 62-year-old male was admitted to our hospital with consciousness disturbance (JCS 20), total aphasia and right hemiparesis. The CT scan showed left putaminal hemorrhage. The volume of the hematoma was 45 ml by CT criteria. Left carotid angiography did not demonstrate any abnormal findings. Case 2: 69-year-old male was admitted with consciousness disturbance (JCS 10) and right hemiparesis. Left putaminal hemorrhage (volume 25 ml) was recognized on the CT scan. Two hours after admission, the consciousness level suddenly deteriorated (JCS 100). At that moment, the volume of the putaminal hematoma had increased to 100 ml. AV malformation was not detected by left carotid angiography. Case 3: A 50-year-old male was admitted with consciousness disturbance (JCS 20), total aphasia and right hemiparesis. The CT scan showed left putaminal hemorrhage of 73 ml. Pathohistological examination proved AV malformation in each case. The three cases described here suggest the following; 1) The incidence of the basal ganglia cryptic AV malformation has been considered low, but meticulous examination shows that among the cases diagnosed as hypertensive hemorrhage, AV malformation is not infrequently the hidden cause.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0090_2151", "title": "[Lobar intracerebral hemorrhage secondary to cerebral amyloid angiopathy: a clinicopathologic study of three operated cases].", "score": 0.015025877900829206, "content": "Three operated cases of lobar intracerebral hemorrhage (LICH) related to cerebral amyloid angiopathy (CAA) were studied clinicopathologically. They constituted about 8% of all LICH cases (n = 37) operated upon in our institute (DUSM) during the past 3 years. Case 1, 2 and 3 aged 71, 67 and 73 years, respectively. There were 2 males (Cases 1 &amp; 2) and 1 female (Case 3). Only one case (Case 3) had both hypertension and dementia before hemorrhage. In all 3 cases, neurologic symptoms deteriorated after admission. The hematoma involved the right temporo-parietal in 1 (Case 1), the right parieto-occipital in 1 (Case 2) and the left fronto-parietal region in 1 (Case 3). Case 1 developed a new hematoma in the right occipital lobe on the day following surgery. On CT, the hematoma was multilobular in shape and located very superficially extending to the subarachnoid space in all cases. There was no abnormal enhancement in and around the hematoma upon contrast infusion. Angiography showed only an avascular mass sign in case. At surgery, the hematoma was extruded onto the cortical surface in all cases. The surgical outcome was good in 2 (Cases 1 &amp; 2) and fair in 1 (Case 3). Removed hematomas, solid nodular tissues and adjacent brain tissues were examined histologically using hematoxylin and eosin, Azan-Mallory, elastica van Gieson, silver and Congo red stains. Arteries in the hematoma wall, the subarachnoid space and the adjacent brain parenchyma were intensely stained with Congo red and showed birefringence on polarized light.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0390_6587", "title": "[Two cases of elderly patients with ruptured AVM with contrast medium extravasation during cerebral angiography].", "score": 0.015, "content": "Two cases are reported of elderly patients who experienced intracranial extravasation of contrast medium (CM) during carotid angiography (CAG) for ruptured cerebral arteriovenous malformations (AVM). The first patient, an 87-year-old male with no history of hypertension, was admitted immediately following a loss of consciousness after swimming in a pool. CT scan revealed a large intracranial hematoma in the left frontal lobe. CAG performed 1 hour after his arrival revealed a small AVM, fed by the left anterior cerebral artery with concomitant extravasation of CM. The patient's condition subsequently deteriorated and he died the following day. The second patient, a 71-year-old female, was admitted to our hospital in a comatose state after complaining of a severe headache. CT scan revealed a right parietal lobe hemorrhage extending into the ventricles. CAG was performed and demonstrated a small AVM in the right parietal lobe with extravasation of CM. Following emergency removal of the hematoma and AVM, the patient regained consciousness although some motor deficits persisted. A literature review revealed that only 6 cases of CM extravasation with ruptured AVM have been previously reported. The 4 previous cases involved patients 9, 15, 33 and 66-year-old, the younger three of which had a good outcome. The patients reported here were much older, and had a much less favorable outcome. Thus, AVM with CM extravasation may have a better prognosis in younger individuals." }, { "id": "pubmed23n0134_1105", "title": "[A case favorably progressed after operation for hypertensive intracerebral hemorrhage showed extravasation on angiogram occurred in chronic alcoholism].", "score": 0.014687032685323648, "content": "It is said that the prognosis is generally unfavorable in patients with hypertensive intracerebral hemorrhage showed extravasation on angiogram. Recently, we experienced a case whose prognosis was eventful after the removal of hematoma. So we reported this case and discussed between alcoholism and intracerebral hemorrhage accompanied with extravasation on angiogram in this paper. A 59-year-old male was transferred to our emergency center because of right hemiplegia and mild clouding of consciousness at around nine in the evening on December 12, 1983. At the time of admission, his neurological state was classified into grade II, exhibiting the right putamenal hemorrhage and pyramidal destruction type of hematoma by CT scan with 58 ml of hematoma volume. The right carotid angiography was immediately performed and confirmed the hematoma being of lateral type. At that time, extravasation proximal to the lateral lenticulostriate artery was noted. Repeated CT scan revealed the enlarged hematoma (105 ml) accompanying with ventricular hemorrhage. At the completion of these examinations, the neurological grade was III. The hematoma was surgically removed after 4 hours following the onset of cerebral hemorrhage. His postoperative course was very favorable. Although acute hydrocephalus appeared later on, it was cured by ventricular drainage. The patient become possible to walk with a helper by 1 month after operation. CT scan obtained 1 month after operation revealed a remarkable brain atrophy, which was probably derived from chronic alcoholism.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0019_3148", "title": "[A case of hypertensive intracerebral hemorrhage associated with cerebral arteriovenous malformation and aneurysm (author's transl)].", "score": 0.014145551533625452, "content": "A 45-year-old man suddenly developed right hemiparesis and aphasia during work and lost conciousness next day, when he was admitted to us. Lumbar puncture showed bloody C.S.F. with the initial pressure of 220 mm H2O. Physical examination revealed hypertension and arteriosclerosis. Cerebral angiogram revealed an arteriovenous malformation in the left frontoparietal-parasagittal region and a saccular aneurysm at the left internal carotid-posterior communicating artery junction. In addition, the existence of putaminal hematoma was suspected on account of the displacement of the left anterior cerebral artery and the left lenticulostriate arteries. On the fourth day after admission his consciousness returned and the right hemiparesis gradually improved. One month later the disappearance of the displacement of the anterior cerebral artery was demonstrated by cerebral angiogram. A frontoparietal craniotomy was done and no hematoma was found around the arteriovenous malformation and the basis of the aneurysm did not adhere to the temporal lobe. Taking these findings into consideration, it is presumed that the hematoma in putaminal region was due to neither arteriovenous malformation nor aneurysm but was a hypertensive intracerebral hemorrhage." }, { "id": "wiki20220301en100_5623", "title": "List of MeSH codes (C14)", "score": 0.013563993762013563, "content": "– intracranial arterial diseases – cerebral arterial diseases – cadasil – cerebral amyloid angiopathy – cerebral amyloid angiopathy, familial – infarction, anterior cerebral artery – infarction, middle cerebral artery – infarction, posterior cerebral artery – intracranial aneurysm – intracranial arteriosclerosis – dementia, vascular – intracranial arteriovenous malformations – intracranial hemorrhages – cerebral hemorrhage – basal ganglia hemorrhage – putaminal hemorrhage – cerebral hemorrhage, traumatic – intracranial hemorrhage, hypertensive – intracranial hemorrhage, traumatic – brain hemorrhage, traumatic – brain stem hemorrhage, traumatic – cerebral hemorrhage, traumatic – hematoma, epidural, cranial – hematoma, subdural – hematoma, subdural, acute – hematoma, subdural, chronic – hematoma, subdural, intracranial – subarachnoid hemorrhage, traumatic – pituitary apoplexy – subarachnoid hemorrhage" }, { "id": "pubmed23n0872_10023", "title": "Density heterogeneity and fluid-blood levels in patients aged over 55 with lobar hematoma.", "score": 0.01340542472854015, "content": "Density heterogeneity and fluid-blood levels (FBLs) are frequently seen on acute CT scans of deep brain hemorrhage. Our aim was to analyze the density heterogeneity and FBLs seen on acute/subacute CT in patients aged&gt;55 with lobar haemorrhage (LH), and to study the relationship of these brain abnormalities with other parameters, including cerebral amyloid angiopathy (CAA)-related abnormalities. This was an observational study and retrospective analysis of early CT scans (&lt;7 days) in patients aged&gt;55 years with acute lobar hemorrhage who, between 2012 and 2015, were entered into our stroke database. A total of 37 LH episodes (without trauma, abnormal coagulation/platelet counts, vascular malformation, tumor or vasculitis) in 35 patients were analyzed. Other studied parameters were gender, age, history of hypertension, blood pressure on admission, prior antiplatelet treatment, aPTT, PTT, platelet count, hematocrit, timing of first CT, LH volume, involved lobe, cortical superficial siderosis, microbleeds, chronic LH and CAA (classic and modified Boston) criteria. CAA-related abnormalities seen on MRI were also scored. Overall, in 26 LH episodes (70%), CT was performed within 24h. Density heterogeneity and FBLs were seen in 19 (51%) and 9 (24%) LH episodes, respectively. Also, according to classic and modified Boston criteria, 18 (51%) and 24 (69%) patients, respectively, fulfilled criteria for probable/definite CAA. As for the presence of FBLs, a statistically significant association was found with both the presence of probable/definite CAA according to modified Boston criteria (P=0.033) and the presence of superficial siderosis (P=0.019). Density heterogeneity and, to a lesser degree, FBLs are frequently seen in patients aged&gt;55 with LH. FBLs may also be associated with CAA-related hemorrhage." }, { "id": "pubmed23n0979_5006", "title": "Mixed cerebrovascular disease in an elderly patient with mixed vascular risk factors: a case report.", "score": 0.013332750480853296, "content": "Mixed cerebrovascular disease is a diagnostic entity that presents with hemorrhagic and ischemic stroke clinically and/or subclinically. Here, we report a patient with mixed vascular risk factors, who presented with multiple intracerebral hemorrhages and a simultaneously occurring cerebral infarction with hemorrhagic transformation. A 63-year-old male with no history of trauma or prior neurological disease presented with a sudden onset of weakness in his right limbs, followed by an episode of focal seizure without impaired awareness. The patient had a 4-year history of deep vein thrombosis in the lower limbs, and a 2-year history of Raynaud's phenomenon in the hands. He also had a family history of hypertension and thrombophilia. Head computed tomography plain scans showed two high densities in the bilateral parietal lobes and one mixed density in the left frontal lobe. The patient was diagnosed with mixed cerebrovascular disease. In this report, we make a systematic clinical reasoning regarding the etiological diagnosis, and discuss the possible pathogenic mechanisms leading to mixed cerebrovascular disease. We exclude coagulopathy, endocarditis, atrial fibrillation, patent foramen ovale, brain tumor, cerebral venous thrombosis, cerebral vascular malformation, cerebral amyloid angiopathy and vasculitis as causative factors. We identify hypertension, hereditary protein S deficiency, hypercholesteremia and hyperhomocysteinemia as contributing etiologies in this case. This case presents complex underlying mechanisms of mixed cerebrovascular disease, in which hypertension and hyperhomocysteinemia are considered to play a central role." }, { "id": "First_Aid_Step2_605", "title": "First_Aid_Step2", "score": 0.012129334896967665, "content": "(A) CT scan without contrast reveals blood in the subarachnoid space at the base of the brain (arrows). (B) A normal CT scan without contrast shows no density in this region (arrows). (Reproduced, with permission, from Aminoff MJ. Clinical Neurology, 3rd ed. Stamford, CT: Appleton & Lange, 1996: 78.) ■ Surgical clipping is the defnitive treatment for aneurysms. Endovascular coiling is an option for poor surgical candidates. Risk factors include hypertension, tumor, amyloid angiopathy (in the elderly), anticoagulation, and vascular malformations (AVMs, cavernous hemangiomas). Hx/PE: Presents with focal motor and sensory defcits that often worsen as the hematoma expands. Severe headache of sudden onset, nausea/ vomiting, seizures, lethargy, or obtundation may also be seen. Dx: Immediate noncontrast head CT (see Figure 2.10-5). Look for mass effect or edema that may predict herniation." }, { "id": "wiki20220301en100_5705", "title": "List of MeSH codes (C10)", "score": 0.011948369091226235, "content": "– hematoma, epidural, cranial – hematoma, subdural – hematoma, subdural, acute – hematoma, subdural, chronic – hematoma, subdural, intracranial – subarachnoid hemorrhage, traumatic – pituitary apoplexy – subarachnoid hemorrhage – subarachnoid hemorrhage, traumatic – leukomalacia, periventricular – sneddon syndrome – vascular headaches – vasculitis, central nervous system – aids arteritis, central nervous system – lupus vasculitis, central nervous system – temporal arteritis – vasospasm, intracranial – vertebral artery dissection – dementia – aids dementia complex – alzheimer disease – primary progressive aphasia – creutzfeldt-jakob syndrome – dementia, vascular – dementia, multi-infarct – huntington disease – Klüver-Bucy syndrome – lewy body disease – pick disease of the brain – diffuse cerebral sclerosis of schilder – encephalitis – encephalomyelitis – limbic encephalitis – meningoencephalitis" }, { "id": "pubmed23n0113_8465", "title": "[A case of multiple cerebral hemorrhage related to cerebral amyloid angiopathy].", "score": 0.01170715249662618, "content": "A case of multiple cerebral hemorrhage in the bilateral parietal lobes related to cerebral amyloid angiopathy (CAA) is reported. A 66-year-old man was admitted to our hospital because of headache and vomiting on Feb. 21, 1983. He had no history of hypertension, diabetes mellitus, recent head injury, or dementia. Four days prior to admission, he had behaved as if he were blind, but, had denied any blindness. On examination, he was confused and disoriented. Blood pressure was 130/80 mmHg. Abnormal findings on neurological examination included memory disturbance, apraxia for dressing, right-left disorientation, finger agnosia and Balint's syndrome. A CT scan showed multiple subcortical hematomas in the bilateral parietal lobes. Intracerebral hemorrhage related to CAA was suspected. Confirmation of the presence of amyloid in the cerebral vessels was established by examination of brain biopsy specimens. The characteristics of cerebral hemorrhage related to CAA are as follow--occurrence in elderly, sometimes demented people; localization to the cortex and subcortical white matter, with direct extension into the subarachnoid space; frequent multiple occurrence in time and/or at several sites within the cerebral hemispheres; sometimes occurrence after operative procedures or head injuries. A specific diagnosis of CAA can only be made by histological examination, but the indication of brain biopsy should be carefully decided because of hemostatic difficulty and tendency to rebleed. In conclusion, CAA should be considered as a cause of hemorrhage in elderly patients who are often normotensive and demented." }, { "id": "pubmed23n0236_12618", "title": "[Spontaneous intracerebral hematomas: occipital lobe hemorrhages].", "score": 0.01120527306967985, "content": "Spontaneous intracerebral hematomas can be diagnosed immediately and localized exactly by the means of cranial computerized tomography. The occipital lobe is a relatively rare site of hypertensive hematomas which are the most frequent etiologic group. Out of 264 patients with intracerebral hematomas ion cranial computerized tomography we found the occipital lobes affected in 24 cases i.e. 9%. 116 patients with intracerebral hematomas treated in the neurologic clinic demonstrated in 15 cases (13%) occipital localization. In 7 patients bleedings were of hypertensive origin, in 4 cases etiology was unknown, in one case it originated from an arteriovenous angioma and in 3 cases congophilic (amyloid) angiopathy was the basic disease. In smaller occipital hematomas the clinical symptoms are relatively mild, mainly consisting of acute headache and hemianopsia. If the hematoma is limited to the occipital lobe the prognosis is favorable both with or without neurosurgical treatment." }, { "id": "First_Aid_Step1_571", "title": "First_Aid_Step1", "score": 0.011197565963389696, "content": "Crescent-shaped hemorrhage (red arrows in C and D ) that crosses suture lines. Can cause midline shift (yellow arrow in C ), findings of “acute on chronic” hemorrhage (blue arrows in D ). EF due to trauma, or rupture of an aneurysm (such as a saccular aneurysm E ) or arteriovenous malformation. Rapid time course. Patients complain of “worst headache of my life.” Bloody or yellow (xanthochromic) lumbar puncture. Vasospasm can occur due to blood breakdown Ž ischemic infarct; nimodipine used to prevent/reduce vasospasm.  risk of developing communicating and/or obstructive hydrocephalus. Most commonly caused by systemic hypertension. Also seen with amyloid angiopathy (recurrent lobar hemorrhagic stroke in elderly), vasculitis, neoplasm. May be 2º to reperfusion injury in ischemic stroke. Hypertensive hemorrhages (Charcot-Bouchard microaneurysm) most often occur in putamen of basal ganglia (lenticulostriate vessels G ), followed by thalamus, pons, and cerebellum H ." }, { "id": "wiki20220301en060_28591", "title": "Cerebral amyloid angiopathy", "score": 0.011093822037805439, "content": "Diagnosis CAA can only be definitively diagnosed by a post-mortem autopsy. Biopsies can play a role in diagnosing probable cases. When no tissue is available for biopsy, the Boston Criteria are used to determine probable CAA cases from MRI or CT scan data. The Boston Criteria require evidence of multiple lobar or cortical hemorrhages to label a patient as probably having CAA. Susceptibility weighted imaging has been proposed as a tool for identifying CAA-related microhemorrhages. Imaging Cerebral amyloid angiopathy can be presented with lobar intracerebral hemorrhage or microbleeds in the brain. The bleeding usually occurs on the surfaces of the brain in contrast with intracranial haemorrhage due to high blood pressure which occurs deep locations of the brain such as basal ganglia and pons. In lobar intracerebral bleed, computed tomography (CT) scan would show hyperdense haemorrhage area and hypodense odema around the haemorrhagic site." }, { "id": "pubmed23n0663_2622", "title": "[A case of cerebral amyloid angiopathy in which a restricted subarachnoid hemorrhage recurred in the cortical sulcus following a subcortical hemorrhage].", "score": 0.009900990099009901, "content": "Cerebral amyloid angiopathy (CAA) is predominantly recognized in elderly people and repeatedly causes a huge subcortical hemorrhage. Some cases of CAA can cause secondary subarachnoid hemorrhage (SAH), but cases in which it causes primary SAH is very rare. We describe a valuable reference case of a 75-year-old man in whom a restricted SAH recurred in the cortical sulcus following a huge subcortical hemorrhage. He presented with an unknown restricted SAH in the left frontal sulcus twice before neck clipping for a right IC-PC unruptured aneurysm. Postoperative computed tomography (CT) revealed a recurrent SAH in the left frontal lobe, and it spread gradually. T2(*) weighted imaging (T2(*)WI) revealed subarachnoid hemosiderosis and superficial cortical hemosiderosis in the frontal and parietal lobe. On the 21st postoperative day, he suddenly presented right hemiplegia and a huge subcortical hemorrhage was observed in the left frontal lobe on CT. Emergent removal of the hematoma was performed, but the patient had become bedridden. Pathological diagnosis of CAA was made. A recurrent restricted SAH in the frontal sulcus might have been a warning sign of a huge subcortical hemorrhage. In the aging society, a radiological prediction of CAA is very important. Although it is generally thought to be very difficult, T2(*)WI may be useful for predicting CAA. When we plan surgery for elderly people, we must always take CAA into consideration." }, { "id": "Neurology_Adams_6572", "title": "Neurology_Adams", "score": 0.009760189883778032, "content": "readily corroborated by an unenhanced CT. Of our 26 patients, 14 had normal blood pressure, and in several of the fatal cases there was amyloidosis of the affected vessels; 2 patients were receiving anticoagulants, 2 had an arteriovenous malformation, and 1 had a metastatic tumor. Similarly, in the series of 22 patients with lobar clots reported by Kase and colleagues, 55 percent were normotensive; metastatic tumors, arteriovenous malformations, and blood dyscrasias were found in 14, 9, and 5 percent of the patients, respectively. The role of amyloid angiopathy in lobar hemorrhage in the elderly patient is discussed further on." }, { "id": "wiki20220301en100_5704", "title": "List of MeSH codes (C10)", "score": 0.009708737864077669, "content": "– infarction, middle cerebral artery – infarction, posterior cerebral artery – intracranial aneurysm – intracranial arteriosclerosis – dementia, vascular – intracranial arteriovenous malformations – intracranial arteriovenous malformations – intracranial embolism and thrombosis – intracranial embolism – intracranial thrombosis – sinus thrombosis, intracranial – cavernous sinus thrombosis – lateral sinus thrombosis – sagittal sinus thrombosis – intracranial hemorrhages – cerebral hemorrhage – basal ganglia hemorrhage – putaminal hemorrhage – cerebral hemorrhage, traumatic – intracranial hemorrhage, hypertensive – intracranial hemorrhage, traumatic – brain hemorrhage, traumatic – brain stem hemorrhage, traumatic – cerebral hemorrhage, traumatic – hematoma, epidural, cranial – hematoma, subdural – hematoma, subdural, acute – hematoma, subdural, chronic – hematoma, subdural, intracranial – subarachnoid hemorrhage, traumatic" }, { "id": "wiki20220301en023_84308", "title": "Stroke", "score": 0.009615384615384616, "content": "Intracerebral hemorrhage It generally occurs in small arteries or arterioles and is commonly due to hypertension, intracranial vascular malformations (including cavernous angiomas or arteriovenous malformations), cerebral amyloid angiopathy, or infarcts into which secondary hemorrhage has occurred. Other potential causes are trauma, bleeding disorders, amyloid angiopathy, illicit drug use (e.g., amphetamines or cocaine). The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. A third of intracerebral bleed is into the brain's ventricles. ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or subarachnoid hemorrhage (which technically may also be classified as a type of stroke). Other Other causes may include spasm of an artery. This may occur due to cocaine." }, { "id": "pubmed23n0309_14135", "title": "[Clinical presentation and surgical indication in intracerebral lobar hemorrhage of elderly patients associated with amyloid angiopathy].", "score": 0.009615384615384616, "content": "There is controversy concerning the surgical indications for cerebral lobar hemorrhage secondary to amyloid angiopathy in the elderly. We encountered 14 patients with such a lesion, operated on 10 of them, and evaluated their clinical findings and surgical outcome. There were 7 males and 7 females, and their ages ranged from 66 to 87 years (mean age: 75.9 years). Consciousness, CT and surgical findings, and outcome were examined. Nine patients were alert or somnolent and five were semicomatose or comatose. The most common sites of the hemorrhages were the parietal lobe and occipital lobe, and the bleeding was massive, with volume of 28-120 ml. The hematomas were solitary and there had been no previous bleeding. They were evacuated thoroughly by open surgery, and there was difficulty in achieving hemostasis. The arteries in the involved cortex of 6 patients were positive for Congo red staining. There was no rebleeding postoperatively. Five of the six alert or somnolent patients with hematoma volume of 28-60 ml recovered clinically, and their outcome was good. One developed rebleeding four months later at a different site and became bed-ridden. Four of the patients who were semicomatose or comatose and whose hematoma volume 70-120 ml either died or became bed-ridden. Surgery may be indicated in patients with cerebral lobar hemorrhage if their consciousness level in good, but it would be of limited value in elderly patients whose underlying disorder is amyloid angiopathy." }, { "id": "pubmed23n0360_20425", "title": "[A 59-year-old woman with recurrent convulsive seizures, cerebral infarctions, dementia, and intracranial calcifications].", "score": 0.009523809523809525, "content": "A 59-year-old woman with recurrent seizures and progressive dementia is reported. Her past history and familial history were unremarkable. She became short-tempered at 56 years old (Oct. 1991). She had the first seizure attack and was admitted to a hospital at March 4, 1993, with prolonged disturbance of consciousness and subsequent mental deterioration. Her brain CT showed multiple small calcifications in the subcortical white matter and pons. The laboratory data including blood count, serum chemistry, serological studies and CSF was normal. MRI and digital subtraction angiography of the cranial vessels were unremarkable. There was a decrease in accumulation in the right cerebral hemisphere on 123I IMP SPECT. Despite anti-convulsant therapy, she had recurrent seizures several times, with gradual worsening of her mental state. She had the latest seizure attack and was transferred to Matsusaka Chuo Hospital, on August 29, 1993. After the attack she had been in the apallic state, and died on Nov. 13, 1995. This case was discussed in a neurological CPC. The discussants suggested that the isolated angiitis of the central nervous system caused secondary seizures and cerebral infarctions. Post-mortem examination revealed the CNS findings of vasculitis at various stages, calcification or mineralization mainly in the subcortical white matter and pons, massive cerebral infarctions with massive exudate, fresh and old small bleedings and exudate around the inflamed or calcified vessels. The white matter degeneration resembled that of Binswanger leukoencephalopathy. The final pathological diagnosis was isolated angiitis of the central nervous system since there was no inflammatory changes or atherosclerotic change of the blood vessels in the extracranial organs." }, { "id": "pubmed23n0328_4287", "title": "[Indications for surgery to determine the etiology of subcortical hemorrhage].", "score": 0.009433962264150943, "content": "We studied the etiology of subcortical hemorrhage in 55 patients (30 males, 25 females), aged 19-83 years (mean 60 years). CT scan was made in all patients on admission, with the use of intravenous infusion of contrast agent in 35 patients. Cerebral angiography was performed in 37 patients and MRI was performed in 22 patients. Forty-one patients underwent surgery and the other fourteen patients were treated conservatively. The cause of bleeding had been discovered before surgery in 12 cases; 10 arteriovenous malformations and 2 brain tumors. They were discovered by meticulous neuroradiological investigations including cerebral angiography, MRI, dynamic MRI, MRA and enhancing CT. The cause of bleeding was newly discovered after surgery in 7 cases; all of amyloid angiopathy. It remained unknown in the other 22 surgical cases although hypertensive angiopathy was suspected in eleven of them. Among the 14 patients who received conservative therapy, hemorrhagic diathesis including the use of Warfarin and DIC was the cause of bleeding in four cases and the etiology remained unknown in other ten, although hypertensive angiopathy was suspected in eight of them. The 32 patients in whom the etiology remained unknown had been observed as long as 12-120 months (mean, 40 months) and although bleeding has occurred at different locations in two of these patients, there has been no recurrence of bleeding at the same location in any of them. In conclusion, surgery is not indicated to determine the etiology of subcortical hemorrhage when meticulous neuroradiological investigations fail to disclose any vascular or tumorous lesions." }, { "id": "pubmed23n0252_4572", "title": "[Cerebral amyloid angiopathy (congophilic angiopathy): a rare cause of massive cerebral hemorrhage. Report of an \"age-related\" sporadic case].", "score": 0.009345794392523364, "content": "Cerebral amyloidosis is a form of organ-limited amyloidosis, which doesn't involve any organ other than brain and which comprises several subtypes, including \"congophilic angiopathy\" (CA), \"senile plaques\" (SP), \"neurofibrillary degeneration\" (ND), \"stellate amyloid cores\" of spongiform encephalopathies. It is found in 5 to around 20% of human population in people aged 60 to 90 years, the increasing being strictly related to ageing. Usually it is associated to SP and occasionally to ND, being distinguished into familial and non-familial (age-related) variants. It affects intracortical and leptomeningeal variously sized vessels of the brain and is a leading pathogenetic factor in determining a rare but possibly even recurrent form of a massive intraparenchymal cerebral hemorrhage, constituting a 0.2 per cent of brain vascular accidents of any origin and a 5-10 per cent if only primary non traumatic brain hemorrhages are considered. A case of non-familial CA in a previously non-demented nor hypertensive female patient aged 65 years is reported on, who was admitted due to an almost abrupt onset of neurologic symptoms mainly dominated by a sudden loss of consciousness together with a left sensory-motor deficiency syndrome. The patient who had been operated on of unilateral mastectomy eight years earlier due to an invasive ductal carcinoma of the breast was found affected by a devastating brain hemorrhage in the right temporo-occipital lobes with subsequent deflection of the brainstem axis toward the opposite side detected by means of CT/MRI and angiographic investigations.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0113_8449", "title": "[Clinical evaluation of subarachnoid hemorrhage of unknown etiology].", "score": 0.009259259259259259, "content": "This study concerns 16 cases with spontaneous subarachnoid hemorrhage (SAH) of unknown etiology experienced in our department during a period from September 1979 through August 1986. SAH was confirmed by computed tomographic scanning (CT) or lumbar puncture. All cases were studied by four or three-vessel study. In the case of three-vessel study, adequate opacification of the posterior inferior cerebellar artery contralateral to the injected vertebral artery was considered as a necessary condition. Panangiography was repeated in all patients one to two weeks after the initial study and was negative. The severity of SAH in these patients on admission was relatively mild (Hunt and Kosnik grade I + II = 75%), and the degree of subarachnoid bleeding on CT was also mild. Medium to long-term outcome was excellent or good in 81% of cases, and none of them experienced rebleeding. Only one patient died of severe vasospasm on the 20th hospital day, but no aneurysm was found at autopsy. Illustrative 3 patients in whom the cause of SAH had been finally found was briefly reported. In the first patient, SAH was secondary to a paraventricular cryptic angioma. In the second patient, a microaneurysm had been concealed at the initial angiography by the parent arteries or intra-aneurysmal clot. In the third case of a fusiform aneurysm of the vertebral artery, the aneurysm proximal to the posterior inferior cerebellar artery could not be found at the first three-vessel angiography. Importance of CT and the necessity of repeat panangiography including magnification or oblique views so as not to over-look the causative vascular abnormalities were emphasized." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 291 ] ], "word_ranges": [ [ 0, 47 ] ], "text": "The 5A summarizes the activities that should be performed by healthcare personnel during the brief intervention with the patient to stop smoking and are: find out, advise, analyze, help, accompany or agree. Therefore, the one that is not included in the strategy would be option 2: increase." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Inquire: ask about risk factors and risk behaviors (ask the patient if she smokes).", "2": "Increase: increase risk perception to facilitate change (explain the consequences of smoking).", "3": "Advise: give clear, specific and personalized advice (advise smoking cessation).", "4": "Agree: collaboratively agree on goals for change (assess readiness to make a quit attempt).", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0325_17841", "title": "A population-based survey of physician smoking cessation counseling practices.", "score": 0.018637309292649097, "content": "To be most effective, physicians' smoking cessation interventions must go beyond advice, to include counseling and follow-up. A full profile of physician performance on the recommended activities to promote smoking cessation has not been provided previously. We surveyed a representative sample of 246 community-based primary care physicians who had agreed to participate in a 3-year study to evaluate a strategy for disseminating smoking cessation interventions, based on the National Cancer Institute 4-A model and on the Transtheoretical Model of Change. A majority reported they Ask (67%) and Advise (74%) their patients about smoking, while few go beyond to Assist (35%) or Arrange follow-up (8%) with patients who smoke. The criteria for \"thorough\" counseling was met by only 27% of physicians. More than half were not intending to increase counseling activity in the next 6 months. After controlling for other variables, physicians in private offices were more likely than physicians in HMO or other settings to be active with smoking cessation counseling. General Internal Medicine physicians were most active, and Ob/Gyn physicians were least active, with smoking cessation counseling among primary care specialty groups. Innovative approaches are needed to motivate, support, and reward physicians to counsel their patients who smoke, especially when considering the movement toward managed health care. A survey of primary care physicians focusing on national guidelines for smoking cessation counseling showed a majority Ask (67%) and Advise (74%) patients about smoking, but few Assist (35%) or Arrange follow-up (8%)." }, { "id": "pubmed23n0751_5660", "title": "Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings.", "score": 0.016845434543454343, "content": "Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance. To evaluate a new approach--Ask-Advise-Connect (AAC)--designed to address barriers to linking smokers with treatment. A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011. Ten clinics in Houston, Texas. Smoking status assessments were completed for 42,277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics. Linking smokers with quitline-delivered treatment. Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment. In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t4 = 9.19 [P &lt; .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment. The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality." }, { "id": "pubmed23n0544_2100", "title": "Best practices for smoking cessation in pregnancy: do obstetrician/gynecologists use them in practice?", "score": 0.01675320179993077, "content": "To assess Ohio obstetrician/gynecologists' perceptions and use of the 5As method of smoking cessation (ask, advise, assess, assist, and arrange) with pregnant patients who smoke. A three-wave mailing procedure was used with a statewide random sample of obstetrician/ gynecologists who responded to a valid and reliable 31-item questionnaire. Regarding the 5As method of smoking cessation, almost all (98%) asked their pregnant patients about smoking, but fewer respondents engaged in advising (66%), assessing (42%), assisting (29%), and arranging for follow-up visits or referrals (6%). Higher efficacy expectations were associated with greater use of the 5As method (r = 0.52, p &lt; 0.001). A majority believed that two cessation activities would result in smoking cessation in pregnant smokers: explaining the dangers of smoking (65%) and referring pregnant smokers to smoking cessation programs (57%). However, 26% of physicians reported that they were \"slightly confident\" or \"not confident at all\" in their ability to refer pregnant smokers to such programs, and 6% of physicians reported always providing smoking cessation referrals. A significant proportion of respondents believed that prenatal smoking would not cause severe effects for the unborn child but would likely lead to moderate (46%) or minor (3%) health effects. Obstetrician/gynecologists face many competing demands for their time and energy, yet 62% believed smoking cessation advice would be of significant value. Physicians with higher levels of efficacy expectations reported significantly greater use of the 5 As. Future research should explore ways to facilitate obstetrician/gynecologists' use of the 5As method." }, { "id": "pubmed23n0827_11532", "title": "Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians.", "score": 0.016488651535380507, "content": "The US Public Health Service clinical practice guideline treating tobacco use and dependence: 2008 update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication. To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended \"any\" (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange). This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued." }, { "id": "pubmed23n0552_9946", "title": "\"Should I give you my smoking lecture now or later?\" Characterizing emergency physician smoking discussions and cessation counseling.", "score": 0.016483145308383435, "content": "We determine frequency and manner in which emergency physicians address smoking with their patients. This was a descriptive secondary analysis of 871 audiotapes of physician-patient interactions collected during a trial assessing the effect of computer-based health risk assessment on emergency physician-patient communication. Consenting nonemergency female patients, ages 18 to 65 years, were enrolled from 2 socioeconomically diverse academic emergency department (EDs) for audiotaping of the ED visit. All audio files with any mention of smoking were independently coded with an in-depth structured coding form to characterize the nature of smoking-related discussions. Logistic regression was used to determine factors associated with emergency physician screening and discussion of tobacco exposure with women patients. Overall, 484 of 871 (56%) participants were verbally screened for smoking, with 156 of 484 (32%) disclosing current smoking, with similar incidence at both sites. Tobacco screening was higher (odds ratio 2.2; 95% confidence interval 1.3 to 3.5), whereas rates of smoking-related discussions were lower (odds ratio 0.41; 95% confidence interval 0.17 to 0.98) at the urban site. At both sites, physicians tended to screen and discuss smoking when patients presented with a health condition that could be aggravated by smoking. Only 56% of discussions with current smokers contained advice to quit, 16% included assessment of readiness to quit, and a minority (13%) included a referral. Physician empathy/encouragement was associated with patients' detailing quit attempts. Emergency physicians were likely to gather information about smoking but not to counsel or advise patients to quit. These results raise the question of whether emergency medicine resident training should include additional emphasis on smoking cessation counseling and motivational interviewing techniques." }, { "id": "pubmed23n0530_5045", "title": "[A review of the evidence based smoking cessation interventions delivered by the family physician].", "score": 0.015710259639023807, "content": "Smoking is one of the most preventable causes of morbidity and mortality resulting in almost 10,000 deaths each year in Israel. Since tobacco-related disease is preventable, efforts to promote cessation in patients who smoke should be a routine step in preventive primary care measures. In Israel, 26% of the adult population smoke. Within this group, a third want to quit but only two percent succeed in abstaining from smoking for a whole year. Family physicians are in an ideal position to facilitate patients' attempts to quit smoking: 70% of smoking patients report that firm, supportive messages from their family physician can act as an important motivating factor to quit smoking. The updated Clinical Practice Guidelines from the US Public Health Service recommend that family physicians should opportunistically advise smokers to stop smoking during routine consultation, encourage and assist smokers in the use of nicotine replacement therapies or bupropion and refer smokers to professional behavioral or psychological counselors specializing in smoking cessation. Most physicians rank smoking as the most important behavior affecting health, but few physicians are confident in their own ability to help their patients stop smoking. In this review the authors present several evidence-based strategies that were found to be helpful in promoting smoking cessation when delivered by general practitioners. The power of the physician's advice, first and second line agents, behavioral counseling and stage based interventions, are all discussed in detail." }, { "id": "pubmed23n0615_17649", "title": "Initiation of health behavior discussions during primary care outpatient visits.", "score": 0.015318168730204435, "content": "Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits. Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed. Physicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change. Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice. Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance." }, { "id": "pubmed23n0800_7186", "title": "Delivering evidence-based smoking cessation treatment in primary care practice: experience of Ontario family health teams.", "score": 0.014284384887399963, "content": "To report on the delivery of evidence-based smoking cessation treatments (EBSCTs) within a sample of 40 Ontario family health teams (FHTs). In each FHT, consecutive patients were screened for smoking status and eligible patients completed a questionnaire immediately following their clinic visits (index visits). Multilevel analysis was used to examine FHT-level, provider-level, and patient-level predictors of EBSCT delivery. Forty FHTs in Ontario. Across the 40 participating FHTs, 24,033 patients were screened and 2501 eligible patients contributed data. Provider performance in the delivery of EBSCTs during the preceding 12 months and during the index visits was assessed. The rate of provider delivery of EBSCT for the previous 12 months was 74.0% for the advise strategy. At the index visit, rates of EBSCT strategy delivery were 56.8% for ask; 46.9% for advise; 38.7% for assist; 11.6% for prescribing pharmacotherapy; and 11.3% for arrange follow-up. Significant intra-FHT and intraprovider variability in the rates of EBSCT delivery was identified. Family health teams with a physician champion (odds ratio [OR] 2.0; 95% CI 1.1 to 3.6; P &lt; .01) and providers who highly ranked the importance of smoking cessation (OR 1.7; 95% CI 1.1 to 2.7; P &lt; .01) were more likely to deliver EBSCTs. Patient readiness to quit (OR 1.6; 95% CI 1.3 to 1.9; P &lt; .001), presence of smoking-related illness (OR 1.6; 95% CI 1.2 to 2.1; P &lt; .01), and presenting for an annual health examination (OR 2.0; 95% CI 1.6 to 2.5; P &lt; .001) were associated with the delivery of EBSCTs. Rates of smoking cessation advice were higher than previously reported for Canadian physicians; however, rates of assistance with quitting were lower. Future quality improvement initiatives should specifically target increasing the rates of screening and advising among low-performing FHTs and providers within FHTs, with a particular emphasis on doing so at all clinic appointments; and improving the rate at which assistance with quitting is delivered." }, { "id": "pubmed23n0728_21090", "title": "Tobacco use screening and counseling during physician office visits among adults--National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005-2009.", "score": 0.01407147726166131, "content": "Tobacco use continues to be the leading cause of preventable disease and death in the United States; cigarette smoking accounts for approximately 443,000 premature deaths annually. In 2009, the prevalence of smoking among U.S. adults was 20.6% (46 million smokers), with no significant change since 2005 (20.9%). In 2010, approximately 69% of smokers in the United States reported that they wanted to quit smoking. Approximately 44% reported that they tried to quit in the past year for ≥1 day; however, only 4%-7% were successful each year. Tobacco dependence has many features of a chronic disease: most patients do not achieve abstinence after their first attempt to quit, they have periods of relapse, and they often require repeated cessation interventions. At least 70% of smokers visit a physician each year, and other smokers visit other health-care professionals, providing key opportunities for intervention. The 2008 update to the U.S. Public Health Service (PHS) Clinical Practice Guideline: Treating Tobacco Use and Dependence recommends that clinicians and health-care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health-care setting using the 5 A's model: 1) ask about tobacco use, 2) advise tobacco users to quit, 3) assess willingness to make a quit attempt, 4) assist in quit attempt, and 5) arrange for follow-up. The PHS guideline also recommends the following as effective methods for increasing successful cessation attempts: individual, group, and telephone counseling; any of the seven first-line medications for tobacco dependence that are approved by the Food and Drug Administration (FDA); and provision of coverage for these treatments by health-care systems, insurers, and purchasers. However, clinicians and health-care systems often do not screen for and treat tobacco use consistently and effectively." }, { "id": "wiki20220301en013_79820", "title": "Smoking cessation", "score": 0.014005602240896357, "content": "Dental professionals also provide a key component in increasing tobacco abstinence rates in the community through counseling patients on the effects of tobacco on oral health in conjunction with an oral exam. According to the 2008 Guideline, based on two studies the training of clinicians in smoking cessation methods may increase abstinence rates; however, a Cochrane review found and measured that such training decreased smoking in patients. Reducing or eliminating the costs of cessation therapies for smokers increased quit rates in three meta-analyses. In one systematic review and meta-analysis, multi-component interventions increased quit rates in primary care settings. \"Multi-component\" interventions were defined as those that combined two or more of the following strategies known as the \"5 A's\": Ask — Systematically identify all tobacco users at every visit Advise — Strongly urge all tobacco users to quit Assess — Determine willingness to make a quit attempt" }, { "id": "Obstentrics_Williams_1070", "title": "Obstentrics_Williams", "score": 0.013139492086860508, "content": "TABLE 9-2. Five A's of Smoking Cessation ASK about smoking at the first and subsequent prenatal visits. ADVISE with clear, strong statements that explain the risks of continued smoking to the woman, fetus, and newborn. ASSESS the patient's willingness to attempt cessation. ASSIST with pregnancy-specific, self-help smoking cessation materials. Ofer a direct referral to the smoker's quit line (1-800-QUIT NOW) to provide ongoing counseling and support. ARRANGE to track smoking progress at subsequent visits. Adapted from Fiore, 2008." }, { "id": "article-29164_3", "title": "Smoking Cessation -- Introduction", "score": 0.012504396076745732, "content": "Assisting patients with smoking cessation is one of the most important primary care tasks, and the benefits of assessing patients’ smoking behavior are well established. The US Preventive Services Task Force (USPSTF) recommends using the 5 As: Ask about smoking Office systems should ensure that smoking status is documented at every visit. Advise to quit Use clear, personalized messages.  Even brief advice from a physician can improve quit rates compared with patients who receive no advice. Assess willingness to quit Patients assessed as not yet willing to quit should receive the motivational intervention. Assist in quitting Ask patients who are willing to set a quit date. Arrange follow-up and support" }, { "id": "pubmed23n0800_21888", "title": "Do doctors' smoking habits influence their smoking cessation practices? A systematic review and meta-analysis.", "score": 0.012499032582617444, "content": "To assess the association between doctors' smoking status and the use of the '5As' of smoking cessation. A systematic search of 11 databases covering English and Spanish language publications since 1996 was undertaken. Studies were included if they reported doctors' smoking status (current, former or never smoker) and rates of practising any of the 5As of smoking cessation (Ask; Advise; Assess; Assist; and Arrange). Frequencies and proportions were extracted from individual papers and risk ratios (RR) were calculated. A random-effects meta-analysis model was used to assess the effect of the doctor's personal smoking history. Covariate effects were explored using meta-regression for three pre-specified study characteristics: doctors' role, smoking prevalence of the sample and study quality. Twenty studies were included in this systematic review. The RR of always asking patients about their smoking was not associated significantly with doctors' smoking status [RR = 0.98; 95% confidence interval (CI) = 0.94-1.02; P = 0.378; I(2)  = 0.00%; 10 studies]. Meta-analysis suggested that doctors who were current smokers had a 17% increased risk of not advising their patients to quit compared with never-smokers (RR = 0.83; 95% CI = 0.77-0.90; P &lt; 0.000; I(2)  = 82.14%; 14 studies). However, high levels of heterogeneity were found that were not explained by the meta-regression. Regarding assisting patients to quit, never smokers were more likely to counsel than current smokers (RR = 0.92; 95% CI = 0.85-0.99; P = 0.036; I(2)  = 0.00%; three studies) but less likely to make a referral (RR = 1.40; 95% CI = 1.09-1.79; P = 0.009; I(2)  = 0.00%; five studies). No statistically significant differences were found in arranging future contact by smoking status (RR = 0.80; 95% CI = 0.52-1.23; P = 0.315; I(2)  = 47.03%; four studies). Smoking status of doctors may affect their delivery of smoking cessation treatments to patients, with smokers being less likely than non-smokers or ex-smokers to advise and counsel their patients to quit but more likely to refer them to smoking cessation programmes." }, { "id": "pubmed23n0383_1948", "title": "How do residents prioritize smoking cessation for young \"high-risk\" women? Factors associated with addressing smoking cessation.", "score": 0.012125220458553791, "content": "Sixty-seven percent of physicians report advising their smoking patients to quit. Primary care residents' priorities for preventive health for a young \"high-risk\" female are unknown. Factors related to residents addressing smoking also need examining. One hundred residents completed a survey about preventive health issues for a woman in her 20s \"who leads a high-risk lifestyle.\" Residents indicated which topics they would address, and the likelihood that they would address each of 12 relevant preventive health topics, their outcome expectancies that the patient would follow their advice on each topic, their confidence that they could address the topic, and perceived barriers for addressing the topic. Residents listed STD prevention most frequently. Drug use and smoking cessation were second and third most frequently listed. Residents who believed that the patient would follow their advice were more likely to list smoking cessation than residents who had lower outcome expectancies for that patient. Higher barriers were negatively related to addressing smoking cessation. When time is not a barrier, residents are likely to address smoking cessation. Teaching residents how to incorporate this subject into their clinical practice is needed. Raising residents' outcome expectancies may increase their likelihood of addressing smoking cessation." }, { "id": "pubmed23n0622_15023", "title": "Realistic approaches to counseling in the office setting.", "score": 0.010856488952788942, "content": "Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A's (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional." }, { "id": "wiki20220301en013_79821", "title": "Smoking cessation", "score": 0.009992046132431895, "content": "Ask — Systematically identify all tobacco users at every visit Advise — Strongly urge all tobacco users to quit Assess — Determine willingness to make a quit attempt Assist — Aid the patient in quitting (provide counselling-style support and medication) Arrange — Ensure follow-up contact" }, { "id": "pubmed23n1032_15722", "title": "Reducing pediatric exposure to environmental tobacco smoke: The effects of pediatric exposure to environmental tobacco smoke and the role of pediatric perioperative care.", "score": 0.009900990099009901, "content": "Exposure to environmental tobacco smoke (ETS) has deleterious effects on a child's general health and their perioperative risk; specifically, it doubles a child's perioperative risk of adverse respiratory events, particularly laryngospasm. It increases the risk of sudden infant death syndrome, bacterial meningitis, middle ear infection, asthma, and lower respiratory tract infection. The preoperative assessment of children presenting for procedures under general anesthesia is an opportune moment to screen for exposure to ETS and give information about the risks and cessation support (if applicable). This can be described as a \"teachable moment\"; there is a documented need for this public health education and it aligns with the NHS Long Term Plan, aiming to embed public health information into every consultation a patient or family has with a healthcare practitioner. The period preceding and following surgery is a time when patients or their families are motivated to make a behavioral change. It has been shown that parents who smoke are more likely to attempt smoking cessation if their child has had recent surgery but not to maintain their abstinence; however, we know that subsequent quit attempts increase the likelihood that a smoker will succeed in permanently abstaining so aiming for a quit attempt rather than permanent abstinence is a valid aim. A suggested screening method would be to firstly ask all parents or carers in the preoperative health screening questionnaire about their child's exposure to ETS, accepting this lacks both the sensitivity and specificity of a valid screening tool. This can be augmented by measuring exhaled carbon monoxide in any child who is able to comply with the test; exhaled carbon monoxide has been shown to be a valid screening tool for exposure to ETS in adolescents but not children under 12 years of age, perhaps because smaller children may not be able to cooperate with the test which requires a vital capacity maneuver to provide an adequate endtidal sample. A suggested model for smoking cessation intervention is called Very Brief Advice and comprises three parts: Ask about a child's exposure to ETS with/without exhaled carbon monoxide measurement Advise about the risks to the child's general and perioperative health and the health of the smoker and wider family plus the benefits of smoking cessation Act on the response by referring to local smoking cessation support. Referral to local smoking cessation services should be along established pathways. Thus, recording a household smoking status and referring to local smoking cessation services targets a public health measure with benefits beyond the individual patient and planned anesthetic. There is no evidence in the literature of the effect of environmental exposure to electronic cigarettes (\"vaping\") on a child's perioperative health. Further research is needed to establish if preoperative reduction in or removal from exposure to ETS reduces the risk of respiratory adverse events in the child." }, { "id": "pubmed23n0724_12863", "title": "Promoting smoking cessation.", "score": 0.00980392156862745, "content": "Cigarette smoking causes significant morbidity and mortality in the United States. Physicians can use the five A's framework (ask, advise, assess, assist, arrange) to promote smoking cessation. All patients should be asked about tobacco use and assessed for motivation to quit at every clinical encounter. Physicians should strongly advise patients to quit smoking, and use motivational interviewing techniques for patients who are not yet willing to stop smoking. Clinical contacts with unmotivated patients should emphasize the rewards and relevance of quitting, as well as the risks of smoking and anticipated barriers to abstinence. These messages should be repeated at every opportunity. Appropriate patients should be offered pharmacologic assistance in quitting, such as nicotine replacement therapies, bupropion, and varenicline. Use of pharmacologic support during smoking cessation can double the rate of successful abstinence. Using more than one type of nicotine replacement therapy (\"patch plus\" method) and combining these therapies with bupropion provide additional benefit. However, special populations pose unique challenges in pharmacotherapy for smoking cessation. Nicotine replacement therapies increase the risk of birth defects and should not be used during pregnancy. They are usually safe in patients with cardiovascular conditions, except for those with unstable angina or within two weeks of a coronary event. Varenicline may increase the risk of coronary events. Nicotine replacement therapies are safe for use in adolescents; however, they are less effective than in adults. Physicians also should arrange to have repeated contact with smokers around their quit date to reinforce cessation messages." }, { "id": "pubmed23n0564_6423", "title": "Randomized controlled trial of a computer-based, tailored intervention to increase smoking cessation counseling by primary care physicians.", "score": 0.009708737864077669, "content": "The primary care visit represents an important venue for intervening with a large population of smokers. However, physician adherence to the Smoking Cessation Clinical Guideline (5As) remains low. We evaluated the effectiveness of a computer-tailored intervention designed to increase smoking cessation counseling by primary care physicians. Physicians and their patients were randomized to either intervention or control conditions. In addition to brief smoking cessation training, intervention physicians and patients received a one-page report that characterized the patients' smoking habit and history and offered tailored recommendations. Physician performance of the 5As was assessed via patient exit interviews. Quit rates and smoking behaviors were assessed 6 months postintervention via patient phone interviews. Intervention effects were tested in a sample of 70 physicians and 518 of their patients. Results were analyzed via generalized and mixed linear modeling controlling for clustering. Intervention physicians exceeded controls on \"Assess\" (OR 5.06; 95% CI 3.22, 7.95), \"Advise\" (OR 2.79; 95% CI 1.70, 4.59), \"Assist-set goals\" (OR 4.31; 95% CI 2.59, 7.16), \"Assist-provide written materials\" (OR 5.14; 95% CI 2.60, 10.14), \"Assist-provide referral\" (OR 6.48; 95% CI 3.11, 13.49), \"Assist-discuss medication\" (OR 4.72;95% CI 2.90, 7.68), and \"Arrange\" (OR 8.14; 95% CI 3.98, 16.68), all p values being &lt; 0.0001. Intervention patients were 1.77 (CI 0.94, 3.34,p = 0.078) times more likely than controls to be abstinent (12 versus 8%), a difference that approached, but did not reach statistical significance, and surpassed controls on number of days quit (18.4 versus 12.2, p &lt; .05) but not on number of quit attempts. The use of a brief computer-tailored report improved physicians' implementation of the 5As and had a modest effect on patients' smoking behaviors 6 months postintervention." }, { "id": "pubmed23n1107_22483", "title": "Strategies to improve smoking cessation rates in primary care.", "score": 0.009615384615384616, "content": "Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials). To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers. We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020. We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer. We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I<sup2</sup = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I<sup2</sup = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I<sup2</sup = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I<sup2</sup = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I<sup2</sup = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I<sup2</sup = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation. There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further." }, { "id": "pubmed23n0541_2781", "title": "A pilot study on inducement of smoking cessation by a simple 5A (asking, advice, assess, assist, and arrange) approach at outpatient clinics.", "score": 0.009615384615384616, "content": "Asking smokers about their smoking status, followed by advice to quit smoking, assessing the intention to quit, assistance with cessation, and arrange of follow-up (5A) is recommended for induction of smoking cessation. To obtain preliminary data on effects of \"5A\" , we investigated the smoking cessation rate with two modes in the phase I: 1) self-administered questionnaire and 2) doctor's interview at respiratory disease clinics of three general hospitals in Japan, and another mode in phase II: 3) doctor's interview with an additional pamphlet at one of the three hospitals. The interviews for smokers were conducted by doctors in charge of treatment. Subject smoking habits were followed up by postal surveys three months after the enrollment. In phase I, 359 outpatients were recruited and 189 smokers responded, among whom 27 patients (7.5% of 359 outpatients) had quit smoking at the three months after the enrollment. The cessation rate of the self-administered questionnaire group (8.4% of 238 smokers) did not differ significantly from that of doctors' interview group (5.8% of 121 smokers). Age and intention to quit at enrollment were found to be independent predictors of smoking cessation. Patients aged 50 years or older (odds ratio=5.05, 95% confidence interval 1.89-13.54), and participants with an intention to quit (odds ratio=6.78, 95% confidence interval 2.66-17.30) were more likely to be successful in quitting. In phase II, another 212 smokers of one hospital were interviewed by doctors in charge and provided with an additional pamphlet describing how to practice to dislike smoking. No significant difference in the cessation rate was observed between phase I and phase II (5.8% vs. 8.0%). In conclusion, there were no differences among the three modes of \"5A\", but 7.7% of the 571 outpatients visiting respiratory divisions quit smoking with this simple \"5A\". The findings may indicate that this simple practice at clinics is useful for smoking cessation strategy, although randomized trials are now required." }, { "id": "pubmed23n0570_8362", "title": "Chinese physicians and their smoking knowledge, attitudes, and practices.", "score": 0.009523809523809525, "content": "China has the most smokers among the world's nations. Physicians play a key role in smoking cessation, but little is known about Chinese physicians and smoking. This 2004 clustered randomized survey of 3552 hospital-based physicians from six Chinese cities measured smoking attitudes, knowledge, personal behavior, and cessation practices for patients. Descriptive statistics and multivariate analysis of factors associated with asking about or advising against smoking were conducted in 2005 and 2006. Smoking prevalence was 23% among all Chinese physicians, 41% for men and 1% for women. Only 30% report good implementation of smoke-free workplace policies and 37% of current smokers have smoked in front of their patients. Although 64% usually advise smokers to quit, only 48% usually ask about smoking status, and 29% believe most smokers will follow their cessation advice. Less than 7% set quit dates or use pharmacotherapy when helping smokers quit. Although 95% and 89%, respectively, know that active or passive smoking causes lung cancer, only 66% and 53%, respectively, know that active or passive smoking causes heart disease. Physicians were significantly more likely to ask about or advise against smoking if they believed that counseling about health harms helps smokers quit and that most smokers would follow smoking-cessation advice. Physician smoking cessation, smoke-free workplaces, and education on smoking-cessation techniques need to be increased among Chinese physicians. Strengthening counseling skills may result in more Chinese physicians helping smoking patients to quit. These improvements can help reduce the Chinese and worldwide health burden from smoking." }, { "id": "pubmed23n0554_15554", "title": "[Practitioners confronted with the four main health behavioral risk factors].", "score": 0.009523809523809525, "content": "Four behavioural risk factors are common in primary care and are often clustered in individuals. Smoking is present from I cigarette per day, excessive alcohol use is defined either by drinking regularly more than 2-3 standard glasses per day or by occasional heavy drinking of more than 4-5 glasses at a time. Patients who don't have regular moderate physical activity of at least 30 minutes during 5 days of a week or intensive physical activity of at least 20 minutes 3 times a week are sedentary. A Body Mass Index of over 30 defines obesity. We propose a \"generic\" counselling tool in 5 steps, the 5 As, that can be used for any of the four behavioural risk factors during routine consultations. With this counselling guide, practitioners can help patients change behaviour in a motivational style that allows shared decision-making." }, { "id": "pubmed23n0560_19240", "title": "Determinants of smoking and cessation in older women.", "score": 0.009433962264150943, "content": "although the benefits of quitting smoking even at an advanced age have been proved, few campaigns target the older population. The goals of this study were to analyse the characteristics of older women smokers help and support those wanting to quit. we assessed the determinants of smoking cessation in a prospective cohort study performed in 7,609 older women. A questionnaire about smoking habits was sent to the 486 eligible smokers. Smoking dependence and smokers' readiness to quit was assessed. Participants who had quit smoking during follow-up were asked about their previous reasons for quitting and the methods used to quit. 372 women of the 424 (88%) responded to our questionnaire and were included. The most common reasons for smoking were relaxation, pleasure, and habit. Major obstacles to quitting smoking were 'no benefit to quitting at an advanced age', 'smoking few or \"light\" cigarettes yields no negative health consequences', and 'smoking does not increase osteoporotic risk'. During the 3-year follow-up period, 57 of the 372 (15%) women successfully quit smoking. Being an occasional smoker (OR=2.4) and reporting 'quitting is not difficult' (OR=3.7) were positively associated with having recently quit smoking. Only 11% of successful cessations were reported to have received physician advice. these data illustrate the specific smoking behaviour of older women, suggesting that cessation interventions ought to be tailored to these characteristics. Willingness to quit was associated with a low education level. The most frequent obstacles to quitting were all based on incorrect information." }, { "id": "pubmed23n0638_15154", "title": "Are obstetricians following best-practice guidelines for addressing pregnancy smoking? Results from northeast Tennessee.", "score": 0.009433962264150943, "content": "In 2000, the American College of Obstetricians/Gynecologists(ACOG) established the 5 A's method of brief smoking cessation counseling (ask, advise, assess, assist, arrange) as a standard component of prenatal care. The purpose of this study was to describe use of the 5 A's in prenatal care in Northeast Tennessee, where pregnancy smoking rates are three times the national average, and to evaluate provider attitudes toward addressing pregnancy smoking. Surveys were distributed to all obstetric practices in a6-county area. One-quarter of respondents indicated they always asked pregnant patients about smoking, with two-thirds always giving their pregnant smokers advice to quit. Over half reported always assessing willingness to quit, while one-quarter or fewer always provided quit assistance, or arranged follow up. Over half believed addressing smoking was of significant value. Secondhand smoke was infrequently addressed. Demographics, efficacy, and outcome beliefs predicted use of the 5 A's. Most obstetric providers in Northeast Tennessee are not following ACOG recommendations for pregnancy smoking. Efforts to address pregnancy smoking and associated adverse pregnancy outcomes in the region should include facilitation of smoking cessation interventions in prenatal care." }, { "id": "InternalMed_Harrison_31963", "title": "InternalMed_Harrison", "score": 0.009281991644053926, "content": "The process of stopping smoking is commonly a cyclical one, with the smoker sometimes making multiple attempts to quit and failing before finally being successful. Approximately 70–80% of smokers would like to quit smoking. More than one-half of current smokers attempted to quit in the last year, but only 6% quit for 6 months, and only 3% remain abstinent for 2 years. Clinician-based smoking interventions should repeatedly encourage smokers to try to quit and to use different forms of cessation assistance with each new cessation attempt rather than focusing exclusively on immediate cessation at the time of the first visit. Advice from a physician to quit smoking, particularly at the time of an acute illness, is a powerful trigger for cessation attempts, with up to half of patients who are advised to quit making a cessation effort. Other triggers include the cost of cigarettes, media campaigns, and changes in rules to restrict smoking in the workplace." }, { "id": "pubmed23n0878_5478", "title": "Don't give up on it: Smoking cessation.", "score": 0.009259259259259259, "content": "The aim of this Learning Unit is to give you the facts about smoking in order to enhance your assessment of your clients' health risks and the benefits they are likely to gain from stopping smoking, and to target intervention appropriately to help them stop. " }, { "id": "article-27609_38", "title": "Preconception Counseling -- Issues of Concern -- Substance Use and Smoking Cessation", "score": 0.009174504534766544, "content": "Tobacco use is associated with preterm labor, fetal growth restriction, low birth weight, and placental abruption. Smoking cessation can reduce perinatal mortality and low birth weight by at least 20%. Smoking cessation counseling should be offered to the woman and her partner before and during early pregnancy. Women should be counseled that secondhand smoke can also impact the child's health after birth, including increased risks for asthma and childhood obesity. Healthcare providers can provide structured counseling, for example, using the 5A's intervention, which includes: Asking about tobacco use Advising patients quit Assessing willingness to quit Assisting patients with quitting through appropriate medications, counseling, referrals, and support groups. Arrange follow-up and support [1]" }, { "id": "pubmed23n0264_8884", "title": "The Physician-Delivered Smoking Intervention Project: factors that determine how much the physician intervenes with smokers.", "score": 0.009174311926605505, "content": "To determine factors that affect how much physicians trained to use a patient-centered smoking intervention intervene with their smoking patients. Forty internal medicine residents and ten internal medicine attending physicians trained in a patient-centered counseling approach were randomized to an algorithm condition (provision of intervention algorithm at each patient visit) or a no-algorithm condition. Smoking intervention steps used by physicians with patients were assessed with Patient Exit Interviews (PEIs). Ambulatory clinic; academic medical center. Five hundred twenty-seven adult smokers seen in clinic between June 1990 and April 1992. There was no difference in overall PEI scores or in individual PEI steps taken between the algorithm and no-algorithm conditions. Two patient baseline factors (reporting thinking of stopping smoking within six months and higher Fagerstrom Tolerance Score) and one physician factor (older age) were significantly predictive of higher PEI score. Provision of an intervention algorithm at each patient visit does not increase the likelihood that trained physicians who are cued to intervene will perform more of the intervention steps taught. Trained physicians are more likely to intervene with smokers who are more nicotine-dependent and who expect and desire to stop smoking." }, { "id": "pubmed23n0314_14208", "title": "[Mid-term evaluation of a help program for smokers].", "score": 0.00909090909090909, "content": "Medical counsel to smokers is an intervention that has proved useful to motivate smokers to stop smoking. This study pretends evaluate the long-term impact (2 years and 9 months) of systematic and structured health counsel on the smoke habit from the primary health care. In April 1990, in four primary care centers from Barcelona and Zaragoza, Spain, a program of systematic counselling to stop smoking with an offer of subsequent follow-up was initiated in all adult smokers (15-65 years of age). According to the answer, every patient was classified on one of seven established categories that allowed a individualized follow-up. Data from the total population included in the program from the beginning till January 1993, are analyzed. From 683 known smokers (59.2% males and 40.8% women), 20 were excluded for different reasons and 343 were included in the program (56.4% cover). Average age of included smokers was 35.1 years (SE = 0.6) and average number of visits of 5.3 (SE = 0.2) which was significantly higher than those not included in the program (33.4; SE = 0.6, and 2.7; SE = 0.1). An average follow-up of 14.3 months (SE = 0.5) and of 2.6 (SE = 0.1) interventions on each individual were done. The average daily number of cigarettes was 18.4 (SE = 0.6) in the initial period and 13.3 (SE = 0.6) on the last program evaluation. The final answers showed a 18.1% of quitters and a decrease of more than 50% on the initial consume on 32.6%. In 12% the answer was negative. Programs of systematic help for smokers show a higher level of favourable responses than does normal counselling." }, { "id": "pubmed23n0972_10069", "title": "Smoking and HIV: what are the risks and what harm reduction strategies do we have at our disposal?", "score": 0.009009009009009009, "content": "The World Health Organization estimates that smoking poses one of the greatest global health risks in the general population. Rates of current smoking among people living with HIV (PLHIV) are 2-3 times that of the general population, which contributes to the higher incidence of non-AIDS-related morbidity and mortality in PLHIV. Given the benefit of smoking cessation, strategies to assist individuals who smoke to quit should be a primary focus in modern HIV care. Tobacco harm reduction focuses on reducing health risk without necessarily requiring abstinence. However, there remains uncertainty about the safety, policy and familiarity of specific approaches, particularly the use of vaporised nicotine products. Evidence suggests that vaporised nicotine products may help smokers stop smoking and are not associated with any serious side-effects. However, there is the need for further safety and efficacy data surrounding interventions to assist quitting in the general population, as well as in PLHIV specifically. In addition, official support for vaping as a harm reduction strategy varies by jurisdiction and this determines whether medical practitioners can prescribe vaporised products and whether patients can access vaporised nicotine products. When caring for PLHIV who smoke, healthcare workers should follow general guidelines to assist with smoking cessation. These include: asking the patient about their smoking status; assessing the patient's readiness to quit and their nicotine dependence; advising the patient to stop smoking; assisting the patient in their attempt to stop smoking through referral, counselling, pharmacotherapy, self-help resources and/or health education; and arranging follow-up with the patient to evaluate their progress." }, { "id": "pubmed23n0688_12274", "title": "Do the five A's work when physicians counsel about weight loss?", "score": 0.009009009009009009, "content": "More than two thirds of Americans are overweight or obese. Physician counseling may help patients lose weight; however, physicians perceive these discussions as somewhat futile and time-consuming. An effective and efficient tool for smoking cessation is the Five A's (Ask, Advise, Assess, Assist, and Arrange). We studied the effectiveness of the Five A's in weight-loss counseling. We audiorecorded primary care encounters between 40 physicians and 461 of their overweight or obese patients. All were told the study was about preventive health, not weight specifically. Encounters were coded for physician use of the Five A's. Patients' motivation and confidence were assessed before and immediately after the encounter. Three months later, we assessed patient change in dietary fat intake, exercise, and weight. Generalized linear models were fit adjusting for patient clustering within physician. Physicians used at least one of the Five A's often (83%). Physicians routinely Ask and Advise patients to lose weight; however, they rarely Assess, Assist, or Arrange. Assist and Arrange were related to diet improvement, whereas Advise was associated with increases in motivation and confidence to change dietary fat intake and confidence to lose weight. Similar to smoking cessation counseling, physicians routinely Asked and Advised patients to lose weight; however, they rarely Assessed, Assisted, or Arranged. Given the potential impact of using all of these counseling tools on changing patient behavior, physicians should be encouraged to increase their use of the Five A's when counseling patients to lose weight." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 0, 85 ] ], "word_ranges": [ [ 0, 14 ] ], "text": "The fourth noise usually appears when there is a certain degree of valvular stenosis." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The third noise coincides with the rapid filling phase of the ventricular diastole of the cardiac cycle.", "2": "The most likely diagnosis is heart failure.", "3": "The holosystolic murmur may correspond to mitral insufficiency.", "4": "The fourth noise usually appears when there is a certain degree of valvular stenosis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en063_19521", "title": "Valvular heart disease", "score": 0.01818331413526411, "content": "Medical signs of aortic stenosis include pulsus parvus et tardus, that is, diminished and delayed carotid pulse, fourth heart sound, decreased A2 sound, sustained apex beat, precordial thrill. Auscultation may reveal a systolic murmur of a harsh crescendo-decrescendo type, heard in 2nd right intercostal space and radiating to the carotid arteries. Aortic regurgitation Patients with aortic regurgitation may experience heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea, palpitations, and angina pectoris. In acute cases patients may experience cyanosis and circulatory shock." }, { "id": "wiki20220301en068_46138", "title": "Cardiac examination", "score": 0.017630683575626353, "content": "Finally the sacrum and ankles are checked for pitting edema which is caused by right ventricular failure in isolation or as part of congestive cardiac failure. Auscultation One should comment on S1 and S2 – if the splitting is abnormal or louder than usual. S3 – the emphasis and timing of the syllables in the word Kentucky is similar to the pattern of sounds in a precordial S3. S4 – the emphasis and timing of the syllables in the word Tennessee is similar to the pattern of sounds in a precordial S4. If S4 S1 S2 S3 Also known as a gallop rhythm. diastolic murmurs (e.g. aortic regurgitation, mitral stenosis) systolic murmurs (e.g. aortic stenosis, mitral regurgitation) pericardial rub (suggestive of pericarditis) The base of the lungs should be auscultated for signs of pulmonary oedema due to a cardiac cause such as bilateral basal crepitations." }, { "id": "pubmed23n0991_5593", "title": "Ultimate Third Heart Sound.", "score": 0.016680339075745145, "content": "A 79-year-old man with dilated cardiomyopathy and severe functional mitral regurgitation presented with general fatigue and dyspnea. Auscultation revealed a systolic regurgitant murmur with a minimized second heart sound due to a low output. On the other hand, the third heart sound was ultimately enhanced, being visible and palpable as a pulsatile knock of the precordium. Phonocardiography and echocardiography successfully confirmed early-diastolic rapid distension of the left ventricle along with rapid ventricular filling and abrupt deceleration of the atrioventricular blood flow to be the precise etiology of the ultimate third heart sound, indicating critically deteriorated hemodynamics due to massive mitral regurgitation combined with a low output." }, { "id": "wiki20220301en224_15446", "title": "Third heart sound", "score": 0.01655719759168035, "content": "It has also been termed a ventricular gallop or a protodiastolic gallop because of its place in early diastole. It is a type of gallop rhythm by virtue of having an extra sound; the other gallop rhythm is called S4. The two are quite different, but they may sometimes occur together forming a quadruple gallop. If the heart rate is also very fast (tachycardia), it can become difficult to distinguish between S3 and S4 thus producing a single sound called a summation gallop. S3 is a dull, low-pitched sound best heard with the bell placed over the cardiac apex with the patient lying in the left lateral decubitus position. This heart sound when present in a child or young adult implies the presence of a supple ventricle that can undergo rapid filling. Conversely, when heard in a middle-aged or older adult, an S3 is often a sign of disease, indicating increased ventricular filling due to congestive heart failure or severe mitral or tricuspid regurgitation." }, { "id": "pubmed23n0276_19500", "title": "Cardiac pearls.", "score": 0.015407407407407408, "content": "Most diagnoses of cardiovascular disease are made in the office or at the bedside. For example, in pulsus alternans of the radial pulse, observed when first greeting a patient, alteration of intensity of the second sound and systolic murmur and a ventricular (S3) gallop are clinical pearls--often subtle--that diagnose cardiac decompensation. A faint gallop, ventricular (S3) or atrial (S4), might be overlooked in a patient who has an emphysematous chest and an increase in anteroposterior diameter if one listens over the usual areas of the precordium. However, the gallop might be detected easily by listening over the xiphoid or epigastric area. How do you tell the difference between an S4, a split first sound, and an ejection sound? The S4 is eliminated with pressure on the stethoscope, but pressure does not eliminate the ejection sound or the splitting of S1. The atrial sound (S4) is most frequently found in patients who have coronary heart disease, and it is a constant finding in patients who have hypertension. It does not denote heart failure, as does the S3 (ventricular) gallop. In some patients, both atrial (S4) and ventricular (S3) diastolic gallops may be present. This occurrence is common in patients with cardiac decompensation associated with coronary heart disease, hypertensive heart disease, and dilated cardiomyopathy. When these diastolic filling sounds occur in close proximity, a short rumbling murmur may be heard, which causes confusion of this sound with that of a valvular or congenital lesion. When both sounds occur exactly simultaneously, a single sound results. Often, this sound is louder than either the first or second sound and can be misinterpreted as either a valvular or congenital lesion. This, however, is a summation gallop, which is rare. For the most accurate timing of heart sounds and murmurs, the simple technique called \"inching\" is the best. Keeping the second sound in mind as a reference, the physician moves (inches) the stethoscope from the aortic area to the apex. An extra sound may be noted to occur in systole before the second sound, thereby diagnosing a systolic click. If the sound occurs after the second sound, however, it is an S3 or ventricular diastolic gallop. If a murmur appears before S2, it is a systolic murmur; if it appears after S2, it is a diastolic murmur. When the Austin-Flint murmur is heard, significant aortic regurgitation exists.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "wiki20220301en063_19522", "title": "Valvular heart disease", "score": 0.015365470973326842, "content": "Medical signs of aortic regurgitation include increased pulse pressure by increased systolic and decreased diastolic blood pressure, but these findings may not be significant if acute. The patient may have a diastolic decrescendo murmur best heard at left sternal border, water hammer pulse, Austin Flint murmur, and a displaced apex beat down and to the left. A third heart sound may be present Mitral stenosis Patients with mitral stenosis may present with heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea, palpitations, chest pain, hemoptysis, thromboembolism, or ascites and edema (if right-sided heart failure develops). Symptoms of mitral stenosis increase with exercise and pregnancy" }, { "id": "wiki20220301en011_153736", "title": "Heart sounds", "score": 0.014718614718614718, "content": "Murmurs can be heard in many situations in adults without major congenital heart abnormalities: Regurgitation through the mitral valve is by far the most commonly heard murmur, producing a pansystolic/holosystolic murmur which is sometimes fairly loud to a practiced ear, even though the volume of regurgitant blood flow may be quite small. Yet, though obvious using echocardiography visualization, probably about 20% of cases of mitral regurgitation do not produce an audible murmur. Stenosis of the aortic valve is typically the next most common heart murmur, a systolic ejection murmur. This is more common in older adults or in those individuals having a two-leaflet, not a three-leaflet, aortic valve." }, { "id": "pubmed23n0126_250", "title": "Phonoechocardiography and intracardiac phonocardiography in hypertrophic cardiomyopathy.", "score": 0.014706677480400108, "content": "The salient phonoechocardiographic features of patients having hypertrophic cardiomyopathy (HCM) with or without left ventricular outflow tract (LVOT) gradients are reviewed. Intracardiac sound and pressure recordings from high fidelity catheter-tipped micromanometers have documented that the precordial murmur is the summation of both the systolic ejection murmur (SEM) arising from the LVOT, as well as the mitral regurgitant murmur recorded from the left atrium. The intensity of the precordial murmur varies directly with the LVOT gradient, which in turn is determined primarily by the contractility and loading conditions of the left ventricle. Reversed splitting of the second heart sound (S2) with paradoxical respiratory movement is a common finding in HCM, and when present, almost always denotes a significant LVOT gradient. It is due to marked lengthening of the left ventricular ejection time secondary to prolongation of the contraction and relaxation phases of left ventricular systole. The presence of a fourth heart sound (S4) is the rule in HCM when normal sinus rhythm is present, and is a reflection of a forceful left atrial contraction into a hypertrophied noncompliant left ventricle. A third heart sound (S3) is also common in HCM, and often the initial vibrations occur before the 0 point of the apexcardiogram (ACG) and continue giving the auscultatory impression of a diastolic rumble. When associated with a loud S1, which is frequently present, the clinical presentation may mimic mitral stenosis. This is particularly true when the patient has chronic atrial fibrillation. Careful attention to evidence of marked left ventricular hypertrophy as well as the typical echocardiographic findings of HCM preclude this diagnosis. In conclusion, phonoechocardiography is a simple non-invasive technique which almost always makes the definitive diagnosis of HCM." }, { "id": "wiki20220301en029_14960", "title": "Mitral regurgitation", "score": 0.014414414414414415, "content": "Findings on clinical examination depend on the severity and duration of MR. The mitral component of the first heart sound is usually soft and with a laterally displaced apex beat, often with heave. The first heart sound is followed by a high-pitched holosystolic murmur at the apex, radiating to the back or clavicular area. Its duration is, as the name suggests, the whole of systole. The loudness of the murmur does not correlate well with the severity of regurgitation. It may be followed by a loud, palpable P2, heard best when lying on the left side. A third heart sound is commonly heard. Patients with mitral valve prolapse may have a holosystolic murmur or often a mid-to-late systolic click and a late systolic murmur. Cases with a late systolic regurgitant murmur may still be associated with significant hemodynamic consequences. Mitral regurgitation as a result of papillary muscle damage or rupture may be a complication of a heart attack and lead to cardiogenic shock. Cause" }, { "id": "wiki20220301en063_19524", "title": "Valvular heart disease", "score": 0.014181594661046716, "content": "On auscultation of a patient with mitral stenosis, there may be a holosystolic murmur at the apex, radiating to the back or clavicular area, a third heart sound, and a loud, palpable P2, heard best when lying on the left side. Patients also commonly have atrial fibrillation. Patients may have a laterally displaced apex beat, often with heave In acute cases, the murmur and tachycardia may be only distinctive signs. Tricuspid regurgitation Patients with tricuspid regurgitation may experience symptoms of right-sided heart failure, such as ascites, hepatomegaly, edema and jugular venous distension." }, { "id": "pubmed23n0135_14273", "title": "[Traumatic mitral insufficiency: a case report].", "score": 0.014161220043572984, "content": "A 25-year-old man was admitted to Juntendo University Hospital with chief complaints of nocturnal dyspnea and shortness of breath on Sept. 22, 1983. He had no history of rheumatic fever or bacterial endocarditis. He was violently kicked in the chest while practicing Shorinji-Kempo (Karate) in July 1977. His heart murmur was first noticed in April 1978, but he was asymptomatic for six years after the accident until transient nocturnal dyspnea developed January 1983. Physical examination on admission revealed a grade 4/6 apical holosystolic murmur, a markedly accentuated third sound, and hepatomegaly of two finger breadth in the right midclavicular line. An electrocardiogram revealed sinus tachycardia (100/min), left atrial overload and left ventricular hypertrophy. Chest radiography showed slight cardiac enlargement with a cardiothoracic ratio of 55%, and slightly increased pulmonary vascular markings. Two-dimensional echocardiography showed a markedly prolapsed posterior mitral leaflet and fluttering in diastole. Cardiac catheterization showed elevated pressure of pulmonary capillaries (a: 16, v: 30, mean: 19 mmHg), the pulmonary artery and the right ventricle. Left ventriculography revealed grade four (Sellers) mitral regurgitation. Mitral valve replacement was performed on October 13, 1983. A chorda tendinae supporting the posterior leaflet of the mitral valve was found to be ruptured just above its origin from the posterior papillary muscle. Histological examination of the resected valve showed increased spongiosa tissue which mimicked so-called myxomatous changes, but it seemed preferable to interpret this as a \"secondary change due to increased hemodynamic stress\" rather than the \"primary change\"." }, { "id": "pubmed23n0268_12554", "title": "[Phonocardiographic and Doppler echocardiographic study on the mechanism of the presystolic murmur in mitral stenosis, especially the relationship to mitral inflow dynamics].", "score": 0.013862039700127305, "content": "The cause of the \"presystolic murmur\" in mitral stenosis was investigated by phonocardiography and continuous wave Doppler echocardiography in 31 patients with mitral stenosis and sinus rhythm classified into two groups: 18 patients with and 13 without \"presystolic murmur\". 1. The \"presystolic murmur\" group demonstrated high frequency vibrations preceding the first heart sound coinciding with the initial low frequency component of the first heart sound recorded at the apex in both groups. 2. There were two types of \"presystolic murmur\": The first type observed in three of the 18 patients occurred during the accelerated phase of the atrial (A) wave of mitral inflow signals and lasted until the first heart sound. The A wave velocity in mitral inflow signals was high at the onset and peak, and rapidly decreased after the peak. The second type observed in 15 patients occurred during the decelerated phase of the A wave and lasted until the first heart sound. The A wave velocity in mitral inflow signals was low at the onset, but high at the peak and rapidly decreased after the peak. 3. The mitral orifice area tended to be smaller in all patients with \"presystolic murmur\". The peak flow velocity, deceleration rate of the A wave, and maximal pressure gradient across the mitral valve during atrial contraction were significantly increased in all patients with \"presystolic murmur\". 4. Five patients with newly developed \"presystolic murmur\" after amyl nitrite inhalation had an increased initial low frequency component of the first heart sound coinciding with the latter half of \"presystolic murmur\". The rate of increase in the peak flow velocity and the deceleration rate of the A wave were significantly larger and the maximal atrioventricular pressure gradient during atrial contraction tended to be larger in these five patients than those in five who did not develop \"presystolic murmur\". 5. The peak flow velocity, deceleration rate of the A wave and the maximal atrioventricular pressure gradient during atrial contraction had increased 1 year later compared with those immediately after cardioversion of atrial fibrillation, and newly developed \"presystolic murmur\" appeared according to the recovery of left atrial mechanical function. These results suggest that the latter half of \"presystolic murmur\" originates from augmentation and prolongation of the initial low frequency component of the first heart sound up to the audible range caused by the sudden deceleration of mitral inflow velocity due to left ventricular contraction, and that the early half of \"presystolic murmur\" is the atriosystolic murmur produced by the increase in mitral inflow velocity during atrial contraction." }, { "id": "wiki20220301en011_153782", "title": "Heart murmur", "score": 0.01367318711717052, "content": "Mitral regurgitation typically is a holosystolic (pansystolic) murmur heard best at the apex, and may radiate to the axilla or precordium. A systolic click may be heard if there is associated mitral valve prolapse. Valsalva maneuver in mitral regurgitation associated with mitral valve prolapse will decrease left ventricular preload and move the murmur onset closer to S1, and isometric handgrip, which increases left ventricular afterload, will increase murmur intensity. In acute severe mitral regurgitation, a holosystolic (pansystolic) murmur may not be heard. Pulmonary valve stenosis typically is a crescendo-decrescendo systolic murmur heard best at the left upper sternal border, associated with a systolic ejection click that increases with inspiration (due to increased venous return to the right side of the heart) and sometimes radiates to the left clavicle." }, { "id": "pubmed23n0128_4272", "title": "[Mitral valvular disease secondary to mitral ring calcification: a clinicopathologic study].", "score": 0.013428486972678517, "content": "Fifteen cases with mitral valvular disease caused by mitral ring calcification (MRC) were observed among 2,800 consecutive autopsy patients more than 60 years of age. They consisted of one man and 14 women whose average age was 86.4 years. All had been diagnosed as having mitral valvular disease during life. For this clinicopathologic study, the cases were categorized as nine cases with mitral regurgitation (MR Group) and six with mitral stenosis (MS Group). Among the 15 cases, phonocardiograms were obtained in 14 and echocardiograms in 6. In addition, 122 cases with MRC, the length of which was 5 mm or more, were selected from 900 recent consecutive autopsies of senile patients, to evaluate the site of calcification and to analyze the ratio of calcification length to mitral valve ring circumference. The following conclusions were obtained: The prevalence of mitral valvular disease due to MRC in the aged was 15/2,800 (0.5%). MR was observed in nine cases and MS in six. Phonocardiograms of the MR Group revealed a holosystolic murmur in seven cases, a late systolic murmur in one, a third heart sound in four and a fourth heart sound in five. In the MS Group, a holosystolic murmur was found in four, a presystolic murmur in four, a diastolic rumble in one, but no opening snap in any case. A diamond-shaped systolic murmur was found in nine cases with MS or MR, suggesting an ejection systolic murmur caused by an associated calcified aortic valve. Echocardiograms showed markedly decreased DDR in five cases and increased echo intensity of the aortic valve in four. Pathologic findings revealed that the mean length of MRC was 36.6 mm in the MR Group and 58.0 mm in the MS Group. The calcification ring ratio (CRR = MRC/MVR X 100) was 50.3% in the MR Group and 69.8% in the MS Group. In the MR Group, MRC involved the anterolateral commissure in three, posteromedial commissure in five, and both in one. In five of six cases with MS, both commissures were involved by MRC. The study of 122 cases with MRC length greater than or equal to 5 mm suggested that MRC occurred first in the middle scallop of the posterior mitral leaflet, and extended to the posterior scallop, subsequently extending up to the anterior scallop, and finally involved the anterior mitral leaflet beyond the commissures.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "First_Aid_Step2_9", "title": "First_Aid_Step2", "score": 0.013064516129032259, "content": "Systolic murmurs: Aortic stenosis: Harsh systolic ejection murmur; radiation to carotids. Mitral regurgitation: Holosystolic murmur; radiation to axillae or to carotids. Mitral valve prolapse: Midsystolic or late-systolic click. Flow murmur: Very common, and does not imply cardiac disease. Diastolic murmurs: Always abnormal. Aortic regurgitation: Early decrescendo murmur. Mitral stenosis: Midto late, low-pitched murmur. Heart auscultation locations from the upper right sternal border, upper left sternal border, lower left sternal border, and apex: All (Aortic) People (Pulmonic) Try (Tricuspid) McDonald’s (Mitral). Causes of CHF— Hypertension Endocrine Anemia Rheumatic heart disease Toxins Failure to take meds Arrhythmia Infection Lung (pulmonary Gallops: S3 gallop: Dilated cardiomyopathy (floppy ventricle), mitral valve disease; often normal in younger patients and in high-output states (e.g., pregnancy)." }, { "id": "pubmed23n0006_10965", "title": "[Various etiologies of systolic murmurs radiating from the apex of the heart to the neck].", "score": 0.013051090243514245, "content": "The authors studied systolic murmurs in 89 cases, 50 of aortic stenosis, 14 cases of obstructive cardiomyopathy and 20 cases of mitral incompetence. This systolic murmur is characterised by its exceptional intensity, its raspy character at the base, becoming softer at the apex and in the axilla, the presence of a thrill and irradiation into the neck in 50 to 75% of cases. The etiological diagnosis was ensured precisely by 1) pharmaco-dynamic tests: amyl nitrite accentuates the systolic ejection murmurs and attenuates murmurs due to mitral regurgitation. 2) careful analysis of diastole: a systolic murmur extending into early diastole, a third sound or an opening snap and a low-pitched diastolic murmur, suggest mitral incompetence. A high-pitched diastolic murmur is in favour of aortic stenosis. 3) the carotid arteriogram and catheterisation show the characteristic abnormalities of the carotid arteriogram found in aortic valve disease and the existence of a trans-aortic or intra-ventricular pressure gradient, when there is an obstruction to left ventricular jection. The F wave of the apex cardiogram or left atrial reflux of the contrast medium during cineangiocardiography, confirm mitral incompetence. The main phono-hemodynamic and phono-anatomical correlations have been emphasized: 1. The intensity of the systolic murmur is directly proportional to the degree of obstructive cardiomyopathy or mitral incompetence, but does not parallel the degree of the sub-valvular apparatus. 3. The maximum intensity of the murmur occurs all the later when the stenosis is tight, whilst it is earlier in severe obstructive cardio-myopathy. 4. The lozange shape of the murmur of mitral incompetence on phono-cardiography is, above all, due to those cases with lesions of the sub-valvular apparatus. Finally, a study of the sound recorded by the Allard-Laurens micromanometer permitted us to determine the mechanism of this irradiating systolic murmur." }, { "id": "wiki20220301en063_19525", "title": "Valvular heart disease", "score": 0.01276179291446467, "content": "Tricuspid regurgitation Patients with tricuspid regurgitation may experience symptoms of right-sided heart failure, such as ascites, hepatomegaly, edema and jugular venous distension. Signs of tricuspid regurgitation include pulsatile liver, prominent V waves and rapid y descents in jugular venous pressure. Auscultatory findings include inspiratory third heart sound at left lower sternal border (LLSB) and a blowing holosystolic murmur at LLSB, intensifying with inspiration, and decreasing with expiration and Valsalva maneuver. Patients may have a parasternal heave along LLSB. Atrial fibrillation is usually present in patients with tricuspid regurgitation Causes" }, { "id": "wiki20220301en011_153785", "title": "Heart murmur", "score": 0.012700144142740271, "content": "Mitral stenosis typically presents as a diastolic low-pitched decrescendo murmur best heard at the cardiac apex in the left lateral decubitus position. It may be associated with an opening snap. Increasing severity will shorten the time between S2(A2) and the opening snap. (i.e. In severe MS the opening snap will occur earlier after A2) Tricuspid valve stenosis presents as a diastolic decrescendo murmur at the left lower sternal border, and signs of right heart failure may be seen on exam. Pulmonary valve regurgitation presents as a diastolic decrescendo murmur at the left lower sternal border. A palpable S2 in the second left intercostal space correlates with pulmonary hypertension due to mitral stenosis. Continuous and Combined Systolic/Diastolic Patent ductus arteriosus may present as a continuous murmur radiating to the back." }, { "id": "wiki20220301en063_19523", "title": "Valvular heart disease", "score": 0.012661064425770308, "content": "On auscultation of a patient with mitral stenosis, typically the most prominent sign is a loud S1. Another finding is an opening snap followed by a low-pitched diastolic rumble with presystolic accentuation. The opening snap follows closer to the S2 heart tone with worsening stenosis. The murmur is heard best with the bell of the stethoscope lying on the left side and its duration increases with worsening disease. Advanced disease may present with signs of right-sided heart failure such as parasternal heave, jugular venous distension, hepatomegaly, ascites and/or pulmonary hypertension (presenting with a loud P2). Signs increase with exercise and pregnancy. Mitral regurgitation Patients with mitral regurgitation may present with heart failure symptoms, such as dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea, palpitations, or pulmonary edema." }, { "id": "wiki20220301en011_153734", "title": "Heart sounds", "score": 0.0125, "content": "\"ta-lub-dub\" or \"a-stiff-wall\" It is a sign of a pathologic state, usually a failing or hypertrophic left ventricle, as in systemic hypertension, severe valvular aortic stenosis, and hypertrophic cardiomyopathy. The sound occurs just after atrial contraction at the end of diastole and immediately before S1, producing a rhythm sometimes referred to as the \"Tennessee\" gallop where S4 represents the \"Ten-\" syllable. It is best heard at the cardiac apex with the patient in the left lateral decubitus position and holding his breath. The combined presence of S3 and S4 is a quadruple gallop, also known as the \"Hello-Goodbye\" gallop. At rapid heart rates, S3 and S4 may merge to produce a summation gallop, sometimes referred to as S7. Atrial contraction must be present for production of an S4. It is absent in atrial fibrillation and in other rhythms in which atrial contraction does not precede ventricular contraction. Murmurs" }, { "id": "wiki20220301en340_257", "title": "Cardiovascular examination", "score": 0.012483872092617778, "content": "For the best cardiac examination, it is important to have the patient both sit up and lay down at a 30-45˚ angle. Tapping with the fingertips (also known as percussion) can be used to estimate the size of the heart, though palpation is more accurate. From the left side of the chest, the doctor can tap the spaces between the ribs with the tips of their middle finger to listen for the dullness that will be present over the heart. Listening with a stethoscope (also known as auscultation) to all four areas of the heart: aortic, pulmonic, tricuspid and mitral. Any murmurs, rubs or gallops should be noted. Gallops are also known as a third (S3) or fourth (S4) heart sound. The absence of abnormalities (normal) may be recorded as \"no m/r/g\". The ACC and the AHA have called cardiac auscultation \"the most widely used method of screening for valvular heart disease.\" Because of its importance to the cardiac examination, cardiac auscultation has been covered in-depth elsewhere." }, { "id": "article-25200_13", "title": "Mitral Valve Insufficiency -- History and Physical", "score": 0.011398176291793313, "content": "The majority of patients suffering from chronic MR are asymptomatic, but serial quantitative assessment and follow-up of a patient with asymptomatic MR have shown a significant impact on the survival and clinical outcome. [28] Due to the insidious and slowly progressive nature of chronic MR, patients may not report any specific symptoms and may not notice a progressive decline in functional status during the early phase of the disease by gradual modification of their activities. Bedside evaluation for valvular heart disease is very important as management highly depends on symptoms as well as the severity of valvular lesions. Patients with MR are usually referred due to symptoms of chest pain, shortness of breath, palpitations, leg swelling, or just incidental finding of systolic murmur on physical examination. A thorough history of prior bacterial or viral infections, rheumatic fever, trauma, ischemic events, invasive cardiac/noncardiac procedures and family history with a comprehensive review of systems should be obtained. A detailed physical examination with particular attention to the cardiovascular system, including pulse, apical impulse, jugular veins, edema, signs of congestive heart failure, and assessment of characteristic systolic murmur with other pertinent findings should be documented. [29] [3] A characteristic holosystolic murmur present at the apex and radiating to the left axilla can be present most of the time except in cases of MVP where the murmur appears in mid-late systole with or without midsystolic click. The murmur should not be confused with other systolic murmurs such as aortic stenosis, tricuspid regurgitation, pulmonic stenosis, ventricular septal defect, benign flow murmurs, and other cardiac disorders in the spectrum. [30]" }, { "id": "wiki20220301en257_19885", "title": "Heart click", "score": 0.01091715976331361, "content": "With newer, non-invasive imaging techniques, the origin of other, so-called adventitial sounds or heart clicks has been appreciated. These are short, high-pitched sounds. The mitral valve in cases of mitral stenosis may open with an opening snap on the beginning of diastole. Patients with mitral valve prolapse may have a mid-systolic click along with a murmur, referred to as apical late systolic murmur. Early systolic clicks may also be present in some patients. Aortic and pulmonary stenosis may cause an ejection click immediately after S1. References Symptoms and signs: Cardiac Audible medical signs" }, { "id": "pubmed23n0859_17506", "title": "The maverick heart sound.", "score": 0.010901081744173079, "content": "An asymptomatic 29-year-old woman presented for prenatal counselling. She had a history of a heart murmur since childhood and a previous echocardiogram suggesting 'enlargement of the heart'. Physical exam revealed normal jugular venous pressure and contour. Precordial palpation was unremarkable. Auscultation, however, was abnormal; findings on inspiration and expiration are presented in Figure 1, sound clip. Based on the phonocardiogram and online supplementary audio clip, which of the following is correct? An early diastolic filling sound (S3) is heard, indicating increased right ventricular filling pressures.An ejection click without respiratory variation and a systolic ejection murmur are heard, consistent with bicuspid aortic valve stenosis.An ejection click with respiratory variation and a systolic ejection murmur are heard, consistent with pulmonic valve stenosis.A holosystolic murmur with inspiratory augmentation is heard, indicating tricuspid regurgitation." }, { "id": "article-25198_32", "title": "Mitral Regurgitation -- History and Physical -- Chronic Mitral Regurgitation [27]", "score": 0.010826635733421713, "content": "Patients often remain asymptomatic until late in the course. Clinical findings common to all etiologies include fatigue, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, weight gain, widening of pulse pressure, apical holosystolic murmur with radiation to the axilla, dependent edema, displaced apical impulse, and jugular venous distension. In more advanced cases, there may also be syncope or near syncope, cyanosis, clubbing of digits, gross anasarca, hepatomegaly, evidence of ascites with a fluid wave, or shifting dullness, and evidence of pleural or pericardial effusions. These latter findings are reflective of the development of pulmonary hypertension and resultant right ventricular systolic dysfunction from chronic pressure overload. The differential diagnosis is also considerably broader, and specific clinical findings are dependent on the etiology." }, { "id": "pubmed23n0641_22756", "title": "NEW THORACIC MURMURS, WITH TWO NEW INSTRUMENTS, THE REFRACTOSCOPE AND THE PARTIAL STETHOSCOPE.", "score": 0.010121765601217657, "content": "1. An understanding of the physics of sound is essential for a better comprehension of refined auscultation, tone analysis, and the use of these instruments. 2. The detection of variations of the third heart sound should prove a valuable aid in predicting mitral disease. 3. The variations of the outflow sound should prove a valuable aid in determining early aortic lesions with the type of accompanying intimal changes. 4. The character of chamber timbre as distinct from loudness heard as the first and second heart sounds denotes more often the condition of heart muscle, and must not be confounded with valvular disease. 5. The full significance of sound shadows is uncertain. Cardiac sound shadows appear normally in the right axilla and below the left clavicle. Their mode of production is quite clear. 6. Both the third heart sound and the outflow sound may be heard with the ordinary stethoscope." }, { "id": "InternalMed_Harrison_18513", "title": "InternalMed_Harrison", "score": 0.009937934091916654, "content": "Auscultation In patients with severe AR, the aortic valve closure sound (A2) is usually absent. A systolic ejection sound is audible in patients with BAV disease, and occasionally an S4 also may be heard. The murmur of chronic AR is typically a high-pitched, blowing, decrescendo diastolic murmur, heard best in the third intercostal space along the left sternal border (see Fig. 267-5B). In patients with mild AR, this murmur is brief, but as the severity increases, it generally becomes louder and longer, indeed holodiastolic. When the murmur is soft, it can be heard best with the diaphragm of the stethoscope and with the patient sitting up, leaning forward, and with the breath held in forced expiration. In patients in whom the AR is caused by primary valvular disease, the diastolic murmur is usually louder along the left than the right sternal border. However, when the murmur is heard best along the right sternal border, it suggests that the AR is caused by aneurysmal dilation of the" }, { "id": "pubmed23n0035_1006", "title": "When does a fourth sound become an atrial gallop?", "score": 0.009900990099009901, "content": "A study of the fourth sound was conducted on 100 normal subjects (ages 1-88 years) and 42 clinical cases with either aortic stenosis, systemic hypertension or coronary heart disease. This study was based on the graphic recognition of a presystolic sound when the tracing was taken with the use of one or more of 5 different high pass filters. Attention was paid to the existence of the fourth sound, its magnitude, and its vibrational frequency. In general it was accepted that a magnitude of 1/2 of the first heart sound or a frequency of 30 Hz denoted a pathologic fourth sound. However, exceptions were found among normal subjects, so that only the combination of the two criteria could be considered highly significant for a pathologic phenomenon (gallop). Patients with aortic stenosis presented an increase in magnitude of the fourth sound but incidence and vibrational frequency were similar to those of controls. Patients with hypertension had a greater incidence of fourth sounds, especially in middle age (100%); middle age patients usually had a greater magnitude while older patients had more often an increase in vibrational frequency. Patients with coronary heart disease (evidence of old infarcts) had an increase in the incidence, magnitude, and vibrational frequency in comparison with controls. These data and the cause of the fourth sound are discussed. The fourth sound has been repeatedly studied in the past, both as an auscultatory finding and a graphic phenomenon. Attempts were made for separating the normal fourth sound from that denoting a pathological phenomenon but, so far, no clear cut criteria for the differentiation have been obtained. We thought, therefore, that a new study was indicated." }, { "id": "wiki20220301en262_6339", "title": "Gallavardin phenomenon", "score": 0.009881422924901186, "content": "The Gallavardin phenomenon is a clinical sign found in patients with aortic stenosis. It is described as the dissociation between the noisy and musical components of the systolic murmur heard in aortic stenosis. The harsh noisy component is best heard at the upper right sternal border radiating to the neck due to the high velocity jet in the ascending aorta. The musical high frequency component is best heard at the cardiac apex. The presence of a murmur at the apex can be misinterpreted as mitral regurgitation. However, the apical murmur of the Gallavardin phenomenon does not radiate to the left axilla and is accentuated by a slowing of the heart rate (such as a compensatory pause after a premature beat) whereas the mitral regurgitation murmur does not change. The sign is named after Louis Gallavardin, having been described by Gallavardin and Ravault in 1925. References Symptoms and signs: Cardiac" }, { "id": "pubmed23n0042_2106", "title": "\"Presystolic\" augmentation of diastolic heart sounds in atrial fibrillation.", "score": 0.009823509823509824, "content": "In the presence of atrial fibrillation, the diastolic murmur of mitral stenosis can appear augmented during early systole before the mitral valve closure sound. This phenomenon has previously been thought to be due to increased blood flow velocity across the narrowing mitral valve orifice. We have observed patients in whom the third heart sound (S3) gallop, the diastolic flow murmur of atrial septal defect and mitral insufficiency and the initial muscular component of the first heart sound become more intense during this period with short, critically timed cycle lengths. This phenomenon appears to be neither peculiar to nor indicative of mitral stenosis and is probably a direct result of the initial muscular contraction of an underfilled ventricle. Either the contraction itself or the sudden deceleration of the rapidly moving flow of blood across the atrioventricular orifice may produce the sound." }, { "id": "pubmed23n0054_8960", "title": "Implications of third heart sounds in patients with valvular heart disease. The Veterans Affairs Cooperative Study on Valvular Heart Disease.", "score": 0.00980392156862745, "content": "The presence of third heart sounds in patients with valvular heart disease is often regarded as a sign of heart failure, but it may also depend on the type of valvular disease. We assessed the prevalence of third heart sounds and the relation between third heart sounds and cardiac function in 1281 patients with six types of valvular heart disease. The prevalence of third heart sounds was higher in patients with mitral regurgitation (46 percent) or aortic regurgitation (28 percent) than in those with aortic stenosis (11 percent) or mitral stenosis (8 percent). The left ventricular ejection fraction was significantly lower (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (0.38, vs. 0.56 in those without third heart sounds) or mixed aortic valve disease (0.40 vs. 0.55). However, the ejection fraction was only slightly lower in patients with mitral regurgitation and third heart sounds (0.51 vs. 0.57, P = 0.03). The pulmonary-capillary wedge pressure was higher (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (18.6 mm Hg, vs. 12.1 mm Hg in those without third heart sounds). There was no association between the wedge pressure and third heart sounds in patients with mitral regurgitation. The prevalence of third heart sounds increased with the severity of mitral regurgitation. In patients with mitral regurgitation, third heart sounds are common but do not necessarily reflect left ventricular systolic dysfunction or increased filling pressure. In patients with aortic stenosis, third heart sounds are uncommon but usually indicate the presence of systolic dysfunction and elevated filling pressure." }, { "id": "wiki20220301en012_66431", "title": "Heart failure", "score": 0.00979707445776588, "content": "Additional signs indicating left ventricular failure include a laterally displaced apex beat (which occurs if the heart is enlarged) and a gallop rhythm (additional heart sounds) may be heard as a marker of increased blood flow or increased intracardiac pressure. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of heart failure." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 231, 298 ] ], "word_ranges": [ [ 41, 53 ] ], "text": "Option 1 does not explain the involvement of the wrist and fingers." }, "2": { "exist": true, "char_ranges": [ [ 299, 435 ] ], "word_ranges": [ [ 53, 76 ] ], "text": "The elbow dislocation does not explain the lack of finger mobility as well as the diaphyseal fracture of the humerus and double forearm." }, "3": { "exist": true, "char_ranges": [ [ 622, 796 ] ], "word_ranges": [ [ 103, 128 ] ], "text": "Proximal humerus fracture-dislocation would have greater involvement at the shoulder, elbow dislocation at the elbow, and there is no data to suggest double forearm fracture." }, "4": { "exist": true, "char_ranges": [ [ 58, 230 ] ], "word_ranges": [ [ 10, 41 ] ], "text": "after trauma we have pain in the arm with soft tissue involvement and the impossibility of extending the wrist and fingers. The only option that includes all the data is 4." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Dislocation fracture of proximal humerus.", "2": "Elbow dislocation.", "3": "Diaphyseal fracture of the humerus associated with double forearm fracture.", "4": "Diaphyseal fracture of humerus with radial nerve injury.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en176_2750", "title": "Humerus fracture", "score": 0.019049346879535557, "content": "A humerus fracture is a break of the humerus bone in the upper arm. Symptoms may include pain, swelling, and bruising. There may be a decreased ability to move the arm and the person may present holding their elbow. Complications may include injury to an artery or nerve, and compartment syndrome. The cause of a humerus fracture is usually physical trauma such as a fall. Other causes include conditions such as cancer in the bone. Types include proximal humeral fractures, humeral shaft fractures, and distal humeral fractures. Diagnosis is generally confirmed by X-rays. A CT scan may be done in proximal fractures to gather further details." }, { "id": "wiki20220301en247_22460", "title": "Supracondylar humerus fracture", "score": 0.018375566370196342, "content": "Mechanism Extension type of supracondylar humerus fractures typically result from a fall on to an outstretched hand, usually leading to a forced hyperextension of the elbow. The olecranon acts as a fulcrum which focuses the stress on distal humerus (supracondylar area), predisposing the distal humerus to fracture. The supracondylar area undergoes remodeling at the age of 6 to 7, making this area thin and prone to fractures. Important arteries and nerves (median nerve, radial nerve, brachial artery, and ulnar nerve) are located at the supracondylar area and can give rise to complications if these structures are injured. Most vulnerable structure to get damaged is Median Nerve. Meanwhile, the flexion-type of supracondylar humerus fracture is less common. It occurs by falling on the point of the elbow, or falling with the arm twisted behind the back. This causes anterior dislocation of the proximal fragment of the humerus." }, { "id": "wiki20220301en176_2752", "title": "Humerus fracture", "score": 0.016741071428571428, "content": "Signs and symptoms After a humerus fracture, pain is immediate, enduring, and exacerbated with the slightest movements. The affected region swells, with bruising appearing a day or two after the fracture. The fracture is typically accompanied by a discoloration of the skin at the site of the fracture. A crackling or rattling sound may also be present, caused by the fractured humerus pressing against itself. In cases in which the nerves are affected, then there will be a loss of control or sensation in the arm below the fracture. If the fracture affects the blood supply, then the patient will have a diminished pulse at the wrist. Displaced fractures of the humerus shaft will often cause deformity and a shortening of the length of the upper arm. Distal fractures may also cause deformity, and they typically limit the ability to flex the elbow." }, { "id": "pubmed23n0774_26227", "title": "[Results after internal fixation of humerus distal fractures in patients over than 65 years old].", "score": 0.01562595373252762, "content": "Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures. Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005-2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65-89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach. Mean elbow flexion reached 118.86°, with a mean extension deficit of 25°. More than 3-quarters (79.1%) of the patients showed 0-1 grade degenerative changes on the X-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score scores. Non-union occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation. Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life." }, { "id": "wiki20220301en420_26359", "title": "Olecranon fracture", "score": 0.015050167224080268, "content": "Olecranon fracture is a fracture of the bony portion of the elbow. The injury is fairly common and often occurs following a fall or direct trauma to the elbow. The olecranon is the proximal extremity of the ulna which is articulated with the humerus bone and constitutes a part of the elbow articulation. Its location makes it vulnerable to direct trauma. Signs and symptoms People with olecranon fractures present with intense elbow pain after a direct blow or fall. Swelling over the bone site is seen and an inability to straighten the elbow is common. Due to the proximity of the olecranon to the ulnar nerve, the injury and swelling may cause numbness and tingling at the fourth and fifth fingers. Examination can bring out a palpable defect at the site of the fracture." }, { "id": "wiki20220301en529_6571", "title": "Proximal humerus fracture", "score": 0.015042253521126762, "content": "Signs and symptoms Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, musculature may cause absence of deformity on inspection. Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury. Symptoms from poor blood circulation in the arm is uncommon due to collateral circulation in the arm. Cause Young adults without risk factors usually require significant trauma, such as in the setting of a motor vehicle collision. Older adults more commonly experience proximal humerus fractures after a fall from standing height. Risk factors People with increased risk of falls are more likely to have a proximal humerus fracture, as this is also the most common mechanism of injury. Osteoporosis increases the risk of proximal humerus fractures. Pathophysiology" }, { "id": "wiki20220301en011_122245", "title": "Median nerve", "score": 0.014709063378758382, "content": "Injury Injury of median nerve at different levels causes different syndromes with varying motor and sensory deficits. At the shoulder Injury can occur at the brachial plexus Above the elbow Common mechanism of injury: A supracondylar humerus fracture Motor deficit: Loss of pronation of forearm, weakness in flexion of the hand at the wrist, loss of flexion of radial half of digits and thumb, loss of abduction and opposition of thumb. Presence of an ape hand deformity when the hand is at rest, due to an hyperextension of index finger and thumb, and an adducted thumb Presence of benediction sign when attempting to form a fist, due to loss of flexion of radial half of digits Sensory deficit: Loss of sensation in lateral digits including their nail beds, and the thenar area At the elbow Entrapment at the level of the elbow or the proximal forearm could be due to the pronator teres syndrome." }, { "id": "wiki20220301en176_2756", "title": "Humerus fracture", "score": 0.013871635610766046, "content": "Definitive diagnosis of humerus fractures is typically made through radiographic imaging. For proximal fractures, X-rays can be taken from a scapular anteroposterior (AP) view, which takes an image of the front of the shoulder region from an angle, a scapular Y view, which takes an image of the back of the shoulder region from an angle, and an axillar lateral view, which has the patient lie on his or her back, lift the bottom half of the arm up to the side, and have an image taken of the axilla region underneath the shoulder. Fractures of the humerus shaft are usually correctly identified with radiographic images taken from the AP and lateral viewpoints. Damage to the radial nerve from a shaft fracture can be identified by an inability to bend the hand backwards or by decreased sensation in the back of the hand. Images of the distal region are often of poor quality due to the patient being unable to extend the elbow because of pain. If a severe distal fracture is suspected, then a" }, { "id": "wiki20220301en247_22478", "title": "Supracondylar humerus fracture", "score": 0.013673318551367332, "content": "Epidemiology Supracondylar humerus fractures is commonly found in children between 5 and 7 years (90% of the cases), after the clavicle and forearm fractures. It is more often occurs in males, accounting of 16% of all pediatric fractures and 60% of all paediatric elbow fractures. The mechanism of injury is most commonly due to fall on an outstretch hand. Extension type of injury (70% of all elbow fractures) is more common than the flexion type of injury (1% to 11% of all elbow injuries). Injury often occurs on the non-dominant part of the limb. Flexion type of injury is more commonly found in older children. Open fractures can occur for up to 30% of the cases. References Bibliography External links Injuries of shoulder and upper arm Bone fractures" }, { "id": "wiki20220301en477_29368", "title": "Radial nerve dysfunction", "score": 0.013644688644688645, "content": "Signs and symptoms Anyone experiencing radial nerve dysfunction could also experience any of the following symptoms: Lost ability or discomfort in extending the elbow Lost ability or discomfort bending hand back at the wrist Numbness Abnormal sensations near the thumb, index and middle fingers Sharp or burning pain Weakness in grip Drooping of the hand, also called wrist drop Cause There are many ways to acquire radial nerve palsy. The term Saturday Night Palsy refers to an injury to the radial nerve in the spiral groove of the humerus caused while sleeping in a position that would under normal circumstances cause discomfort. It can occur when a person falls asleep while heavily medicated and/or under the influence of alcohol with the underside of the arm compressed by a bar edge, bench, chair back, or like object. Sleeping with the head resting on the arm can also cause radial nerve palsy. Breaking the humerus and deep puncture wounds can also cause the condition." }, { "id": "wiki20220301en529_6570", "title": "Proximal humerus fracture", "score": 0.013578201233545062, "content": "A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus). Symptoms include pain, swelling, and a decreased ability to move the shoulder. Complications may include axillary nerve or axillary artery injury. The cause is generally a fall onto the arm or direct trauma to the arm. Risk factors include osteoporosis and diabetes. Diagnosis is generally based on X-rays or CT scan. It is a type of humerus fracture. A number of classification systems exist. Treatment is generally with an arm sling for a brief period of time followed by specific exercises. This appears appropriate in many cases even when the fragments are separated. Less commonly surgery is recommended. Proximal humerus fractures are common. Older people are most commonly affected. In this age group they are the third most common fractures after hip and Colles fractures. Women are more often affected than men." }, { "id": "wiki20220301en028_33457", "title": "Bone fracture", "score": 0.012326538911198087, "content": "Rib fracture Sternal fracture Shoulder fracture Clavicle fracture Scapular fracture Arm fracture Humerus fracture (fracture of upper arm) Supracondylar fracture Holstein-Lewis fracture – a fracture of the distal third of the humerus resulting in entrapment of the radial nerve Forearm fracture Ulnar fracture Monteggia fracture – a fracture of the proximal third of the ulna with the dislocation of the head of the radius Hume fracture – a fracture of the olecranon with an associated anterior dislocation of the radial head Radius fracture Essex-Lopresti fracture – a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane Distal radius fracture Galeazzi fracture – a fracture of the radius with dislocation of the distal radioulnar joint Colles' fracture – a distal fracture of the radius with dorsal (posterior) displacement of the wrist and hand" }, { "id": "article-32384_24", "title": "Anatomy, Shoulder and Upper Limb, Arm Nerves -- Clinical Significance", "score": 0.012259758272240934, "content": "The radial nerve can get compressed at the axilla, known as Saturday night palsy.  Injury at this level leads to loss of extension of the forearm, wrist, and fingers combined with sensory loss in the radial nerve distribution. In the arm, the radial nerve can incur damage with a mid-shaft humeral fracture leading to weakness of wrist and finger extension and corresponding sensory loss distally. Damage can also occur in the forearm. [7] [25]" }, { "id": "pubmed23n0895_16239", "title": "An Uncommon Combination of Fractures around the Elbow: Capitellum Fracture Associated with Radial Head Fracture.", "score": 0.012179065174456879, "content": "The coexistence of fractures of capitulum humeri and radial head in the elbow joint is a rare entity. A 30-year-old woman was admitted to our hospital after having sustained a fall on her outstretched right arm. She complained of pain, swelling, and restriction of motion of the right elbow joint. Anteroposterior and lateral radiographs revealed displaced fractures in the capitellum and the radial head. The patient was operated. Fractures were exposed through a lateral (Kocher) incision. Fracture was reduced, and fixation was performed with 2 AO compression screw. Two fragments of radial head fracture were also reduced and fixed with AO compression screw. Clinical and radiographic outcomes were excellent at the end of a 5-year follow-up. These fractures occurred following a fall on the palm with outstretched arm. The success of the treatment depends greatly on surgical approach and suitable technique which requires comprehensive knowledge of detailed anatomy and biomechanics of the elbow." }, { "id": "article-145102_24", "title": "Anatomy, Shoulder and Upper Limb, Hand Thenar Eminence -- Clinical Significance", "score": 0.011796536796536798, "content": "Supracondylar humerus fractures may also cause this deformity. The anterior interosseus nerve (AIN), a significant motor branch of the median nerve, lies anterior to the supracondylar humerus and is at risk of being stretched, impinged, or pierced during fracture. This type of fracture is most common in children due to falling on an outstretched arm. [7]" }, { "id": "wiki20220301en002_159221", "title": "Arm", "score": 0.011738206275181625, "content": "Clinical significance The cubital fossa is clinically important for venepuncture and for blood pressure measurement. When the arm is fractured this may refer to a fracture of the humerus bone. Veins on the arm may be taken when a coronary artery bypass graft is needed. Other animals In other animals, the term arm can also be used for homologous or analogous structures (such as one of the paired forelimbs of a four-legged animal or the arms of cephalopods, respectively). In anatomical usage, the term arm may sometimes refer specifically to the segment between the shoulder and the elbow, while the segment between the elbow and wrist is the forearm. However, in common, literary, and historical usage, arm refers to the entire upper limb from shoulder to wrist. This article uses the former definition; see upper limb for the wider definition." }, { "id": "article-32399_18", "title": "Anatomy, Shoulder and Upper Limb, Cutaneous Innervation -- Clinical Significance -- Radial Nerve", "score": 0.0115527950310559, "content": "The radial nerve is particularly disposed to in compression type injuries and humerus fractures due to its proximity to the humerus as it passes through the arm. Fractures to the humerus can cause severe injury requiring repair. It can also suffer an injury due to improper and prolonged use of crutches causing continued pressure on the medial side of the arm or axilla. [3]" }, { "id": "wiki20220301en011_104465", "title": "Radial nerve", "score": 0.010957792207792208, "content": "Clinical significance Injury Injury to the radial nerve at different levels causes different syndromes with varying motor and sensory deficits. At the axilla Common mechanisms of injury: Saturday night palsy, crutch palsy, lesions Motor deficit: Loss of extension of forearm, weakness of supination, and loss of extension of hand and fingers. Presence of wrist drop, due to inability to extend the hand and fingers. Sensory deficit: Loss of sensation in lateral arm, posterior forearm, the radial half of dorsum of hand, and dorsal aspect of radial digits, excluding their nail beds. At mid-arm Common mechanism of injury: Mid-shaft humeral fracture Motor deficit: Weakness of supination, and loss of extension of hand and fingers. Presence of wrist drop, due to inability to extend the hand and fingers. Sensory deficit: Loss of sensation in posterior forearm, the radial half of dorsum of hand, and dorsal aspect of radial digits, excluding their nail beds." }, { "id": "pubmed23n1132_7235", "title": "Diaphyseal Fracture of the Humerus during Elective Cesarean Section - A Rare Case Report.", "score": 0.010922458478789802, "content": "Humeral fractures are the second common long bone fractures of the neonatal period after clavicle. Most cases of birth-related humerus fracture are reported during a vaginal breech delivery. The cesarean section does not eliminate the risk of long bone fractures. A humerus fracture is less common but still can happen due to forceful maneuvers like traction during cesarean which can go unnoticed to operating obstetrician or misinterpreted as brachial plexus injury by an inexperienced orthopedic surgeon. We received a call from the neonatal intensive care unit (NICU) for a 2-day-old 2.4 kg male baby delivered to primigravida at 37 weeks by elective cesarean for transverse lie, for not moving his right upper limb. On examination by orthopedic surgeon, swelling, contusion, crepitus, and abnormal mobility at the right arm were noticed. Gentle manipulation made the neonate cry. Range of movements (ROMs) of wrist, elbow, and hand were within normal limit without any neurovascular deficit. Hence, the initial diagnosis of brachial plexus injury/Erb's palsy was revised. X-ray of the right upper limb was ordered which showed an isolated mid-shaft humerus bicortical fracture. A high above elbow slab was applied with an arms chest bandage for a week and the baby was discharged with proper advice to the mother to follow-up on the next week. Obstetricians and pediatricians should remain vigilant for the rare occurrence of humerus fracture during cesarean so that they are not missed and managed timely to prevent future disability and deformity." }, { "id": "article-32384_26", "title": "Anatomy, Shoulder and Upper Limb, Arm Nerves -- Clinical Significance", "score": 0.01091426763682379, "content": "The median nerve can become impaired with a supracondylar humerus fracture.  Injury at this level can cause adduction of the wrist, loss of pronation of the forearm, weakness of wrist flexion, loss of thumb flexion, thenar muscle atrophy, and loss of sensation over the corresponding area.  When attempting to form a fist, the radial digits will not flex, resulting in the hand of benediction sign.  At rest, loss of thumb abduction leads to the ape hand deformity.  Distally, the anterior interosseous nerve can be injured, and the median nerve can be damaged at the wrist or compressed within the carpal tunnel. [27]" }, { "id": "wiki20220301en247_22458", "title": "Supracondylar humerus fracture", "score": 0.010826635733421713, "content": "to do an \"OK\" sign; instead a pincer grasp is performed). Radial nerve would be injured if the distal humerus is displaced postero-medially. This is because the proximal fragment will be displaced antero-laterally. Ulnar nerve is most commonly injured in the flexion type of injury because it crosses the elbow below the medial epidcondyle of the humerus." }, { "id": "article-28166_7", "title": "Radial Head Fractures -- History and Physical", "score": 0.010791451662307674, "content": "The fracture occurs when a patient has direct traumatic to the elbow or falls with the wrist and the hand in extension. The usual signs are pain and functional impotence, there may be blockages in the elbow." }, { "id": "wiki20220301en477_29367", "title": "Radial nerve dysfunction", "score": 0.010545905707196029, "content": "Radial nerve dysfunction is a problem associated with the radial nerve resulting from injury consisting of acute trauma to the radial nerve. The damage has sensory consequences, as it interferes with the radial nerve's innervation of the skin of the posterior forearm, lateral three digits, and the dorsal surface of the lateral side of the palm. The damage also has motor consequences, as it interferes with the radial nerve's innervation of the muscles associated with the extension at the elbow, wrist, and fingers, as well the supination of the forearm. This type of injury can be difficult to localize, but relatively common, as many ordinary occurrences can lead to the injury and resulting mononeuropathy. One out of every ten patients suffering from radial nerve dysfunction do so because of a fractured humerus." }, { "id": "wiki20220301en038_74753", "title": "Distal radius fracture", "score": 0.010537295640326976, "content": "The most common cause of this type of fracture is a fall on an outstretched hand from standing height, although some fractures will be due to high-energy injury. People who fall on the outstretched hand are usually fitter and have better reflexes when compared to those with elbow or humerus fractures. The characteristics of distal radius fractures are influenced by the position of the hand at the time of impact, the type of surface at point of contact, the speed of the impact, and the strength of the bone. Distal radius fractures typically occur with the wrist bent back from 60 to 90 degrees. Radial styloid fracture would occur if the wrist is ulnar deviated and vice versa. If the wrist is bent back less, then proximal forearm fracture would occur, but if the bending back is more, then the carpal bones fracture would occur. With increased bending back, more force is required to produce a fracture. More force is required to produce a fracture in males than females. Risk of injury" }, { "id": "article-32394_19", "title": "Anatomy, Shoulder and Upper Limb, Brachial Plexus -- Clinical Significance", "score": 0.010433090024330901, "content": "Ulnar nerve lesion affects the sensation of the medial one and a half digits including the hypothenar eminence. It also causes weakness of wrist flexion, finger abduction and adduction, thumb adduction, and finger extension. Claw hand sign and radial deviation at the wrist are the usual signs. Causes of lesions at the ulnar nerve can be the result of fracture of the medial epicondyle of the humerus, the hook of the hamate (from a fall on an outstretched hand), or the clavicle. [12] [34]" }, { "id": "wiki20220301en529_6577", "title": "Proximal humerus fracture", "score": 0.010225385527876631, "content": "They are more common in women than men, and occur more often in older adults. The average age of people who sustain a proximal humerus fracture is 63–66 years. Special populations Children A proximal humerus fracture in a young child may be a sign of child abuse. In older children and adolescents proximal humerus fractures frequently occur in the setting of sports or trauma. Proximal humerus fractures in children can commonly be treated non-operatively due to the large amount of bone growth that occurs at the proximal humerus. In older children where there is less time for bone remodeling, surgery may be indicated more frequently. References Wikipedia medicine articles ready to translate Bone fractures Injuries of shoulder and upper arm" }, { "id": "pubmed23n1112_20908", "title": "Fracture profiles of a 4-year cohort of 266,324 first incident upper extremity fractures from population health data in Ontario.", "score": 0.010194887109646526, "content": "Understanding the profiles of different upper extremity fractures, particularly those presenting as a 1st incident can inform prevention and management strategies. The purpose of this population-level study was to describe first incident fractures of the upper extremity in terms of fracture characteristics and demographics. Cases with a first adult upper extremity (UE) fracture from the years 2013 to 2017 were extracted from administrative data in Ontario. Fracture locations (ICD-10 codes) and associated characteristics (open/closed, associated hospitalization within 1-day, associated nerve, or tendon injury) were described by fracture type, age category and sex. Standardized mean differences of at least 10% (clinical significance) and statistical significance (p &lt; 0.01) in ANOVA were used to identify group differences (age/sex). We identified 266,324 first incident UE fractures occurring over 4 years. The most commonly affected regions were the hand (93 K), wrist/forearm(80 K), shoulder (48 K) or elbow (35 K). The highest number of specific fractures were: distal radius (DRF, 47.4 K), metacarpal (30.4 K), phalangeal (29.9 K), distal phalangeal (24.4 K), proximal humerus (PHF, 21.7 K), clavicle (15.1 K), radial head (13.9 K), and scaphoid fractures (13.2 K). The most prevalent multiple fractures included: multiple radius and ulna fractures (11.8 K), fractures occurring in multiple regions of the upper extremity (8.7 K), or multiple regions in the forearm (8.4 K). Tendon (0.6% overall; 8.2% in multiple finger fractures) or nerve injuries were rarely reported (0.3% overall, 1.5% in distal humerus). Fractures were reported as being open in 4.7% of cases, most commonly for distal phalanx (23%). A similar proportion of females (51.5%) and males were present in this fracture cohort, but there were highly variant age-sex profiles across fracture subtypes. Fractures most common in 18-40-year-old males included metacarpal and finger fractures. Fractures common in older females were: DRF, PHF and radial head, which exhibited a dramatic increase in the over-50 age group. UE fracture profiles vary widely by fracture type. Fracture specific prevention and management should consider fracture profiles that are highly variable according to age and sex." }, { "id": "wiki20220301en176_2764", "title": "Humerus fracture", "score": 0.010118840435582517, "content": "Epidemiology Humerus fractures are among the most common of fractures. Proximal fractures make up 5% of all fractures and 25% of humerus fractures, middle fractures about 60% of humerus fractures (12% of all fractures), and distal fractures the remainder. Among proximal fractures, 80% are one-part, 10% are two-part, and the remaining 10% are three- and four-part. The most common location of proximal fractures is at the surgical neck of the humerus. Incidence of proximal fractures increases with age, with about 75% of cases occurring among people over the age of 60. In this age group, about three times as many women than men experience a proximal fracture. Middle fractures are also common among the elderly, but they frequently occur among physically active young adult men who experience physical trauma to the humerus. Distal fractures are rare among adults, occurring primarily in children who experience physical trauma to the elbow region. References Bibliography External links" }, { "id": "article-28168_30", "title": "Anatomy, Shoulder and Upper Limb, Radial Nerve -- Other Issues", "score": 0.010077047850770479, "content": "The radial nerve lies in the radial groove of the humerus, making it vulnerable to injury after a humeral shaft fracture. Radial nerve damage at this level can cause wrist drop, a condition notable for the inability to extend the wrist. A lateral supracondylar fracture may also damage the radial nerve but will present differently from a midhumeral injury. Nerve branches to the brachioradialis and extensor carpi radialis longus arise above this fracture so that these muscles are largely unaffected. Instead of presenting with a wrist drop, the patient's wrist weakly extends radially when asked to extend the hand. [16] [20] [21]" }, { "id": "InternalMed_Harrison_31547", "title": "InternalMed_Harrison", "score": 0.009984111306737663, "content": "Radial nerve injury classically presents with weakness of extension of the wrist and fingers (“wrist drop”) with or without more proximal weakness of extensor muscles of the upper extremity, depending on the site of injury. Sensory loss is in the distribution of the radial nerve, which includes the dorsum of the hand (Fig. 463e-3A). Compression at the level of the axilla, e.g., resulting from use of crutches, leads to weakness of the triceps, brachioradialis, and supinator muscles in addition to wrist drop. A more common site of compression occurs in the spiral groove of the upper arm in the setting of a humerus fracture or from sleeping with the arm draped over a bench or chair (“Saturday night palsy”). Sparing of the triceps is the rule when the nerve is injured in this location. Because extensors of the upper extremity are injured preferentially in radial nerve injury, these lesions may be mistaken for the pyramidal distribution of weakness that accompanies upper motor neuron" }, { "id": "pubmed23n0917_13122", "title": "Proximal Humerus Fracture-Dislocation with Laceration of the Axillary Artery: A Case Report.", "score": 0.009982574060243964, "content": "Proximal humerus fractures account for approximately 4-6% of all fractures. While the majority of these fractures are treated non-operatively, the amount of fracture displacement, concomitant injuries, and patient factors often result in the need for surgical stabilization. Although concomitant neurovascular injury in the setting of low-energy trauma is rare, injury to the surrounding neurovascular structures have previously been reported. We report a case of a 79-year-old male who sustained a low energy fall resulting in a two-part fracture dislocation of the proximal humerus with an associated brachial plexopathy and axillary artery laceration. The patient underwent emergent open reduction internal fixation of his fracture in addition to an axillary-brachial artery bypass using a reverse-saphenous vein graft. The current article reports the presentation, management and prognosis of this rare injury. At 6 months, the patient demonstrated limited active shoulder abduction with no observed motor function at this elbow, wrist or hand. Radiographic follow up demonstrated a reduced glenohumeral joint with evidence avascular necrosis of the humeral head. Fracture-dislocations of the proximal humerus may be associated with significant neurovascular injury in the setting of low energy trauma. Despite early treatment, the prognosis of patients with this constellation of injuries is guarded." }, { "id": "article-32394_18", "title": "Anatomy, Shoulder and Upper Limb, Brachial Plexus -- Clinical Significance", "score": 0.009941470132552935, "content": "Injury or damage to the radial nerve could also develop lesions, as seen in Saturday night palsy, where the axilla is mainly affected. This condition is characterized by a wrist drop brought about by the weakened elbow, wrist, and finger extension. Also, there is a loss of sensory function over the posterior arm, forearm, and dorsal hand. Wrist drop presents as a result of compression to the axilla, usually due to crutches or when sleeping with the arm over a chair (Saturday night palsy). It can also happen from a midshaft fracture of the humerus." } ] } } }

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{ "1": "Add magnesium sulfate.", "2": "Increase the dose of prednisone to 30 mg/day.", "3": "Add omalizumab.", "4": "Nebulized treatment at home.", "5": "Switch to a combination with high doses of budesonide and formoterol." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0286_22755", "title": "Addition of anticholinergic solution prolongs bronchodilator effect of beta 2 agonists in patients with chronic obstructive pulmonary disease.", "score": 0.019424799622819428, "content": "A randomized, double-blind placebo-controlled clinical trial was designed to assess the safety, efficacy, and duration of the bronchodilation resulting from the addition of 500 micrograms of ipratropium bromide (Atrovent; Boehringer Ingelheim, CT) inhalation solution to standard small volume nebulizer treatments with 2.5 mg albuterol inhalation solution. A total of 195 patients (63% men, average age 64 years) with &gt; 10 pack-year smoking histories and stable, moderate-to- severe chronic obstructive pulmonary disease (COPD; forced expiratory volume in 1 second [FEV1] 1.02 liter, 38.8% predicted) from eight university-affiliated chest clinics in seven U.S. cities were enrolled into the study. Asthma, rhinitis, and eosinophilia were exclusions, as was daily use of &gt; 10 mg of prednisone (or 20 mg on alternate days). There was a 2-week stabilization period during which the patients were instructed in the use of the small volume nebulizers, which they used three times daily with albuterol alone. They were asked to keep daily logs of peak flow rates, pulmonary symptoms, and additional medication usage. On their test day 1 the subjects came to the pulmonary function laboratory having been off theophylline for 24 hours and beta 2-agonists for 12 hours and performed a baseline spirometry. They then received their morning small volume nebulizer treatment of albuterol to which was added either 500 micrograms if ipratropium bromide or a saline placebo. Spirometry was repeated at 15, 30, and 60 minutes, and then hourly for 8 hours. Subjects then took home a 2-week supply of albuterol and test drug for thrice daily use in their small volume nebulizer. They were evaluated for pulmonary symptoms and adverse effects every 14 days. The 8-hour spirometry was repeated on test day 43 and finally on test day 85. Primary data evaluated were the peak increase in FEV1 and the area between the FEV1 baseline value and the 8-hour FEV1 curve. Similar calculations were made for forced vital capacity (FVC) and 25-75% forced expiratory flow (FEF25-75%). On test day 1 the peak increase in FEV1 for the ipratropium bromide + albuterol subjects was 26% greater than those on placebo + albuterol (p &lt; 0.003). The area under the 8-hour FEV1 curve was 64% greater in those given ipratropium bromide on test day 1 (p &lt; 0.0002). Similar increases were seen in FVC and FEF25-75%. The peak improvements in FEV1 and FVC with the addition of ipratropium bromide to albuterol were maintained on test days 43 and 85. Considering the safety and efficacy profiles of this combination, the data would suggest that ipratropium bromide inhalation solution should be considered first-line therapy for those patients with COPD requiring small volume nebulizer treatments." }, { "id": "pubmed23n0400_6905", "title": "Effect of long-term treatment with inhaled budesonide or theophylline on lung function, airway reactivity and asthma symptoms.", "score": 0.0179549114331723, "content": "Asthma is characterized by inflammation of the airways and long-term treatment with inhaled glucocorticosteroids improve clinical control in patients previously treated with inhaled rescue beta-2 agonist. We investigated whether the dose of inhaled glucocorticosteroid was related to outcome compared with oral theophylline. Budesonide 800 microg bd, budesonide 200 microg bd, or theophylline (Theo-Dur 300 mg bd was given double-blind, double-dummy and randomized, in a parallel group design for 9 months; when therapy was stopped patients were followed for an additional 3 months. Forced expiratory volume in 1 sec (FEV1), bronchial reactivity and asthma symptom scores were assessed before entering the study and after 1, 2, 3, 5, 7, and 9 months of treatment and monthly after treatment was stopped. Eighty-five patients (38 females and 47 males) were enrolled in the study during 1 1/2 year. Withdrawal from the study due to exacerbations during the treatment period was significantly increased (P &lt;0.01) in the theophylline group. After treatment was stopped more patients withdrew in the budesonide group. In the budesonide 800 microg bd group, FEV1 improved significantly after 1 months treatment (P &lt;0.01) and persisted throughout the study period. In the budesonide 200 microg bd group, FEV1 improved slightly and reached significance (P=0.05) after 5 months of treatment. In the theophylline group, FEV1 was unchanged during the 9 months of treatment. In both budesonide groups, FEV1 deteriorated significantly (P&lt;0.01 and P&lt;0.02, respectively) after termination of study medication and reached pretreatment values during the first month. In the budesonide 800 microg bd group, the concentration of histamine causing a 20% fall in FEV1 (PC20) increased significantly (P&lt;0.01) after 1 months treatment and increased further after 9 months (P&lt;0.0001), equivalent to two doubling dilutions. In the budesonide 200 microg bd, group PC20 histamine significantly increased (P &lt;0.005) after 2 months of treatment and remained constant; theophylline was unchanged. After treatment with budesonide 800 microg bd and 200 microg bd were stopped, PC20 decreased significantly (P&lt;0.002 and P=0.05, respectively) within the first month. PC20 remained unchanged after theophylline was stopped. After budesonide 800 microg bd and 200 microg bd treatment, symptom severity decreased in a dose-related and highly significant manner (P &lt; 0.00001 and P &lt; 0.0001, respectively). With theophylline, asthma symptoms decreased slightly after 1 and 2 months treatment (P &lt; 0.01 and P &lt; 0.02, respectively) and when treatment was stopped no increase in asthma symptoms was evident. Oral theophylline slightly reduced airways symptoms and had no influence on FEV1 and PC20 histamine. Maintenance treatment with inhaled budesonide gave a dose-related reduction in airways obstruction, bronchial reactivity and asthma symptom severity. The efficacy of inhaled corticosteroid was superior to oral theophylline." }, { "id": "pubmed23n0519_11719", "title": "The CONCEPT trial: a 1-year, multicenter, randomized,double-blind, double-dummy comparison of a stable dosing regimen of salmeterol/fluticasone propionate with an adjustable maintenance dosing regimen of formoterol/budesonide in adults with persistent asthma.", "score": 0.016950369891546364, "content": "A patient-driven, adjustable maintenance dosing (AMD) approach to asthma therapy, in which the dose is adjusted by patients according to the severity of their symptoms, has recently been compared with fixed-dose therapy in open-label studies. This study used a double-blind, double-dummy design to compare the efficacy of 2 treatment approaches: stable dosing of salmeterol/fluticasone propionate (SAL/FP) and AMD of formoterol/budesonide (FOR/BUD). This was a 1-year, multicenter, randomized, double-blind, double-dummy study in adult patients with symptomatic asthma that was not controlled by therapy with 200 to 500 microg/d inhaled corticosteroid (ICS) plus a long-acting beta2 agonist, or with &gt;500 to 1000 microg/d ICS alone. Patients were randomized to receive 1 inhalation of SAL/FP 50/250 microg BID or 2 inhalations of FOR/BUD 6/200 microg BID, both delivered via dry powder inhaler devices. After 4 weeks of stable dosing in both groups, eligible patients continued the study for an additional 48 weeks, receiving either a stable dose of SAL/FP or AMD of FOR/BUD. According to the AMD treatment plan, patients initially halved their dose and subsequently stepped up or down as indicated by the presence or absence of nocturnal awakenings due to asthma, frequency of rescue medication use, and changes in morning peak expiratory flow (PEF). The primary end point was the percentage of symptom-free days. Other parameters included daily asthma symptom scores, morning PEF, percentage of days free of rescue medication use, daily rescue medication use, percentage of nighttime awakenings due to asthma, percentage of weeks with well-controlled asthma, and number of exacerbations requiring oral corticosteroids or emergency department (ED) visits/hospitalizations. Tolerability was assessed in terms of adverse events spontaneously reported or elicited at clinic visits. The intent-to-treat population comprised 688 patients (344 per treatment arm) with a mean age of 45 years and a mean baseline forced expiratory volume in 1 second 81% of the predicted normal value. After 4 weeks' stable dosing, 581 patients (295 SAL/FP, 286 FOR/BUD) continued beyond visit 3 into the remaining 48-week treatment period. Over weeks 1 through 52, patients receiving stable dosing of SAL/FP had a significantly greater percentage of symptom-free days compared with those receiving AMD of FOR/BUD (median, 58.8% vs 52.1%, respectively; P = 0.034). The incidence of asthma exacerbations requiring oral steroids or an ED visit/hospitalization was 47% lower with SAL/FP compared with FOR/BUD (adjusted annual mean rate, 0.18 vs 0.33; P = 0.008). During weeks 5 through 52, patients in the FOR/BUD AMD group used a mean of 1.8 inhalations/d (equivalent to BUD 360 microg/d), and 235 (82.2%) patients stepped down to 1 inhalation/d. Mean (SD) daily ICS exposure over 52 weeks was 463 (81) microg FP and 480 (238) microg BUD in the respective treatment arms. In this adult population with persistent asthma, stable dosing of SAL/FP 50/250 microg BID resulted in significantly greater increases in symptom-free days, days free of rescue medication, and morning PEE, as well as almost halving the exacerbation rate, compared with AMD of FOR/BUD 6/200 microg. The results suggest that there is a minimum daily amount of maintenance therapy necessary to prevent exacerbations in adults with persistent asthma." }, { "id": "pubmed23n0490_20845", "title": "Adjustable maintenance dosing with budesonide/formoterol compared with fixed-dose salmeterol/fluticasone in moderate to severe asthma.", "score": 0.01685159500693481, "content": "Current asthma guidelines recommend that patients are educated to adjust their medication according to their asthma severity using physician-guided self-management plans. However, many patients take a fixed dose of their controller medication and adjust their reliever medication according to asthma symptoms. This study examined whether asthma control improved if patients adjusted the maintenance dose of budesonide/formoterol (Symbicort Turbuhaler* 160/4.5 microg) according to asthma severity compared with traditional fixed dosing (FD) regimens. Symptomatic patients with asthma (n = 658, mean symptom score 1.5, mean inhaled corticosteroids 735 microg/day, mean forced expiratory volume in 1 second [FEV(1)] 84% predicted) were randomised after 2 weeks' run-in to either: budesonide/formoterol adjustable maintenance dosing (AMD), budesonide/formoterol FD or salmeterol/fluticasone (Seretide Diskus dagger 50/250 microg) FD. In a 4-week double-blind period, both budesonide/formoterol AMD and FD groups received two inhalations twice daily (bid) and salmeterol/fluticasone FD patients received one inhalation bid. In the following 6-month open extension, both FD groups continued with the same treatment. Patients in the AMD group with well-controlled asthma stepped down to one inhalation bid; others continued with two inhalations bid. All AMD patients could increase to four inhalations bid for 7-14 days if symptoms worsened. All patients used terbutaline or salbutamol for symptom relief throughout. The primary variable was the odds of achieving a well-controlled asthma week (WCAW). The odds ratio for achieving a WCAW did not differ between the FD regimens; however, during the open period, budesonide/formoterol AMD increased the odds of achieving a WCAW vs. budesonide/formoterol FD (odds ratio 1.335; 95% CI: 1.001, 1.783; p = 0.049) despite a 15% reduction in average study drug use. Budesonide/formoterol AMD patients had a lower exacerbation rate over the study: 40% lower vs. salmeterol/fluticasone FD (p = 0.018); 32% lower vs. budesonide/formoterol FD (NS). During the double-blind period, there were no clinically relevant differences between the budesonide/formoterol FD and salmeterol/fluticasone FD groups. Budesonide/formoterol AMD patients used less reliever medication in the open extension: 0.58 vs. 0.92 occasions/day for budesonide/formoterol FD (p = 0.001) and 0.80 occasions/day for salmeterol/fluticasone FD (p = 0.011). Adjustable maintenance dosing with budesonide/formoterol provides more effective asthma control by reducing exacerbations and reliever medication usage compared with fixed-dose salmeterol/fluticasone." }, { "id": "pubmed23n0046_12273", "title": "Acute bronchodilator trials in chronic obstructive pulmonary disease.", "score": 0.013819927176431645, "content": "Short-term trials of bronchodilator drugs are widely used to assess patients with stable chronic obstructive pulmonary disease (COPD), but there is an uncertainty about the equivalence of the FEV1 response to beta-agonists and anticholinergic drugs, their relative ability to identify patients likely to improve with corticosteroids, the most appropriate way to express the results of these tests, and whether age or allergic status affects the beta-agonist and anticholinergic response differently. We studied 100 consecutive patients with stable COPD (mean FEV1, 0.96 +/- 0.48 L; mean age, 62 +/- 8 yr). Spirometry was measured before and after either 5 mg of nebulized salbutamol or 500 micrograms of nebulized ipratropium bromide and repeated after 2 wk of 30 mg of oral prednisolone daily. Total IgE, specific RAST, and skin prick testing values were recorded. Using modified American Thoracic Society response criteria, 33 patients failed to bronchodilate after the acute trials, 16 responded only to nebulized salbutamol, 17 to nebulized ipratropium, and 34 to both drugs. Twenty-two patients improved after corticosteroids. This was usually detected by a positive acute trial response (salbutamol 90% specific; ipratropium 84% specific). Baseline FEV1 differed between days, and in those who responded on only 1 day, this variation correlating with the response to ipratropium (r = 0.66). Expressing the response criterion as a percentage change in the available bronchodilatation increased the numbers responding with a high baseline FEV1, and vice versa. Neither age nor allergic status was related to the change in FEV1 after either drug in these patients. In COPD patients, testing with high-dose nebulized bronchodilators identifies a substantial number of partially reversible patients whatever age it is employed.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0501_8439", "title": "[Efficacy of nebulized budesonide in severe exacerbation of bronchial asthma].", "score": 0.013366503626243885, "content": "The study was undertaken to examine the clinical effectiveness of nebulizer inhalations of budesonide suspension during severe attacks of bronchial asthma (BA) and the possibility of its use versus systemic glucocorticosteroids (GCSs). Sixty-eight patients admitted for a severe attack of BA were examined. The forced expiratory volume per sec (FEV1) was less than 40% and the peak forced expiration rate (PFER) was less than 150 l/min. First-line therapy included inhaled salbutamol (5-10 mg within 1.5-2 hours), oxygen, and intravenous prednisolone (120 mg). Thirty-two patients showed a good response to first-line therapy (a more than 50% increase in FEV1) as compared with the normal values) (Group 1) and 36 patients with concurrent obstructive lung disease (COLD) had an inadequate response (FEV1 was less than 40% of the normal values) was found in 32 patients (Group 2). Then the patients were randomized: 16 patients from Group 1 took budesonide, 4 mg/day, the other 16 received intravenous prednisolone, 120 mg/day. In Group 2, the efficacy of the drug added to therapy with oral prednisolone, 30 mg/day, was evaluated: 18 patients were given budesonide, 4 mg/day, and 18 received placebo. In patients with a good response to primary therapy, positive clinical and functional changes were found on day 6 of treatment. Group 2 patients receiving budesonide showed a significantly (p &lt; 0.05) more marked positive changes in BA symptoms, FEV1, and PFER, which allowed a course of therapy with systemic GCSs to be reduced. Nebulized budesonide may be used instead of systemic GCSs to treat exacerbated BA if there is a good clinical and functional response to first-line broncholytic therapy, which is indicative of successful abatement of bronchospasm. If there is a poor response to first-line therapy in patients with more severe BA concurrent COLD, the early use of budesonide suspension in addition to systemic GCSs may enhance the efficiency of therapy for BA attacks and reduce the volume of systemic steroidal therapy." }, { "id": "pubmed23n0327_9983", "title": "High-dose inhaled budesonide may substitute for oral therapy after an acute asthma attack.", "score": 0.013154533844189017, "content": "Patients attending the emergency room with acute asthma, participating in a study comparing salbutamol (albuterol in the United States) via a dry powder inhaler (Turbuhaler) with pressurized metered-dose inhaler (pMDI), were included in this 1-week follow-up study with the aim of assessing whether inhaled budesonide via Turbuhaler may be an alternative to prednisolone tablets after an acute asthma attack. Eighty-one patients with a mean age of 38 years and forced expiratory volume in 1 sec (FEV1) of 64% predicted normal value after treatment with salbutamol were randomized in this double-blind, double-dummy, parallel-group study. The doses given were budesonide 1600 microg b.i.d. or prednisolone in daily doses from 40 mg (day 1) decreased to 5 mg (day 7). FEV1 was recorded before and after the 7-day treatments and peak expiratory flow (PEF) morning and evening, clinical symptoms (visual analogue scale 0-100), and doses of rescue medication (terbutaline Turbuhaler 0.25 mg/dose) were recorded daily. The mean increase in FEV1 from baseline to day 7 was 17.3% in the budesonide Turbuhaler group and 17.6% in the prednisolone group. Mean values of morning PEF increased from day 1 to day 7 by 67 L/min in the budesonide Turbuhaler group and by 57 L/min in the prednisolone group (not significant). There were no statistically significant differences between the groups in clinical symptoms and in the number of doses of rescue medication. Because of disease deterioration, five patients in the Turbuhaler group and three in the prednisolone group needed additional symptomatic as well as corticosteroid treatment. Inhaled budesonide in high doses may be a substitute for oral therapy as follow-up treatment after an acute asthma attack." }, { "id": "pubmed23n0536_8843", "title": "Budesonide/formoterol in a single inhaler for maintenance and relief in mild-to-moderate asthma: a randomized, double-blind trial.", "score": 0.013121665806229563, "content": "To compare a novel asthma management strategy--budesonide/formoterol in a single inhaler for both maintenance therapy and symptom relief--with a higher dose of budesonide plus as-needed terbutaline. This was a 6-month, randomized, double-blind, parallel-group study in patients with mild-to-moderate asthma (n = 697; mean age, 38 years [range, 11 to 79 years]; mean baseline FEV1, 75% of predicted; mean inhaled corticosteroid [ICS] dosage, 348 microg/d). Following a 2-week run-in period, all patients received two blinded, dry powder inhalers, one containing maintenance medication and one containing medication to be used as needed for the relief of symptoms. Patients were randomized to receive either budesonide/formoterol (80 microg/4.5 microg, two inhalations qd) for maintenance plus additional inhalations as needed for symptom relief, or budesonide (160 microg, two inhalations qd) for maintenance medication plus terbutaline (0.4 mg) as needed. The primary efficacy variable was morning peak expiratory flow (PEF). Patients receiving budesonide/formoterol showed greater improvements in morning PEF than patients receiving budesonide (increases of 34.5 L/min vs 9.5 L/min, respectively; p &lt; 0.001). The risk of having a severe exacerbation (hospitalization/emergency department [ED] treatment, oral steroids for asthma, or a &gt; or = 30% decrease from baseline in morning PEF on 2 consecutive days) was 54% lower with budesonide/formoterol vs budesonide (p = 0.0011). Budesonide/formoterol patients experienced 90% fewer hospitalizations/ED treatments due to asthma than budesonide patients (1 vs 10, respectively; p = 0.026). The increased efficacy with budesonide/formoterol was achieved with less ICS than was used in the budesonide group (mean dose, 240 microg/d vs 320 microg/d, respectively) and with 77% fewer oral steroid treatment days vs budesonide (114 days vs 498 days, respectively). Both treatments were well tolerated. Budesonide/formoterol for both maintenance and relief improves asthma control with a lower steroid load compared with a higher dose of budesonide plus terbutaline." }, { "id": "wiki20220301en528_22935", "title": "Beclometasone/formoterol/glycopyrronium bromide", "score": 0.012899543378995433, "content": "In the first study lasting a year, after 26 weeks of treatment the combination improved participants' FEV1 (the maximum volume of air a person can breathe out in one second) by 82 ml before a dose and 261 ml after a dose. By comparison, the FEV1 increased by 1 and 145 ml before and after dosing respectively in participants treated with a medicine containing only two of the active substances found in the combination (beclometasone plus formoterol). In the second study lasting a year, participants treated with the combination had 20% fewer exacerbations (flare-ups of symptoms) a year than participants treated with tiotropium (a muscarinic receptor antagonist). In this study, the combination was as effective as tiotropium plus a combination of beclometasone and formoterol at reducing the number of exacerbations." }, { "id": "pubmed23n0664_17831", "title": "Treatment comparison of budesonide/formoterol with salmeterol/fluticasone propionate in adults aged &gt; or =16 years with asthma: post hoc analysis of a randomized, double-blind study.", "score": 0.01243894993894994, "content": "Three fixed maintenance-dose inhaled corticosteroid/long-acting beta(2)-agonist (ICS/LABA) combinations for the treatment of asthma are currently available: salmeterol/fluticasone propionate (Seretide/Advair/Adoair) budesonide/formoterol (Symbicort) and beclometasone/formoterol (Foster). All of these combinations have proven efficacy in terms of controlling symptoms, improving lung function and reducing the rate of exacerbations compared with ICSs and LABAs administered separately. Budesonide/formoterol is also approved for use as maintenance and reliever therapy in a number of countries (Symbicort SMART). Many of the studies supporting the use of budesonide/formoterol combination therapies have included populations of adolescents and adults aged &gt;11 years. This post hoc analysis compared the efficacy of ICS/LABA fixed maintenance-dose treatment with budesonide/formoterol and salmeterol/fluticasone propionate versus budesonide/formoterol maintenance and reliever therapy in patients with persistent asthma aged &gt; or =16 years. Following 2-weeks' run-in, 2866 adults aged &gt; or =16 years were randomized to: fixed maintenance-dose budesonide/formoterol 640 microg/18 microg per day, salmeterol/fluticasone propionate 100 microg/500 microg per day plus terbutaline as needed, or budesonide/formoterol 320 microg/9 microg per day plus additional inhalations as needed (budesonide/formoterol maintenance and reliever therapy). Outcome measures included time to first severe asthma exacerbation (primary outcome) and number of severe asthma exacerbations. Budesonide/formoterol maintenance and reliever therapy prolonged time to first severe exacerbation versus budesonide/formoterol and salmeterol/fluticasone propionate fixed maintenance dose (p = 0.037 and p = 0.0089, respectively). Compared with salmeterol/fluticasone propionate fixed maintenance-dose treatment, fixed maintenance-dose budesonide/formoterol reduced the risk of hospitalizations/emergency-room visits by 28% (relative rate [RR] 0.72; 95% CI 0.53, 0.98; p = 0.034) and budesonide/formoterol maintenance and reliever therapy by 37% (RR 0.63; 95% CI 0.46, 0.87; p = 0.0043). All treatments provided similar improvements in lung function, asthma control days and asthma-related quality of life. Budesonide/formoterol fixed maintenance dose or maintenance and reliever therapy provides similar improvements in current asthma control and reduces the future risk of hospitalizations/emergency-room treatments versus salmeterol/fluticasone propionate fixed maintenance-dose treatment, providing additional clinical benefit to asthma patients aged &gt; or =16 years." }, { "id": "wiki20220301en038_67960", "title": "Budesonide/formoterol", "score": 0.012103174603174602, "content": "Use for both maintenance and as needed treatment is also known as single maintenance and reliever therapy ( SMART) and is a well-established treatment. It has been shown to reduce asthma exacerbations that require oral corticosteroids, hospital visits better than maintenance inhaled corticosteroids alone at a higher dose, or inhaled corticosteroid at the same or higher dose with a long acting bronchodilator (LABA)), with a short-acting bronchodilator (SABA) as a reliever. More studies using budesonide/formoterol SMART in children are needed. Side effects Common (up to 1 in 10 people) Mild throat irritation Coughing Hoarseness Oral candidiasis (thrush. significantly less likely if the patient rinses their mouth out with water after inhalations) Headache Often mild, and usually disappear as the medication continues to be used: Heart palpitations Trembling Uncommon (up to 1 in 100 people)" }, { "id": "pubmed23n0529_16808", "title": "Budesonide/formoterol maintenance and reliever therapy: an effective asthma treatment option?", "score": 0.011365819299481335, "content": "This 12-month dose-titration study assessed the effectiveness of budesonide/formoterol for maintenance plus relief with a control group using salmeterol/fluticasone for maintenance plus salbutamol for relief. Adolescents and adults (n = 2,143; mean forced expiratory volume in one second (FEV1) 73% predicted; mean inhaled corticosteroid (ICS) 884 microg.day(-1)) were randomised to budesonide/formoterol 160/4.5 microg two inhalations b.i.d. plus additional inhalations as needed, or salmeterol/fluticasone 50/250 microg b.i.d. plus salbutamol as needed. Treatment was prescribed open label; after 4 weeks, physicians could titrate maintenance doses in accordance with normal clinical practice. Maintenance plus as-needed budesonide/formoterol prolonged the time to first severe exacerbation versus salmeterol/fluticasone (25% risk reduction). The total number of severe exacerbations was significantly reduced in the budesonide/formoterol group (255 versus 329). Both regimens provided sustained improvements in symptoms, as-needed use, quality of life and FEV1, with differences in favour of the budesonide/formoterol group for as-needed use (0.58 versus 0.93 inhalations.day(-1)) and FEV1 (post-beta2-agonist values). Mean ICS dose during treatment was similar in both groups (653 microg budesonide.day(-1) (maintenance plus as-needed) versus 583 microg fluticasone.day(-1)). The simplified strategy using budesonide/formoterol for maintenance and reliever therapy is feasible, safe and at least as effective as salmeterol/fluticasone plus salbutamol." }, { "id": "wiki20220301en038_67959", "title": "Budesonide/formoterol", "score": 0.011361941226194619, "content": "Budesonide/formoterol was approved for medical use in the United States in 2006. It is on the World Health Organization's List of Essential Medicines, the safest and most effective medicines needed in a health system. In 2019, it was the 57th most commonly prescribed medication in the United States, with more than 12million prescriptions. Medical uses Maintenance Budesonide/formoterol has shown efficacy to prevent asthma attacks. It is unclear if budesonide/formoterol differs from fluticasone and salmeterol in chronic asthma. Exacerbation The combination is approved in the United States only as a maintenance medication in asthma and chronic obstructive pulmonary disease (COPD). However, a 2020 review of the literature does support use as needed during acute worsening in those with mild disease, and as maintenance followed by extra doses during worsening." }, { "id": "pubmed23n0946_888", "title": "Case study: A Combination of Mepolizumab and Omaluzimab injections for severe asthma.", "score": 0.009900990099009901, "content": "A Combination of Mepolizumab and Omaluzimab injections for severe asthma. Patients with severe persistent asthma account for a large proportion of asthma morbidity and health care expenditures. In this case report we describe the use of a combination of omalizumab and mepolizumab in severe asthma with elevated IgE levels and eosinophilic phenotype. We are treating a 55 year old woman with severe persistent eosinophilic asthma and elevated IgE levels. Her regimen included salmeterol/fluticasone propionate inhaler 500/50 one puff twice a day, budesonide nebulizer twice a day, tiotropium respimat inhaler two puffs daily, montelukast 10 mg daily, Albuterol as needed, Azithromycin 250 mg three times a week, and also omalizumab injections. She was having recurrent asthma exacerbations requiring the use of oral corticosteroids. Due to frequent exacerbations, we referred her for Bronchial Thermoplasty. This procedure was denied by insurance and therefore the patient was started on 20 mg PO prednisone daily. Mepolizumab was added approximately 4 months after starting chronic PO prednisone. We were able to taper down the steroids and she is currently on 4 mg daily. Since we added the mepolizumab injections along with the omalizumab injections, we have been able to decrease the prednisone steadily and currently the patient is on 4 mg daily. The plan is to taper off the corticosteroids slowly as the clinical status allows. Combination of omalizumab and mepolizumab could become the gold standard for severe asthma patients that have elevated IgE levels and an eosinophilic phenotype. A Combination of Mepolizumab and Omaluzimab injections for severe asthma." }, { "id": "pubmed23n1031_1348", "title": "Health-Related Effects of Home Nebulization With Glycopyrronium on Difficult-to-Treat Asthma: Post-Hoc Analyses of an Observational Study.", "score": 0.00980392156862745, "content": "Bronchial asthma remains a clinical enigma with poorly controlled symptoms or exacerbations despite regular use of inhaled corticosteroids. Home nebulization offers a simplified solution for the delivery of rescue and maintenance bronchodilators, which is especially true for patients with frequent exacerbations during management of uncontrolled or difficult-to-treat asthma. We aimed to assess the clinical impact and outcomes associated with home nebulization-delivered long-acting bronchodilators for uncontrolled or difficult-to-treat asthma. This observational, concurrent study was conducted with 60 patients at 2 centers during November 2018. Statistical analyses for prebronchodilator forced expiratory volume in one second (FEV1) and Global Initiative for Asthma (GINA) asthma control score in patients on long-acting bronchodilators and corticosteroids were conducted, with two-tailed P values &lt;.05 considered statistically significant. Per protocol analyses (53/60) for consecutive cases receiving home nebulization with long-acting bronchodilators and corticosteroids were conducted. The baseline demographics included a male-to-female ratio of 30:23 and mean values of the following: age, 60.3 years (SD 11.8 years); weight, 64 kg (SD 16.8 kg); FEV1, 43% (SD 16%); GINA asthma control score, 3.0 points (SD 0.8 points); serum eosinophil level, 4% (SD 3%); fractional exhaled nitric oxide (FeNO), 12.1 ppb (SD 6 ppb). Of the patients, 100% (53/53) had uncontrolled symptoms, 69.8% (37/53) had prior exacerbations, 100% (53/53) used formoterol/budesonide, and 75.5% (40/53) used glycopyrronium. The per protocol group (n=53) had significantly improved mean prebronchodilator FEV1 (23.7%, SD 29.8%; 0.46 L, SD 0.58 L; P&lt;.001) and GINA asthma control score (2.1 points, SD 0.8 points, P&lt;.001). At baseline, patients (n=40) receiving glycopyrronium/formoterol/budesonide (25/20/500 mcg) nebulization admixture had the following mean values: prebronchodilator FEV1, 38% (SD 15%); GINA asthma control score, 3.0 points (SD 0.8 points); reversibility, 12% (SD 6%); peripheral eosinophil level, 4% (SD 3%); FeNO, 12 ppb (SD 5.7 ppb). In the post hoc analyses, these patients had significantly improved mean prebronchodilator FEV1 of 27.7% (SD 26.2%; 0.54 L, SD 0.51 L; P&lt;.001) at 8 weeks compared with baseline. At baseline, patients (n=13) receiving formoterol/budesonide (20/500 mcg) nebulization had the following mean values: FEV1, 55% (SD 12%); GINA asthma control score, 3.0 points (SD 1.2 points); reversibility, 14% (SD 7%); serum eosinophil level, 4% (SD 3%); FeNO, 13.3 ppb (SD 6.8 ppb). In the post hoc analyses, these patients showed a significant improvement in prebronchodilator FEV1 of 11.2% (SD 13.1%; 0.22 L, SD 0.25 L; P&lt;.001) from baseline. Breathlessness of mild to moderate intensity was reported by 10 cases (10/53, 18.9%), with no other treatment-emergent adverse events or serious adverse events. Home nebulization remains a viable option for symptomatic difficult-to-treat asthma cases with frequent use of rescue medications. Glycopyrronium as add-on therapy offers a synergistic response in patients on corticosteroids with difficult-to-treat asthma. Clinical Trial Registry of India CTRI/2018/11/016319; https://tinyurl.com/y78cctm3." }, { "id": "pubmed23n0261_8244", "title": "Efficacy of Uniphyl, salbutamol, and their combination in asthmatic patients on high-dose inhaled steroids.", "score": 0.00980392156862745, "content": "A group of 32 patients with moderately severe, chronic asthma (mean FEV1 55% of predicted), maintained on moderately high doses of inhaled corticosteroids (mean dose 1,100 micrograms/d), participated in this double-blind, placebo-controlled crossover study. The effect on pulmonary function of adding theophylline (U, once daily Uniphyl), inhaled salbutamol (S, 200 micrograms four times per day), and their combination (C) or placebo (P) was assessed on Day 14 of each treatment phase. Patients recorded peak expiratory flow, asthma symptom severity (morning and evening), and use of rescue salbutamol inhaler in daily diaries. Mean FEV1 between 0730 and 1800 h and maximum FEV1 between 0730 and 1300 h were significantly higher on U, S, and C compared with P (p &lt; 0.006). Morning peak flow and FEV1 (0730 h) were significantly higher on U and C compared with S and P (p &lt; 0.01). Evening peak flow was higher on U than P (p &lt; 0.001), and C was higher than S and P (p &lt; 0.01). Rescue salbutamol inhaler use was significantly higher on P than on U, C, or S (p = 0.0001). Patient rating of asthma symptoms during C was significantly better than on S or P (p &lt; 0.05). Patient rating of asthma control and study phase preference was significantly higher on combination and Uniphyl alone than on placebo, the combination also being superior to salbutamol alone. Addition of Uniphyl or a combination of Uniphyl and salbutamol significantly improves pulmonary function and asthma symptoms in patients treated with high doses of inhaled corticosteroids and as-needed beta agonists.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0811_15161", "title": "Comparing the efficacy and influence on the quality of life of three classes of drugs used in bronchial asthma - a prospective study.", "score": 0.009708737864077669, "content": "To compare the efficacy of formoterol, montelukast and acebrophylline when used in combination with budesonide in patients with bronchial asthma and to determine their role in the improvement of the quality of life of patients. A total of 75 patients were divided into 3 groups based on treatment given - formoterol 6 mcg/puff + budesonide 100 mcg/puff combination inhaler, 2 puffs twice daily; oral montelukast 10 mg once daily + budesonide 100 mcg/puff, 2 puffs twice daily and oral acebrophylline 100 mg twice daily + budesonide 100 mcg/puff, 2 puffs twice daily. The patients were followed-up for 4 wk after initiating treatment. Spirometry values - forced expiratory volume in 1 second (FEV1) and peak expiratory flow rate (PEFR), before and after treatment were recorded. The quality of life was assessed before and after treatment using Asthma Quality of Life Questionnaire (AQLQ). Analysis was done using repeated measures ANOVA followed by Bonferroni's post-hoc test. As compared to baseline values, FEV1, PEFR and Quality of Life showed significant improvement in all 3 groups after 4 wk of treatment (p-value &lt; 0.01). Three patients in acebrophylline-treated group reported gastric irritation while no adverse effects were reported in the other groups. Formoterol, montelukast or acebrophylline combined with inhaled corticosteroids have similar efficacy in the treatment of asthma." }, { "id": "pubmed23n0779_4569", "title": "Combination formoterol and budesonide as maintenance and reliever therapy versus combination inhaler maintenance for chronic asthma in adults and children.", "score": 0.009615384615384616, "content": "Asthma is characterised by chronic inflammation of the airways and recurrent exacerbations with wheezing, chest tightness and cough. Treatment with inhaled steroids and bronchodilators often results in good control of symptoms, prevention of further morbidity and mortality and improved quality of life. Several steroids and beta2-agonists (long- and short-acting) as well as combinations of these treatments are available in a single inhaler to be used once or twice a day, with a separate inhaler for relief of symptoms when needed (for patients in Step three or higher, according to Global Initiative for Asthma (GINA) guidelines). Budesonide/formoterol is also licenced for use as maintenance and reliever therapy from a single inhaler (SiT; sometimes referred to as SMART therapy). SiT can be prescribed at a lower dose than other combination therapy because of the additional steroid doses being received as reliever therapy. It has been suggested that using SiT improves compliance and hence reduces symptoms and exacerbations, but it is unclear whether it increases side effects associated with the use of inhaled steroids. To assess the efficacy and safety of budesonide/formoterol in a single inhaler (SiT) to be used for both maintenance and reliever therapy in asthma in comparison with maintenance treatment provided through combination inhalers with a higher maintenance steroid dose (either fluticasone/salmeterol or budesonide/formoterol), along with additional fast-acting beta2-agonists for relief of symptoms. We searched the Cochrane Airways Group Specialised Register of trials, online trial registries and drug company websites. The most recent search was conducted in November 2013. We included parallel-group, randomised controlled trials of at least 12 weeks' duration. Studies were included if they compared single-inhaler therapy with budesonide/formoterol (SiT) versus combination inhalers at a higher maintenance dose of steroids than was given in the SiT arm (either salmeterol/fluticasone or budesonide/formoterol). We used standard methods expected by The Cochrane Collaboration. Primary outcomes were exacerbations requiring hospitalisation, exacerbations requiring oral corticosteroids and serious adverse events (including mortality). Four studies randomly assigning 9130 people with asthma were included; two were six-month double-blind studies, and two were 12-month open-label studies. No trials included children younger than age 12. Trials included more women than men, with mean age ranging from 38 to 45, and mean baseline steroid dose (inhaled beclomethasone (BDP) equivalent) from 636 to 888 μg. Mean baseline forced expiratory volume in one second (FEV1) percentage predicted was between 70% and 73% in three of the trials, and 96% in another. All studies were funded by AstraZeneca and were generally free from methodological biases, although the two open-label studies were rated as having high risk for blinding, and some evidence of selective outcome reporting was found. These possible sources of bias did not lead us to downgrade the quality of the evidence. The quantity of inhaled steroids, including puffs taken for relief from symptoms, was consistently lower for SiT than for the comparison groups.Separate data for exacerbations leading to hospitalisations, to emergency room (ER) visits or to a course of oral steroids could not be obtained. Compared with higher fixed-dose combination inhalers, fewer people using SiT had exacerbations requiring hospitalisation or a visit to the ER (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.57 to 0.90; I(2) = 0%, P = 0.66), and fewer had exacerbations requiring a course of oral corticosteroids (OR 0.75, 95% CI 0.65 to 0.87; I(2) = 0%, P = 0.82). This translates to one less person admitted to hospital or visiting the ER (95% CI 0 to 2 fewer) and two fewer people needing oral steroids (95% CI 1 to 3 fewer) compared with fixed-dose combination treatment with a short-acting beta-agonist (SABA) reliever (per 100 treated over eight months). No statistical heterogeneity was observed in either outcome, and the evidence was rated of high quality. Although issues with blinding were evident in two of the studies, and one study recruited a less severe population, sensitivity analyses did not change the main results, so quality was not downgraded.We could not rule out the possibility that SiT increased rates of serious adverse events (OR 0.92, 95% CI 0.74 to 1.13; I(2) = 0%, P = 0.98; moderate-quality evidence, downgraded owing to imprecision).We were unable to say whether SiT improved results for several secondary outcomes (morning and evening peak expiratory flow (PEF), rescue medication use, symptoms scales), and in cases where results were significant, the effect sizes were not considered clinically meaningful (predose FEV1, nocturnal awakenings and quality of life). SiT reduces the number of people having asthma exacerbations requiring oral steroids and the number requiring hospitalisation or an ER visit compared with fixed-dose combination inhalers. Evidence for serious adverse events was unclear. The mean daily dose of inhaled corticosteroids (ICS) in SiT, including the total dose administered with reliever use, was always lower than that of the other combination groups. This suggests that the flexibility in steroid administration that is possible with SiT might be more effective than a standard fixed-dose combination by increasing the dose only when needed and keeping it low during stable stages of the disease. Data for hospitalisations alone could not be obtained, and no studies have yet addressed this question in children younger than age 12." }, { "id": "pubmed23n0729_22023", "title": "Step-down from high dose fixed combination therapy in asthma patients: a randomized controlled trial.", "score": 0.009615384615384616, "content": "Asthma guidelines suggest that therapy can be reduced once asthma is controlled. Despite these recommendations, asthmatic patients are seldom stepped down in clinical practice, and questions remain about when and how to reduce asthma therapy. The purpose of the present study was to evaluate lung function and asthma control in patients who were stepped down from the highest recommended dose of inhaled corticosteroid/long acting β2 agonist combination therapy. This was a prospective, randomised, controlled, two-arm parallel group study. Asthmatic patients who were fully controlled with a high daily dose (1000/100 μg) of fluticasone/salmeterol were randomly assigned to 6 months of open-label treatment with either 500/100 μg fluticasone/salmeterol Diskus daily or 400/24 μg extrafine beclomethasone/formoterol pMDI daily. The primary outcome was the change in morning peak expiratory flow (PEF) values between baseline and the end of treatment. The secondary outcomes included asthma control and exacerbation frequency. Four hundred twenty-two patients were included in the analysis. The PEF values remained above 95% of the predicted values throughout the study. The end-study morning PEF rates showed equivalence between the groups (difference between means, 2.49 L/min; 95% CI, -13.43 to 18.42). No changes from baseline were detected in PEF and forced expiratory volume in 1 second measured at the clinics, in the symptom scores or in the use of rescue medication. Asthma control was maintained in 95.2% of the patients at 6 months. No significant differences between the groups were detected in any other parameter, including exacerbation frequency and adverse events. Stepping down patients whose asthma is controlled with the highest recommended dose of fluticasone/salmeterol to either 500/100 μg fluticasone/salmeterol daily or 400/24 μg extra-fine beclomethasone/formoterol daily provides comparable maintenance of lung function and asthma control. clinicaltrials.gov NCT00497237." }, { "id": "pubmed23n0334_10545", "title": "Comparison of salmeterol with beclomethasone in adult patients with mild persistent asthma who are already on low-dose inhaled steroids.", "score": 0.009523809523809525, "content": "Current guidelines on asthma management recommend the early use of inhaled corticosteroids. Recent studies of patients with moderate to severe asthma show that the addition of salmeterol is superior to a further increase of the steroids. In this study with adult, mild persistent asthma patients, we compared the effects of adding salmeterol 50 microg b.i.d. versus beclomethasone dipropionate (BDP) 200 microg b.i.d. (both via Diskhaler dry powder inhaler) to the low-dose inhaled steroids. A double-blind, randomized, parallel-group study was conducted with a run-in period of 2 weeks and a treatment period of 12 weeks. Patients (n = 233) were randomized with a peak expiratory flow (PEF) reversibility of 22 +/- 10% (mean +/- SD) in the run-in period. The morning PEF was 84 +/- 17% predicted and the age was 42 +/- 14 years (45% males). The average prestudy inhaled steroid dose was 361 microg daily. Within a week of salmeterol treatment the daily PEF recordings reached maximal levels. At the end of the treatment period the evening PEF remained significantly better in the salmeterol group than in the BDP group (p = 0.036). The PEFs, measured at the general practitioners' (GPs') office, were at least 95% of the predicted values and the post-salbutamol values at the end of both treatments. However, the salmeterol group had already obtained this level after 2 weeks and differed significantly from the beclomethasone group (p = 0.003 for percent predicted and p = 0.0007 for post-salbutamol PEF values). The symptom scores and the use of rescue medication showed a similar profile. Quality of life improved with both treatments, but without significant statistical differences between the groups. The frequency of adverse events, typical for beta2-agonists, was low and showed no differences between the groups. These results showed that the addition of salmeterol is at least as effective as adding beclomethasone in normalizing peak flows and improving asthma control in mild persistent asthma patients. Furthermore, salmeterol has a much faster onset of action." }, { "id": "pubmed23n0778_12817", "title": "Efficacy and safety of maintenance and reliever combination budesonide-formoterol inhaler in patients with asthma at risk of severe exacerbations: a randomised controlled trial.", "score": 0.009433962264150943, "content": "The Single combination budesonide-formoterol inhaler Maintenance And Reliever Therapy (SMART) regimen reduces severe asthma exacerbations in patients, but whether the high doses of corticosteroid and β agonist increase the risk of adverse effects with both short-term and cumulative exposure is not certain. Our aim was to investigate whether the SMART regimen would reduce the risk of overuse of β agonist, reduce the likelihood of patients to seek medical review when such episodes occurred, and if any reduction in severe asthma exacerbations would be at the cost of a higher burden of systemic corticosteroid. In this 24-week trial undertaken at four primary health-care practices and one hospital in New Zealand, patients (aged 16-65 years) with a recent asthma exacerbation were randomly assigned in a 1:1 ratio to the SMART or standard fixed-dose regimen. Treatment in the SMART group consisted of two actuations of budesonide-formoterol (200 μg and 6 μg, respectively, per actuation) twice daily, delivered through a combination metered dose inhaler (MDI), with one extra actuation as needed for relief of symptoms; treatment in the standard group consisted of two actuations of budesonide-formoterol (200 μg and 6 μg, respectively, per actuation) twice daily through a combination MDI with one to two actuations of salbutamol (100 μg per actuation) by MDI as needed for relief of symptoms. MDIs were monitored electronically to measure actual use of medication. The allocation sequence for randomisation was computer generated, with a block size of eight per site. Participants, investigators, and the statistician were not masked to group assignment. The primary outcome was the proportion of participants with at least one high-use episode of β agonist (more than eight actuations per day of budesonide-formoterol in addition to the four maintenance doses in the SMART group or more than 16 actuations per day of salbutamol in the standard group). Analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000515099. 303 patients were randomly assigned to the SMART (n=151) or standard group (n=152). No significant difference was noted between the SMART and standard groups in the proportion of participants with at least one high-use episode of β agonist (84 [56%] vs 68 [45%], respectively, relative risk 1·24 [95% CI 0·99-1·56]; p=0·058). There were fewer days of high use in the SMART group (mean 5·1 days [SD 14·3] vs 8·9 days [20·9], relative rate 0·58 [0·39-0·88]; p=0·01). Of the patients who had at least one high-use episode, those in the SMART group had fewer days of high use without medical review (8·5 days [17·8] vs 18·3 days [24·8], 0·49 [0·31-0·75]; p=0·001). The SMART regimen resulted in higher inhaled corticosteroid exposure (943·5 μg budesonide per day [1502·5] vs 684·3 μg budesonide per day [390·5], respectively; ratio of means 1·22 [1·06-1·41]; p=0·006), but reduced oral corticosteroid exposure (77·5 mg prednisone [240·5] vs 126·6 mg prednisone [382·1], respectively; p=0·011), with no significant difference in composite systemic corticosteroid exposure (793·7 mg prednisone equivalent per year [893·1] vs 772·1 mg prednisone equivalent per year [1062·7], respectively; 1·03 [0·86-1·22]; p=0·76). Participants in the SMART group had fewer severe asthma exacerbations (35 [weighted mean rate per year 0·53] vs 66 [0·97]; relative rate 0·54 [0·36-0·82]; p=0·004). The SMART regimen has a favourable risk-to-benefit profile and can be recommended for use in adults at risk of severe asthma exacerbations. Health Research Council of New Zealand." }, { "id": "pubmed23n0726_13575", "title": "Budesonide/formoterol maintenance and reliever therapy in Asian patients (aged ≥16 years) with asthma: a sub-analysis of the COSMOS study.", "score": 0.009345794392523364, "content": "The combination of an inhaled corticosteroid (ICS), budesonide, and a rapid long-acting β(2)-agonist (LABA), formoterol, in a single inhaler for use as maintenance and reliever therapy (Symbicort Turbuhaler SMART™) effectively achieves a high level of asthma control and reduces exacerbations and asthma-related hospitalizations. The COSMOS study, a multinational, 12-month study (N = 2143), compared budesonide/formoterol maintenance and reliever therapy with salmeterol/fluticasone propionate plus as-needed salbutamol, allowing physicians to modify maintenance doses of both combinations according to routine clinical practice. The aim of this post hoc sub-group analysis of the COSMOS study is to provide focused data on budesonide/formoterol maintenance and reliever therapy compared with salmeterol/fluticasone propionate plus as-needed salbutamol in patients (aged ≥16 years) enrolled across Asian countries, specifically China, Korea, Taiwan and Thailand. This sub-analysis of the COSMOS study concerns all 404 randomized patients ≥16 years of age (mean forced expiratory volume in 1 second [FEV(1)] 69.1%) who were recruited from Asian countries. Patients received either budesonide/formoterol (Symbicort Turbuhaler SMART™, n = 198), starting dose 160 mg/4.5 mg two inhalations twice daily (bid) [plus additional as-needed inhalations], or salmeterol/fluticasone propionate (Seretide(®) Diskus(®), n = 206), starting dose 50 mg/250 mg bid (plus salbutamol [Ventolin(®)] as needed). Maintenance doses could be titrated by clinicians after the first 4 weeks (budesonide/formoterol maintenance plus as needed, n = 198; salmeterol/fluticasone propionate plus salbutamol, n = 206). To allow for free adjustment in maintenance doses in both arms, the trial was performed open-label; maintenance doses could be titrated by clinicians after the first 4 weeks. The time to first severe exacerbation (defined as deterioration in asthma resulting in hospitalization/emergency room treatment, oral corticosteroids for ≥3 days or unscheduled visit leading to treatment change) was the primary variable. The time to first severe exacerbation was prolonged in patients using maintenance plus as-needed budesonide/formoterol compared with salmeterol/fluticasone propionate plus salbutamol (log-rank p = 0.024). The risk of a first exacerbation was reduced by 44% (hazard ratio 0.56; 95% confidence interval [CI] 0.32, 0.95; p = 0.033) in patients using the adjusted budesonide/formoterol regimen versus titrated salmeterol/fluticasone propionate. The overall exacerbation rates were 0.16 versus 0.26 events/patient-year, respectively, with a 38% reduction (rate ratio 0.62/patient/year; 95% CI 0.41, 0.94; p = 0.024) in favour of the budesonide/formoterol regimen. Compared with baseline, both regimens provided clinically relevant improvements in asthma control, quality of life and FEV(1); no statistically significant differences between the treatment groups were observed. Mean adjusted (standard deviation) ICS dose (expressed as beclomethasone dose equivalents) during treatment, including as-needed budesonide doses, was 944 (281) and 1034 (394) μg/day, respectively, in patients using maintenance plus as-needed budesonide/formoterol compared with salmeterol/fluticasone propionate. In patients (aged ≥16 years) enrolled from Asian countries as part of the COSMOS study, the budesonide/formoterol maintenance and reliever regimen was associated with a lower future risk of exacerbations versus the physicians' free choice of salmeterol/fluticasone propionate dose plus salbutamol. Single inhaler combination treatment with maintenance plus as-needed budesonide/formoterol was also at least as efficacious as salmeterol/fluticasone propionate dose plus salbutamol in improving current asthma control." }, { "id": "pubmed23n0323_10566", "title": "[Comparison of addition of theophylline to inhaled steroid with doubling of the dose of inhaled steroid in asthma].", "score": 0.009345794392523364, "content": "The anti-asthmatic effect of theophylline may supplement those of inhaled steroids in asthma. The aim of the present trial was to study how the addition of theophylline compares to doubling the dose of inhaled steroid in asthmatics who remain symptomatic on beclomethasone dipropionate (BDP) 400 micrograms/day. The trial was designed as a randomized, double-blind, parallel-group study in several European countries. 69 patients were treated for 6 weeks with theophylline plus BDP 400 micrograms/day, compared to 64 patients treated with BDP 800 micrograms/day. The mean +/- SD serum theophylline concentration was 10.1 +/- 4.2 mg/l. Lung function measurements were made throughout the study and patients kept daily records of peak expiratory flow rate (PEF), symptoms and salbutamol usage. Forced expiratory volume in one second and PEF at week 6 were significantly increased by both treatments (p &lt; 0.01). PEF variability was reduced by about 30% in both groups. There were significant improvements in asthma symptoms and rescue medication use (p &lt; 0.001). There were no significant differences between the treatment groups. The study demonstrated clinical equivalence of theophylline plus beclomethasone dipropionate 400 micrograms/day and beclomethasone dipropionate 800 micrograms/day in patients whose asthma is not controlled on beclomethasone dipropionate 400 micrograms/d. The results support the use of theophylline as steroid-sparing agent. The combination of low-dose inhaled steroid plus theophylline is a suitable treatment for moderate asthma." }, { "id": "wiki20220301en038_67992", "title": "Formoterol", "score": 0.009308409509179126, "content": "Nowadays, available long-acting β2 agonists include salmeterol, formoterol, bambuterol, and sustained-release oral salbutamol. Combinations of inhaled steroids and long-acting bronchodilators are becoming more widespread – combination preparations include fluticasone/salmeterol and budesonide/formoterol. Mechanism of action Inhaled formoterol works like other β2 agonists, causing bronchodilation by relaxing the smooth muscle in the airway so as to treat the exacerbation of asthma. Society and culture Brand names It is marketed in three forms: a dry-powder inhaler (DPI), a metered-dose inhaler (MDI) and an inhalation solution, under various brand names including Atock, Atimos/Atimos Modulite, Foradil/Foradile, Fostair, Oxeze/Oxis, and Perforomist." }, { "id": "pubmed23n0792_6529", "title": "Comparing clinical efficacy of Symbicort versus Pulmicort in reducing asthma symptom and improving its control.", "score": 0.009259259259259259, "content": "Recently, higher efficacy of the combination of long-acting beta2-adrenoceptor agonist and inhaled corticosteroids on controlling asthma symptoms has been hypothesized. This study aimed to examine the clinical effects of the combination of Budesonide with formoterol (Symbicort) and Budesonide (Pulmicort) alone in persistent asthma. In a randomized double-blinded clinical trial, 76 patients with definite diagnosis of moderate-to-severe asthma were randomized to receive Pulmicort 180 mcg/inhalation two puffs twice daily, or receive Symbicort 80/4.5 mg/inhalation two puffs twice daily, or receive Symbicort 160/4.5 mg/inhalation two puffs twice daily for 3 months. All participants were initially evaluated by spirometry for assessing respiratory parameters and also the level of asthma control was assessed by Asthma Control Test (ACT). More significant improvement in spirometry parameters, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, as well as in peak expiratory flow (PEF) in both groups of Symbicort with the regimens 80/4.5 mg/inhalation or 160/4.5 mg/inhalation 2 puffs twice daily compared with Pulmicort group, ACT score was significantly improved in Symbicort group with the regimens 160/4.5 mg/inhalation compared with both Symbicort groups with lower dosage and Pulmicort group. Response to treatment in PEF parameter and also in ACT level was significantly more in those who received Symbicort with the regimens 160/4.5 mg/inhalation compared with other two interventional groups adjusted for gender and age. Symbicort with the regimens 160/4.5 mg/inhalation has higher efficacy in reducing asthma symptom and improving its control compared with low doses of this drug and with Pulmicort." }, { "id": "wiki20220301en115_376", "title": "Management of ulcerative colitis", "score": 0.009174311926605505, "content": "Oral anti-inflammatory drugs require four to six weeks to work. Once remission is induced, maintenance levels can be used: sulfasalazine 2 g/day, mesalamine 1.2-2.4 g/day, or olsalazine 1 g/day. Patients on high dose sulfasalazine require folic supplementation (1 mg/day) because it inhibits folate absorption. If oral Mesalazine is still not working, prednisone is often given, starting at 40–60 mg/day. Prednisone often takes effect within 10–14 days. The dose should then be tapered by about 5 mg/week until it can be stopped altogether." }, { "id": "pubmed23n0315_9063", "title": "Comparison of addition of theophylline to inhaled steroid with doubling of the dose of inhaled steroid in asthma.", "score": 0.009174311926605505, "content": "The anti-asthmatic effects of theophylline may supplement those of inhaled steroids in asthma. The aim of the present trial was to study how the addition of theophylline compares to doubling the dose of inhaled steroid in asthmatics who remain symptomatic on beclomethasone dipropionate (BDP) 400 microg x day(-1). The trial was designed as a randomized, double-blind, parallel-group study in several European countries. Sixty nine patients were treated for 6 weeks with theophylline plus BDP 400 microg x day(-1), compared to 64 patients treated with BDP 800 micro x day(-1). The mean+/-SD serum theophylline concentration was 10.1+/-4.2 mg x L(-1). Lung function measurements were made throughout the study and patients kept daily records of peak expiratory flow (PEF), symptoms and salbutamol usage. Forced expiratory volume in one second and PEF at week 6 were significantly increased by both treatments (p&lt;0.01). PEF variability was reduced by about 30% in both groups. There were significant improvements in asthma symptoms and rescue medication use (p&lt;0.001). There were no significant differences between the treatment groups. The study demonstrated clinical equivalence of theophylline plus beclomethasone dipropionate 400 microg x day(-1) and beclomethasone dipropionate 800 microg x day(-1) in patients whose asthma is not controlled on beclomethasone dipropionate 400 microg x day(-1). The results support the use of theophylline as a steroid-sparing agent. The combination of low-dose inhaled steroid plus theophylline is a suitable treatment for moderate asthma." }, { "id": "wiki20220301en191_31191", "title": "Lacosamide", "score": 0.00909090909090909, "content": "Dosage Lacosamide is initially prescribed in oral doses of 50 mg twice per day, with a total dose of 100 mg/day. The dosing can be increased by 100 mg/day following a twice-daily dose up to a total dose of 200–400 mg/day. Clinical trials showed that a dose of 600 mg/day was not more effective than a dose of 400 mg/day, but resulted in more adverse reactions. Lacosamide is administered orally through film-coated tablets of 50 mg (pink), 100 mg (dark yellow), 150 mg (salmon), and 200 mg (blue). It can also be administered by injection at a concentration of 200 mg/20 mL or by oral solution at a concentration of 10 mg/mL. Contraindications The FDA has assigned lacosamide to pregnancy category C. Animal studies have reported incidences of fetal mortality and growth deficit. Lacosamide has not been tested during human pregnancy, and should be administered with caution. In addition, it has not been determined whether the excretion of lacosamide occurs in breast milk." }, { "id": "pubmed23n0482_8424", "title": "Salmeterol/fluticasone propionate (50/250 microg) combination is superior to double dose fluticasone (500 microg) for the treatment of symptomatic moderate asthma.", "score": 0.00909090909090909, "content": "if patients with asthma remain symptomatic in spite of chronic treatment with inhaled corticosteroids (ICS), increasing the ICS dosage or adding another drug to the treatment regimen are possible therapeutic alternatives. We compared the efficacy and safety of combined salmeterol fluticasone therapy (SFC, 50/250 microg twice daily) with twice the dose of fluticasone propionate (FP, 500 microg b.i.d.) in symptomatic asthmatics. this prospective, double-blind study was conducted in 76 study centres. 365 symptomatic patients with moderate asthma aged &gt;18 years and receiving ICS in a dose equivalent to 1000 microg beclomethasone propionate per day were randomly assigned to receive either salmeterol xinafoate (50 microg) and fluticasone propionate (250 microg) in a single dry powder inhaler (Diskus) or 500 microg FP twice daily. The primary efficacy endpoint was morning peak expiratory flow rate (PEFR). Secondary measurements included forced expiratory volume in 1 second (FEV1), asthma symptom scores, and use of rescue medication. combined salmeterol fluticasone therapy resulted in significantly greater improvements in PEFR and symptom control than doubling the dose of FP. At week 12, morning PEFR had increased by 52 L/min from baseline in patients on SFC and by 36 L/min in subjects receiving FP. The adjusted difference between groups was 16.6 L/min (95% confidence interval, 1.1 to 32.0 L/min). In the SFC group, the percentage of symptom-free days increased from baseline by 49% of days as compared with 38% of days after FP (adjusted difference: 12.6% of days, 95% CI 4.0 to 20.7). Quality of life improved to a greater degree after SFC therapy, and patients regarded study drugs as superior to their previous asthma medication. Adverse event profiles were similar between groups. the combination of salmeterol 50 microg and fluticasone 250 microg in a single dry powder inhaler was superior to twice the dose of FP (500 microg). It seems justified to add salmeterol rather than increasing the ICS dose if symptomatic asthmatics require supplementary therapy." }, { "id": "pubmed23n0580_22881", "title": "Budesonide/formoterol for maintenance and relief in uncontrolled asthma vs. high-dose salmeterol/fluticasone.", "score": 0.009009009009009009, "content": "Budesonide/formoterol maintenance and reliever therapy (Symbicort SMART) improves asthma control compared with fixed-dose inhaled corticosteroid/long-acting beta(2)-agonist (ICS/LABA) regimens, but its efficacy has not been assessed in comparison with sustained high-dose salmeterol/fluticasone (Seretide) plus a short-acting beta(2)-agonist (SABA). Patients (N=2309) with symptomatic asthma (aged 12 years; forced expiratory volume in 1s 50% predicted), who had experienced an asthma exacerbation in the previous year, were randomised to receive budesonide/formoterol 160/4.5 microg two inhalations twice daily and as needed, or one inhalation of salmeterol/fluticasone 50/500 microg twice daily plus terbutaline as needed, for 6 months. Time to first severe exacerbation, the pre-specified primary outcome, was not significantly prolonged (risk ratio 0.82; 95% confidence interval 0.63, 1.05). Budesonide/formoterol maintenance and reliever therapy reduced total exacerbations from 31 to 25 events/100 patients/year (P=0.039), and exacerbations requiring hospitalisation/emergency room (ER) treatment from 13 to 9 events/100 patients/year (P=0.046). The treatments showed no difference in measures of lung function or asthma symptoms. The mean dose of ICS received was lower using budesonide/formoterol maintenance and reliever therapy (792 microg/day budesonide [1238 microg/day beclomethasone dipropionate (BDP) equivalent] versus 1000 microg/day fluticasone [2000 microg/day BDP equivalent] with salmeterol/fluticasone therapy; P&lt;0.0001). Both treatments were well tolerated. In the treatment of uncontrolled asthma, budesonide/formoterol maintenance and reliever therapy reduces the incidence of severe asthma exacerbations and hospitalisation/ER treatment with similar daily symptom control compared with sustained high-dose salmeterol/fluticasone plus SABA. This benefit is achieved with substantially less ICS exposure." }, { "id": "pubmed23n0043_4839", "title": "[A new steroid therapy for difficult asthmatics--an induction and maintenance, two-step therapy].", "score": 0.009009009009009009, "content": "Beclomethasone dipropionate (BDP) administered by inhaler is a very useful drug for the treatment of bronchial asthma. In this therapy, it is very important to use steroids systematically to induce a complete remission of asthma attack (first step) and then begin to use BDP a dose of more than 800 micrograms to maintain remission (second step). We treated 27 difficult asthmatics with this therapy and found this new method very useful. The characteristics of asthmatics were as follows. 1) The age ranged from 37 to 82, and the mean age (+/- S.E.) was 58.9 (+/- 2.6) years old. 2) The onset age ranged from 27 to 74 with a mean age (+/- S.E.) of 46.9 (+/- 2.6) year old. 3) The number of non-atopy was 22 cases. 4) The follow-up duration ranged from 5 to 45 months with a mean (+/- S.E.) of 15 (+/- 2.0) months. The results were as follows. 1) The complete remission rate was 48%, partial remission 37% and unchanged 15%. 2) There was a significant increase only in %VC. 3) The peripheral eosinophil count was decreased significantly. 4) The log value of PC20 concentration by acetylcholine increased significantly by a factor of 2.94 to 3.28. 5) After this therapy, the mean serum cortisol level at 9:00 a.m. was 10.1 (+/- 3.8, S.E.) micrograms/ml. There were only 2 cases whose cortisol level were under the normal. 6) There were many oral side effects, namely stomatitis with 5 cases and hoarseness with 8." }, { "id": "pubmed23n0348_7598", "title": "Fluticasone alone or in combination with salmeterol vs triamcinolone in asthma.", "score": 0.008928571428571428, "content": "To compare the efficacies of medium-dose fluticasone propionate (FP), medium-dose triamcinolone acetonide (TAA), and combined low-dose FP plus salmeterol (SL). Randomized, double-blind, triple-dummy, multicenter, 12-week clinical trial. Allergy/respiratory care clinics. Six hundred eighty patients with asthma previously uncontrolled with low-dose inhaled corticosteroids. FP, 220 microg bid; TAA, 600 microg bid; or FP, 88 microg plus SL, 42 microg bid. Outcome measures included FEV1, peak expiratory flow (PEF), supplemental albuterol use, nighttime awakenings, asthma symptoms, and physician global assessment. Compared with TAA, 600 microg bid, treatment with FP 220, microg bid, significantly increased FEV1, morning and evening PEF, and percent symptom-free days, and significantly reduced rescue albuterol use, number of nighttime awakenings, and overall asthma symptom scores (p &lt; or = 0.035). Improvements with low-dose FP, 88 microg, plus SL, 42 microg bid, were significantly (p &lt; or = 0.004) greater than TAA, 600 microg bid, in all the aforementioned efficacy measures as well as percent of rescue-free days. Combined low-dose FP, 88 microg, plus SL, 42 microg bid, also significantly increased FEV1 and percent of rescue-free days, and significantly reduced albuterol use compared with medium-dose FP, 220 microg bid (p &lt; or = 0.018). At endpoint, both FP, 220 microg bid, and FP, 88 microg, plus SL, 42 microg bid, significantly increased FEV1 by 0.48 L and 0.58 L, respectively, compared with 0.34 L with TAA, 600 microg bid. In patients who are symptomatic while taking low-dose inhaled corticosteroids, medium-dose FP (440 microg/d) and combination treatment with low-dose FP (176 microg/d) plus SL (84 microg/d) are both more effective than medium-dose TAA (1200 microg/d) in improving pulmonary function and asthma symptom control." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 226 ] ], "word_ranges": [ [ 0, 36 ] ], "text": "Among the options presented, the only measure not included in the Surviving Sepsis Campaign guidelines on the management of sepsis and septic shock (like the patient we are dealing with) is the administration of IV dobutamine." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Intravenous perfusion of dobutamine.", "2": "Serum lactate measurement.", "3": "Extraction of blood cultures.", "4": "Fluid administration.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0712_25044", "title": "Sepsis, severe sepsis, and septic shock: current evidence for emergency department management.", "score": 0.017427884615384616, "content": "In the middle of a busy shift, a patient arrives by ambulance from a local long-term care facility with a report of altered mental status. You enter the room to find a chronically ill-appearing 85-year-old man with fever, tachycardia, and hypotension, and it is instantly apparent that this patient is septic. What is not clear is what the source is, what modifications in treatment might be necessary based on preexisting microbial resistance, and which of the array of invasive resuscitation techniques are appropriate when meaningful recovery is questionable and efforts may not be desired by the patient and family. You order IV fluids and broad-spectrum antibiotics; send lab tests, including lactate and cultures of blood, urine, and sputum; and begin to review his extensive history to discuss goals of care with his family and primary doctor. While reviewing these issues, a 54-year-old woman with a history of asthma is brought straight back from triage with respiratory distress. You listen to her lungs, expecting wheezes, but hear decreased lung sounds at the right base, preserved air movement elsewhere, and her skin radiates heat. Now, on the monitor, she has a heart rate of 135 beats per minute, blood pressure of 90/60 mm Hg, O2 saturation of 86%, and a temperature of 39.4 degrees C (103 degrees F). You again identify sepsis and instruct your team that you will be using your department's severe sepsis protocol. Equipment for monitoring and procedures is assembled, your staff provides preprinted order and monitoring flow sheets, and the ICU is alerted. Within an hour, the patient is intubated, has a central line placed, and has received IV fluids, broad-spectrum antibiotics and norepinephrine, and you are pleased to see a MAP of 67 mm Hg, a lactate decreasing from an initial value of 7.0, CVP of 10, and ScvO2 of 78%." }, { "id": "InternalMed_Harrison_20890", "title": "InternalMed_Harrison", "score": 0.011382344592676697, "content": "Bacteremia Presence of bacteria in blood, as evidenced by positive blood cultures Signs of possibly harmful systemic Two or more of the following condi response tions: (1) fever (oral temperature >38°C [>100.4°F]) or hypothermia (<36°C [<96.8°F]); (2) tachypnea (>24 breaths/min); (3) tachycardia (heart rate >90 beats/min); (4) leukocytosis (>12,000/μL), leukopenia (<4000/μL), or >10% bands Sepsis (or severe sepsis) The harmful host response to infection; systemic response to proven or suspected infection plus some degree of organ hypofunction, i.e.: 1. Cardiovascular: Arterial systolic blood pressure ≤90 mmHg or mean arterial pressure ≤70 mmHg that responds to administration of IV fluid 2. Renal: Urine output <0.5 mL/kg per hour for 1 h despite adequate fluid resuscitation 3. Respiratory: PaO2/FIO2 ≤250 or, if the lung is the only dysfunctional organ, ≤200 4." }, { "id": "Obstentrics_Williams_7292", "title": "Obstentrics_Williams", "score": 0.01101866983608181, "content": "One scheme for management of acute pyelonephritis is shown in Table 53-2. Urine cultures are taken, but prospective trials show that blood cultures are of limited clinical utility (Gomi, 2015; Wing, 2000). We obtain blood cultures if the temperature is >39°C. Intravenous hydration to ensure adequate urinay ouput is the cornerstone of treatment. Antimicrobials are also begun promptly with the caveat that they may initially worsen endotoxemia from bacterial lysis. Surveillance for worsening sepsis syndrome includes serial monitoring of urinary output, blood pressure, pulse, temperature, and oxygen saturation. High fevers are lowered with a cooling blanket and acetaminophen. his is especially important in early pregnancy because of possible teratogenic efects from hyperthermia." }, { "id": "Surgery_Schwartz_1332", "title": "Surgery_Schwartz", "score": 0.010389132783230285, "content": "tachycardic, but they do not exhibit a reduction in blood pressure until over 1500 mL of blood loss, or class III shock. Physical findings should be used as an aid in the evaluation of the patient’s response to treatment. The goal of fluid resuscitation is to re-establish tissue perfusion. Fluid resuscitation usually begins with isotonic crystalloid, typically Ringer’s lactate. However, for patients arriving in shock (persistent SBP <90 mmHg in an adult), instead of crystalloid the current practice is to activate a massive trans-fusion protocol (MTP) in which red blood cells (RBC) and fresh frozen plasma (FFP) are administered. The details of a MTP are discussed later. Patients who have a good response to Brunicardi_Ch07_p0183-p0250.indd 19110/12/18 6:17 PM 192BASIC CONSIDERATIONSPART Ifluid infusion (i.e., normalization of vital signs, clearing of the sensorium) and evidence of good peripheral perfusion (warm extremities with normal capillary refill) are presumed to have adequate" }, { "id": "First_Aid_Step2_497", "title": "First_Aid_Step2", "score": 0.009990097920563318, "content": "■Signs and symptoms are similar to those of cystitis but show evidence of upper urinary tract disease. ■ Symptoms include f ank pain, fever/chills, and nausea/vomiting. Dysuria, frequency, and urgency are also possible. ■UA and culture: Results are similar to those of cystitis, but with WBC casts. Send blood cultures to rule out urosepsis. Pyelonephritis is the most common serious medical complication of pregnancy. Twenty to thirty percent of patients with untreated bacteriuria will develop pyelonephritis. When in doubt, admit a patient with pyelonephritis and administer IV antibiotics. Urosepsis must be considered in any elderly patient with altered mental status. SIRS = two or more of the following: 1. Temperature: Either < 36°C or > 38°C (i.e., hypothermia or fever). 2. Tachypnea: > 20 breaths per minute or PaCO2 < 32 mmHg on ABG. 3. Tachycardia: HR > 90 bpm. 4. Leukocytosis/leukopenia: WBC < 4000 cells/mm3 or > 12,000 cells/mm3. CBC: Reveals leukocytosis." }, { "id": "pubmed23n0583_9222", "title": "Rapidly progressive fatal pneumococcal sepsis in adults: a report of two cases.", "score": 0.009900990099009901, "content": "We report two cases of a rapidly progressive fatal overwhelming pneumococcal infection. Patient 1 was a 67-year-old man with a 24-h history of fever and malaise and was transferred to our department. He was severely ill, tachypneic, and felt a chill. A purpuric discoloration with ecchymosis of the skin was noted over the body. The chest X-ray findings demonstrated thickening of the bronchovascular bundle in the right lower lung field, which later revealed the presence of bronchopneumonia. Laboratory studies revealed the presence of metabolic acidosis and disseminated intravascular coagulation. After presentation, rapid deterioration occurred followed by cardiopulmonary arrest. Despite cardiopulmonary resuscitation, the patient died only 3 h after presentation. The isolates from the patient's blood revealed penicillin-susceptible Streptococcus pneumoniae, serotype 4. Patient 2 was a 30-year-old woman with a prior history of uneventful pregnancies was transferred to our department with a 2-day history of fever, nausea, headache, and malaise. Although she was in the 19th week of pregnancy at the time, she suffered a miscarriage just prior to admission. Upon presentation to our department, she demonstrated unstable vital signs, diminished consciousness, anuria, and icterus. Purpuric discoloration with ecchymosis of the skin was noted in over most of her body, including the distal extremities. The chest X-ray findings were close to normal. Initial laboratory studies revealed the presence of severe metabolic acidosis and disseminated intravascular coagulation with multiple organ failure. Despite aggressive cardiopulmonary support, normal neurological responses disappeared on the 2nd day following admission and the patient died on the 16th day after admission. The patient's isolates from blood and vaginal swabs both later revealed penicillin-susceptible Streptococcus pneumoniae, serotype 12F. The presentation of rapidly progressive septic shock should raise the treating physician's suspicion of overwhelming pneumococcal infection, which has limited management options." }, { "id": "pubmed23n0599_9063", "title": "Who needs a blood culture? A prospectively derived and validated prediction rule.", "score": 0.009900990099009901, "content": "The study objective was to derive and validate a clinical decision rule for obtaining blood cultures in Emergency Department (ED) patients with suspected infection. This was a prospective, observational cohort study of consecutive adult ED patients with blood cultures obtained. The study ran from February 1, 2000 through February 1, 2001. Patients were randomly assigned to derivation (2/3) or validation (1/3) sets. The outcome was \"true bacteremia.\" Features of the history, co-morbid illness, physical examination, and laboratory testing were used to create a clinical decision rule. Among 3901 patients, 3730 (96%) were enrolled with 305 (8.2%) episodes of true bacteremia. A decision rule was created with \"major criteria\" defined as: temperature &gt; 39.5 degrees C (103.0 degrees F), indwelling vascular catheter, or clinical suspicion of endocarditis. \"Minor criteria\" were: temperature 38.3-39.4 degrees C (101-102.9 degrees F), age &gt; 65 years, chills, vomiting, hypotension (systolic blood pressure &lt; 90 mm Hg), neutrophil% &gt; 80, white blood cell count &gt; 18 k, bands &gt; 5%, platelets &lt; 150 k, and creatinine &gt; 2.0. A blood culture is indicated by the rule if at least one major criterion or two minor criteria are present. Otherwise, patients are classified as \"low risk\" and cultures may be omitted. Only 4 (0.6%) low-risk patients in the derivation set and 3 (0.9%) low-risk patients in the validation set had positive cultures. The sensitivity was 98% (95% confidence interval [CI] 96-100%) (derivation) and 97% (95% CI 94-100%) (validation). We developed and validated a promising clinical decision rule for predicting bacteremia in patients with suspected infection." }, { "id": "wiki20220301en009_14185", "title": "Sepsis", "score": 0.00980392156862745, "content": "Early recognition and focused management may improve the outcomes in sepsis. Current professional recommendations include a number of actions (\"bundles\") to be followed as soon as possible after diagnosis. Within the first three hours, someone with sepsis should have received antibiotics and, intravenous fluids if there is evidence of either low blood pressure or other evidence for inadequate blood supply to organs (as evidenced by a raised level of lactate); blood cultures also should be obtained within this time period. After six hours the blood pressure should be adequate, close monitoring of blood pressure and blood supply to organs should be in place, and the lactate should be measured again if initially it was raised. A related bundle, the \"Sepsis Six\", is in widespread use in the United Kingdom; this requires the administration of antibiotics within an hour of recognition, blood cultures, lactate, and hemoglobin determination, urine output monitoring, high-flow oxygen, and" }, { "id": "InternalMed_Harrison_32531", "title": "InternalMed_Harrison", "score": 0.00980392156862745, "content": "The disposition of younger, previously healthy heat-exhaustion patients who have no major laboratory abnormalities may include hospital observation and discharge after IV rehydration. Older patients with comorbidities (including cardiovascular disease) or predisposing factors often require inpatient fluid and electrolyte replacement, monitoring, and reassessment. The clinical manifestations of heatstroke reflect a total loss of thermo-regulatory function. Typical vital-sign abnormalities include tachypnea, various tachycardias, hypotension, and a widened pulse pressure. Although there is no single specific diagnostic test, the historical and physical triad of exposure to a heat stress, CNS dysfunction, and a core temperature >40.5°C helps establish the preliminary diagnosis." }, { "id": "pubmed23n0991_9316", "title": "Near-infrared Spectroscopy in Transport With a Patient in Multi-factorial Shock.", "score": 0.009708737864077669, "content": "A 14-year-old male with a history of repaired truncus arteriosus presented to an outside hospital emergency room in respiratory distress. The triage report to the transport referral center included the following vital signs: temperature of 36.6°C, respiratory rate (RR) of 26 breaths/min, heart rate (HR) of 144 beats/min, and blood pressure (BP) of 113/52 mm Hg with peripheral capillary oxygen saturation (SpO<sub2</sub) of 95% on 4 L via an OxyMask (SouthMedic, Barrie, Ontario, Canada). Additional information indicated severe right ventricle to pulmonary artery conduit stenosis; anuria for 2 days; and cool, mottled extremities. The transport team was dispatched via helicopter. The vital signs upon arrival were as follows: temperature of 36.5°C, HR of 153 beats/min, RR of 48 breaths/min, BP of 81/52, mean arterial pressure of 62, and SpO<sub2</sub of 96% on 8 L via an OxyMask. Physical assessment revealed the patient was alert and oriented, tachypneic, tachycardic, and displaying poor perfusion. An epinephrine drip was initiated while the patient was being prepared for transport. Near-infrared spectroscopy (NIRS) was initiated with cerebral NIRS of 71% and renal NIRS of 39%. The epinephrine drip was escalated, and norepinephrine was initiated and titrated up for continued poor perfusion and low renal NIRS. Vitals at the transfer of care at the receiving facility were HR of 142 beats/min, BP of 91/51 mm Hg, RR of 56 breaths/min, SpO<sub2</sub of 99%, and cerebral NIRS of 75% and renal NIRS of 53%. The patient required mechanical circulatory support shortly after admission. NIRS monitoring was used to help measure perfusion and reassess interventions made during transport." }, { "id": "pubmed23n0546_6181", "title": "Risk factors for heat related death during the August 2003 heat wave in Paris, France, in patients evaluated at the emergency department of the Hôpital Européen Georges Pompidou.", "score": 0.009708737864077669, "content": "This study sought to determine the risk factors for short term mortality in the victims of the heat wave of August 2003 in France from among patients evaluated in our emergency department (ED). It was hypothesised that age, temperature, and some long term therapies and pre-existing pathologies were factors associated with short term mortality. A retrospective analysis of a seven day period. Four experts decided blindly, in pairs, whether a patient had presented with a heat related problem. Inclusion criteria were: core temperature &gt; or =38 degrees C and/or clinical signs of dehydration. Comparisons were made between the survivors and one month non-survivors for 57 different items. Short term mortality was defined as death in the ED or within the first month of the ED visit. Of 841 patients attending the ED in the study period, 165 were included in the study, of which most were elderly women. Thirty one (18.8%) died within one month. Factors associated with short term mortality were: a greater degree of dependent living; more severe clinical condition on admission (higher temperature and heart rate, lower blood pressure, hypoxia, and altered mental status); higher values of blood glucose, troponin, and white blood cell count; lower values of serum protein and prothrombin levels; pre-existing ischaemic cardiomyopathy; pneumonia as associated infection; and previous psychotropic treatment. The total number of survivors at one year was 91. Although this study is limited because of the small sample size, the results have helped determine factors useful for future identification of patients at greatest risk of death in order to implement a more efficient patient care protocol." }, { "id": "pubmed23n0088_2504", "title": "[Status epilepticus induced by prolonged immersion in hot herb bath: report of one case].", "score": 0.009615384615384616, "content": "A 6-year-old girl with cerebral palsy developed conscious disturbance and generalized convulsion after one-hour hot herb drug bath. Physical examination on admission revealed rectal temperature 41 degrees C, hot skin, respiration 46/min, regular heart beat 98/min, BP 130/60 mmHg, Glascow coma scale 4 (E2M1V1), soft and flat abdomen, no hepatosplenomegaly, no skin rash, no focal neurological sign, increased generalized muscle ton. Laboratory data showed CBC: WBC 20400 cumm (Neutrophils 31%, Lymphocytes 69%), Hb 11.6gm%, ESR 11 mm/hr, arterial blood gas: PH 7.077, PO2 43mmHg, PCO2 57.1mmHg, HCO3- 16 mEq/L, BE-11.5mEq/L, serum sodium 143 mEq./L, potassium 5.2 mEq/L, chloride 101 mEq/L, free calcium ion 3.8mg%, GOT 63IU/L, GPT 263 IU/L, amylase 193 IU/L, alkaline phosphatase 388 IU/L, LDH 1245 IU/L, CPK 677 IU/L, total bilirubin 0.8 mg/dl, direct type 0.1 mg/dl, BUN 18 mg/dl, Glucose 35 mg/dl. Urinalysis revealed proteinuria( ) trace hematuria and pyuria, but no cast. Lumbar puncture is within normal limits. Bacteriology including blood and CSF are normal. Multiple organ failure was noted at that time. Intensive cooling methods were performed including central and peripheral cooling. We used luminal and valium to control the seizure. Condition didn't improve. Afterwards cardiopulmonary arrest developed. Patient expired 8 hours after admission despite of resuscitation. Heat stroke in infancy and childhood is different from that in adulthood. The predisposing factors are high ambient temperature, dehydration, very young baby, sweat gland dysfunction, or ectodermal dysplasia. Definition of heat stroke includes 1) rectal temperature above 41 degrees C, 2) behavioral change, 3) warm skin, wet or dry.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en020_27369", "title": "Hypotension", "score": 0.009523809523809525, "content": "Volume resuscitation (usually with crystalloid or blood products) Blood pressure support with a vasopressor (all seem equivalent with respect to risk of death, with norepinephrine possibly better than dopamine). Trying to achieve a mean arterial pressure (MAP) of greater than 70 mmHg does not appear to result in better outcomes than trying to achieve a MAP of greater than 65 mm Hg in adults. Ensure adequate tissue perfusion (maintain SvO2 >70 with use of blood or dobutamine) Address the underlying problem (i.e., antibiotic for infection, stent or CABG (coronary artery bypass graft surgery) for infarction, steroids for adrenal insufficiency, etc...) The best way to determine if a person will benefit from fluids is by doing a passive leg raise followed by measuring the output from the heart." }, { "id": "pubmed23n0124_8843", "title": "[Electrocardiographic and hemodynamic changes during systemic hyperthermia (42 degrees C)].", "score": 0.009523809523809525, "content": "During systemic hyperthermia (42 degrees C), depression of ST segments or T wave changes in the left precordial leads were noticed in 56% of patients, and 29% of cases showed right bundle branch block. Supraventricular tachycardia was found in 26% and temporary deviation of mean frontal vector to the left axis was observed in 15%. These changes disappeared following recovery to normal temperature. The ECG findings for any particular patient were similar even during a second period of hyperthermia. Pulse rate became elevated by 1.7 times, and cardiac output became up to 2.4 times higher at 42 degrees C." }, { "id": "pubmed23n1041_1216", "title": "A Middle-Aged Woman With Hematochezia, Hypotension, and Leg Cramps.", "score": 0.009433962264150943, "content": "A 57-year-old woman with a history of mantle cell lymphoma presented to the ED with complaints of vomiting, bleeding per rectum, and leg cramps, that started 6 h prior to her arrival. She had received chemotherapy a week prior. Her leg cramps were not associated with pain or swelling of the legs; she also denied any trauma to the legs. She did complain of mild lower abdominal pain at presentation. Review of systems was negative for fever, chills, diarrhea, chest pain, and dizziness. She denied using alcohol or nonsteroidal anti-inflammatory drugs. The patient was tachycardic with a systolic BP (SBP) of 85 mm Hg and was administered 1-L normal saline, with improvement in her SBP to 90 mm Hg. The hematocrit level was 24%, the WBC count was 0.3 × 10<sup9</sup/L, and the platelet count was 6 × 10<sup9</sup/L in the ED. On arrival in the ICU, she was noted to have an SBP of 70 mm Hg. Resuscitation with IV fluids was initiated, followed by transfusion of packed RBCs and platelets, based on the blood counts. Despite aggressive fluid resuscitation and improvement in her hemoglobin, the patient remained persistently hypotensive. The diagnosis of underlying septic shock because of neutropenia was considered; the patient was started on vasopressors and empirical broad-spectrum antibiotics, with improvement in her BP. After this, the patient was sent to radiology for a CT scan of the abdomen and pelvis with contrast to evaluate for mesenteric infarction, enteric or colonic bleeding, and the need for arterial embolization." }, { "id": "pubmed23n0495_3220", "title": "Cases from the Osler Medical Service at Johns Hopkins University.", "score": 0.009433962264150943, "content": "PRESENTING FEATURES: A 70-year-old African American man was admitted with a history of fever, chills, and malaise of several days' duration. His past medical history was notable for end-stage renal disease requiring hemodialysis, coronary artery disease, and aortic stenosis requiring a bioprosthetic aortic valve replacement. On the day of admission, the patient was noted to have a shaking chill while undergoing dialysis through his catheter and was admitted to the hospital. He complained of pain at the catheter insertion site, shortness of breath, and dyspnea on exertion, but denied chest pain. On physical examination, the patient had a temperature of 100.4 degrees F, with a heart rate of 64 beats per minute, blood pressure of 127/72 mm Hg, and an oxygen saturation of 97% on room air. He was a mildly obese man in no apparent distress. He had shotty cervical lymphadenopathy and a right subclavian dialysis catheter in place, with erythema and pus at the entry site. His jugular venous pressure was 10 cm H(2)O. Lung examination showed bibasilar rales. Heart sounds were normal, with no rub or gallop. He had a 2/6 systolic ejection murmur best heart at the left sternal border as well as a 3/6 holosystolic murmur at the apex that radiated to his left axilla. Examination of the abdomen and extremities was unremarkable. The patient's neurological examination was unremarkable, and he was alert and oriented to person, place, and time. Laboratory studies showed an elevated white blood cell count of 16,700 cells/microL. His blood urea nitrogen level was 43 mg/dL and his serum creatinine level was 4.9 mg/dL. Multiple blood cultures grew methicillin-resistant Staphylococcus aureus. An admission, chest radiograph showed no infiltrate. An admission electrocardiogram showed normal sinus rhythm with first degree atrioventricular block, left anterior fascicular block, and left ventricular hypertrophy. shows rhythm strips from lead II electrocardiograms 5 months before admission (top), on admission (middle) and 5 days after admission (bottom). What is the diagnosis?" }, { "id": "pubmed23n0597_11615", "title": "A middle-aged female with recurrent sinopulmonary infections: a case report.", "score": 0.009345794392523364, "content": "Common variable immunodeficiency (CVID) is a form of severe antibody deficiency with an estimated prevalence of 1 in 25,000 to 1 in 100,000. The disorder apparently results from currently undefined immune deregulations resulting in failed B-cell differentiation with impaired secretion of immunoglobulins. It has a broad range of clinical symptoms including recurrent infections of the respiratory tract, chronic lung disease, autoimmune diseases, liver and gastrointestinal disorders, granulomatous infiltrations, lymphoma and solid tumors. A 42-year-old Caucasian female presented with a one-day history of high-grade fever and productive cough associated with retrosternal chest pain. The patient had been discharged one week prior after a prolonged stay in an intensive care unit with multiorgan failure requiring temporary hemodialysis for two weeks secondary to sepsis. Past medical history was significant for chronic obstructive pulmonary disease, recurrent pneumonias and recurrent sinus infections since adolescence. She had a temperature of 99.8 degrees F, was tachycardic (137/min), tachypneic (26/min) with a blood pressure of 109/59 mmHg and oxygen saturation of 88% on 2 l/min nasal oxygen. Physical examination was significant for bibasilar rhonchi. Laboratory data were significant for leukocytosis of 15,700/mm3. Chest X-ray demonstrated bibasilar infiltrates. The patient was started on intravenous levofloxacin and vancomycin, and sputum gram stain and cultures were performed. Given the patient's recurrent respiratory infections, an underlying immunologic disorder was considered. Work-up revealed immunoglobulin A (IgA) 11 mg/dl (normal 70-400 mg/dl), immunoglobulin M (IgM) 2 mg/dl (normal 40-230 mg/dl) and IgG 53 mg/dl (normal 700-1,600 mg/dl). The patient was diagnosed with CVID and started on intravenous immunoglobulin. She was initially started on a four-week regimen of intravenous immunoglobulin, which was later switched to a three-week regimen as the patient had respiratory infections on the four-week regimen. She remained asymptomatic on a three times/week intravenous immunoglobulin regimen. This case emphasizes the need for a high index of clinical suspicion for CVID in patients presenting with recurrent sinopulmonary infections. Although intravenous immunoglobulin provides improvement in these patients, early diagnosis is the key to preventing significant morbidity and mortality and improving prognosis." }, { "id": "pubmed23n0004_14676", "title": "[Factor analysis fever in the early postoperative period following cardiopulmonary bypass surgery in adults. Correlation with bacteriological data. Statistical study of 518 case histories by computer].", "score": 0.009345794392523364, "content": "The results of a continuous series of 518 adults undergoing cardiopulmonary bypass surgery, operated on by the same surgeon, comprising valvular replacement and aorto-coronary bypass surgery with a peroperative protocol of asepsis and a short prophylactic course of Penicillin and Streptomycin, a preoperative and postoperative bacteriological study, were treated by computer. The postoperative temperature chart showed a progressively decreasing pyrexia in the first 8 days after cardiopulmonary bypass. The nature of the operation, the bypass time, the quantity of blood used during operation and the blood loss were statistically significant factors. Patients with a clinical infection had significantly higher temperatures from the first on. 8,9% of patients had a febrile reaction which continued after the 10th day after cardiopulmonary bypass. The cause was not always apparent but the appearance of their temperature graphs was distinguishable after the first week. Analysis of the systematic bacterial specimens showed bacterial contamination of nearly 10% of drains, 10% of blood cultures, over 15% of intravenous infusion catheters and 70% of urinary catheters. The significance of these results is discussed. The normal appearance of the temperature chart after cardiopulmonary bypass surgery in the absence of clinical complications and bacterial contamination has been established." }, { "id": "pubmed23n0360_11272", "title": "[Autoimmune hepatitis complicated by intolerable pain of lower extremities and shock due to azathioprine].", "score": 0.009259259259259259, "content": "A 24-year-old woman was followed for about ten months with oral administration of prednisolone (22.5-35 mg/d) for autoimmune hepatitis. In June 1995, she noticed fatigue and appetite loss and blood chemistry revealed markedly deteriorated liver function. She was admitted to our hospital. The daily dose of prednisolone was increased to 60 mg. Her elevated levels of transaminases decreased gradually. Administration of azathioprine (100 mg/d) was started with tapering of prednisolone on August 18th. Ten days later, tender cervical lymphadenopathy and high fever occurred. Azathioprine administration was stopped immediately and intravenous antibiotics were given. On September 5th, 50 mg of azathioprine was administered again. Two hours later, the patient complained of intolerable pain from the lumbar region to the knee joints, which subsided following two injections of analgesics within a few hours. However, chills, high fever and hypotension (86/30 mmHg) subsequently developed. No bacterial growth was detected in blood culture. She was discharged on September 12th. On October 4th, she visited our out-patient clinic. The next day, she took one tablet (50 mg) of azathioprine at 10 o'clock. She noted intense pain from the thighs to the knees and calves around noon again. Her home doctor found that she exhibited shock (BP 67/?). She was immediately taken to our department. The same symptoms and signs as the above-mentioned occurred. Azathioprine was considered responsible for these two adverse reactions (shock) as an allergen. Later, systemic lupus eythematosus was diagnosed in 1996. And she died to pulmonary hypertension in May 1999. Physicians should be aware of the potential adverse effect of azathioprine administered in order to manage the patients with autoimmune disorders." }, { "id": "pubmed23n0573_19564", "title": "[Influence of axillary temperature on blood culture yield in the emergency department].", "score": 0.009259259259259259, "content": "To determine the clinical and epidemiological characteristics of patients undergoing blood culture in the emergency department and to identify the relation between the results of blood culture and axillary temperature at blood extraction. We performed a prospective, observational study. All patients who underwent blood extraction by 2 emergency department nurses, as indicated by physicians, between January 2004 and December 2005 were included. The patients were stratified into subgroups according to their temperature on extraction and final diagnosis. Bivariate analysis was performed to compare the clinical and epidemiological characteristics of the patients in relation to the presence of bacteremia and the distinct subgroups established. Isolates of common contaminating microorganisms were discarded. A total of 603 patients were included. The highest percentages of bacteremia were found in patients with high fever or hypothermia. Among the overall group of patients, a significant correlation was found between axillary temperature and bacteremia. However, when patients with a final diagnosis of a disease with a low probability of bacteremia were excluded, this correlation disappeared and no association was found between temperature and the risk of bacteremia in specific infectious processes (pneumonia, pyelonephritis, etc). The main factor associated with bacteremia was the disease prompting blood culture rather than patient temperature." }, { "id": "pubmed23n0921_24414", "title": "2-Methyl-4-chlorophenoxyacetic acid (MCPA) and bromoxynil herbicide ingestion.", "score": 0.009174311926605505, "content": "Ingestion of bromoxynil and 2-methyl-4-chlorophenoxyacetic acid (MCPA) in combination is associated with high mortality. Toxicity is characterised by hyperthermia and metabolic acidosis. Dialysis is a proposed treatment, but little data exist regarding its effectiveness. Case 1: A 50-year-old female presented 18 h post-ingestion of 200  mL of bromoxynil(200 g/L) and MCPA(200 g/L). She was agitated, tachycardic and tachypnoeic. She was intubated and continuous venovenous haemodiafiltration (CVVHDF) was commenced. She deteriorated, becoming hypotensive, hyperthermic (39.5 °C) and hypercapnic (80 mmHg). She was cooled, paralysed, received CVVHDF for 2d and was extubated on day 4 making a full recovery. Case 2: A 60-year-old male presented 6 h post-ingestion of an unknown amount of bromoxynil (200 g/L) and MCPA (200 g/L). On arrival, he was tachycardic and tachypneic (pCO<sub2</sub 25 mmHg). At 8h post-ingestion he became hyperthermic, hypercapnic and acidotic (pH 7.15), and was intubated, paralysed, cooled and received CVVHDF for 36 h. He was extubated after 42 h and made a full recovery. Bromoxynil and MCPA serum and effluent concentrations were measured. Peak MCPA serum concentrations were 161 µg/ml and 259 µg/ml and peak bromoxynil concentrations were 119 µg/ml and 155 µg/ml in case 1 and 2, respectively. The estimated clearance of both herbicides by CVVHDF was low (&lt;10 mL/min). CVVHDF did not result in significant clearance of either herbicide but may have assisted with hyperthermia control. Both patients survived with vigorous cooling, paralysis and ventilatory support." }, { "id": "pubmed23n0678_2820", "title": "[Blood cultures when fever?].", "score": 0.009174311926605505, "content": "A 78-year-old man was referred from his residency where he lives to the emergency division due to general deterioration and frequent falls in the last week. His personal history is remarkable for arterial hypertension and diabetes. Two weeks before he needed a vesical catheterism that was traumatic and profilactic ciprofloxacin was prescribed. On physical exploration he appears disoriented, blood pressure is 9/40 mm Hg, cardiac rythm 120 beats per minute, temperature 37,3 °C and 24 respirations per minute. He appears to have pain on his upper left abdomen cuadrant. When the nurse gets a peripheral vein she asks, ¿should I obtain hemocultures?" }, { "id": "wiki20220301en027_60985", "title": "Major trauma", "score": 0.00909090909090909, "content": "A FAST exam may help assess for internal bleeding. In certain traumas, such as maxillofacial trauma, it may be beneficial to have a highly trained health care provider available to maintain airway, breathing, and circulation. Intravenous fluids Traditionally, high-volume intravenous fluids were given to people who had poor perfusion due to trauma. This is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries. In general, however, giving lots of fluids appears to increase the risk of death. Current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. Targets include a mean arterial pressure of 60 mmHg, a systolic blood pressure of 70–90 mmHg, or the re-establishment of peripheral pulses and adequate ability to think. Hypertonic saline has been studied and found to be of little difference from normal saline." }, { "id": "pubmed23n0900_20858", "title": "The Absence of Fever Is Associated With Higher Mortality and Decreased Antibiotic and IV Fluid Administration in Emergency Department Patients With Suspected Septic Shock.", "score": 0.00909090909090909, "content": "This study evaluates whether emergency department septic shock patients without a fever (reported or measured) receive less IV fluids, have decreased antibiotic administration, and suffer increased in-hospital mortality. This was a secondary analysis of a prospective, observational study of patients with shock. The study was conducted in an urban, academic emergency department. The original study enrolled consecutive adult (aged 18 yr or older) emergency department patients from November 11, 2012, to September 23, 2013, who met one of the following shock criteria: 1) systolic blood pressure less than 90 mm Hg after at least 1L IV fluids, 2) new vasopressor requirement, or 3) systolic blood pressure less than 90 mm Hg and IV fluids held for concern of fluid overload. The current study is limited to patients with septic shock. Patients were grouped as febrile if they had a subjective fever or a measured temperature &gt;100.4°F documented in the emergency department; afebrile patients lacked both. Among 378 patients with septic shock, 207 of 378 (55%; 50-60%) were febrile by history or measurement. Afebrile patients had lower rates of antibiotic administration in the emergency department (81% vs 94%; p &lt; 0.01), lower mean volumes of IV fluids (2,607 vs 3,013 mL; p &lt; 0.01), and higher in-hospital mortality rates (33% vs 11%; p &lt; 0.01). After adjusting for bicarbonate less than 20 mEq/L, lactate concentration, respiratory rate greater than or equal to 24 breaths/min, emergency department antibiotics, and emergency department IV fluids volume, being afebrile remained a significant predictor of in-hospital mortality (odds ratio, 4.3; 95% CI, 2.2-8.2; area under the curve = 0.83). In emergency department patients with septic shock, afebrile patients received lower rates of emergency department antibiotic administration, lower mean IV fluids volume, and suffered higher in-hospital mortality." }, { "id": "pubmed23n1007_14583", "title": "A successful management after preterm delivery in a patient with severe sepsis during third-trimester pregnancy.", "score": 0.009009009009009009, "content": "A 33-year-old woman visited the emergency department presenting with fever and dyspnea. She was pregnant with gestational age of 31 weeks and 6 days. She had dysuria for 7 days, and fever and dyspnea for 1 day. The vital signs were as follows: blood pressure 110/70 mmHg, heart rate 118 beats/minute, respiratory rate 28/minute, body temperature 38.7℃, and oxygen saturation by pulse oximetry 84% during inhalation of 5 liters of oxygen by nasal prongs. Crackles were heard over both lung fields. There were no signs of uterine contractions. Chest X-ray and chest computed tomography scan showed multiple consolidations and air bronchograms in both lungs. According to urinalysis, there was pyuria and microscopic hematuria. She was diagnosed with community-acquired pneumonia and urinary tract infection (UTI) that progressed to severe sepsis and acute respiratory failure. We found extended-spectrum beta-lactamase producing <iEscherichia coli</i in the blood culture and methicillin-resistant Staphylococcus aureus in the sputum culture. The patient was transferred to the intensive care unit with administration of antibiotics and supplementation of high-flow oxygen. On hospital day 2, hypoxemia was aggravated. She underwent endotracheal intubation and mechanical ventilation. After 3 hours, fetal distress was suspected. Under 100% fraction of inspired oxygen, her oxygen partial pressure was 87 mmHg in the arterial blood. She developed acute kidney injury and thrombocytopenia. We diagnosed her with multi-organ failure due to severe sepsis. After an emergent cesarean section, pneumonia, UTI, and other organ failures gradually recovered. The patient and baby were discharged soon thereafter." }, { "id": "article-31671_2", "title": "EMS Clinical Diagnosis Without The Use Of A Thermometer -- Issues of Concern", "score": 0.009009009009009009, "content": "The subjective assessment of fever, as well as the assessment of other signs and symptoms that occur with infectious disease, is important in EMS. Pulse can be high due to fever, or with possible associated dehydration or shock. Palpating a pulse not only gives an accurate rate, but it also gives information about the effectiveness of blood pressure and flow. This can be of significant concern with a severe infectious disease, especially sepsis. Shock can develop quickly and differentiating infectious cause for shock will be important for definitive treatment. Unfortunately, people taking medications affecting the heart rate (such as beta blockers or calcium channel blockers) may not mount a tachycardic response, so a normal heart rate does not rule out fever or infection. Additionally, sepsis, especially in the elderly, can actually cause bradycardia (associated with end-organ failure.)" }, { "id": "wiki20220301en018_74247", "title": "Septic shock", "score": 0.008928571428571428, "content": "Treatment Treatment primarily consists of the following: Giving intravenous fluids Early antibiotic administration Early goal directed therapy Rapid source identification and control Support of major organ dysfunction Fluids Because lowered blood pressure in septic shock contributes to poor perfusion, fluid resuscitation is an initial treatment to increase blood volume. Patients demonstrating sepsis-induced hypoperfusion should be initially resuscitated with at least 30 ml/kg of intravenous crystalloid within the first three hours. Crystalloids such as normal saline and lactated Ringer's solution are recommended as the initial fluid of choice, while the use of colloid solutions such as hydroxyethyl starch have not shown any advantage or decrease in mortality. When large quantities of fluids are given, administering albumin has shown some benefit." }, { "id": "pubmed23n0120_14524", "title": "[Accidental deep hypothermia and circulatory arrest. Treatment with extracorporeal circulation].", "score": 0.008928571428571428, "content": "A 27-year old female was discovered at 4 a.m. lying in a wet field, the ambient temperature being of 4 degrees C. Her rectal temperature had fallen to 19 degrees C. She was comatose and failed to respond to noxious stimuli. Her pupils were dilated and fixed. Her respiratory rate was reduced to three to four breaths per min. Her blood pressure was not measurable and neither femoral or carotid pulse could be detected. The heart was in sinus rhythm with a rate of 40 b X min-1. During her transfer to hospital, she was ventilated with oxygen, a tidal volume of 300 ml and a rate of 10 b X min-1. On arrival in the emergency room, a short period of ventricular fibrillation preceded cardiac arrest. Cardiac massage and sodium bicarbonate infusion were continued during the transfer of the patient to the operating theatre. A femoro-femoral cardiopulmonary bypass was started with a bloodless priming, 3 mg X kg-1 heparin and a flow of 3,000 to 3,500 ml X min-1. Mean arterial pressure was maintained between 65 and 85 mmHg; cardiac massage was discontinued during the bypass. Within 50 min, ventricular fibrillation appeared, rectal temperature had increased to 33 degrees C. Electrical defibrillation (300 J) was successful. Cardiopulmonary bypass was stopped after 63 min. The postoperative course was uneventful, apart from transient pulmonary oedema. At the time of discharge, a week later, no loss of intellect or change in behaviour could be perceived.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en008_58101", "title": "Shock (circulatory)", "score": 0.008849557522123894, "content": "of 40 mmHg from baseline) despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may have a normalized blood pressure at the time that perfusion abnormalities are identified. The pathophysiology behind septic shock is as follows: 1) Systemic leukocyte adhesion to endothelial cells 2) Reduced contractility of the heart 3) Activation of the coagulation pathways, resulting in disseminated intravascular coagulation 4). Increased levels of neutrophils" }, { "id": "pubmed23n0493_1726", "title": "Mycotic pseudoaneurysm of the brachiocephalic artery.", "score": 0.008849557522123894, "content": "A 73-year-old woman with a history of hypertension and hyperlipidemia presented with a sharp pain ranging from the right shoulder to the upper limb. She had suffered a sharp pain at rest accompanied by general fatigue and nausea for about ten months prior to admission. Her white blood cell count was 12,800/microl, and her serum C-reactive protein was 17.5 mg/dl. A chest computed tomography scan revealed an aneurysmal change of the origin of the brachiocephalic artery. Pseudoaneurysm due to infection and aortic dissection was considered as a preoperative diagnosis. A total arch replacement was performed under cardiopulmonary bypass, deep hypothermia, and selective cerebral perfusion. Postoperatively, a bacteriologic culture of the contents of the aneurysm revealed Staphylococcus aureus. Perioperative administration of antibiotics was effective and the postoperative course was uneventful." }, { "id": "wiki20220301en009_14154", "title": "Sepsis", "score": 0.008771929824561403, "content": "Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is followed by suppression of the immune system. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. There may also be symptoms related to a specific infection, such as a cough with pneumonia, or painful urination with a kidney infection. The very young, old, and people with a weakened immune system may have no symptoms of a specific infection, and the body temperature may be low or normal instead of having a fever. Severe sepsis causes poor organ function or blood flow. The presence of low blood pressure, high blood lactate, or low urine output may suggest poor blood flow. Septic shock is low blood pressure due to sepsis that does not improve after fluid replacement." }, { "id": "pubmed23n0253_4620", "title": "[An elder case of accidental hypothermia].", "score": 0.008771929824561403, "content": "A 87-year-old woman with accidental hypothermia was admitted to our hospital. On admission, she showed consciousness disturbance (JSC III-200) the decorticate rigidity and shock. Her body temperature was too low to been measured and her ECG revealed a J wave. She received the external rewarming and warm fluid replacement. Her consciousness level recovered to JSC II-20 after 2.5 hours of treatment, to JCSI-1 after 7.5 hours. Her body temperature reached 34.5 degrees C 9.5 hours later, and the J wave on ECG disappeared. She was discharged without complications on the 6th hospital day. it was suggested that early diagnosis and the proper therapy improves the mortality of accidental hypothermia." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 372, 777 ] ], "word_ranges": [ [ 55, 130 ] ], "text": "In this clinical case, the one who has the disease and has the mutated gene in heterozygosis is the brother (26 years old) of the pregnant woman. I think that before doing the chorion biopsy, the pregnant woman should be tested to know her ATXN3 gene status. She has a 50% chance of carrying the mutation and having the disease, but since she is 31 years old, I think she should have already had symptoms." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "It is indicated after studying the Consultant's genotype and only if it is heterozygous.", "2": "This is not indicated, since SCA3 ataxia is full penetrance and the Consultant is asymptomatic and therefore has not inherited the mutation.", "3": "It may be indicated in the next pregnancy, after studying the genotype of the first child and detecting the mutation in it.", "4": "SCA3 ataxia is recessively inherited, so there is no appreciable risk of disease transmission and PND is not indicated.", "5": "This is indicated regardless of the Consultant's genotype, since SCA3 ataxia is maternally inherited (transmitted by women)." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0479_23146", "title": "Preimplantation genetic diagnosis of spinocerebellar ataxia 3 by (CAG)(n) repeat detection.", "score": 0.019327731092436976, "content": "Spinocerebellar ataxia 3 (SCA3) is an autosomal dominant neurodegenerative disorder characterized by variable expression and a variable age of onset. SCA3/MJD (Machado-Joseph disease) is caused by an expansion of a (CAG)(n) repeat in the MJD1 gene on chromosome 14q32.1. A single cell PCR protocol has been developed for preimplantation genetic diagnosis (PGD) of SCA3 to select unaffected embryos on the basis of the CAG genotype. Single leukocytes and blastomeres served as a single cell amplification test system to determine the percentage of allelic drop-out (ADO) and PCR efficiency. Out of 105 tested heterozygous single leukocytes, 103 (98.1%) showed a positive amplification signal, while five cells (4.9%) showed ADO. Amplification in single blastomeres was obtained in 13 out of a total of 14, and ADO was observed in two out of the 13 single blastomeres. PGD of SCA3 was performed in a couple with paternal transmission of the SCA3 allele. Seven embryos were available for biopsy, all biopsied blastomeres showed amplification and no ADO occurred. One embryo was diagnosed as affected whereas six embryos were diagnosed as unaffected. Two unaffected embryos were transferred and resulted in a singleton pregnancy and the birth of a healthy girl." }, { "id": "pubmed23n0321_317", "title": "Prenatal diagnosis of Machado-Joseph disease by direct mutation analysis.", "score": 0.018624393624393623, "content": "MJD is the most frequent dominant ataxia and an incapacitating disorder. Onset is most frequently during the reproductive years, and genetic counseling is its only means of prevention. The causative mutation--an expansion of a (CAG)n on chromosome 14q32.1--can now be directly detected. We now report the first two cases of prenatal diagnosis (PND). The first presented as a simultaneous request for predictive testing and PND at 14 weeks of pregnancy. Owing to time constraints, we performed a full protocol of counseling with shorter inter between sessions, while psycho-social evaluation of the other parent obstetric consults were also begun. We ensured that the couple wished termination if the fetus was a carrier, to avoid a presymptomatic test for the unborn child. We were thus able to deliver test results two weeks before PND. As the fetus carried an expanded allele (77 CAGs) inherited from his father, termination was performed and the couple received counselling, psychological and social support. The second case was the fetus of a carrier-mother that was diagnosed as non-carrier, also after amniocentesis." }, { "id": "pubmed23n0347_1130", "title": "Spinocerebellar ataxias in Spanish patients: genetic analysis of familial and sporadic cases. The Ataxia Study Group.", "score": 0.017470247177296307, "content": "Autosomal dominant cerebellar ataxias (ADCA) are a clinically heterogeneous group of neurodegenerative disorders caused by unstable CAG repeat expansions encoding polyglutamine tracts. Five spinocerebellar ataxia genes (SCA1, SCA2, SCA3, SCA6 and SCA7) and another related dominant ataxia gene (DRPLA) have been cloned, allowing the genetic classification of these disorders. We present here the molecular analysis of 87 unrelated familial and 60 sporadic Spanish cases of spinocerebellar ataxia. For ADCA cases 15% were SCA2, 15% SCA3, 6% SCA1, 3% SCA7, 1% SCA6 and 1% DRPLA, an extremely rare mutation in Caucasoid populations. About 58% of ADCA cases remained genetically unclassified. All the SCA1 cases belong to the same geographical area and share a common haplotype for the SCA1 mutation. The expanded alleles ranged from 41 to 59 repeats for SCA1, 35 to 46 [corrected] for SCA2, 67 to 77 for SCA3, and 38 to 113 for SCA7. One SCA6 case had 25 repeats and one DRPLA case had 63 repeats. The highest CAG repeat variation in meiotic transmission of expanded alleles was detected in SCA7, this being of +67 units in one paternal transmission and giving rise to a 113 CAG repeat allele in a patient who died at 3 years of age. Meiotic transmissions have also shown a tendency to more frequent paternal transmission of expanded alleles in SCA1 and maternal in SCA7. All SCA1 and SCA2 expanded alleles analyzed consisted of pure CAG repeats, whereas normal alleles were interrupted by 1-2 CAT trinucleotides in SCA1, except for three alleles of 6, 14 and 21 CAG repeats, and by 1-3 CAA trinucleotides in SCA2. No SCA or DRPLA mutations were detected in the 60 sporadic cases of spinocerebellar ataxia, but one late onset patient was identified as a recessive form due to GAA-repeat expansions in the Friedreich's ataxia gene." }, { "id": "pubmed23n0348_13915", "title": "[Clinico-genetic study of type I spinocerebelllar ataxia].", "score": 0.016567656765676567, "content": "Inherited, autosomal-dominant cerebellar ataxia (ADCA) comprises a genetically and clinically heterogenous group of neurodegenerative disorders. Clinical classification of these disorders was an important step [2] in differentiation among several types, the most common one being ADCA-I, accompanied with supranuclear ophthalmoplegia, optic nerve atrophy, symptoms of the basal ganglia lesions, dementia and amyotrophia. Molecular-genetic studies indicated genetic heterogeneity of ADCA-I with mutations of genetic loci on chromosome 6p (spinocerebellar ataxia type 1; SCA1), 12q (SCA2), 14q (SCA3), 19p (SCA6) and 16q (SCA4) [3]. Spinocerebellar ataxia type 1 (SCA1) is characterized by cerebellar ataxia, ophthalmoplegia and pyramidal signs [4], but also with other neurological findings that tend to prevent clinical differentiation among patients with SCA1, SCA2 and SCA3. The mutation inducing SCA1 is an instable expansion of trinucleotide (CAG) repeats in the coding region on chromosome 6 [5]. Herein, we report clinical features in patients from two families with SCA1: family I with 15 and family II with 8 affected members in 4 consecutive generations. The acceptable data (history, examination and/or insight into medical records) were obtained for 9 patients in family I and 7 patients in family II. The age at the onset of the disease was 37.8 +/- 11.3 years (mean value +/- SD) (range: 27-60) for all the patients, or 31.8 +/- 10.7 years (range: 7-60) for family I and 45.0 +/- 8.4 years (range: 35-55) for family II. Duration of the disease was 8.9 +/- 4.6 years (range: 3-15); 10.8 +/- 4.1 (range 5-15) and 5.7 +/- 3.8 years (range: 3-10) for families I and II, respectively. The mean number of CAG repeats in the mutated allele for SCA1 of the affected individuals was 50.5 +/- 6.2 (range 45-64). A significant inverse correlation (p &lt; 0.05) was noted between the number of CAG repeats and the age at the onset of the disease (Figure 3). Similarity of initial symptoms in SCA1 was noted. They include simultaneous gait-related problems and dysarthria (usually slurred speech). Occurrence of other neurological signs (Table 3) was also predictable in most cases and depended on the phase of SCA1 at the time of examination. Generally, it is believed that intra- and interfamilial phenotypic heterogeneity in SCA1 is lower than in SCA2 and SCA3 [12]). In conclusion, typical clinical manifestations of SCA1, at least in early phases of the disease, according to our study, include gait ataxia, dysarthria, brisk muscle reflexes and marked hand ataxia; the age at the onset of the disease was inverse, and clinical progression was directly related to the number of CAG repeats in the mutated allele on chromosome 6. Nevertheless, significant differences in clinical properties of this inherited disease are possible among different affected families." }, { "id": "pubmed23n0377_13301", "title": "[Autosomal dominant cerebellar ataxias in the Netherlands: a national inventory].", "score": 0.016036949130797357, "content": "To provide a comprehensive estimate of the number of Dutch autosomal dominant cerebellar ataxias (ADCA) families and patients and thus estimate the minimal prevalence of ADCA in the Netherlands. Furthermore, to observe the relative frequency of SCA mutations and to study genotype-phenotype correlations. Descriptive study and prevalence computation. Genotyping was based on cytosine-adenine-guanine (CAG)-repeat expansion detection in the SCA1, SCA2, SCA3, SCA6 and SCA7 genes. We analysed the results of SCA mutation analysis with respect to the number of genotyped families, gene carriers, and clinically affected individuals per SCA locus, as well as individual repeat length and age of onset. Parent-offspring couples were studied for anticipation. The minimal prevalence was extrapolated, based on the observation that at least 36% of ADCA families cannot be genotyped. Per May 1st 2000, 137 Dutch ADCA families were genotyped (SCA1: 15 families; SCA2: 14; SCA3: 64; SCA6: 28; SCA7: 16) and 382 affected individuals had been identified within these families. The extrapolated minimal prevalence was 2.8 per 100,000. All lengths of expanded trinucleotide repeats identified confirmed earlier results regarding pathogenic sizes. Anticipation with an associated increase of repeat length was observed in SCA2 and SCA3 families. The length of the trinucleotide repeat accounted for 65% of the variance in age of onset in SCA3." }, { "id": "pubmed23n0880_9148", "title": "Clinical features and genetic diagnosis of hereditary spinocerebellar ataxia 3.", "score": 0.015838509316770187, "content": "Spinocerebellar ataxia type 3 (SCA3) is a rare inherited autosomal dominant progressive neurological disorder, which results from a CAG‑repeat expansion in the gene encoding the deubiquitinating enzyme, ataxin‑3. At present, no effective treatment is available for this fatal disorder; however, certain studies have suggested that reducing the levels of mutant ataxin‑3 protein may reverse or halt the progression of disease in patients with SCA3. In the present study, clinical examinations were performed on a patient with SCA3 who exhibited disease features including coughing, expectoration and was bedridden with mobility limitation. CAG repetitions at SCA‑associated genes were detected in the patient's family by performing standard polymerase chain reaction (PCR) and triple‑repeat primed PCR. The numbers of CAG‑repeats within the two alleles of the gene of interest in the patient were 15 and 78. Notably, the patient's brother, who harbored 76 CAG‑repeats in one allele of the gene of interest, did not exhibit severe disease symptoms. These results suggest that the number of CAG‑repeats is a critical for determination of SCA3 disease severity and time of onset. In addition, the defined phenotypic characteristics of the patient in the present study provide useful insight for more accurate clinical diagnosis and genotyping of future patients. " }, { "id": "pubmed23n0483_1203", "title": "[Analysis and application of SCA1 and SCA3/MJD gene CAG repeats in Han population in Northeastern China].", "score": 0.015671870217324763, "content": "To investigate the normal range of (CAG)n in spinocerebellar ataxia type 1 (SCA1) gene and spinocerebellar ataxia type 3 (SCA3/MJD) gene in 110 normal subjects of Han population in Northeastern China, to assess the genotypes for clinically diagnosed spinocerebellar ataxia(SCA) individuals including 25 patients from 8 families and 6 sporadic patients, and to make presymptomatic and prenatal diagnosis. DNA fragments from the normal subjects and the patients were detected by fluorescence-PCR. Homozygosities were selected for DNA sequencing. The normal ranges of (CAG)n of SCA1 and SCA3/MJD were 20-39 and 14-38 repeats respectively, SCA1 was found mostly to be 26 and 27 repeats, allele frequency 34.09% and 20.91%; heterozygosity was 84.55%, SCA3/MJD was found mostly to be 14 repeats, allele frequency 39.55%, heterozygosity was 78.18%.(CAG)(68) of SCA3/MJD gene of one affected individual had been found in a family but no CAG mutative expansion in related members was observed. The normal ranges of CAG repeats vary with areas and races. SCAs genotyping is the first choice in presymptomatic and prenatal diagnosis." }, { "id": "pubmed23n0786_15145", "title": "[Analysis of SCA3/MJD3 gene mutation and genetic polymorphism in a guangxi family with spinocerebellar ataxia 3].", "score": 0.015243206211463804, "content": "Autosomal dominant cerebellar ataxias (ADCAs) comprise a group of genetically heterogeneous neurodegenerative disorders among which spinocerebellar ataxia type 3 (SCA3) represents the most common form of SCAs worldwide. The fragments of SCA3/MJD gene,which is the member of family GXPL1,were amplified by polymerase chain reaction (PCR). The PCR products of SCA3/MJD gene were detected with capillary electrophoresis (CE) and sequencing to evaluate the size of CAG repeats, feature in the transmission and the mutation in the family with SCA3 in Guangxi province. The results showed that the exon 10 of the SCA3/MJD gene contains 64-71 CAG repeats in all of the affected individuals and three asymptomatic carriers of the family. The number of the CAG repeats during transmission in the normal individuals carrying CGG allele remains consistent, suggesting that CGG allele could have no effect on intergenerational stability of CAG repeats in normal individuals. In addition, two novel point mutations were identified: IVS9-113 T &gt; C in the intronic region and a missense mutation 220 G &gt; A (Glu &gt; Gly) in the encoding region. These two novel point mutations have not been reported and the effect of the mutations on the phenotype of SCA3 is not clear." }, { "id": "pubmed23n0393_2347", "title": "Autosomal dominant cerebellar ataxias in ethnic Bengalees in West Bengal - an Eastern Indian state.", "score": 0.014998621450234353, "content": "Phenotypic and genotypic patterns of a hereditary disease in a large multiethnic country like India need to be studied in relation to geographical location and ethnicity of the population. The few reported studies from India on dominant ataxias (ADCA) have mostly been conducted on multiethnic populations and hence may not reflect the patterns observed in specific ethnic groups or geographical locations. The present study attempted to look into the patterns of ADCA amongst ethnic Bengalee patients hailing from the eastern Indian state of West Bengal. Between mid-1996 and mid-2000, in a clinic based study, 37 cases (from 14 families) with ADCA were studied. This included 33 affected and four asymptomatic members with abnormal physical signs. Genotypic analyses were performed on more than one affected member from each family. Clinical, neuroradiological and electrophysiological aspects were studied. Genotype analysis revealed: two families with SCA-1,4 families with SCA2,5 families with SCA3 and three families with undetermined genotype. Of the latter, phenotypically 2 were of ADCA 1 and one of ADCA 2 type. No clear preponderance of one particular genotype over another was observed. We noted significant intra- and interfamily variations in phenotype within the same genotype form as well as overlapping of clinical signs between different genotypes. Slow saccadic eye movements and peripheral neuropathy were not seen consistently in our ethnic Bengalee subjects with SCA2 genotypes. Similarly, extrapyramidal features, ophthalmoplegias and distal amyotrophy were seen in some but not in all families with SCA3 mutation. A peculiar form of abduction lag during slow pursuit movement of eyes was observed in an asymptomatic girl in an SCA3 family. Although SCA2 has been claimed to be the commonest form of ADCA in India, this does not appear to be so in our ethnic Bengalee subjects. Phenotypic expression of the genotype also appears to be variable amongst families and individuals. Hence, phenotypic expression appears to be an inconsistent marker of the SCA genotype in our patients." }, { "id": "pubmed23n1090_13173", "title": "Homozygous spinocerebellar ataxia type 3 in China: a case report.", "score": 0.01440511307767945, "content": "Spinocerebellar ataxia type 3 (SCA3) is a neurodegenerative disease caused by a heterozygous CAG repeat expansion in the ataxin 3 gene (<iATXN3</i). However, patients with homozygous SCA3 carrying expanded CAG repeats in both alleles of <iATXN3</i are extremely rare. Herein, we present a case of a 50-year-old female who had homozygous SCA3 with expansion of 62/62 repeats. Segregation analysis of the patient's family showed both a contraction pattern of CAG repeat length and stable transmission. The present case demonstrated an earlier onset and more severe clinical phenotype than that seen in heterozygous individuals, suggesting that the gene dosage enhances disease severity." }, { "id": "pubmed23n0356_6821", "title": "SCA2 trinucleotide expansion in German SCA patients.", "score": 0.014185367633643496, "content": "Autosomal dominant spinocerebellar ataxias (SCA) are a group of clinically and genetically heterogeneous neurodegenerative disorders which lead to progressive cerebellar ataxia. A gene responsible for SCA type 2 has been mapped to human chromosome 12 and the disease causing mutation has been identified as an unstable and expanded (CAG)n trinucleotide repeat. We investigated the (CAG)n repeat length of the SCA2 gene in 842 patients with sporadic ataxia and in 96 German families with dominantly inherited SCA which do not harbor the SCA1 or MJD1/SCA3 mutation, respectively. The SCA2 (CAG)n expansion was identified in 71 patients from 54 families. The (CAG)n stretch of the affected allele varied between 36 and 64 trinucleotide units. Significant repeat expansions occurred most commonly during paternal transmission. Analysis of the (CAG)n repeat lengths with the age of onset in 41 patients revealed an inverse correlation. Two hundred and forty-one apparently healthy octogenerians carried alleles between 16 and 31 repeats. One 50-year old, healthy individual had 34 repeats; she had transmitted an expanded allele to her child. The small difference between 'normal' and disease alleles makes it necessary to define the extreme values of their ranges. With one exception, the trinucleotide expansion was not observed in 842 ataxia patients without a family history of the disease. The SCA2 mutation causes the disease in nearly 14% of autosomal dominant SCA in Germany." }, { "id": "pubmed23n0249_19072", "title": "Detection of the Machado-Joseph disease/spinocerebellar ataxia three trinucleotide repeat expansion in families with autosomal dominant motor disorders, including the Drew family of Walworth.", "score": 0.014021421616358325, "content": "Affected members of 63 families with a variety of autosomal dominant late onset cerebellar ataxias (ADCA), and 29 patients with similar phenotypes but no affected relatives, were investigated for the trinucleotide (CAG) repeat expansion described in Japanese families with Machado-Joseph disease (MJD). This disorder had previously been shown to map to the region of chromosome 14 which also contains a locus causing ADCA in French families, spinocerebellar ataxia 3 (SCA3). The MJD/SCA3 mutation was identified in nine families with ADCA type I, and a further family in which affected members had parkinsonism, peripheral neuropathy, dystonia, and spasticity, but little evidence of cerebellar disease. Only one of the 10 families was British (the Drew family of Walworth); the others originated from India, Jamaica, Ghana, Brazil and France. There was no single clinical feature which distinguished patients with the MJD/SCA3 mutation from those with the CAG expansion on chromosome 6 (SCA1) or ADCA type I families with no known mutation. The CAG repeat length ranged from 13-41 copies on normal chromosomes and 62-80 copies on affected chromosomes. There was a significant inverse correlation between age of onset of symptoms and repeat length, but no significant effect of parental sex on repeat length or age of onset in offspring. DNA analysis for the MJD/SCA3 mutation is useful for diagnosis in patients with familial ataxic or extrapyramidal syndromes, and will aid genetic counselling in these disorders." }, { "id": "pubmed23n1046_7036", "title": "Genotype-phenotype correlation in 667 Chinese families with spinocerebellar ataxia type 3.", "score": 0.01369798971482001, "content": "Due to diverse symptoms of spinocerebellar ataxia type 3 (SCA3) and the high prevalence of SCA3 in China, a more in-depth study of Chinese SCA3 patients in a large cohort is well merited. During the last 10 years, 730 patients and 133 premanifest individuals from 667 SCA3 families genetically confirmed to have SCA3 were enrolled from three leading academic hospitals in China. The clinical profile and genotype-phenotype correlation were analyzed. A quadratic equation best explained the relationship between the logarithmically transformed age at onset (AAO) and expanded CAG repeats (expCAGs) (r<sup2</sup = 0.634, p &lt; 0.001). The expCAG and AAO in Asian populations and western populations were compared with the Chinese population. SCA3 individuals had shorter normal CAG repeats (norCAGs) than healthy controls (Mann-Whitney, p &lt; 0.0001). Most (92.1%) SCA3 patients had gait-ataxia onset. Their AAO and expCAGs were not significantly different from SCA3 patients with non-gait-ataxia onset. Limb ataxia and pyramidal impairment occurred less in patients with disease duration &gt;10 years. Intriguingly, onset after parturition happened in 10 female patients with the AAO of 26.7 ± 4.3 years and the expCAG of 77.4 ± 1.4 repeats. Five out of 12 patients with subtype V and larger expCAGs (78.8 ± 4.8 repeats) suffered from spastic gait initially, and 10 out of 12 showed no limb ataxia. Nystagmus happened most frequently (10.5%) in premanifest individuals. We demonstrated the genotype-phenotype correlation in the largest cohort of SCA3 individuals to date, and interestingly found some new phenomena in Chinese SCA3 individuals." }, { "id": "pubmed23n0648_6259", "title": "Spinocerebellar ataxias: microsatellite and allele frequency in unaffected and affected individuals.", "score": 0.013433756166314306, "content": "The diagnosis and incidence of spinocerebelar ataxias (SCA) is sometimes difficult to analyze due the overlap of phenotypes subtypes and are disorders of mutations caused by CAG trinucleotide repeat expansion. To investigate the incidence of the SCA in Southern Brazil, we analyzed the trinucleotide repeats (CAG)n at the SCA1, SCA2, SCA3, SCA6 and SCA7 loci to identify allele size ranges and frequencies. We examined blood sample from 154 asymptomatic blood donors and 115 individuals with progressive ataxias. PCR products were submitted to capillary electrophoresis. In the blood donors, the ranges of the five loci were: SCA1, 19 to 36 (CAG)n; SCA2, 6 to 28 (CAG)n; SCA3, 12 to 34 (CAG)n; SCA6, 2 to 13 (CAG)n; and SCA7, 2 to 10 (CAG)n. No deviations from Hardy-Weinberg equilibrium were detected. In the ataxia group, we found (CAG)n above the range of the asymptomatic blood donors in SCA3 (21.74%) followed by SCA2 (5.22%), SCA7 (2.61%), SCA6 (0.87%), and no cases of SCA1. The remaining 80 cases (69.56%) have different diagnoses from the type here studied. These data defined the alleles and their frequencies, as well as demonstrated their stability in the population not affected. The molecular diagnosis test confirmed the clinical diagnosis in 28/45 cases and classified another 7/70 from the clinical unclassified ataxias group." }, { "id": "pubmed23n0358_20536", "title": "Hereditary spastic paraplegia and hereditary ataxia, Part 2: A family demonstrating various phenotypic manifestations with the SCA3 genotype.", "score": 0.013347873500545256, "content": "Clinical descriptions of the dominantly inherited ataxic motor syndromes in a 7-generation family of German origin were first reported in 1951. To provide follow-up clinical, pathological, and genetic data for 9 patients in this family. Clinical histories and neurologic findings, gross and microscopic pathological features, and DNA analysis. Clinical presentations in this closely followed up portion of the family include fairly uniform ataxic and upper motor neuron symptoms. Nystagmus was a conspicuous and early sign, but generational anticipation was not evident. Although often present, amyotrophy was not a major source of disability. Major pathological degeneration was noted in the pons, spinal cord, and upper brainstem, where ubiquitin-immunoreactive intranuclear inclusion bodies were demonstrated. The diagnosis of Machado-Joseph disease (SCA3 [spinocerebellar ataxia type 3] genotype) was established from autopsy tissue in 1 patient and from blood specimens in 6 others. Clinical variation within this family and between this family and families with the SCA1 and SCA3 genotypes is so broad as to make the genetic diagnosis from clinical criteria alone practically impossible. The pathological definition of Machado-Joseph disease is more reliable, but some findings do overlap those of other genotypes. To our knowledge, the basis for the phenotypic variations in Machado-Joseph disease, genetic or otherwise, has not been established." }, { "id": "pubmed23n0365_19268", "title": "Genetic background of apparently idiopathic sporadic cerebellar ataxia.", "score": 0.013105389171252153, "content": "Disease-causing mutations have been identified in various entities of autosomal dominant ataxia and in Friedreich's ataxia. However, no molecular pathogenic factor is known to cause idiopathic cerebellar ataxias. We investigated the CAG/CTG trinucleotide repeats causing spinocerebellar ataxia types 1, 2, 3, 6, 7, 8 and 12, and the GAA repeat of the frataxin gene in 124 patients apparently suffering from idiopathic sporadic ataxia, including 20 patients with the clinical diagnosis of multiple system atrophy. Patients with a positive family history, a typical Friedreich phenotype, or symptomatic ataxia were excluded. Genetic analyses uncovered the most common Friedreich mutation in 10 patients with an age at onset between 13 and 36 years. The SCA6 mutation was present in nine patients with disease onset between 47 and 68 years of age. The CTG repeat associated with SCA8 was expanded in three patients. One patient had SCA2 attributable to a de novo mutation from a paternally transmitted, intermediate allele. We did not identify the SCA1, SCA3, SCA7 or SCA12 mutation in idiopathic sporadic ataxia patients. No trinucleotide repeat expansion was detected in the MSA subgroup. This study has revealed the genetic basis in 19% of apparently idiopathic ataxia patients. SCA6 is the most frequent mutation in late onset cerebellar ataxia. The frataxin trinucleotide expansion should be investigated in all sporadic ataxia patients with onset before age 40, even when the phenotype is atypical for Friedreich's ataxia." }, { "id": "wiki20220301en060_6324", "title": "Machado–Joseph disease", "score": 0.012299411439207203, "content": "Machado–Joseph disease (MJD), also known as Machado–Joseph Azorean disease, Machado's disease, Joseph's disease or spinocerebellar ataxia type 3 (SCA3), is a rare autosomal dominantly inherited neurodegenerative disease that causes progressive cerebellar ataxia, which results in a lack of muscle control and coordination of the upper and lower extremities. The symptoms are caused by a genetic mutation that results in an expansion of abnormal \"CAG\" trinucleotide repeats in the ATXN3 gene that results in an abnormal form of the protein ataxin which causes degeneration of cells in the hindbrain. Some symptoms, such as clumsiness and rigidity, make MJD commonly mistaken for drunkenness or Parkinson's disease. Machado–Joseph disease is a type of spinocerebellar ataxia and is the most common cause of autosomal-dominant ataxia. MJD causes ophthalmoplegia and mixed sensory and cerebellar ataxia." }, { "id": "wiki20220301en406_6863", "title": "Autosomal dominant cerebellar ataxia", "score": 0.011795859412614348, "content": "Subtype 1 -subtypes in the first subclass are caused by CAG nucleotide repeats in the DNA, which code for the amino acid glutamine. This glutamine is toxic to the cell on the level of proteins and has degenerative effects. Within the first subclass of Type 1 are SCA1, SCA2, SCA3, SCA17, and DRPLA. This first subclass is the most common of Type 1 ADCAs with SCA3 being the most common subtype of all of Type 1. SCA3, Machado-Joseph disease, is the most common because the mutation repeats more than 56 times while the regular length is around 13 to 31. Subtype 2 -the second subclass of Type 1 ADCA is also caused by the same nucleotide repeats but instead in RNA and in a region that does not code for proteins. Gene expression is affected instead of proteins in subtype two SCAs because of this. Subtype 2 contains SCA8, SCA10, and SCA12." }, { "id": "wiki20220301en059_8816", "title": "Spinocerebellar ataxia", "score": 0.011299435028248588, "content": "Many SCAs below fall under the category of polyglutamine diseases, which are caused when a disease-associated protein (i.e., ataxin-1, ataxin-3, etc.) contains a large number of repeats of glutamine residues, termed a polyQ sequence or a \"CAG trinucleotide repeat\" disease for either the one-letter designation or codon for glutamine respectively. The threshold for symptoms in most forms of SCA is around 35, though for SCA3 it extends beyond 50. Most polyglutamine diseases are dominant due to the interactions of resulting polyQ tail. The first ataxia gene was identified in 1993 and called \"Spinocerebellar ataxia type 1\" (SCA1); later genes were called SCA2, SCA3, etc. Usually, the \"type\" number of \"SCA\" refers to the order in which the gene was found. At this time, there are at least 29 different gene mutations that have been found. The following is a list of some of the many types of Spinocerebellar ataxia. Others include SCA18, SCA20, SCA21, SCA23, SCA26, SCA28, and SCA29." }, { "id": "pubmed23n0327_6716", "title": "Incidence of dominant spinocerebellar and Friedreich triplet repeats among 361 ataxia families.", "score": 0.010739411342426418, "content": "To determine the incidence of spinocerebellar ataxia (SCA) types 1, 2, 3, 6, and 7 and Friedreich's ataxia (FA) among a large panel of ataxia families. The ataxias are a clinically and genetically heterogeneous group of neurodegenerative diseases that variably affect the cerebellum, brainstem, and spinocerebellar tracts. Trinucleotide repeat expansions have been shown to be the mutational mechanism for five dominantly inherited SCAs as well as FA. We collected DNA samples and clinical data from patients representing 361 families with adult-onset ataxia of unknown etiology. Patients with a clinical diagnosis of FA were specifically excluded from our collection. Among the 178 dominant kindreds, we found SCA1 expansion at a frequency of 5.6%, SCA2 expansion at a frequency of 15.2%, SCA3 expansion at a frequency of 20.8%, SCA6 expansion at a frequency of 15.2%, and SCA7 expansion at a frequency of 4.5%. FA alleles were found in 11.4% of apparently recessive and 5.2% of apparently sporadic patients. Among these patients the repeat sizes for one or both FA alleles were relatively small, with sizes for the smaller allele ranging from 90 to 600 GAA repeats. The clinical presentation for these patients is atypical for FA, with one or more of the following characteristics: adult onset of disease, retained tendon reflexes, normal plantar response, and intact or partially intact sensory perceptions. Pathogenic trinucleotide repeat expansions were found among 61% of the dominant kindreds. Among patients with apparently recessive or negative family histories of ataxia, 6.8% and 4.4% tested positive for a CAG expansion at one of the dominant loci, and 11.4 and 5.2% of patients with apparently recessive or sporadic forms of ataxia had FA expansions. Because of the significant implications that a dominant versus recessive inheritance pattern has for future generations, it is important to screen patients who do not have a clearly dominant inheritance pattern for expansions at both the FA and the dominant ataxia loci." }, { "id": "pubmed23n0309_14408", "title": "Spinocerebellar ataxia type 2. Genotype and phenotype in German kindreds.", "score": 0.010691717445271948, "content": "Spinocerebellar ataxia type 2 (SCA2) is an autosomal dominant cerebellar ataxia (ADCA) for which the disease-causing mutation has recently been characterized as an expanded CAG trinucleotide repeat. We investigated 64 families of German ancestry with ADCA and 55 patients with sporadic ataxia for the SCA2 mutation. Expanded alleles were found in 6 of the 64 families and in 1 patient with sporadic ataxia. This patient had a de novo mutation from an intermediate paternal allele. Length of repeats in 21 patients with SCA2 ranged from 36 to 52 CAG motifs and was inversely correlated with age at onset and progression of the disease. Expanded alleles were unstable during meiosis; paternal transmission especially caused significant anticipation of onset up to 26 years earlier. The SCA2 phenotype differed from those of SCA1 and SCA3 with higher frequencies of slowed ocular movements, postural and action tremor, myoclonus, and hyporeflexia. However, no single feature was sufficient to permit a specific clinical diagnosis. Spinocerebellar ataxia type 2 accounts for about 10% of German families with ADCA but may also be present in sporadic ataxia due to de novo mutations. Clinical features are highly variable among and even within families. However, the size of the expanded repeat influences the phenotype and is relevant for course and prognosis of the disease." }, { "id": "pubmed23n0948_6346", "title": "Homozygote of spinocerebellar Ataxia type 3 correlating with severe phenotype based on analyses of clinical features.", "score": 0.01044450504499591, "content": "Spinocerebellar ataxia type 3 (SCA3) is the most common subtype of SCAs worldwide. SCA3 homozygote is defined as expanded CAG repeats in both alleles that might exhibit severe phenotype due to gene dosage effect. However, a study on the systematic comparison of clinical phenotypes between homozygotes and heterozygotes to indicate these verity of phenotypes of homozygotes is still lacking. A total of 14 SCA3 homozygotes (3 Chinese participants and 11 participants from various ethnicity in different published studies) and 143 Chinese heterozygotes of SCA3 were recruited for this study. The 95% confidence intervals (CIs) of age at onset and disease severity expected from heterozygous patients were analyzed to detect the phenotypic differences between homozygotes and heterozygotes. Almost all the homozygotes (13 of 14) were found to present a significant earlier age at onset compared with heterozygotes, because age at onset of most homozygotes was lower than the 95% CIs of age at onset of heterozygotes. Also, the clinical severity in most of the homozygotes (3 of 4) with identified clinical phenotypes was higher than the 95% CIs of severity in heterozygotes, indicating more severe clinical phenotypes in SCA3 homozygotes. The homozygosity for SCA3 could lead to an earlier age of onset and putative severe clinical features. The findings of the present study suggested an influence of gene dosage on SCA3 phenotypes." }, { "id": "InternalMed_Harrison_30521", "title": "InternalMed_Harrison", "score": 0.010360557717584599, "content": "Classification of the Spinocerebellar Ataxias Roger N. Rosenberg Ataxias with autosomal dominant, autosomal recessive, X-linked, or mitochondrial forms of inheritance are present on a worldwide 451e basis. Machado-Joseph disease (SCA3) (autosomal dominant) and Friedreich’s ataxia (autosomal recessive) are the most common types in most populations. Mutation markers are now commercially available to identify carriers at risk in their families, which allows for precise identification of the genetic mutation for correct diagnosis and also for family planning. Identification of positive mutation carriers with family planning has allowed for early detection of asymptomatic preclinical disease to reduce or eliminate the inherited form of ataxia in specific families on a global, worldwide basis." }, { "id": "pubmed23n0662_19400", "title": "[Molecular and prenatal diagnosis of a pedigree with spinocerebellar ataxia].", "score": 0.009900990099009901, "content": "To identify the type of a pedigree with spinocerebellar ataxia, and carry out asymptomatic carrier detection and prenatal diagnosis. The blood samples of two patients in the spinocerebellar ataxia pedigree were collected. Based on the clinical characteristics of the pedigree and the disease incidence in China, the regions containing the CAG repeat of the SCA1, SCA2 and SCA3/MJD genes were amplified by polymerase chain reaction (PCR). The numbers of CAG repeats in the normal and abnormal allele fragments were identified by using agarose gel electrophoresis and DNA sequencing. We further carried out tests on the children of the patients and fetus to identify the presence of the abnormal allele. The numbers of CAG repeat in the SCA1 and SCA2 genes were in the normal range. The CAG repeat number in one allele of SCA3/MJD gene was in the normal range, while that in the other allele was in the abnormal range. One of the children of the patients and the fetus carried the abnormal allele. It was confirmed that the pedigree was SCA3/MJD by gene diagnosis. One of the children of the patients was asymptomatic carrier and the fetus also carried the abnormal allele." }, { "id": "InternalMed_Harrison_30520", "title": "InternalMed_Harrison", "score": 0.009879277401424353, "content": "1. Baylor College of Medicine; Houston, Texas, 1-713-798-6522 http://www.bcm.edu/genetics/index.cfm?pmid=21387 2. GeneDx http://www.genedx.com 3. Transgenomic, 1-877-274-9432 http://www.transgenomic.com/labs/neurology Ataxias with autosomal dominant, autosomal recessive, X-linked, or mitochondrial forms of inheritance are present on a worldwide basis. Machado-Joseph disease (SCA3) (auto somal dominant) and Friedreich’s ataxia (autosomal recessive) are the most common types in most populations. Genetic markers are now commercially available to precisely identify the genetic mutation for correct diagnosis and also for family planning. Early detection of asymptomatic preclinical disease can reduce or eliminate the inherited form of ataxia in some families on a global, worldwide basis." }, { "id": "wiki20220301en002_93759", "title": "Huntington's disease", "score": 0.00980392156862745, "content": "Prenatal testing Obtaining a prenatal diagnosis for an embryo or fetus in the womb is also possible, using fetal genetic material acquired through chorionic villus sampling. An amniocentesis can be performed if the pregnancy is further along, within 14–18 weeks. This procedure looks at the amniotic fluid surrounding the baby for indicators of the HD mutation. This, too, can be paired with exclusion testing to avoid disclosure of parental genotype. Prenatal testing can be done when parents have been diagnosed with HD, when they have had genetic testing showing the expansion of the HTTgene, or when they have a 50% chance of inheriting the disease. The parents can be counseled on their options, which include termination of pregnancy, and on the difficulties of a child with the identified gene." }, { "id": "wiki20220301en060_6326", "title": "Machado–Joseph disease", "score": 0.009769174845510722, "content": "Spinocerebellar ataxia type 3 (SCA3) on the Azores are believed to have come from Portugal's northeast where Sephardic Jews lived. Belgium, French-Guiana and Algeria have their own MJD mutation origins. Portuguese have two mutations, while Brazil and France have one mutation, and Germans make up the majority of MJD patients in the United States. Azorean MJD sufferers have their locus on the 14q24.3-32 chromosome, the same as some Japanese with MJD. It was an Azorean, William Machado, whose offspring in New England were the first to be diagnosed with MJD. The Azorean Joseph family, living in California, were also diagnosed with MJD. The same origin for MJD is found in the Azores and in America's north-west coast. Not only Portuguese have it since African Americans, Indians, Italians and Japanese also developed MJD. In China, the mutation causing SCA type 3 has been estimated to have occurred 8,000 to 17,000 years ago." }, { "id": "pubmed23n0389_20555", "title": "[Type 2 spinocerebellar ataxia: acceptance of prenatal diagnosis in descendents at risk].", "score": 0.009708737864077669, "content": "Type 2 spinocerebellar ataxia is a hereditary degenerative disorder of the nervous system. Advances in molecular genetics have made it possible to carry out presymptomatic and prenatal studies. A programme to define the strategies and principles for doing this has been devised. To find the level of acceptance of prenatal diagnosis in couples at risk, and to determine the effect of different variables on this acceptance. We made a descriptive type study of a series of cases. The study group included 226 persons. Forty of these were couples of descendents and the remainder were asymptomatic descendents. We applied a questionnaire, after prior information as to the aims of the study and obtaining the consent of the participants. Regarding acceptance of prenatal diagnosis by couples of descendents, we found that most (77.5%) accepted this and only 2.5% did not. Prenatal diagnosis was accepted by 67.74% of the descendents themselves. In general there was a high level of acceptance. 159 of the 226 questioned claimed that they would like to have more children and 98.7% of these accepted the test, whilst only 0.01% refused it. The main reasons given were the hope of having healthy children and that the disease would not occur in future generations." }, { "id": "pubmed23n0649_9143", "title": "[Clinical features and gene mutation analysis in Machado-Joseph disease of spinocerebellar ataxia type 3 in littoral of Zhejiang].", "score": 0.009615384615384616, "content": "To study the clinical features and gene mutation analysis in Machado-Joseph disease of spinocerebellar ataxia type 3 in littoral of Zhejiang. Clinical manifestation and brain MRI data 18 patients with SCA in family were analyzed. The gene mutations of 18 patients and 10 family numbers without abnormal presentation, and 12 healthy persons of controls. The gene mutations of 18 patients is SCA3/MJD, and 2 asymptomatic SCA3/MJD had been detected in SCA family. Normal alleles of SCA3/MJD have CAG repeats ranging from 14 to 27, patients from 67 to 82, asymptomatic and carrier SCA3/MJD from 28 to 45. The main features of 18 patients included gait ataxia, ambiguity in speech and action clumsiness. Brain MRI showed remarkable atrophy on cerebellum and brain stem. CAG expansions were related to SCA3/MJD. The clinical manifestations are ataxia and dysarthria. The detection of repeated times CAG can provide an effective way for the genetic and asymptomatic diagnosis." }, { "id": "pubmed23n0762_18631", "title": "Large normal and intermediate alleles in the context of SCA2 prenatal diagnosis.", "score": 0.009523809523809525, "content": "In 2001 a program for predictive testing of Spinocerebellar Ataxia type 2 was developed in Cuba, based on the detection of an abnormal CAG trinucleotide repeat expansion in the ATXN2 gene. A descriptive study was designed to assess the implications of ATXN2 large normal and intermediate alleles in the context of the SCA2 Prenatal Diagnosis Program. Four clinical scenarios were selected based upon the behaviour of large normal and intermediate alleles when passing from one generation to the next, showing expansions, contractions, or stability in the CAG repeat size. In some populations, traditional Mendelian risk figures of 0 % or 50 % may not be applicable due to the high frequency of unstable large normal alleles. Couples with no family history of SCA2 may have a &gt;0 % risk of having an affected offspring. Similarly, couples in which there is both an expanded and a large normal allele may have a recurrence risk &gt;50 %. It is imperative that these issues be addressed with these couples during genetic counseling. These recurrence risks have to be carefully estimated in the presence of such alleles (particularly alleles ≥27 CAG repeats), carriers need to be aware of the potential risk for their descendants, and programs for prenatal diagnosis must be available for them. " }, { "id": "wiki20220301en328_15645", "title": "Imerslund–Gräsbeck syndrome", "score": 0.009433962264150943, "content": "The disease is autosomal recessive, and can therefore skip generations. Mutations in either amnionless (AMN) or cubilin can be the culprit. Due to its autosomal recessive pattern of inheritance, affected individuals (persons possessing a homozygous recessive genotype) need to undergo genetic counseling to identify the risk of family members who might be heterozygous genetic carriers. Certain mutations on the CUBN or AMN (genes that encode cubilin and amnionless respectively) have been identified through genetic analysis, and ethnic susceptibility of some of the mutations was indicated from the current research. It has been further suggested that mutations on CUBN were restricted to exon 1-28 which encoded amnionless binding domains (EGF) and IF-Cbl binding region of cubilin, while AMN mutations primarily clustered in intron 8-11 and transmembrane domain in exon 10. Some interesting aspects of particular mutations were also elucidated by the researchers, for example, CUBN mutation" }, { "id": "pubmed23n0591_8978", "title": "Birth after pre-implantation genetic diagnosis (PGD) of spinocerebellar ataxia 2 (Sca2).", "score": 0.009433962264150943, "content": "Spinocerebellar ataxia 2 (SCA2) is an autosomal-dominant neurodegenerative disease caused by an extended polyglutamine sequence in the ATXN2 protein. We describe the development of a new single-cell multiplex PCR protocol for pre-implantation genetic diagnosis (PGD) of SCA2 and its successful clinical application. Three duplex tests have been developed, one, which combines the detection of the CAG repeats in addition to the D12S821 microsatellite, another, the amplification of the CAG repeats and the D12S1333 microsatellite and the last, the combination of both microsatellites D12S821 and D12S1333. PCR conditions were established using 226 single lymphoblasts or patient lymphocysts. Amplification was obtained in an average of 99.6%, a complete genotype in 86%, a conclusive result in 96% and an allelic drop-out (ADO) rate of 10.7% was observed. PGD for SCA2 was performed for a couple with a paternal risk of transmitting the pathology. Two cycles were done from which 18 embryos were biopsied, 8 were diagnosed as unaffected, 9 as affected and 1 gave no results. In both cycles 2 embryos were transferred, with no pregnancy at the first attempt, and a twin pregnancy at the second attempt. The patient delivered one girl and one boy at 36 weeks and 3 days." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": true, "char_ranges": [ [ 25, 186 ] ], "word_ranges": [ [ 5, 30 ] ], "text": "Children born to HBV carrier mothers should be administered hepatitis B vaccine and immunoglobulin at different puncture sites within the first 24 hours of life." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Administer hepatitis B vaccine at birth. Artificial feeding.", "2": "Vaccination and immunoglobulins should be administered at birth. Breastfeeding from one month onwards.", "3": "Immunoglobulins at birth and artificial breastfeeding.", "4": "Vaccination and immunoglobulins at birth. Maternal feeding.", "5": "Artificial feeding and isolation for 4 weeks." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0538_6376", "title": "[Adjustment of the hepatitis-B vaccination scheme for newborns born to hepatitis-B virus carriers as of 1 January 2006].", "score": 0.018883049790683174, "content": "Timely administration of hepatitis-B immunoglobulin postpartum combined with hepatitis-B vaccination will prevent the majority of vertical hepatitis-B virus transmissions. As of January 2006, the Dutch hepatitis-B vaccination scheme for newborns born to HBsAg positive mothers has been modified. Previously, the first vaccination was given at the age of 2 months. Newborns will now receive their first hepatitis-B vaccination preferably immediately following the administration of hepatitis-B immunoglobulin, within 2 hours after birth, or otherwise within 48 hours after birth. Booster vaccinations are scheduled at the ages of 2, 4 and 11 months, which are standard vaccination times in the Dutch national vaccination programme. The vaccination scheme for the other target-group of infants at increased risk of hepatitis-B virus infection has remained unchanged. As before, these infants will be vaccinated at 2, 4 and 11 months. It is also intended to measure the efficacy of vaccination by determining the anti-HBs antibodies 6 weeks after the last vaccination, at the age of 13 to 14 months. With this modification of the vaccination scheme, the Minister of Health follows the advice of the Health Council of the Netherlands. The goal is to increase the efficacy of hepatitis-B prevention in newborns born to HBsAg positive mothers." }, { "id": "pubmed23n0758_3744", "title": "[Identification of risk factors related to the failure of immunization to interrupt hepatitis B virus perinatal transmission].", "score": 0.01725925925925926, "content": "To explore the factors influencing failure of an immunization to interrupt perinatal (mother-to-child) transmission of hepatitis B virus (HBV). Between June 2006 and March 2010, a total of 1355 pregnant women testing positive for the hepatitis B surface antigen (HBsAg), at gestational weeks 20 to 42, and without use of antiviral or immunomodulatory drugs during the pregnancy were prospectively recruited to the study. The mothers were given a choice of receiving hepatitis B immunoglobulin (HBIG; three 200 IU intramuscular injections give at four-week intervals starting from gestation week 28) or not. All neonates (1360, including five sets of twins) received hepatitis B vaccine (10 mug) plus HBIG (200 IU) combined immunization within 24 h of birth, as early as possible. Peripheral venous blood samples were collected from the neonates within 24 h of birth and at 7 and 12 months of age for detection of HBV markers, including hepatitis B e antigen (HBeAg) and HBV DNA. The infants were classified according to HBV perinatal transmission status (infection group and non-infection group) and various factors (maternal-related: age, gravidity, parity; pregnancy/birth-related: threatened premature labor, complications; neonate-related: sex, birth weight, apgar score) were compared between the two groups by using non-conditional logistic regression analysis to determine their potential influence on failure of immunization to inhibit transmission. After 12 months of follow-up, 1.54% (21/1360) of the neonates had presented with HBV infection. Analysis of the HBV-infected neonates revealed differences in infection rates between neonates born to mothers with HBIG injection (2.22% vs. without HBIG injection: 1.11%, P less than 0.05) and caesarean section (1.35% vs. vaginal delivery: 1.73%) but neither reached statistical significance (P less than 0.05); only the practice of breastfeeding showed a significant difference for infection rate, with neonates fed artificial formula having higher infection rate (3.13%) than the breastfed neonates (0.27%, P less than 0.05). The neonate HBV infection rate was also significantly higher for neonates born to HBeAg-positive mothers (4.44% vs. HBeAg-negative mothers: 0%, P less than 0.05) and HBV DNA-positive mothers (3.13% vs. HBV DNA-negative mothers: 0%, P less than 0.05). When the mothers were stratified by serum level of HBV DNA, there was a significant difference in HBV-infected neonates born to mothers with more than or equal to 1*10(7) IU/ml(6.01% vs. 10(3)-10(6) IU/ml: 0.56% and less than 1*10(3) IU/ml: 0%, both P less than 0.05). Logistic regression analysis indicated that the independent risk factors for HBV perinatal transmission despite immunization were maternal serum HBeAg-positive status (relative risk (RR)=31.74, 95% confidence interval (CI): 3.88-259.38) and maternal HBV DNA of ≥ 10⁷ copies/mL (RR=22.58, 95% CI: 4.75-107.40). Failure of vaccine plus HBIG to interrupt mother-to-child transmission of HBV is influenced by maternal serum HBeAg-positive status and maternal HBV DNA of ≥10⁷ copies/mL." }, { "id": "pubmed23n0867_23831", "title": "[Hepatitis B and pregnancy. Part 2. Nine practical issues about delivery and neonatal care].", "score": 0.016230104023060535, "content": "In France, the hepatitis B maternal-fetal transmission prevention strategy is based on serovaccination at birth. Serum therapy is to inject 30IU/kg of anti-HBs specific immunoglobulins of human origin in the first hours of life, which in practice corresponds to 1ml or 100IU. Vaccination should also be performed during the first hours of life, and a new injection should be performed at 1month and 6months. In infants less than 32weeks and/or less than 2kg, lower vaccine response leads to prescribe an additional injection at 2months. This serovaccination reduces the risk of mother to child transmission from 57 to 4 %. The failure risk factors of serovaccination are high maternal viral load (greater than or equal to 7 log) and/or the presence of HBeAg. The delivery route does not change the risk of maternal-fetal transmission of hepatitis B when serovaccination at birth was well conducted. Likewise, breastfeeding does not change the risk of maternal-fetal transmission of hepatitis B after serovaccination. It is recommended by WHO. During labor, the pH in utero should be done only when strictly necessary, the published data do not allow to conclude on the risk of transmission. " }, { "id": "pubmed23n0657_15211", "title": "Hepatitis B and breastfeeding in Hangzhou, Zhejiang Province, People's Republic of China.", "score": 0.015621244893054553, "content": "This study examined infant feeding methods in hepatitis B-positive mothers in Zhejiang Province, People's Republic of China. A cohort study was undertaken in Hangzhou in Zhejiang Province. A sample of 638 mothers was recruited at birth from the city of Hangzhou and was followed up until their infants were 6 months of age. Chronic hepatitis B is a continuing public health issue in pregnant women. Breastfeeding is the foundation of infant nutrition, sets the scene for lifetime health, and is important for all mothers. In the Hangzhou cohort of 638 mothers, 38 were identified as hepatitis B positive, a rate of 6.0%. All of the infants of the hepatitis B-positive mothers were fed on formula immediately after birth while their breastmilk was tested for virus transmission and their infants were vaccinated. At 1 month of age 61.8% of the hepatitis B-positive mothers were breastfeeding compared to 92% of the remainder of the cohort. The rates at 3 months were 60.6% and 89% and at 6 months were 45.5% and 64%, respectively. The hazard ratio for hepatitis B-positive mothers discontinuing breastfeeding before 6 months was 3.69 (95% confidence interval, 2.28, 5.98). The World Health Organization recommends that all mothers who are hepatitis B positive breastfeed their infants and that their infants be immunized at birth. In this study breastfeeding rates of hepatitis B-positive mothers were substantially less than those of the other mothers." }, { "id": "pubmed23n0643_21108", "title": "Treatment of viral hepatitis in pregnancy.", "score": 0.015063540753724802, "content": "Viral hepatitis can be caused by the hepatitis A, B, C, D and E viruses. In the Western world, hepatitis A, B or C do not seem to influence the course of pregnancy, whereas hepatitis E infection, when contracted during the second or third trimester, seems to have a higher risk of developing into a fulminant hepatitis. Mother-to-infant transmission of hepatitis A seems to be very uncommon. The majority of HBsAg-positive and HBeAg-positive mothers can transmit the disease vertically. The timing of transmission is predominantly peripartum, and newborns of HBsAg-positive mothers should receive hepatitis B immunoglobulins within 12 h of birth, with HBV vaccine at birth and 1 and 6 months later. Hepatitis C is more often a chronic disease. Vertical transmission of hepatitis C is considered to be relatively rare but high viraemia or coinfection with HIV can increase this risk. There is currently no treatment to prevent this vertical transmission and pregnancies among HCV-positive mothers should not be discouraged. Infants should be tested for anti-HCV at 1 year and followed for the development of hepatitis. Breast feeding does not seem to play an important role in the transmission of hepatitis B and C." }, { "id": "Pediatrics_Nelson_2065", "title": "Pediatrics_Nelson", "score": 0.014875027648750276, "content": "1. Hepatitis B (HepB) vaccine. (Minimum age: birth) Routine vaccination: At birth  Administer monovalent HepB vaccine to all newborns before hospital discharge.  For infants born to hepatitis B surface antigen (HBsAg)–positive mothers, administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months after completion of the HepB series, at age 9 through 18 months (preferably at the next well-child visit).  If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants weighing <2,000 grams, administer HBIG in addition to HepB within 12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if she is HBsAg-positive, also administer HBIG for infants weighing 2,000 grams (no later than age 1 week). Doses following the birth dose  The second dose should be" }, { "id": "Pediatrics_Nelson_2034", "title": "Pediatrics_Nelson", "score": 0.014765173804075406, "content": "1. Hepatitis B (HepB) vaccine. (Minimum age: birth) Routine vaccination: At birth  Administer monovalent HepB vaccine to all newborns before hospital discharge.  For infants born to hepatitis B surface antigen (HBsAg)–positive mothers, administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months after completion of the HepB series, at age 9 through 18 months (preferably at the next well-child visit).  If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants weighing <2,000 grams, administer HBIG in addition to HepB within 12 hours of birth. Determine mother’s HBsAg status as soon as possible and, if she is HBsAg-positive, also administer HBIG for infants weighing 2,000 grams (no later than age 1 week). Doses following the birth dose  The second dose should be" }, { "id": "wiki20220301en001_273621", "title": "Hepatitis", "score": 0.01411988911988912, "content": "Hepatitis B The CDC recommends the routine vaccination of all children under the age of 19 with the hepatitis B vaccine. They also recommend it for those who desire it or are at high risk. Routine vaccination for hepatitis B starts with the first dose administered as a shot into the muscle before the newborn is discharged from the hospital. An additional two doses should be administered before the child is 18 months. For babies born to a mother with hepatitis B surface antigen positivity, the first dose is unique – in addition to the vaccine, the hepatitis immune globulin should also be administered, both within 12 hours of birth. These newborns should also be regularly tested for infection for at least the first year of life. There is also a combination formulation that includes both hepatitis A and B vaccines. Other" }, { "id": "pubmed23n0710_9290", "title": "An algorithm for risk assessment and intervention of mother to child transmission of hepatitis B virus.", "score": 0.014082462253193961, "content": "Despite immunoprophylaxis, mother to child transmission (MTCT) of hepatitis B virus (HBV) still occurs in infants born to hepatitis B surface antigen (HBsAg)-positive mothers. We analyzed methods of risk assessment and interventions for MTCT. We reviewed 63 articles and abstracts published from 1975-2011 that were relevant to MTCT; articles were identified using the PubMed bibliographic database. Administration of HB immunoglobulin and HB vaccine to infants at birth (within 12 hours), followed by 2 additional doses of vaccines within 6-12 months, prevented approximately 95% of HBV transmission from HBsAg-positive mothers to their infants. However, HBV was still transmitted from 8%-30% of mothers with high levels of viremia. It is important to assess the risk for MTCT and identify mothers who are the best candidates for intervention. The most important risk factor is maternal level of HBV DNA &gt;200,000 IU (10(6) copies)/mL; other factors include a positive test result for the HB e antigen, pregnancy complications such as threatened preterm labor or prolonged labor, and failure of immunoprophylaxis in prior children. Antiviral therapy during late stages of pregnancy is the most effective method to reduce transmission from mothers with high levels of viremia, but elective cesarean section might also be effective. Antepartum administration of HB immunoglobulin, giving infants a double dose of HB vaccine, or avoiding breastfeeding had no impact on MTCT. HBsAg-positive mothers should be assessed for risk of MTCT, and infants should receive immunoprophylaxis. Pregnant women with levels of HBV DNA &gt;200,000 IU/mL should be considered for strategies to reduce the risk for MTCT. We propose an algorithm for risk assessment and patient management that is based on a review of the literature and the opinion of a panel of physicians with expertise in preventing MTCT." }, { "id": "pubmed23n0664_14409", "title": "Long-term protection against hepatitis B after newborn vaccination: 20-year follow-up.", "score": 0.013469921534437664, "content": "Hepatitis B vaccination in children born to hepatitis B surface antigen (HBsAg)-positive mothers considerably decreases the risk of vertical transmission. However, whether this protection against carriage of hepatitis B virus is maintained into early adulthood is as yet unknown. A combined passive-active immunization programme for newborns of HBsAg-positive mothers was initiated in the north-eastern part of the Czech Republic in 1988. The number of immunized newborns had reached 665 newborns by the end of 2006. All mothers of immunized infants were HBsAg-positive during pregnancy, and 34 (5%) were also hepatitis B e antigen (HBeAg)-positive. The immunization programme consists of providing newborns with protection at birth with hepatitis B immunoglobulin, followed by three 10-μg doses of plasma-derived or, since 1990, recombinant vaccine administered at 0, 1 and 6 months of life. Only 29 children of HBeAg-positive mothers received vaccine at 0, 1 and 2 months of life. Blood samples were obtained after immunization, at 2 years of age, and biennially thereafter. Samples were tested for HBsAg and hepatitis B surface and core antibodies (anti-HBs, anti-HBc). The immunization schedules were completed in 640 children. A protective anti-HBs level after immunization was proven in 574 of 620 children (93%). Persistence of protective anti-HBs antibodies was detected in 70, 40 and 25% of children at 5, 10 and 15 years of age. Vertical transmission with chronic HBsAg carrier status was detected in two infants. Anti-HBc seroconversion was proven in ten children from 3 to 15 years of age. Natural boosting with an anti-HBs increase was detected in 38 children (twice in one child). Our results show that combined active-passive immunization of newborns against hepatitis B provides persistent protection up to adolescence despite a frequent waning of anti-HBs antibodies, suggesting there is no need for booster vaccination during adolescence." }, { "id": "Obstentrics_Williams_7587", "title": "Obstentrics_Williams", "score": 0.013360702967444541, "content": "Newborns of seropositive mothers are given HBIG very soon after birth. This is accompanied by the first of a three dose hepatitis B recombinant vaccine. Hill and colleagues the 2.4-percent transmission rate was not increased with breast feeding if vaccination was completed. Although virus is present in breast milk, the incidence of transmission is not lowered by formula feeding (Shi, 201l). he American Academy of Pedi atrics and the American College of Obstetricians and Gyne contraindication to breastfeeding." }, { "id": "wiki20220301en178_5864", "title": "Hepatitis B vaccine", "score": 0.013212248377155596, "content": "Hepatitis B vaccination, hepatitis B immunoglobulin, and the combination of hepatitis B vaccine plus hepatitis B immunoglobulin, all are considered as preventive for babies born to mothers infected with hepatitis B virus (HBV). The combination is superior for protecting these infants. The vaccine during pregnancy is not considered to be valuable in protecting babies of the infected mothers. Hepatitis B immunoglobulin before birth has not been well studied. Effectiveness Following the primary course of three vaccinations, a blood test may be taken after an interval of 1–4 months to establish if there has been an adequate response, which is defined as an anti-hepatitis B surface antigen (anti-Hbs) antibody level above 100mIU/ml. Such a full response occurs in about 85–90% of individuals. An antibody level between 10 and 100mIU/ml is considered a poor response, and these people should receive a single booster vaccination at this time, but do not need further retesting." }, { "id": "wiki20220301en206_1635", "title": "Hepatitis B", "score": 0.013042071197411003, "content": "Most vaccines are given in three doses over a course of days. A protective response to the vaccine is defined as an anti-HBs antibody concentration of at least 10 mIU/ml in the recipient's serum. The vaccine is more effective in children and 95 percent of those vaccinated have protective levels of antibody. This drops to around 90% at 40 years of age and to around 75 percent in those over 60 years. The protection afforded by vaccination is long lasting even after antibody levels fall below 10 mIU/ml. For newborns of HBsAg-positive mothers: hepatitis B vaccine alone, hepatitis B immunoglobulin alone, or the combination of vaccine plus hepatitis B immunoglobulin, all prevent hepatitis B occurrence. Furthermore, the combination of vaccine plus hepatitis B immunoglobulin is superior to vaccine alone. This combination prevents HBV transmission around the time of birth in 86% to 99% of cases." }, { "id": "pubmed23n0822_6275", "title": "[Prophylaxis of mother-to-infant transmission of hepatitis B virus].", "score": 0.01219209640262272, "content": "Hepatitis B virus (HBV) infection is a worldwide health problem and mother-to-infant (or vertical) transmission is the main source of chronic infection in Asian countries. Administration of HBV vaccine to the infant at birth, with or without concurrent specific immunoglobulin, efficiently prevents such transmission (efficacy&gt;90%). In France, testing Ag HBs is mandatory during pregnancy in all pregnant women. Infants born to Ag HBs-positive mothers should receive the first injection of vaccine and one injection of specific immunoglobulins at birth. Vaccination should thereafter be completed according to a three-injection protocol (at 1 and 6 months) or a four-injection protocol in case of prematurity. Failure of immunoprophylaxis can be observed when the viral load is very high in the mother during pregnancy (HBV-DNA levels&gt;200,000 IU/mL). In such women, antiviral therapy with analogs (lamivudine, telbivudine, or tenofovir) during the third trimester of pregnancy and 1 month post-partum, in association with accurate immunoprophylaxis, may prevent vertical transmission. The optimal cut-off value of maternal viral load for antiviral therapy in late pregnancy and post-partum to prevent vertical transmission is still under debate. " }, { "id": "pubmed23n0338_16610", "title": "Hepatitis B vaccination in preterm infants.", "score": 0.011637741466220103, "content": "Preterm infants, especially those with very low birth weight, are at risk of hepatitis B virus infection. They often require invasive diagnostic methods in their first weeks of life, intensive treatment and long-term hospitalisation. Therefore, hepatitis B vaccination is particularly justified in these patients. Our aim was to determine the reaction of preterm children to hepatitis B vaccination. The study comprised 64 preterm children whose birth weight ranged from 700 g to 2460 g (mean 1776.6 g +/- 480.4 g) and whose gestational age was between 25 and 36 weeks. A 10 microg dose of the recombinant vaccine Engerix-B (SmithKline Beecham) was given at intervals of 0, 1, 2 and 12 months. In 49.2% of the children vaccination was administered on the 1st day of life, and in the remaining cases between the 2nd and 119th days post delivery. One month after vaccination completion the levels of anti-hepatitis B surface antigen (HBs) antibodies were evaluated. In 98.4% of the vaccinated preterm infants the level of antibodies was &gt; 10 mIU/ml. Mean level of anti-HBs antibodies in the group of children with birth weight &lt; or = 2000 g was 2431.4 mIU/ml, while in those with birth weight &gt;2000 g it was 4803.9 mIU/ml. In children with a birth weight &lt; or = 1000 g, the mean level of anti-HBs antibodies was significantly lower than in those with birth weight &gt;2000 g. The level of anti-HBs antibodies in children who started vaccination &gt; 1 st day of life was significantly lower in preterm children with a birth weight &lt; or = 2000 g than in those with a birth weight &gt;2000 g. Although vaccination was started on the 1st day of his life, one child with birth weight of 2300 g developed a hepatitis B virus infection. One child did not respond to vaccination (anti-HBs &lt; 10 mIU/ml) and in three cases the response was very poor (11 100 mIU/ml). These patients were given a supplementary booster double dose of Engerix B (20 microg). After 1 month the level of anti-HBs antibodies was evaluated again and high values of 657 mIU/ml to 14520 mIU/ml were observed. In the group of children with a birth weight &lt; or = 1000 g the response to vaccination was weaker as compared to children with a birth weight &gt;2000 g (P &lt; 0.05). In systematic mass vaccination programmes, monitoring of antibody levels is not recommended unless the patient is at risk. However, in extremely preterm infants (&lt; 1000 g at birth), especially after very serious infections, monitoring the level of anti-HBs antibodies after complete immunisation should be considered. In preterm infants who show very low postvaccination levels of anti-HBs antibodies, stimulation with an additional double booster dose of vaccine gives positive results. The majority of preterm infants (98.4%) responded well to hepatitis B vaccination given at intervals of 0, 1, 2 and 12 months and developed a protective level of antibodies. The level of anti-hepatitis B surface antigen antibodies in children with a birth weight &gt;2000 g was higher than in those with a birth weight &lt; or = 1000 g." }, { "id": "pubmed23n0227_7758", "title": "Perinatal transmission of hepatitis B virus.", "score": 0.011632960053484874, "content": "Transmission of hepatitis B virus from carrier mothers to their infants seems most likely to occur during birth. Both cord blood and breast milk have been found to be positive (in 35% and 72% of cases respectively) for hepatitis B surface antigen (HBsAg), but they do not appear to play an important role in transmission. To control this problem high-risk women should be tested during pregnancy for HBsAg. The infants of infected women should be given several doses of hepatitis B immunoglobulin starting at birth. In less developed regions, where hepatitis B is endemic, administration of the immunoglobulin in combination with vaccine, or even the vaccine alone, may be preferable in order to provide infants with lasting protection." }, { "id": "pubmed23n0343_1977", "title": "Viral hepatitis and pregnancy.", "score": 0.011493506493506493, "content": "This paper reviews data on the mutual relationship between pregnancy and viral hepatitis and the mother-to-infant transmission of the virus. In the western world, hepatitis A, B or C do not seem to influence the course of pregnancy, or to be associated with foetal risks. In contrast, women who contract a hepatitis E infection in their third trimester of pregnancy have a relatively high probability to develop a fulminant hepatitis. Mother-to-infant transmission of hepatitis A seems to be very uncommon. On the contrary, HBsAg and HBeAg positive mothers have a 80-90% risk to transmit the disease to their offspring, more than 85% of these becoming chronic carriers of HBsAg. The risk depends on the level of viral replication. In HBsAg positive and HBeAg negative mothers the rate of transmission is only 2-15%, these babies rarely become carriers. A possible explanation is the transplacental passage of the HBeAg making the infant tolerant to the hepatitis B virus. As most of the infections occur during or directly after delivery, the neonates are suitable for postexposure prophylaxis. It is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics that newborns of HBsAg positive mothers should receive hepatitis B immunoglobulins within 12 hours after birth concurrently with the first paediatric dose of the vaccine. Vaccination should be completed at 1 and 6 months. This regimen confers a protective efficacy of &gt; or = 90%. Vertical transmission of hepatitis C is considered to be relatively rare, around 11% when HCV-RNA is positive. The highest rates of vertical transmission of HCV are noted in women with high HCV-RNA level or concurrent HIV infection. The risk is extremely low when no HCV-RNA is detected. There is currently no treatment to prevent this vertical transmission; routine screening of all mothers is unwarranted, and pregnancies among HCV-positive mothers should not be discouraged, but their infants should be tested for anti-HCV at 1 year and followed for the development of hepatitis. Breast feeding does not seem to play an important role in the transmission of hepatitis B and C." }, { "id": "Obstentrics_Williams_4479", "title": "Obstentrics_Williams", "score": 0.009914832074562108, "content": "Nursing is contraindicated in women who take street drugs or do not control their alcohol use; have an infant with galactosemia; have human immunodeiciency virus (HIV) infection; have active, untreated tuberculosis; take certain medications; or are undergoing breast cancer treatment (American Academy of Pediatrics, 2017; Faupel-Badger, 2013). Breastfeeding has been recognized for some time as a mode of HIV transmission and is proscribed in developed countries in which adequate nutrition is otherwise available. Other viral infections do not contraindicate breastfeeding. For example, with maternal cytomegalovirus infection, both virus and antibodies are present in breast milk. And, although hepatitis B virus is excreted in milk, breastfeeding is not contraindicated if hepatitis B immune globulin is given to the newborns of afected mothers. Maternal hepatitis C infection is not a contraindication because breastfeeding has not been shown to transmit infection (Society for MaternalFetal" }, { "id": "pubmed23n1052_6818", "title": "Hepatitis B Virus Infection in Pregnancy: An Update on Evidence-Based Management.", "score": 0.00980392156862745, "content": "Vertical hepatitis B virus (HBV) transmission is the important route of chronic HBV infection. Although infant immunoprophylaxis is effective, a significant number of infants still become infected, most are associated with intrauterine infection. New evidences support intrauterine treatment in cases of high risk. The aim of this study was to review the current evidences and recommendations for management of HBV infection in pregnancy. Original research articles, review articles, and guidelines were reviewed. The management can be summarized as follows: (1) all pregnant women should be screened for hepatitis B surface antigen (HBsAg) and antibody to HBsAg. High-risk HBsAg-negative pregnant women without immunity should be vaccinated during pregnancy. (2) HBsAg-positive pregnant women should undergo further workup for liver status and indicative factors for immunoprophylaxis failure. (3) Pregnant women should be treated with HBV DNA levels greater than 200,000 IU/mL or 6 log copies/mL. (4) Antiviral drug should be started around 28 to 32 weeks. The first-line drug is tenofovir disoproxil fumarate. (5) Delivery route should be chosen based only on obstetric indications. (6) Breastfeeding is not contraindicated because it does not increase the risk of transmission in neonates with HBV vaccine and immunoglobulin administration. (7) Neonates born to HBsAg-positive mothers should receive HBV vaccine and immunoglobulin after birth as soon as possible. (8) Follow-up of the mothers and neonates is important. Beware of hepatitis flare after birth and after antiretroviral drug discontinuation; alanine transaminase assessment every 1 to 3 months until 6 months is suggested. Also, the schedule of infant vaccination and follow-up of serologic testing at 9 to 12 months old is needed." }, { "id": "pubmed23n0500_19077", "title": "Breast milk and infection.", "score": 0.00980392156862745, "content": "Three viruses (CMV, HIV, and HTLV-I) frequently cause infection or disease as a result of breast-milk transmission. Reasonable guidelines have been pro-posed for when and how to avoid breast milk in the case of maternal infection. For other viruses, prophylactic immune therapy to protect the infant against all modes of transmission are indicated (VZV, varicella-zoster immunoglobulin, HAV and immunoglobulin, HBV, and HBIg + HBV vaccine). In most maternal viral infections, breast milk is not an important mode of transmission, and continuation of breastfeeding is in the best interest of the infant and mother (see Tables 2 and 3). Maternal bacterial infections rarely are complicated by transmission of infection to their infants through breast milk. In a few situations, temporary cessation of breastfeeding or the avoidance of breast milk is appropriate for a limited time (24 hours for N gonorrheae, H infiuenzae, Group B streptococci, and staphylococci and longer for others including B burgdorferi, T pallidum, and M tuberculosis). In certain situations, prophylactic or empiric therapy may be advised for the infant (eg, T pallidum, M tuberculosis, H influenzae) (see Table 1). Antimicrobial use by the mother should not be a reason not to breastfeed. Alternative regimens that are compatible with breastfeeding can be chosen to treat the mother effectively. In most cases of suspected infection in the breastfeeding mother, the delay in seeking medical care and making the diagnosis means the infant has been ex-posed already. Stopping breastfeeding at this time only deprives the infant of the nutritional and potential immunologic benefits. Breastfeeding or the use of expressed breast milk, even if temporarily suspended, should be encouraged and supported. Decisions about breast milk and infection should balance the potential risk compared with the innumerable benefits of breast milk." }, { "id": "article-28666_8", "title": "Routine Newborn Care -- Issues of Concern -- Newborn Care", "score": 0.00966966966966967, "content": "Within 1 hour of birth, intramuscular vitamin K should be administered. Prophylaxis with erythromycin ointment to both eyes and injection of hepatitis B vaccine are recommendations, while the baby has skin-to-skin with the mother. [1]" }, { "id": "pubmed23n1040_11070", "title": "Increased Protection of Earlier Use of Immunoprophylaxis in Preventing Perinatal Transmission of Hepatitis B Virus.", "score": 0.009523809523809525, "content": "Passive-active immunoprophylaxis against mother-to-child transmission (MTCT) of hepatitis B virus (HBV) recommends administering hepatitis B immunoglobulin (HBIG) and birth-dose hepatitis B vaccine in infants within 12 or 24 hours after birth. With this protocol, MTCT of HBV still occurs in 5-10% infants of HBV-infected mothers with positive hepatitis B e antigen (HBeAg). The present study aimed to investigate whether earlier administration of HBIG and hepatitis B vaccine after birth can further increase protection efficacy. We conducted a prospective, multi-center observational study in infants born to mothers with HBV infection, in whom neonatal HBIG and birth dose hepatitis B vaccine were administered within one hour after birth. The infants were followed up for HBV markers at 7-14 months of age. A total of 1140 pregnant women with HBV were enrolled, and 982 infants (9 twins) of 973 mothers were followed up at 9.6 ± 1.9 months of age. HBIG and birth-dose vaccine were administered in newborn infants within a median of 0.17 (0.02-1.0) hours after birth. The overall rate of MTCT was 0.9% (9/982), with none (0%) of the 607 infants of HBeAg-negative mothers and 9 (2.4%) of 375 infants of HBeAg-positive mothers acquiring HBV. All 9 HBV-infected infants were born to mothers with HBV DNA &gt;2.75 × 106 IU/mL. Maternal HBV DNA levels &gt;2 × 106 IU/mL were an independent risk factor (odds ratio, 10.627; 95% confidence interval, 2.135-∞) for immunoprophylaxis failure. Earlier use (within 1 hour after birth) of HBIG and hepatitis B vaccine can provide better protection efficacy against MTCT of HBV." }, { "id": "pubmed23n0002_9807", "title": "Evidence against breast-feeding as a mechanism for vertical transmission of hepatitis B.", "score": 0.009523809523809525, "content": "A follow-up study of 147 babies born to mothers known to be carriers of hepatitis B surface antigen (HBsAg) revealed no evidence for a relationship between breast-feeding and the subsequent development of antigenaemia in the babies. All babies were tested at three or more months of age, and the mean age at last follow-up was eleven months with a mean of three serum specimens per baby (not counting cord-blood specimens). The frequency of acquisition of HBsAg and anti-HBs was almost identical among breast-fed and non breast-fed infants. The frequency of other variables known to influence the development of antigenaemia among infants of carrier mothers did not vary according to breast-feeding status: mother's HBsAg titre, HBsAg positivity rate in cord-blood specimens, and HBsAg prevalence among siblings. 32 breast-milk specimens from carrier mothers were all HBsAg negative." }, { "id": "pubmed23n0845_6616", "title": "#38: Hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission.", "score": 0.009433962264150943, "content": "Between 800,000-1.4 million people in the United States and more than 240 million people worldwide are infected with hepatitis B virus (HBV). Specific to pregnancy, an estimated prevalence of 0.7-0.9% for chronic hepatitis B infection among pregnant women in the United States has been reported, with &gt;25,000 infants at risk for chronic infection born annually to these women. Vertical transmission of HBV from infected mothers to their fetuses or newborns, either in utero or peripartum, remains a major source of perpetuating the reservoir of chronically infected individuals globally. Universal screening for hepatitis B infection during pregnancy has been recommended for many years. Identification of pregnant women with chronic HBV infection through universal screening has had a major impact in decreasing the risk of neonatal infection. The purpose of this document is to aid clinicians in counseling their patients regarding perinatal risks and management options available to pregnant women with hepatitis B infection in the absence of coinfection with HIV. We recommend the following: (1) perform routine screening during pregnancy for HBV infection with maternal HBsAg testing (grade 1A); (2) administer hepatitis B vaccine and HBV immunoglobulin within 12 hours of birth to all newborns of HBsAg-positive mothers or those with unknown or undocumented HBsAg status, regardless of whether maternal antiviral therapy has been given during the pregnancy (grade 1A); (3) In pregnant women with HBV infection, we suggest HBV viral load testing in the third trimester (grade 2B); (4) in pregnant women with HBV infection and viral load &gt;6-8 log 10 copies/mL, HBV-targeted maternal antiviral therapy should be considered for the purpose of decreasing the risk of intrauterine fetal infection (grade 2B); (5) in pregnant women with HBV infection who are candidates for maternal antiviral therapy, we suggest tenofovir as a first-line agent (grade 2B); (6) we recommend that women with HBV infection be encouraged to breast-feed as long as the infant receives immunoprophylaxis at birth (HBV vaccination and hepatitis B immunoglobulin) (grade 1C); (7) for HBV infected women who have an indication for genetic testing, invasive testing (eg amniocentesis or chorionic villus sampling) may be offered-counseling should include the fact that the risk for maternal-fetal transmission may increase with HBV viral load &gt;7 log 10 IU/mL (grade 2C); and (8) we suggest cesarean delivery not be performed for the sole indication for reduction of vertical HBV transmission (grade 2C). " }, { "id": "pubmed23n0304_18182", "title": "[Rationale for a trial of prevention of perinatal transmission of hepatitis C via specific immunoglobulins].", "score": 0.009433962264150943, "content": "Vertical transmission of the HCV infection is asymptomatic, occurring in 0-25% of infants born to viremic mothers in Europe. Nowadays, the only preventive measure in to advise against breastfeeding. Favourable conditions for a seroprophylaxis trial in neonates at risk are the low viral charge and the absence of former replication or integration. Several impediments to a randomized-controlled trial should be considered: Epidemiological: paucity of recruitment; low risk of transmission; possible antenatal transmission in cases of high maternal viremia; risk for intrafamilial transmission. Methodological: complex randomization of the study groups (genotyping, quantitative PCR, activity of mothers' diseases, modes/durations of delivery and feeding). Ethical: a direct individual benefit is not clearly established; should viremic mothers be allowed to breast feed their babies in the absence of prophylaxis? the risk of the emergence of mutants or quasi-species of the transmitted hepatitis C virus in neonates; the origin and selection of seropositive plasma donors." }, { "id": "wiki20220301en206_1636", "title": "Hepatitis B", "score": 0.009345794392523364, "content": "Tenofovir given in the second or third trimester can reduce the risk of mother to child transmission by 77% when combined with hepatitis B immunoglobulin and the hepatitis B vaccine, especially for pregnant women with high hepatitis B virus DNA levels. However, there is no sufficient evidence that the administration of hepatitis B immunoglobulin alone during pregnancy, might reduce transmission rates to the newborn infant. No randomized control trial has been conducted to assess the effects of hepatitis B vaccine during pregnancy for preventing infant infection. All those with a risk of exposure to body fluids such as blood should be vaccinated, if not already. Testing to verify effective immunization is recommended and further doses of vaccine are given to those who are not sufficiently immunized." }, { "id": "pubmed23n1040_18474", "title": "[The impact of Covid-19 pandemic on breastfeeding and birth care. The importance of recovering good practices.]", "score": 0.009345794392523364, "content": "The SARS-CoV-2 pandemic has had a major impact on birth care and lactation. The lack of knowledge regarding the transmission mechanisms and the potential risks for the mother and the newborn, even when the vertical transmission of the virus has not been demonstrated, has led to the abandonment of practices such as skin-to-skin and the early initiation of breastfeeding (BF), which offer great benefits for maternal and child health. Taking into account the available scientific evidence and the protective effect of BF, the World Health Organization (WHO), and other organisms recommend, in cases of suspected or confirmed SARS-CoV-2 infection of the mother, maintaining mother-child contact and BF, adopting preventive measure procedures to minimize the risk of contagion. These measures include hand hygiene, before and after contact with the newborn and the use of a mask. If a temporary separation of mother and child is required, it is recommended to feed the newborn with expressed breast milk. The presence of IgA antibodies against SARS-CoV-2 has been confirmed in the milk of infected women, so BF could reduce the clinical impact of the disease in the infant, if it becomes infected." }, { "id": "pubmed23n0053_16431", "title": "A comparison of secretory antibodies in breast-fed and formula-fed infants over the first six months of life.", "score": 0.009259259259259259, "content": "In the present study salivary IgA, anti-Escherichia coli, anti-beta-lactoglobulin and anti-poliovirus type 1 IgA and IgM in serum and saliva were evaluated longitudinally in 13 breast-fed and 14 formula-fed infants over the first six months of life. Salivary IgA was quantified by electroimmunodiffusion; specific IgA and IgM antibodies were determined in serum and saliva by ELISA. Salivary IgA was significantly lower at age one month in breast-fed compared with formula-fed infants but in breast-fed infants salivary IgA increased with age and was significantly higher at six months than at one month. In both groups of infants, at the age of six months, salivary IgA levels were significantly lower than in adult controls. No significant differences in secretory anti-E. coli were observed between the two groups of infants. Salivary anti-poliovirus IgA and IgM antibodies increased transiently only to disappear in most babies at age six months, while anti-beta lactoglobulin IgA and IgM, present in saliva at all ages, showed a wide scatter. No important differences in specific serum IgA or IgM antibodies were observed either between the groups or at different times within the groups." }, { "id": "pubmed23n0720_6382", "title": "[Evaluation of serological status of children following hepatitis B vaccination during infancy].", "score": 0.009174311926605505, "content": "The aims of this study were to determine anti-HBs positivity in children who had received three doses of hepatitis B vaccine during infancy and to evaluate the factors that may affect the serological status. Local ethics committee approval was obtained at the beginning of the study. The study was carried out between December 2005 and October 2007 among children attending the outpatient clinics of medical school hospital. The study encompassed 912 children (393 female, 519 male; aged 1-5 years old) who had been immunized with three doses of intramuscular recombinant hepatitis B vaccine during infancy. All of the children were born to HBsAg negative mothers and did not have any known immune system problems. Sociodemographic characteristics and passive smoking status were gathered by a questionnaire. Anthropometric measurements were taken, and a detailed physical examination was carried out for each child. Blood samples were obtained to check serum HBsAg, anti-HBs and anti-HBc levels by commercial micro-ELISA (Sanofi Diagnostics Pasteur, Sydney) method. Levels of anti-HBs ≥ 10 mIU/ml were defined as seropositivity. In seronegative children, anti-HBs levels were re-checked 4 weeks after receiving one booster dose of hepatitis B vaccine. Of the children 877 (96.2%) were found anti-HBs positive, while all of them were negative for anti-HBc or HBsAg. Of children 34.8% were 12-23 months; 28.7% were 24-36 months; and 36.5% were 37-60 months-old, and anti-HBs negativity rate was higher in the older age group with a statistically significant difference (1.4%, 3.9% and 4.2%, respectively; p= 0.003). Anti-HBs antibodies were found negative in 2.8% of children who were born by vaginal route and in 5.8% of children who were born by cesarean section, the difference being statistically significant (p= 0.016). There were no significant differences between anti-HBs seropositivity and gender, working/ educational status of the mothers and the presence of smoking parents in the family (p&gt; 0.05). Logistic regression analysis indicated that the factors that affect antibody levels in vaccinated children were the duration of breastfeeding only (4.77 ± 1.53 months in anti-HBs positives and 3.69 ± 2.13 months in negatives; p= 0.008), birth weight (3328.18 ± 318 g in anti-HBs positives and 3135.27 ± 488 g in negatives; p= 0.037) and pregnancy parity (anti-HBs was negative in 3.4% of children born from mothers who had &lt; 2 parities, and 8.2% of children born from mothers who had &lt; 3 parities; p= 0.037). The remaining 35 (3.8%) children with undetectable antibody levels became seropositive after one dose of hepatitis B vaccination, with the antibody levels of ≥ 100 mIU/ml. This response underlined the presence of immune memory in vaccinated children. The results of this study indicated that almost all 1-5 years old children who had received three doses of hepatitis B vaccine during infancy were protected from hepatitis B virus infection. It was concluded that similar studies should be carried out in different settings." }, { "id": "pubmed23n0084_6449", "title": "The hepatitis B immunization programme in Singapore.", "score": 0.00909090909090909, "content": "A voluntary immunization programme to prevent perinatal transmission of hepatitis B virus (HBV) infection in Singapore was implemented on 1 October 1985 as an integral component of the national childhood immunization programme. Up to April 1988, a total of 68,845 mothers who attended government maternal and child health clinics were screened for the disease. Of these, 2432 (3.5%) were positive for hepatitis B surface antigen (HBsAg) and 904 (1.3%) for hepatitis B e antigen (HBeAg). Virtually all the babies born to carrier mothers completed the full immunization schedule; and in addition, those of HBeAg-positive mothers were given a dose of hepatitis B immunoglobulin at birth. The hepatitis B immunization programme was extended on 1 September 1987 to cover all newborns. About 90% of the 15,943 babies delivered in government institutions from September 1987 to April 1988 were immunized at birth, with the subsequent doses being administered at maternal and child health clinics at 4-6 weeks and 5 months later. More than 85% of the children given the full course of plasma-derived and yeast-derived hepatitis B vaccine from birth continued to have protective antibody to HBV two years after immunization. The programme is being closely monitored to assess the duration of immunity and the need for booster doses, while seronegative adults are also being encouraged to be vaccinated." }, { "id": "pubmed23n0099_7960", "title": "[Hepatitis B: is the current vaccination policy the correct one everywhere?].", "score": 0.00909090909090909, "content": "In this study we have tried to examine retrospectively all the babies born to HBsAg + mothers in the past nine years, in order to evaluate which is the real incidence of perinatal transmission of HBsAg, and then if the actual politic to vaccinate only these babies is right and sufficient. The results demonstrate that the perinatal transmission is not a major problem in our country, so we suggest that for improvement of public health is more advised the vaccination of all infants: those born to HBsAg + mothers at the birth, the others in the third month of life." }, { "id": "wiki20220301en178_5865", "title": "Hepatitis B vaccine", "score": 0.009009009009009009, "content": "An antibody level between 10 and 100mIU/ml is considered a poor response, and these people should receive a single booster vaccination at this time, but do not need further retesting. People who fail to respond (anti-Hbs antibody level below 10mIU/ml) should be tested to exclude current or past hepatitis B infection, and given a repeat course of three vaccinations, followed by further retesting 1–4 months after the second course. Those who still do not respond to a second course of vaccination may respond to intradermal administration or to a high dose vaccine or to a double dose of a combined hepatitis A and B vaccine. Those who still fail to respond will require hepatitis B immunoglobulin (HBIG) if later exposed to the hepatitis B virus." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 102 ] ], "word_ranges": [ [ 0, 17 ] ], "text": "Orlistat acts by decreasing fat absorption; it is currently the only drug approved for use in obesity." }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Orlistat.", "2": "Topiramate.", "3": "Sibutramine.", "4": "Liraglutide.", "5": "Metformin." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0310_13400", "title": "A meta-analysis of the past 25 years of weight loss research using diet, exercise or diet plus exercise intervention.", "score": 0.014034068912117692, "content": "The therapeutic effectiveness of diet, exercise, and diet plus exercise for weight loss in obesity was determined. All human research reported in English, published in peer-reviewed scientific journals within the past 25 y was reviewed. Acceptance criteria (n = 493 from &gt; 700 studies) were that a therapeutic intervention of diet, exercise or diet plus exercise was employed, specifically for weight reduction in obese adult humans and that weight change was reported numerically. Only aerobic exercise studies were included, while drug, hormone and surgical treatments were excluded. All data were extracted by the same investigator from the original research report. Except for gender and program type, all extracted data were numerical. ANOVA, with a Newman-Keuls post hoc test, was used to determine differences among programs (P &lt; 0.05). One analysis was performed on the group mean data and one based on effect sizes. Analyses were repeated using initial body weight, initial percent body fat and program length, as covariates. Primarily, subjects aged 40 y have been studied (39.5 +/- 0.4 y, mean +/- s.e.m.) who are only moderately obese (92.7 +/- 0.9 kg, 33.2 +/- 0.5 body mass index (BMI), 33.4 +/- 0.7% body fat); for short durations (15.6 +/- 0.6 weeks). Exercise studies were of a shorter duration, used younger subjects who weighed less, had lower BMI and percentage body fat values, than diet or diet plus exercise studies. Despite these differences, weight lost through diet, exercise and diet plus exercise was 10.7 +/- 0.5, 2.9 +/- 0.4* and 11.0 +/- 0.6 kg, respectively. However, at one-year follow-up, diet plus exercise tended to be the superior program. Effect size and covariate analyses revealed similar program differences. Weight loss research over the past 25 y has been very narrowly focused on a middle age population that is only moderately obese, while the interventions lasted for only short periods of time. The data shows, however, that a 15-week diet or diet plus exercise program, produces a weight loss of about 11 kg, with a 6.6 +/- 0.5 and 8.6 +/- 0.8 kg maintained loss after one year, respectively." }, { "id": "pubmed23n0770_7808", "title": "Obesity and weight management in the elderly: a focus on men.", "score": 0.013786937699981178, "content": "The rising rate of overweight/obesity among the ever-growing ageing population is imposing massive and rapidly changing burdens of ill health. The observation that the BMI value associated with the lowest relative mortality is slightly higher in older than in younger adults, mainly through its reduced impact on coronary heart disease, has often been misinterpreted that obesity is not as harmful in the elderly, who suffer a large range of disabling consequences of obesity. All medical consequences of obesity are multi-factorial and most alleviated by modest, achievable weight loss (5-10 kg) with an evidence-based maintenance strategy. But severe obesity, e.g. BMI &gt;40 may demand greater weight loss e.g. &gt;15 kg to reverse type 2 diabetes. Since relatively reduced physical activity and reduced muscle mass (sarcopenic obesity) are common in the elderly, combining exercise and modest calorie restriction optimally reduces fat mass and preserves muscle mass - age presents no obstacle and reducing polypharmacy is a valuable outcome. The currently licensed drug orlistat has no age-related hazards and is effective in a low fat diet, but the risks from bariatric surgery begin to outweigh benefits above age 60. For the growing numbers of obese elderly with diabetes, the glucagon-like peptide-1 (GLP-1) receptor analogue liraglutide appears a safe way to promote and maintain substantial weight loss. Obesity and sarcopenia should be prevented from younger age and during life-transitions including retiral to improve future health outcomes and quality of life, with a focus on those in \"obese families\". " }, { "id": "wiki20220301en493_23568", "title": "My 600-lb Life", "score": 0.01312170714735412, "content": "My 600-lb Life is an American reality television series that has aired on the TLC television network since 2012. Each episode follows a year in the life of morbidly obese individuals, who usually begin the episode weighing at least , and documents their attempts to reduce their weight to a healthy level. Update episodes, called \"Where Are They Now?\", feature one or more previous patients, picking up a year or more after their original episodes aired. Patients are placed under the care of Iranian-American Houston surgeon Younan Nowzaradan (often referred to as simply \"Dr. Now\"), who first has them attempt losing weight on their own by following a strict diet, and then depending on the patient's progress may offer gastric bypass surgery or sleeve gastrectomy to further assist in weight loss." }, { "id": "wiki20220301en329_29746", "title": "Management of obesity", "score": 0.012998809747541189, "content": "A number of popular programs exist, including Weight Watchers, Overeaters Anonymous, and Jenny Craig. These appear to provide modest weight loss () over dieting on one's own () over a two-year period, similarly to non-commercial diets. Internet-based programs appear to be ineffective. The Chinese government has introduced a number of \"fat farms\" where obese children go for reinforced exercise, and has passed a law which requires students to exercise or play sports for an hour a day at school (see Obesity in China). In a structured setting with a trained therapist, these interventions produce an average weight loss of up to 8 kg in 6 months to 1 year, and 67% of people who lost greater than 10% of their body mass maintained or continued to lose weight one year later. There is a gradual weight regain after the first year of about 1 to 2 kg per year, but on the long-term this still results in a weight loss." }, { "id": "wiki20220301en000_124659", "title": "Dieting", "score": 0.012868291129160695, "content": "Some studies have found that, on average, short-term dieting results in a \"meaningful\" long-term weight-loss, although limited because of gradual 1 to 2 kg/year weight regain. Others have suggested that dieting is ineffective as a long-term intervention. For each individual, the results will be different, with some even regaining more weight than they lost, while a few others achieve a tremendous loss, so that the \"average weight loss\" of a diet is not indicative of the results other dieters may achieve. A 2001 meta-analysis of 29 American studies found that participants of structured weight-loss programs maintained an average of 23% (3 kg) of their initial weight loss after five years, representing an sustained 3.2% reduction in body mass. Unfortunately, patients are generally unhappy with weight loss of <10%, and reductions even as high as 10% are insufficient for changing someone with a \"obese\" BMI to a \"normal weight\" BMI." }, { "id": "pubmed23n0365_11512", "title": "[Randomized placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients].", "score": 0.01276641782970897, "content": "We undertook a randomised controlled trial to assess the efficacy and tolerance of orlistat, a gastrointestinal lipase inhibitor, in promoting weight loss and preventing weight regain in obese patients over a 2-year period. 743 patients (body-mass index 28-47 kg/m2), recruited at 15 European centres, entered a 4-week, single-blind, placebo lead-in period on a slightly hypocaloric diet (600 kcal/day deficit). 688 patients who completed the lead-in were assigned double-blind treatment with orlistat 120 mg (three times a day) or placebo for 1 year in conjunction with the hypocaloric diet. In a second 52-week double-blind period patients were reassigned orlistat or placebo with a weight maintenance (eucaloric) diet. From the start of lead-in to the end of year 1, the orlistat group lost, on average, more bodyweight than the placebo group (10.2% [10.3 kg] vs 6.1% [6.1 kg]; LSM difference 3.9 kg [p &lt; 0.001] from randomisation to the end of year 1). During year 2, patients who continued with orlistat regained, on average, half as much weight as those patients switched to placebo (p &lt; 0.001). Patients switched from placebo to orlistat lost an additional 0.9 kg during year 2, compared with a mean regain of 2.5 kg in patients who continued on placebo (p &lt; 0.001). Total cholesterol, low-density lipoprotein (LDL) cholesterol, LDL/high-density lipoprotein ratio, and concentrations of glucose and insulin decreased more in the orlistat group than in the placebo group. Gastrointestinal adverse events were more common in the orlistat group. Other adverse symptoms occurred at a similar frequency during both treatments. Orlistat taken with an appropriate diet promotes clinically significant weight loss and reduces weight regain in obese patients over a 2-year period. The use of orlistat beyond 2 years needs careful monitoring with respect to efficacy and adverse events." }, { "id": "wiki20220301en329_29747", "title": "Management of obesity", "score": 0.012564935064935064, "content": "Comprehensive diet programs, providing counseling, targets for calorie intake and exercise, may be more efficient than dieting without guidance (\"self-help\"), although the evidence is very limited. Following comprehensive lifestyle modifications, the average maintained weight loss is more than or 3% of total body mass, and could be sustained for five years, and up to 20% of the individuals maintain a weight loss of at least 10% (average of 33 kg). There is some evidence that fast weight loss produce greater long-term weight loss than gradual weight loss. Moderate on-site comprehensive lifestyle changes produce a greater weight loss than usual care, of 2 to 4 kg on average in 6 to 12 months. High-intensity comprehensive programs usually yield more weight loss than moderate or low-intensity, with about 35% to 60% of overweight individuals maintaining more than 5 kg weight loss after 2 years." }, { "id": "article-131511_4", "title": "Dietary Approaches to Obesity Treatment -- Function", "score": 0.011069828990228013, "content": "One kilogram of fat contains 9000 kilocalories. To lose half a kilogram of fat per week, a person should achieve a 4500 kcal net deficit for a week, 642 kcal in one day. Net energy deficit is achieved by decreasing food intake (dieting) and increasing physical activity. For example, a 55-year old moderately active 136 kg woman needs 2600 kcal for her daily needs. For a person who consumes a 2600 kcal diet, creating a 642 kcal deficit will require a 25 percent reduction in daily energy intake if the individual does not increase physical activity. The patient needs to spend effort, time, and usually some extra money to reach the goal of losing 26 kg of fat in a year. The effort can be too much, and the time to achieve the target weight is too long for some individuals. Reaching ideal body weight might seem too slow for some individuals triggering giving up on lifestyle treatment. It is advisable to set realistic goals that can be achievable." }, { "id": "wiki20220301en329_29749", "title": "Management of obesity", "score": 0.009900990099009901, "content": "Medication Several anti-obesity medications are currently approved by the FDA for long term use. Orlistat reduces intestinal fat absorption by inhibiting pancreatic lipase. Lorcaserin has been found to be effective in the treatment of obesity with a weight loss of 5.8 kg at one year as opposed to 2.2 kg with placebo and it is approved by the Food and Drug Administration for use in the treatment of obesity. Side effects may include serotonin syndrome. The combination drug phentermine/topiramate (Qsymia) is approved by the FDA as an addition to a reduced-calorie diet and exercise for chronic weight management." }, { "id": "pubmed23n0224_14305", "title": "[Long-term results (5-year minimum) of the diet treatment of adult obesity. Elements of weight prognosis. Apropos of 138 patients].", "score": 0.009900990099009901, "content": "One hundred and thirty-eight out of 250 obese patients admitted to hospitals between 1972 and 1976 for dietetic treatment comprising 1,000 calories and 100 g carbohydrates were recontacted with a minimum follow-up of 5 years. Seventy-five patients refused to answer the questionnaire or attend an outpatient appointment. Four patients were later excluded from the study. Finally, fifty-nine patients were reassessed. The percentage of good results at 5 years (defined as greater than or equal to 5 p. 100 loss of initial body weight) was 45.5 p. 100 of those reassessed, a minimum of 20 p. 100 of the total number recontacted. The course of obesity was not linear. During the follow-up period there were 45.5 p. 100 of secondary failures (regain of initial body weight after having lost at least 5 p. 100), but also 17 p. 100 of secondary successes. The prognosis was not related to the age of onset of obesity, its duration, sex, occupation, alleged trigger factors, apparent motivation, duration of hospital admission, or treatment before or after hospitalisation. The prognosis was better in patients under 30 or over 50 years of age at the time of treatment (P less than 0.01) and when the body weight had not varied +/- 5 kg in the years preceding treatment (P less than 0.01). The following factors may also play a favourable role (but not statistically significant): the degree of obesity (better results in major obesity greater than or equal to 50 p. 100 overweight), a positive family history, the detection of a physical factor (glucose intolerance) during investigation, and the repetition of medical check-ups after initial counselling." }, { "id": "pubmed23n0402_2110", "title": "[Estimation of the influence of psychological support on body mass reduction in the obese patients].", "score": 0.009819021948402002, "content": "Obesity is an excessive accumulation of fatty tissue in the organism. Incorrect eating habits and low physical activity are the major cause of overweight and obesity. The aim of the study was to investigate the efficiency of dietetic treatment and increased physical activity in patients with excessive body mass. The study was carried out on 140 patients with overweight or simple obesity (131 women and 9 men), aged 15-65 years, the members of the support group previously instructed in dietetics. The treatment consisted of the application of diet 1000-1500 kcal/day and the participation in the programme of body-mass reducing exercises (physical exercise twice a week and exercise in water once a week for 45 min). The attendance was monitored and those who missed the classes were excluded from the group. The study was terminated after 2 years. In the group I (exercising for 0-3 months) 39 patients reduced their body mass by 7.7 kg on the average. In the group II (exercising for 3-6 months) 59 patients reduced their body mass by the average of 14.5 kg. In the group III (exercising for 6-12 months) in 38 patients the average loss of body mass was 20.9 kg. In the group IV (exercising for over 12 months) 4 patients reduced their weight by 26-70 kg (mean 50 kg), which gave the 26.5-47% loss of the initial body mass. The patients with overweight and obesity included in the present study reduced their body mass through the application of an adequately selected diet and increased physical activity. More than 40% of the patients were able to preserve up to 6 months of the programme, and about 30% up to one year." }, { "id": "pubmed23n0366_18142", "title": "How to help your patients lose weight: current therapy for obesity.", "score": 0.00980392156862745, "content": "Obesity is epidemic and dangerous. Weight loss is difficult but worth the effort. Although new weight-loss drugs are available, there are no magic bullets: to lose weight and keep it off, people must eat less and exercise more. This article presents a practical approach on how physicians can help their patients lose weight through diet, behavior modification, and adjunctive pharmacologic therapy. An appropriate initial goal is to lose 5% to 10% of one's baseline weight over 3 to 6 months. Drug therapy should not be used in isolation, but it can be an adjunct to diet, exercise, and behavior modification if a patient is committed and able to make necessary changes in eating and activity, and if the patient has a BMI of 30 or higher or a BMI greater than 27 with weight-related comorbid conditions. Anorectic therapy is unlikely to succeed and should be stopped if the patient does not lose at least 4 lb in the first 4 weeks of therapy. Orlistat is unlikely to be of benefit if patients do not lose at least 3% of their baseline weight by 12 weeks. Because obesity is a chronic disease, drug treatment should be continued indefinitely. The physician and patient must understand the intention to treat long-term. The weight loss plan devised should improve upon previous plans: for example, implementing a regular, convenient exercise program that had not been included in the past, or offering pharmacotherapy." }, { "id": "pubmed23n0521_4464", "title": "Pharmacotherapy for obesity.", "score": 0.009708737864077669, "content": "Pharmacotherapy for the management of obesity is primarily aimed at weight loss, weight loss maintenance and risk reduction, and has included thyroid hormone, amphetamines, phentermine, amfepramone (diethylpropion), phenylpropanolamine, mazindol, fenfluramines and, more recently, sibutramine and orlistat. These agents decrease appetite, reduce absorption of fat or increase energy expenditure. Primary endpoints used to evaluate anti-obesity drugs most frequently include mean weight loss, percentage weight loss and proportion of patients losing &gt;or=5% and &gt;or=10% of initial bodyweight. Secondary endpoints may include reduction in body fat, risk factors for cardiovascular disease and the incidences of diseases such as diabetes mellitus. Most pharmacotherapies have demonstrated significantly greater weight loss in patients on active treatment than those receiving placebo in short-term (&lt;or=1 year) randomised controlled trials of pharmacological treatment in conjunction with a calorie-controlled diet or lifestyle intervention. The evidence of long-term efficacy is limited to sibutramine (2 years) and orlistat (4 years). These are the only drugs currently approved for the long-term management of obesity in adults. Sibutramine recipients randomised following 6 months' treatment to either sibutramine or placebo demonstrated significantly better weight maintenance at 2 years than those taking placebo (p&lt;0.001), with &gt;or=10% loss of initial bodyweight in 46% of patients. For patients taking orlistat, weight loss was 2.2 kg greater than those on placebo at 4 years (p&lt;0.001), with significantly more patients achieving &gt;or=10% loss of initial bodyweight (26.2% and 15.6%, respectively; p&lt;0.001). Other drugs that have been evaluated for weight loss include ephedrine, the antidepressants fluoxetine and bupropion, and the antiepileptics topiramate and zonisamide. Two clinical trials with fluoxetine both reported no significant difference in weight loss compared with placebo at 52 weeks. Clinical trials evaluating ephedrine, bupropion, topiramate and zonisamide have demonstrated significantly greater weight loss than placebo but have been limited to 16-26 weeks' treatment. A major obstacle to the evaluation of the clinical trials is the potential bias resulting from low study completion rates. Completion rates varied from 52.8% of phentermine recipients in a 9-month study, to 40% of fenfluramine recipients in a 24-week comparative study with phentermine and 18% of amfepramone recipients in a 24-week study. One-year completion rates range from 51% to 73% for sibutramine and from 66% to 85% for orlistat. Other potential sources of bias include run-in periods and subsequent patient selection based on compliance or initial weight loss. Several potential new therapies targeting weight loss and obesity through the CNS pathways or peripheral adiposity signals are in early phase clinical trials. Over the next decade the drug treatment of obesity is likely to change significantly because of the availability of new pharmacotherapies to regulate eating behaviours, nutrient partitioning and/or energy expenditure." }, { "id": "wiki20220301en204_12500", "title": "Liraglutide", "score": 0.009615384615384616, "content": "Liraglutide was approved for medical use in the European Union in 2009, and in the United States in 2010. In 2019, it was the 142nd most commonly prescribed medication in the United States, with more than 4million prescriptions. Medical uses Liraglutide is a medication used for the treatment of type 2 diabetes or obesity. Type 2 diabetes Liraglutide improves control of blood glucose. As of 2017 it is unclear if incretin mimetics like liraglutide affect a person's risk of death. In diabetes it is a less preferred agent. It may be used in those in who metformin and another antidiabetic medication such as a sulfonylurea are not sufficient. Obesity Liraglutide may also be used together with diet and exercise for chronic weight management in adult patients. The body mass index (BMI) needs to be greater than 30 kg/m2, or greater than 27 kg/m2 together with high blood pressure, type 2 diabetes mellitus, or dyslipidemia." }, { "id": "wiki20220301en365_13273", "title": "The Biggest Loser (season 13)", "score": 0.009615384615384616, "content": "Winners $250,000 Winner (among the finalists) $100,000 Winner (among the eliminated contestants) Weigh-In Difference History Notes Conda's 15 pound weight loss in week 9 was displayed as a -14 due to her weight gain the previous week. Megan's 6 pound weight loss in week 11 was displayed as a -7 due to her 1 lb advantage from the challenge. Chris's 3 pound weight loss in week 12 was displayed as -4 due to her 1 lb advantage from the challenge. Mark's 0 pound weight loss in week 13 was displayed as -1 due to his 1 lb advantage from the challenge. Buddy's 9 pound weight loss in week 14 was displayed as -10 due to his 1 lb advantage from the challenge. Conda's 5 pound weight loss in week 14 was displayed as -4 due to her 1 lb disadvantage from the challenge. Weigh-In Percentages History" }, { "id": "pubmed23n0580_22417", "title": "Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up.", "score": 0.009523809523809525, "content": "To assist health professionals who counsel patients with overweight and obesity, a systematic review was undertaken to determine types of weight-loss interventions that contribute to successful outcomes and to define expected weight-loss outcomes from such interventions. A search was conducted for weight-loss-focused randomized clinical trials with &gt;or=1-year follow-up. Eighty studies were identified and are included in the evidence table. The primary outcomes were a measure of weight loss at 6, 12, 24, 36, and 48 months. Eight types of weight-loss interventions-diet alone, diet and exercise, exercise alone, meal replacements, very-low-energy diets, weight-loss medications (orlistat and sibutramine), and advice alone-were identified. By using simple pooling across studies, subjects mean amount of weight loss at each time point for each intervention was determined. Efficacy outcomes were calculated by meta-analysis and provide support for the pooled data. Hedges' gu was combined across studies to obtain an average effect size (and confidence level). A mean weight loss of 5 to 8.5 kg (5% to 9%) was observed during the first 6 months from interventions involving a reduced-energy diet and/or weight-loss medications with weight plateaus at approximately 6 months. In studies extending to 48 months, a mean 3 to 6 kg (3% to 6%) of weight loss was maintained with none of the groups experiencing weight regain to baseline. In contrast, advice-only and exercise-alone groups experienced minimal weight loss at any time point. Weight-loss interventions utilizing a reduced-energy diet and exercise are associated with moderate weight loss at 6 months. Although there is some regain of weight, weight loss can be maintained. The addition of weight-loss medications somewhat enhances weight-loss maintenance." }, { "id": "wiki20220301en180_5549", "title": "Tesofensine", "score": 0.009433962264150943, "content": "Clinical trials Phase IIB trial (TIPO-1) results reported in The Lancet showed levels of weight loss over a 6-month period that were significantly greater than those achieved with any currently available drugs. Patients lost an average of 12.8 kg on the 1 mg dose, 11.3 kg on the 0.5 mg dose and 6.7 kg on the 0.25 mg dose, compared with a 2.2 kg loss in the placebo group. All participants were instructed to follow a diet with a 300 kcal deficit and to increase their physical activity gradually to 30–60 minutes of exercise per day. The placebo-subtracted mean weight losses were 4.5%, 9.2% and 10.6% in the 0.25 mg, 0.5 mg and 1 mg dose groups, respectively. This is approximately twice the weight loss produced by medications currently approved by the US Food and Drug Administration (FDA) for the treatment of obesity." }, { "id": "pubmed23n0556_8260", "title": "[Weight changes and the effect of anti-diabetes treatment in the first 5 years after diabetes diagnosis - secondary publication].", "score": 0.009433962264150943, "content": "We monitored changes in patients' weight during the first 5 years after diabetes diagnosis. Data were from 711 newly diagnosed diabetic patients aged 40 or over managed in general practice. Patients whose only treatment was advice on diet generally maintained an initial weight loss of 5-7 kg over the 5 years. Patients receiving metformin or sulfonylureas maintained an average weight loss of 2-4 kg depending on age and sex, while an acceptable average glycaemic control was achieved. The results indicate that weight reduction is a practicable treatment in diabetic patients." }, { "id": "pubmed23n0608_2975", "title": "[Pharmacological therapy of obesity].", "score": 0.009345794392523364, "content": "Obesity is reaching epidemic proportions worldwide and it is correlated with various comorbidities, among which the most relevant are diabetes mellitus, arterial hypertension, and cardiovascular diseases. Obesity management is a modern challenge because of the rapid evolution of unfavorable lifestyles and unfortunately there are no effective treatments applicable to the large majority of obese/overweight people. The current medical attitude is to treat the complications of obesity (e.g. dyslipidemia, hypertension, diabetes, and cardiovascular diseases). However, the potential of treating obesity is enormous, bearing in mind that a volitional weight loss of 10 kg is associated with important risk factor improvement: blood pressure -10 mmHg, total cholesterol -10%, LDL cholesterol -15%, triglycerides -30%, fasting glucose -50%, HDL cholesterol +8%. Drug treatment for obesity is an evolving branch of pharmacology, burdened by severe side effects and consequences of the early drugs, withdrawn from the market, and challenged by the lack of long-term data on the effect of medications on obesity-related morbidity and mortality, first of all cardiovascular diseases. In Europe three antiobesity drugs are currently licensed: sibutramine, orlistat, and rimonabant; important trials with clinical endpoints are ongoing for sibutramine and rimonabant. While waiting for their results, it is convenient to evaluate these drugs for their effects on body weight and cardiometabolic risk factors. Sibutramine is a centrally acting serotonin/noradrenaline reuptake inhibitor that mainly increases satiety. At the level of brown adipose tissue, sibutramine can also facilitate energy expenditure by increasing thermogenesis. The long-term studies (five) documented a mean differential weight reduction of 4.45 kg for sibutramine vs placebo. Considering the principal studies, attrition rate was 43%. This drug not only reduces body weight and waist circumference, but it decreases triglycerides and uric acid as well and it increases HDL cholesterol; in diabetics it improves glycated hemoglobin. Sibutramine has conflicting effects on blood pressure: in some studies there was a minimal decrease, in some others a modest increase. In all the studies this drug increased pulse rate. Sibutramine is not recommended in patients with uncontrolled hypertension, or in case of history of cardio- and cerebrovascular disease. Orlistat is a pancreatic lipase inhibitor that reduces fat absorption by partially blocking the hydrolysis of dietary triglycerides. A recent meta-analysis evaluated 22 studies lasting for at least 12 months, in obese patients with a mean body mass index of 36.7 kg/m2, where orlistat was associated with hypocaloric diet or behavioral interventions: the net average weight loss was 2.89 kg (confidence interval 2.27-3.51 kg). Considering the principal studies, attrition rate ranged from 33 to 57%. Orlistat significantly decreases waist circumference, blood pressure, total and LDL cholesterol, but has no effect on HDL and triglycerides. This drug significantly reduced the incidence of diabetes only in subjects with impaired glucose tolerance. The major adverse effects with orlistat are mainly gastrointestinal (fatty and oily stool, fecal urgency, oily spotting, fecal incontinence) and attenuate over time. Orlistat should be avoided in patients with chronic malabsorption and cholestasis. Rimonabant is a selective antagonist of cannabinoid type 1 receptor. This drug, by inhibiting the overactivation of the endocannabinoid system, produces anorectic stimuli at the central nervous level, but also has effects on the peripheral systems involved in metabolism control, such as liver, adipose tissue, skeletal muscles, endocrine pancreas, and gastrointestinal apparatus, influencing many processes partially unknown. An ample experimental program named RIO (Rimonabant In Obesity) involved about 6600 obese or overweight patients to identify the effects of rimonabant in weight loss and associated cardiometabolic abnormalities, over and beyond a caloric restriction of 600 kcal in the treatment and placebo arms. In the four double-blind RIO trials published (Rio-North America, RIO-Europe, RIO-Lipids, RIO-Diabetes), rimonabant 20 mg significantly (p &lt;0.001) reduced weight by 6.3-6.9 kg in the non-diabetic groups vs placebo (-1.5-1.8 kg), whereas in the diabetic subjects enrolled in RIO-Diabetes, weight loss was 5.3 vs 1.4 kg in the placebo group. Attrition rate at 1 year ranged between 40 and 50%, similar to the studies with sibutramine or orlistat. Similarly to weight loss, also waist circumference was significantly reduced by rimonabant. As for cardiometabolic parameters, rimonabant induced a significant increase in HDL cholesterol and a significant decrease in triglycerides. Even if no significant LDL reduction was achieved, the RIO-Lipids study showed a significant decrease in small dense LDL particles, more atherogenic, in rimonabant-treated subjects. Non-diabetic treated patients improved basal insulin and indirect indexes of insulin resistance, while in the RIO-Diabetes study, the only one including diabetics, glycated hemoglobin improved by 0.7% in the active treatment arm vs placebo. The effects on HDL cholesterol and glycated hemoglobin seem in a large percentage unrelated to weight loss. These effects have been confirmed by another trial, named SERENADE, evaluating the treatment in naive diabetic patients. Rimonabant is not recommended in patients with a history of depressive disorders or suicidal ideation and with uncontrolled psychiatric illness, and is contraindicated in patients with ongoing major depression or ongoing antidepressive treatment. In conclusion, despite an enormous advancement in basic research to understand the pathogenetic mechanisms at the base of obesity, the pharmacological research did not reach the therapeutic opportunities available for other chronic conditions, like hypertension and dyslipidemia. However, the few molecules available for clinical practice (sibutramine, orlistat, rimonabant) have shown, when properly used, to contribute to reduce body weight and undoubtedly improve cardiometabolic risk factors. With this preamble, according to current guidelines and pharmacoeconomic studies, patients who might benefit from antiobesity treatment are those with a body mass index &gt; or =30 or 27-29.9 kg/m2 with major obesity-related comorbidities such as hypertension, diabetes, dyslipidemia, obstructive sleep apnea, and metabolic syndrome." }, { "id": "pubmed23n0080_1753", "title": "[The base data from Weight Watcher's groups as the parameter for long-term follow-up of weight reduction].", "score": 0.009345794392523364, "content": "The available data of members of Weight Watchers groups were statistically evaluated and their efficiency is discussed with respect to the underlying therapeutic concept. As a result of the data evaluation and the discussion of the literature it can be concluded: 1. The time of active membership in the group correlates with the weight loss. 2. Dropouts can be expected at the beginning of the therapy and have usually a greater obesity than other members. An early motivation has to consider the slower success in those people with a high degree of obesity. 3. A continuous motivation and re-motivation is of greatest importance to prevent any weight gain after the end of group therapy. This re-motivation program should be established within the group; members who succeeded in losing weight should return for meetings at regular intervals." }, { "id": "pubmed23n0610_14679", "title": "Dietary treatment for obesity.", "score": 0.009259259259259259, "content": "In patients with obesity, low-fat diets seem to result in a weight loss of 3-4 kg at 3 years, but long-term data are limited. Calorie-controlled diets seem to outperform low-fat diets with reported weight losses of 6-7 kg at 4 years, but, again, data are very limited; an initial very-low-calorie diet approach does not lead to greater weight loss than low-fat diets in the long term. Use of meal replacements can lead to an 8 kg weight loss at 4 years, but this finding has been reported only in one, uncontrolled study. High-protein, low-carbohydrate (or very-low-carbohydrate) diets have also been evaluated and seem to be superior to high-carbohydrate diets at least for up to 2 years. Very-low-carbohydrate diets can lead to elevations in LDL cholesterol levels in some individuals. Cognitive behavioral therapy added to diet therapy can facilitate approximately 5 kg additional weight loss, and exercise can facilitate an additional 1-1.5 kg weight loss. Drug treatment, particularly with sibutramine and rimonabant, can increase weight loss with a mildly hypocaloric diet by an additional 3-5 kg, but weight-loss drugs are costly and have adverse effects. If dietary and medical therapies fail, gastric banding can lead to a weight loss of approximately 14% at 10 years, with greater losses of up to 25% with gastric bypass and gastroplasty. Bariatric surgery can also lead to a reduction in mortality and comorbidities but adverse effects can occur including nutritional deficiencies and gastrointestinal symptoms." }, { "id": "pubmed23n0516_4490", "title": "[Obesity in adult patients: check up and treatment].", "score": 0.009259259259259259, "content": "Obesity is now one of the major health problems in industrial countries as well as in developing world. Excess caloric intake and reduction of the physical activity are the main causes of obesity. This epidemic precedes a tremendous increase of type 2 diabetes, which is generally linked to weight excess. Obesity and type 2 diabetes are associated with morbidity and mortality and are very expensive for the social security. The important point is to define the risks linked to obesity taking into account the Body Mass Index and the importance of visceral obesity evaluated by waist measurement. After medical check up, a strategy will be discussed with the patient, including moderate caloric restriction and increased physical activity. Our patients and also some doctors suggest \"popular diets\" whose efficacy has not been demonstrated as superior. On a short time basis, low carbohydrate and high protein diets have some advantages, which can help our obese subjects but on long term, only hypocaloric and equilibrated diets are advisable. Drugs that proved their efficacy and tolerance may be prescribed in case of failure. Three drugs are presented, orlistat, sibutramine and metformine: their efficacy, secondary effects, interactions and finally their positioning. Bariatric surgery will be proposed to highly selected patients presenting morbid obesity." }, { "id": "pubmed23n0739_20973", "title": "Bariatric surgery: an evidence-based analysis.", "score": 0.009174311926605505, "content": "To conduct an evidence-based analysis of the effectiveness and cost-effectiveness of bariatric surgery. Obesity is defined as a body mass index (BMI) of at last 30 kg/m(2).() Morbid obesity is defined as a BMI of at least 40 kg/m(2) or at least 35 kg/m(2) with comorbid conditions. Comorbid conditions associated with obesity include diabetes, hypertension, dyslipidemias, obstructive sleep apnea, weight-related arthropathies, and stress urinary incontinence. It is also associated with depression, and cancers of the breast, uterus, prostate, and colon, and is an independent risk factor for cardiovascular disease. Obesity is also associated with higher all-cause mortality at any age, even after adjusting for potential confounding factors like smoking. A person with a BMI of 30 kg/m(2) has about a 50% higher risk of dying than does someone with a healthy BMI. The risk more than doubles at a BMI of 35 kg/m(2). An expert estimated that about 160,000 people are morbidly obese in Ontario. In the United States, the prevalence of morbid obesity is 4.7% (1999-2000). In Ontario, the 2004 Chief Medical Officer of Health Report said that in 2003, almost one-half of Ontario adults were overweight (BMI 25-29.9 kg/m(2)) or obese (BMI ≥ 30 kg/m(2)). About 57% of Ontario men and 42% of Ontario women were overweight or obese. The proportion of the population that was overweight or obese increased gradually from 44% in 1990 to 49% in 2000, and it appears to have stabilized at 49% in 2003. The report also noted that the tendency to be overweight and obese increases with age up to 64 years. BMI should be used cautiously for people aged 65 years and older, because the \"normal\" range may begin at slightly above 18.5 kg/m(2) and extend into the \"overweight\" range. The Chief Medical Officer of Health cautioned that these data may underestimate the true extent of the problem, because they were based on self reports, and people tend to over-report their height and under-report their weight. The actual number of Ontario adults who are overweight or obese may be higher. Diet, exercise, and behavioural therapy are used to help people lose weight. The goals of behavioural therapy are to identify, monitor, and alter behaviour that does not help weight loss. Techniques include self-monitoring of eating habits and physical activity, stress management, stimulus control, problem solving, cognitive restructuring, contingency management, and identifying and using social support. Relapse, when people resume old, unhealthy behaviour and then regain the weight, can be problematic. Drugs (including gastrointestinal lipase inhibitors, serotonin norepinephrine reuptake inhibitors, and appetite suppressants) may be used if behavioural interventions fail. However, estimates of efficacy may be confounded by high rates of noncompliance, in part owing to the side effects of the drugs. In addition, the drugs have not been approved for indefinite use, despite the chronic nature of obesity. Morbidly obese people may be eligible for bariatric surgery. Bariatric surgery for morbid obesity is considered an intervention of last resort for patients who have attempted first-line forms of medical management, such as diet, increased physical activity, behavioural modification, and drugs. There are various bariatric surgical procedures and several different variations for each of these procedures. The surgical interventions can be divided into 2 general types: malabsorptive (bypassing parts of the gastrointestinal tract to limit the absorption of food), and restrictive (decreasing the size of the stomach so that the patient is satiated with less food). All of these may be performed as either open surgery or laparoscopically. An example of a malabsorptive technique is Roux-en-Y gastric bypass (RYGB). Examples of restrictive techniques are vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). The Ontario Health Insurance Plan (OHIP) Schedule of Benefits for Physician Services includes fee code \"S120 gastric bypass or partition, for morbid obesity\" as an insured service. The term gastric bypass is a general term that encompasses a variety of surgical methods, all of which involve reconfiguring the digestive system. The term gastric bypass does not include AGB. The number of gastric bypass procedures funded and done in Ontario, and funded as actual out-of-country approvals,() is shown below. Number of Gastric Bypass Procedures by Fiscal Year: Ontario and Actual Out-of-Country (OOC) ApprovalsData from Provider Services, MOHLTCCourtesy of Provider Services, Ministry of Health and Long Term Care The Medical Advisory Secretariat reviewed the literature to assess the effectiveness, safety, and cost-effectiveness of bariatric surgery to treat morbid obesity. It used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases. The interventions of interest were bariatric surgery and, for the controls, either optimal conventional management or another type of bariatric procedure. The outcomes of interest were improvement in comorbid conditions (e.g., diabetes, hypertension); short- and long-term weight loss; quality of life; adverse effects; and economic analysis data. The databases yielded 15 international health technology assessments or systematic reviews on bariatric surgery. Subsequently, the Medical Advisory Secretariat searched MEDLINE and EMBASE from April 2004 to December 2004, after the search cut-off date of April, 2004, for the most recent systematic reviews on bariatric surgery. Ten studies met the inclusion criteria. One of those 10 was the Swedish Obese Subjects study, which started as a registry and intervention study, and then published findings on people who had been enrolled for at least 2 years or at least 10 years. In addition to the literature review of economic analysis data, the Medical Advisory Secretariat also did an Ontario-based economic analysis. Bariatric surgery generally is effective for sustained weight loss of about 16% for people with BMIs of at least 40 kg/m(2) or at least 35 kg/m(2) with comorbid conditions (including diabetes, high lipid levels, and hypertension). It also is effective at resolving the associated comorbid conditions. This conclusion is largely based on level 3a evidence from the prospectively designed Swedish Obese Subjects study, which recently published 10-year outcomes for patients who had bariatric surgery compared with patients who received nonsurgical treatment. (1)Regarding specific procedures, there is evidence that malabsorptive techniques are better than other banding techniques for weight loss and resolution of comorbid illnesses. However, there are no published prospective, long-term, direct comparisons of these techniques available.Surgery for morbid obesity is considered an intervention of last resort for patients who have attempted first-line forms of medical management, such as diet, increased physical activity, behavioural modification, and drugs. In the absence of direct comparisons of active nonsurgical intervention via caloric restriction with bariatric techniques, the following observations are made:A recent systematic review examining the efficacy of major commercial and organized self-help weight loss programs in the United States concluded that the evidence to support the use of such programs was suboptimal, except for one trial on Weight Watchers. Furthermore, the programs were associated with high costs, attrition rates, and probability of regaining at least 50% of the lost weight in 1 to 2 years. (2)A recent randomized controlled trial reported 1-year outcomes comparing weight loss and metabolic changes in severely obese patients assigned to either a low-carbohydrate diet or a conventional weight loss diet. At 1 year, weight loss was similar for patients in each group (mean, 2-5 kg). There was a favourable effect on triglyceride levels and glycemic control in the low-carbohydrate diet group. (3)A decision-analysis model showed bariatric surgery results in increased life expectancy in morbidly obese patients when compared to diet and exercise. (4)A cost-effectiveness model showed bariatric surgery is cost-effective relative to nonsurgical management. (5)Extrapolating from 2003 data from the United States, Ontario would likely need to do 3,500 bariatric surgeries per year. It currently does 508 per year, including out-of-country surgeries." }, { "id": "wiki20220301en420_15136", "title": "The Biggest Loser (season 15)", "score": 0.009174311926605505, "content": "Winners $250,000 Winner (among the finalists) $100,000 Winner (among the eliminated contestants) Weigh-In Difference History Notes Rachel's 4 pound weight loss in week 10 was displayed as -5 due to her 1-pound advantage from the challenge. Tanya's 3 pound weight loss in week 11 was displayed as -2 due to her 1-pound disadvantage from the challenge. Rachel's 6 pound weight loss in week 12 was displayed as -7 due to her 1-pound advantage from the challenge. Bobby's 8 pound weight loss in week 13 was displayed as -6 due to the weight he gained last week. Weigh-In Percentage History" }, { "id": "pubmed23n0416_4876", "title": "Impact of carbohydrate and fat intake on weight-reducing efficacy of orlistat.", "score": 0.00909090909090909, "content": "Orlistat treatment of obesity results in a poor long-term weight loss (&lt; 5%) in about 30% of patients. Total energy and macronutrient intake were examined to assess the effect of a change in eating habits on weight loss. Sixty-two patients consumed a hypocaloric diet, together with orlistat (3 x 120 mg/day), for 72 weeks, with a maximal fat allowance of 30% of the energy intake. At regular intervals, food diaries were recorded. Fifty-six patients completed the study and lost 8.5 +/- 0.88 kg (P &lt; 0.001). Energy intake was approximately 1500 kcal/day during the entire study period. In three sub-groups established according to weight loss (1, &lt; 5%; 2, &gt; 5% and &lt; 10%; 3, &gt; 10%), fat intake was within the recommended range in all groups during the first 6 months, but thereafter only in group 3. All groups increased their carbohydrate consumption, with the greatest increase in group 1, which could account for the rapid regain of initially lost body weight in this group. At the beginning of a weight management programme in conjunction with orlistat, a low fat intake is advised for an efficient reduction in body weight. Subsequently, in patients with poor long-term weight loss, dietary recommendations must also consider carbohydrate restriction to ensure an adequate hypocaloric diet." }, { "id": "wiki20220301en365_13274", "title": "The Biggest Loser (season 13)", "score": 0.00909090909090909, "content": "Weigh-In Percentages History Notes Conda's 6.10% weight loss in week 9 was displayed as 5.71% due to her weight gain the previous week. Megan's 2.94% weight loss in week 11 was displayed as 3.43% due to her 1 lb advantage from the challenge. Chris's 1.69% weight loss in week 12 was displayed as 2.26% due to her 1 lb advantage from the challenge. Mark's 0.00% weight loss in week 13 was displayed as 0.50% due to his 1 lb advantage from the challenge. Buddy's 3.35% weight loss in week 14 was displayed as 3.72% due to his 1 lb advantage from the challenge. Conda's 2.38% weight loss in week 14 was displayed as 1.90% due to her 1 lb disadvantage from the challenge. Elimination Voting History" }, { "id": "pubmed23n0505_11533", "title": "Comparison of efficacy of sibutramine or orlistat versus their combination in obese women.", "score": 0.009009009009009009, "content": "Sibutramine and orlistat are currently used for weight loss. We aimed to investigate the effect of orlistat and sibutramine combination therapy in treatment of obese women. Study population consisted of 89 obese women who had a body mass index &gt; or = 30 kg/m2, were normotensive, and had normal glucose tolerance. All patients were placed on a diet which contained fat approximately 30% of total calorie intake and the diet was designed to cause an energy deficit of approximately 2.51-3.56 megajoule/day. At the first month of diet (baseline), all patients were randomly divided into three therapy groups: Diet + Orlistat (group 1; n = 30 patients), Diet + Sibutramine (group 2; n = 29 patients), Diet + Orlistat + Sibutramine (group 3; n = 30 patients). Body weight, body fat distribution and serum lipid levels were evaluated baseline and after six months in all subjects. Mean weight loss was 5.5 +/- 4.9 kg (p = 0.024) in group 1, 10.1 +/- 3.6 kg (p &lt; 0.001) in group 2, 10.8 +/- 6.6 kg (p &lt; 0.001) in group 3 after the six months. Weight loss was significantly greater in group 2 (p = 0.003) and group 3 (p = 0.002) when compared with group 1. Percentage of mean weight loss was 5.5 +/- 3.1% in group 1, 10.2 +/- 4.8% in group 2, 10.6 +/- 5.7% in group 3. Percentage of weight loss was higher in group 2 (p = 0.01) and group 3 (p = 0.009) when compared with group 1. Weight loss and percentage of weight loss were not different between group 2 and group 3. These three regimens had different results on weight loss in obese women. Combination drug therapy and sibutramine therapy were both more effective than orlistat therapy alone. However, no significant difference was noted between combination drug therapy and sibutramine treatment groups." }, { "id": "pubmed23n0478_14902", "title": "Great expectations: \"I'm losing 25% of my weight no matter what you say\".", "score": 0.009009009009009009, "content": "This study investigated whether informing obese individuals that they would lose only modest amounts of weight would lead them to adopt more realistic weight loss expectations. At a screening interview, 53 obese women reported that they expected to lose the equivalent of 28% of their initial weight during 1 year of treatment with the medication sibutramine. Prior to beginning treatment, participants were informed, both verbally and in writing, that they could expect to lose 5% to 15% of initial weight, the loss typically induced by current behavioral and pharmacologic approaches. This information, however, had little impact on their weight loss expectations when assessed on subsequent occasions. Results are discussed in terms of the origins, clinical significance, and potential malleability of obese individuals' weight loss expectations." }, { "id": "wiki20220301en247_14798", "title": "The Biggest Loser (season 7)", "score": 0.008928571428571428, "content": "At the weigh-in, teams are shown to have lost a total 382 pounds, including a 30-pound weight loss by Daniel (Orange) who started out as the heaviest contestant in Biggest Loser history, and a 32-pound weight loss by Ron, which Alison says puts him in the Biggest Loser record books for most weight loss in the first week. As Jerry was not present at the first weigh-in to determine the contestants' starting weights due to his fainting spell, they weighed him in at the hospital, and his starting weight was announced as 369 lbs." }, { "id": "pubmed23n0357_843", "title": "One-year treatment of obesity: a randomized, double-blind, placebo-controlled, multicentre study of orlistat, a gastrointestinal lipase inhibitor.", "score": 0.008849557522123894, "content": "To assess the efficacy and tolerability of orlistat (Xenical) in producing and maintaining weight loss over a 12-month period. Patients were randomized to double-blind treatment with either orlistat 120 mg or placebo three times daily, in conjunction with a low-energy diet, for 12 months. Five centres in the UK. 228 obese adult patients with body mass index between 30 and 43 kg/m2 and mean weight 97 kg (range 74-144 kg). All patients were prescribed a low-energy diet, providing 30% of energy from fat, designed to produce an individually tailored energy deficit of approximately 600 kcal/day, for a run-in period of 4 weeks and then 12 months, plus orlistat 120 mg or placebo three times daily. Change in body weight (the primary efficacy parameter), waist circumference and adverse events were reviewed regularly, together with serum lipids, insulin, glucose and plasma levels of fat-soluble vitamins and beta carotene. Based on an intent-to-treat analysis, after 1 y of treatment patients receiving orlistat had lost an average of 8.5% of their initial body weight compared with 5.4% for placebo-treated patients; 35% of the orlistat group lost at least 5% of body weight compared with 21% of the placebo group (P &lt; 0.05), and 28% and 17%, respectively (P = 0.04) lost at least 10% of body weight. Orlistat-treated patients showed significant decreases (P &lt; 0.05) in serum levels of total cholesterol, low density lipoprotein cholesterol, and in the low density lipoprotein: high density lipoprotein ratio in comparison with placebo. Both groups had similar adverse-event profiles, except for gastrointestinal events, which were 26% more frequent in the orlistat group but were mostly mild and transient. To maintain normal plasma levels of fat-soluble vitamins, supplements of vitamins A, D and E were given to 1.8%, 8.0% and 3.6%, respectively, of orlistat-treated patients, compared with 0.9% of placebo-treated patients for each vitamin type. After 1 y, the decrease in vitamin E and beta carotene was significantly greater in orlistat-treated patients compared with those receiving placebo (P &lt; 0.001). No significant change was found in the mean vitamin E:total cholesterol ratio in either group after 52 weeks. Orlistat, in conjunction with a low-energy diet, produced greater and more frequent significant weight loss than placebo during 1 y of treatment. One-third of orlistat-treated patients achieved clinically relevant weight loss (&gt; or = 5% initial body weight). There was also an improvement in relevant serum lipid parameters. Fat-soluble vitamin supplements may be required during chronic therapy. Orlistat was well tolerated and offers a promising new approach to the long-term management of obesity." }, { "id": "pubmed23n0547_1456", "title": "Weight loss and long-term follow-up of severely obese individuals treated with an intense behavioral program.", "score": 0.008849557522123894, "content": "To review weight loss and maintenance for severely obese individuals enrolled in intensive behavioral weight loss program using very-low or low-energy diets. Chart review of consecutively treated patients between 1995 and 2002 seen at three weight loss centers. One thousand five hundred and thirty one patients with severe obesity (&gt;or=40 kg/m(2)) treated in three cities ('Study Group'). Of these, 1100 completed the 12-week core curriculum ('Completer Group'). Weight loss &gt;or=100 lbs (&gt;45 kg) was seen in 268 patients ('100-Pound Group'). Charts were reviewed for baseline characteristics, weekly weights, follow-up weights and side effects. In the Study Group, average weight loss+/-s.e. for 998 women was 23.9+/-0.6 kg (18.5% of initial body weight (IBW)) and for 533 men was 36.0+/-1.0 kg (22.5%) over 30 weeks. For Completers, average weight loss for women was 30.8+/-0.6 kg (23.9%) and for men was 42.6+/-1.1 kg (26.7%) over 39 weeks. In the 100-Pound Group, average weight loss for women was 58.2+/-1.2 kg (41.5%) in 65 weeks and for men was 65.7+/-1.5 kg (37.5%) in 51 weeks. Side effects, assessed in 100 patients losing &gt;45 kg, were mild to moderate in severity. Severe adverse events unrelated to the diet were noted in 5% of patients and during weight loss 1% had elective cholecystectomies. Follow-up weights were available for 86% of Completers at an average of 72 weeks with average maintenance of 23 kg or 59% of weight loss; follow-up weights were available for 94% of the 100-Pound Group at an average of 95 weeks with average maintenance of 41 kg or 65% of weight loss maintained. Intensive behavioral treatment with meal replacements is a safe and effective weight-loss strategy for selected severely obese individuals." }, { "id": "pubmed23n0380_3719", "title": "Obesity treatment with a progressive clinical tri-therapy combining sibutramine and a supervised diet--exercise intervention.", "score": 0.008771929824561403, "content": ": Sibutramine favors a negative energy balance and also has the potential to increase heart rate and blood pressure. We investigated if a progressive supervised sibutramine--diet--exercise clinical intervention could increase the body weight loss previously reported while minimizing the potential cardiostimulatory effects of this drug. : The tri-therapy intervention was divided into two phases of 6 weeks each in which sibutramine (10 mg) was taken once daily by eight obese men (body mass index (BMI) between 30 and 40 kg/m(2)). Part A consisted of a dietary follow-up with an energy restriction, whereas in part B an aerobic exercise program combined with a low-fat diet was introduced. Systolic (SBP) and diastolic (DBP) blood pressure, resting heart rate (RHR) and body weight were measured every 2 weeks while body density, resting metabolic rate (RMR) and respiratory quotient (RQ) were determined before and after the intervention. : This clinical intervention produced a substantial body weight loss (-10.7 kg, P&lt;0.01) which was about twice as much as other 12-week studies. In part A, both RHR (+4 beats/min) and DBP (+5 mmHg, P&lt;0.01) were increased. However, after part B, RHR (-8 beats/min, P=0.02) and DBP (-3 mmHg, P&lt;0.01) were significantly decreased. RMR was decreased at the end of the program but this effect did not persist after adjustments for fat-free mass. RQ was also reduced (-0.05, P&lt;0.01) following the clinical tri-therapy. : In conclusion, these observations suggest that this clinical tri-therapy favored a satisfactory benefit--risk profile since it enhanced weight loss without inducing increases in heart rate and blood pressure or detrimental changes in RMR and substrate oxidation." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 81, 260 ] ], "word_ranges": [ [ 14, 50 ] ], "text": "Option 1: The acute infection would be HBeAg + and ANTI-HBe - . In addition the ANTI-HBec would be IgM type (only for this last data, we would have to discard it in a direct way)." }, "2": { "exist": true, "char_ranges": [ [ 261, 329 ] ], "word_ranges": [ [ 50, 61 ] ], "text": "Option 2: the correct one. It complies with all the characteristics." }, "3": { "exist": true, "char_ranges": [ [ 330, 391 ] ], "word_ranges": [ [ 61, 72 ] ], "text": "Option 3: The vaccinated patient cannot have DNA of the virus" }, "4": { "exist": true, "char_ranges": [ [ 475, 633 ] ], "word_ranges": [ [ 86, 112 ] ], "text": "Option 4: The option that could offer more doubts. In the asymptomatic carrier (chronic carrier / seroconverted) the difference is that there is no viral DNA." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Acute infection.", "2": "Chronic infection.", "3": "Vaccinated patient.", "4": "Asymptomatic carrier.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0220_8430", "title": "Frequency and persistence of serologic markers following three different manifestations of hepatitis B virus infection.", "score": 0.01763791763791764, "content": "30 asymptomatic chronic carriers of hepatitis B surface antigen (HBsAg), 6 asymptomatic blood donors transiently infected with hepatitis B virus, and 38 patients with acute hepatitis B were tested for HBsAg, anti-HBs, HBeAg, anti-HBe and anti-HBc. Comparison of these results revealed significant variation in the frequency of HBeAg which was present in 1 (3.3%) carrier, 2 (33.3%) of the transiently positive donors, and in 24 (63.2%) of the patients with acute hepatitis. Anti-HBe was found in 28 (93.3%) of the carriers, 4 (66.6%) of the transiently positive donors, and in 8 (21%) of the patients. Variation was also seen in the strength of anti-HBc, with only the chronic carriers having titres which were consistently high (above 1,000). Retesting the two groups of donors after a period of approximately 2 years showed no change in the serologic status of the chronic carriers, while amongst the transient HBsAg positives the 2 HBeAg reactives had seroconverted, 1 of the anti-HBe positives had become non-reactive, and 2 of the 6 had developed anti-HBs. 6 of the patients with acute hepatitis B were serologically reexamined during convalescence and showed results similar to those seen in the transiently HBsAg-positive donors, with clearance of HBsAg in all, seroconversion from HBeAg to anti-HBe in 4, and the production of anti-HBs in 4." }, { "id": "pubmed23n0894_14737", "title": "[Atypical serological profiles in hepatitis B infections: investigation of S gene mutations in cases with concurrently positive for HBsAg and anti-HBs].", "score": 0.01562592482983131, "content": "Hepatitis B virus (HBV) causes different clinical manifestations, ranging from asymptomatic carriage to fulminant or chronic hepatitis. Serological tests are widely used for the diagnosis of HBV infections to detect viral markers. However, facing with atypical serological profiles in some patients leads to problems in interpreting of the results and management of the patients. The aims of this study were to investigate the atypical serologic profiles seen in patients screened for HBV infection and the S gene mutations in patients with concurrent positivity of HBsAg and anti-HBs. A total of 592 sera from patients (332 male, 260 female; age range: 13-84 years, mean age: 43.9 years) prediagnosed as HBV infection between January to September 2013, and screened for HBV markers (HBsAg, anti-HBs, HBeAg, anti-HBe, anti-HBc-IgM, anti-HBc-total and HBV-DNA) were included in the study. Of those samples 364 were screened only for HBsAg and anti-HBs markers. S gene mutations were investigated by direct sequencing method in sera which were concurrent positive for HBsAg and anti-HBs. In our study, 5.2% (31/592) of the sera yielded atypical serologic profiles. Of these 13 cases were concurrently positive for HBsAg and anti-HBs; nine were HBeAg positive, anti-HBe and HBV-DNA negative; eight were HBeAg, anti-HBe and HBV-DNA positive; and one was HBsAg and anti-HBs negative, anti-HBe and HBV-DNA positive. The rate of concurrent positivity of HBsAg and anti-HBs was 3.6% (13/364), while 76.9% (10/13) of those cases were also positive for HBV-DNA. DNA sequencing was performed for seven out of 10 samples which were positive for HBsAg, anti-HBs and HBV-DNA, however three samples were not used because of the low amounts. Sequence analysis of seven samples showed S gene mutations in two samples, one was sS143L with sS193L, a HBV vaccine escape mutation, and the other was sP120R, a HBV immune escape mutation. Of the patients 2.7% (10/364) was negative for both HBsAg and anti-HBs; in which nine were HBV-DNA negative and anti-HBe positive, while one was positive for both HBV-DNA and anti-HBe. The rate of concurrent positivity of HBeAg and anti-HBe was found as 1.4% (8/592), and all of these samples were HBV-DNA positive. No single positivity for HBsAg, anti-HBc, anti-HBs or HBV-DNA was not detected in any of the patients. In conclusion, HBsAg and anti-HBs concurrent positivity was the most frequently detected atypical profile in our study (3.6%), and in some (2/7) of these patients S gene mutations were determined." }, { "id": "wiki20220301en023_14705", "title": "Seroconversion", "score": 0.013761993960013763, "content": "On a serological assay, the presence of hepatitis B surface antigen (HBsAg) indicates an individual with a currently active hepatitis B infection, whether acute or chronic. The presence of core antibody (anti-HBc) indicates an individual with an infection in general, whether current or previously resolved. The presence of surface antibody (anti-HBs) indicates an individual with immunity to hepatitis B, whether due to previously resolved infection or due to hepatitis B vaccination. For example, an individual who has never had any exposure to HBV, either by vaccine or by infection, would test negative for the entire serology panel. An individual who has been vaccinated and never had an infection will test seropositive for anti-HBs due to vaccination and negative for markers of infection. An individual with an acute HBV infection would test positive for HBsAg and anti-HBc (total and IgM) while negative for anti-HBs. An individual with a chronic infection would test positive for HBsAg and" }, { "id": "wiki20220301en206_1632", "title": "Hepatitis B", "score": 0.01325483715485781, "content": "Shortly after the appearance of the HBsAg, another antigen called e antigen (HBeAg) will appear. Traditionally, the presence of HBeAg in a host's serum is associated with much higher rates of viral replication and enhanced infectivity; however, variants of the virus do not produce the 'e' antigen, so this rule does not always hold true. During the natural course of an infection, the HBeAg may be cleared, and antibodies to the 'e' antigen (anti-HBe) will arise immediately afterwards. This conversion is usually associated with a dramatic decline in viral replication. If the host is able to clear the infection, eventually the HBsAg will become undetectable and will be followed by IgG antibodies to the surface antigen and core antigen (anti-HBs and anti HBc IgG). The time between the removal of the HBsAg and the appearance of anti-HBs is called the window period. A person negative for HBsAg but positive for anti-HBs either has cleared an infection or has been vaccinated previously." }, { "id": "article-22788_41", "title": "Hepatitis B -- Evaluation -- Interpretation of Serologic Markers", "score": 0.013236844976180951, "content": "Following serologic markers are often tested: Hepatitis B surface antigen (HBsAg), antibody to Hepatitis B surface antigen (anti-HBs), Hepatitis B core Ab (Anti-HBc) IgM, Hepatitis B core Ab (Anti-HBc) IgG, Hepatitis B e antigen (HBeAg), and Hepatitis B e antibody (anti-HBe). [10] HBsAg: Acute infection (less than 6 months) or chronic infection (more than 6 months). Anti-HBs: Recovery from acute infection or immunity from vaccination. HBeAg: Mostly associated with high viral load. Anti-HBe: Low replicative phase. Anti-HBc IgM: Acute infection, an only marker present in the window period, can be present during exacerbation of chronic infection. Anti-HBc IgG: Exposure to infection, chronic infection (if present along with HBsAg), recovery from acute infection (if present with anti-HBs), if isolated presence, may represent occult infection." }, { "id": "wiki20220301en094_18175", "title": "Window period", "score": 0.013111888111888112, "content": "Hepatitis B Two periods may be referred to as window period in hepatitis B infection: (1) the period that elapses during HBsAg to HBsAb seroconversion, i.e. between the disappearance of surface antigen (HBsAg) from serum and the appearance of HBsAb (anti-HBs), and (2) the period between infection and appearance of HBsAg. During the window of HBsAg to HBsAb seroconversion, IgM anti-core (HBc-IgM) is the only detectable antibody. HBV DNA may be positive as well. This window period does not occur in persons who develop chronic hepatitis B, i.e. who continue to have detectable HBV DNA for greater than 6 months (HbsAg remains positive), or in people who develop isolated HBcAb positivity, i.e. who lose HBsAg, but do not develop HBsAb (HBV DNA may or may not remain positive). See also Incubation period, the time between infection and the appearance of symptoms References HIV/AIDS Serology" }, { "id": "wiki20220301en023_14706", "title": "Seroconversion", "score": 0.01283068783068783, "content": "individual with an acute HBV infection would test positive for HBsAg and anti-HBc (total and IgM) while negative for anti-HBs. An individual with a chronic infection would test positive for HBsAg and total anti-HBc (IgM and IgG), but negative for IgM anti-HBc and anti-HBs. An individual who has successfully resolved their HBV infection will test negative for HBsAg, positive for anti-HBc, and may test negative or positive for anti-HBs, although most will test positive." }, { "id": "wiki20220301en023_14702", "title": "Seroconversion", "score": 0.012449424214130096, "content": "In the typical disease course for hepatitis B, the individual will first seroconvert for hepatitis B surface antigen (HBsAg). While some can convert within one week, most individuals take about four weeks after initial infection to convert. Anti-core antibodies (anti-HBc) are the first antibodies produced by the body, first in short-term IgM (anti-HBc IgM), and subsequently in long-term IgG; while levels of IgM anti-HBc will peak around sixteen weeks after exposure and fall within about seven to eight months, IgG anti-HBc will remain detectable in the serum as a sign of chronic infection for years. IgM anti-HBc concentration will fall regardless of whether or not the individual clears the infection. The window period for HBsAg/anti-HBs testing occurs as concentration of HBsAg falls and before the body develops anti-HBs antibodies, lasting approximately six to eight weeks in most individuals. During this time, serology assays can test for total anti-HBc. Levels of anti-surface antibody" }, { "id": "wiki20220301en349_29113", "title": "Vaccine-induced seropositivity", "score": 0.011003726129482999, "content": "Hepatitis B When a person gets a hepatitis B vaccine then the most common test for hepatitis B will show them to be positive. The usual course of action, in this case, is to give the person a panel of tests for HBsAg, anti-HBc, and anti-HBs (hepatitis B surface antigen, anti-hepatitis B core, and anti-hepatitis B surface). A person who has never been exposed to hepatitis B but has gotten the vaccine will be positive for anti-HBs but negative for the other two tests in the panel. Other combinations of positive and negative in this test can mean other things, such as acute, chronic, or past infection." }, { "id": "pubmed23n0806_9756", "title": "Occult hepatitis B virus infection with positive hepatitis B e antigen.", "score": 0.010727638769053782, "content": "Hepatitis B e antigen (HBeAg) is a marker to indicate active replication of hepatitis B virus (HBV). Occult HBV infection (OBI), referred to persistence of HBV DNA in serum and/or liver without detectable serum hepatitis B surface (HBsAg), usually has low HBV DNA levels. The presence of HBeAg in OBI is unusual. We report 2 patients who presented negative for HBsAg but positive for HBeAg and HBV DNA. HBV markers were quantified in the longitudinal sera in a period of 1-2years. The HBV DNA sequences were analyzed in 2 patients' sera and 1 patient's liver. Both patients were also positive for total anti-HBs and anti-HBc but negative for anti-HBe and anti-HBc IgM. HBV DNA levels were 234-567IU/ml in case 1 and 42-1130IU/ml in case 2. The alignment analysis of the S gene showed that HBV in both patients was genotype C, serotype adr. Cloning analysis of the a determinant of HBsAg showed that the immune escape mutants were predominant in both patients over the follow-up period. The HBV had double mutations (A1762T and G1764A) in the basal core promoter but had no mutation in the pre C/C gene in both patients. The patients with negative HBsAg but positive HBeAg may represent a unique type of OBI. Test for HBeAg would be critical to identifying such type of OBI." }, { "id": "wiki20220301en206_1631", "title": "Hepatitis B", "score": 0.010505378212927022, "content": "The surface antigen (HBsAg) is most frequently used to screen for the presence of this infection. It is the first detectable viral antigen to appear during infection. However, early in an infection, this antigen may not be present and it may be undetectable later in the infection as it is being cleared by the host. The infectious virion contains an inner \"core particle\" enclosing viral genome. The icosahedral core particle is made of 180 or 240 copies of the core protein, alternatively known as core antigen, or HBcAg. During this 'window' in which the host remains infected but is successfully clearing the virus, IgM antibodies specific to the core antigen (anti-HBc IgM) may be the only serological evidence of disease. Therefore, most diagnostic panels contain HBsAg and total anti-HBc (both IgM and IgG)." }, { "id": "Obstentrics_Williams_7579", "title": "Obstentrics_Williams", "score": 0.010319069743563416, "content": "Figure 55-2 details the sequence of the various HBV antigens and antibodies in acute infection. The first serological marker to be detected is the hepatitis B surface antigen (HBsAg) , often preceding the increase in transaminase levels. As HBsAg disappears, antibodies to the surface antigen develop (anti-HBs), marking complete resolution of disease. Hepatitis B core antigen is an intracellular antigen and not detectable in serum. However, anti -HBc is detectable wi thin weeks of HBsAg appearance. The hepatitis Be antigen (HBeAg) is present during times of high viral replication and often correlates with detectable HBV DNA. After acute hepatitis, approximately 90 percent of adults recover completely. The 10 percent who remain chronically infected are considered to have chronic hepatitis B. Chronic HBV infection is oten asymptomatic but may be clinically suggested by persistent anorexia, weight loss, fatigue, and" }, { "id": "pubmed23n0022_10512", "title": "The significance of the Australia antigen (HBsAg) persistent healthy carrier \"status\": a long-term follow-up study of 34 cases.", "score": 0.009900990099009901, "content": "Thirty-four persistent healthy carriers of HBsAg (serum HBsAg detectable for longer than 3 months with normal liver function tests and normal liver histology or slight aspecific abnormalities) were discovered by routine testing of household relatives of B virus hepatitis patients. The carriers were followed-up for 11 to 37 months by clinical control, liver function tests and liver needle biopsy. None carrier had previous jaundice. During the follow-up period, in 17 of the 34 subjects, was there no evidence of deterioration in either clinical state, liver function of pathological findings. In 5 of the 34 carriers, HBsAg disappeared from serum after a period ranging from 6 to 12 months. The remaining 12 cases developed clinical and histological picture of acute viral hepatitis after 6 to 29 months (mean 12 months). Of these 12 patients, 6 recovered and become HBsAg; 2 remained HBsAg healthy carriers despite normalization of biochemical and histological abnormalities; 3 progressed from the acute stage to antigen positive CAH. The remaining one case could not be followed-up after the acute hepatitis. Our data indicate that the outcome of the HBsAg carrier state is unpredictable and stress the need of long-term follow-up surveillance." }, { "id": "pubmed23n0283_20693", "title": "[Asymptomatic carriers of HBsAg: is a follow-up necessary?].", "score": 0.00980392156862745, "content": "We evaluated the clinical and epidemiological data of 142 HBsAg carriers. This prospective trial is part of a program of study and follow-up in HVB patients. The median age was 34.58 years old, males 56.3%. The average follow-up was 32.4 months. Complete clinical history, routine analysis, liver function tests, alfa-fetoprotein, serology for HVB, HCV and HDV and abdominal ecography were done in all patients. DNA-HVB was done only in special cases. Patients with less than 6 months of follow-up were excluded. The 118 remaining carriers were classified into two groups, depending on ALT values. Group 1 (normal ALT): included 98 carriers, 3 of them developed an active chronic hepatitis that was treated with interferon. A small CHC was diagnosed in another patient and it was resected. Group 2 (elevated ALT): included 20 carriers, only 9 of them agreed to biopsy and we found severe hepatic lesions in 4 of them. No group presented coinfection with HCV or HDV. No patient died. We conclude that the study and follow-up of asymptomatic HBsAg carriers permits an early diagnosis and treatment of the complications of this pathology (chronic hepatitis, CHC, etc); in our study, three patients developed chronic hepatitis, successfully treated with interferon, and one small size CHC was diagnosed in another patient. The study of relatives permits also detect subclinic liver disease and facilitates vaccination to prevention transmission of this infection." }, { "id": "pubmed23n0040_1913", "title": "The significance of HB antigenemy in apparently healthy persons in the clinic for liver diseases.", "score": 0.009708737864077669, "content": "The study tries to clarify the affliction of liver as a consequence of the permanent HB antigenemy in apparently healthy persons. The study proves beyond doubt that in the majority of the HB antigen carriers such histological changes of the liver can be found that can be attributed only to an infection by the hepatitis virus. The majority of the HB antigen carriers are suffering either from the chronic focal (58%) or from the diffuse (21%) persistent hepatitis. A smaller percentage is suffering from more dangerous hepatopathies (acute viral hepatitis 4,2%, hepatitis chron. aggressiva 4.2%, cirrhosis 1,4%). The kind of the illness can be determined with the histological examination only because of the absence of the clinical symptomatology and because of the liver function tests are in such cases frequently normal. Our investigations indicate that the diffuse and focal forms of persistent hepatitis can remain unchanged overlong periods and the same histological findings over a number of years. The chronic persistent hepatitis, however, may develop through clinically imperceptible changes into a chronic aggressive hepatitis, and the inapparent acute hepatitis can even pass over directly into cirrhosis. The identification of various forms of hepatitis, from light instances to the most severe cases, among the HB antigen carriers proves that the acute viral hepatitis of the type B may have in all the phases of its development a clinically asymptomatic course; it may even asymptomatically pass over into hepatopathies of the most severe kinds. The state of health of persons with HB antigenemy must be systematically followed up. For these reasons the histological examinations of the bioptic liver material that are made from time to time during the follow up of the illness have a decisive role." }, { "id": "article-22784_48", "title": "Hepatitis -- Evaluation -- Chronic Infection", "score": 0.009641297277204721, "content": "Evaluation of hepatitis B virus infection can be complicated, and some uncommon but possible scenarios should be kept in mind while investigating. Patients can test negative for HBsAg and anti-HBs but can have the presence of anti-HBc. This situation is possible when the result is false positive but can also happen in patients who are in the time window where they have cleared HBsAg from the blood, but anti-HBs has not yet appeared. Some patients who have cleared hepatitis B virus infection but have lost the anti-HBs over the years can test negative both for HBsAg and anti-HBs but positive for anti-HBc.  Also, patients infected with the hepatitis B virus many years ago can sometimes develop a core mutant variant of the hepatitis B virus where they can test negative for HBeAg and positive for anti-HBe even though the virus may still be active and is replicating. When lab findings like these are detected, the hepatitis B virus DNA PCR assay to check for viral replication is recommended." }, { "id": "pubmed23n0127_13849", "title": "[Natural history of the state of asymptomatic carrier of HBsAg: 7-year follow-up].", "score": 0.009615384615384616, "content": "Ninety-six chronic asymptomatic HBsAg carriers underwent liver biopsy. Liver histology was normal in 5 cases, showed nonspecific changes in 67, chronic persistent hepatitis in 18, and chronic-active hepatitis in 6. Seventy-four patients were followed for up to 105 months (mean 80 months) in order to evaluate the occurrence of clinical, biochemical, serological or histological changes. Only two patients cleared the HBsAg, respectively 10 and 96 months after undergoing liver biopsy; the latter patient became anti-HBs positive 6 months after he cleared HBsAg. All 10 patients who initially were negative for both HBeAg and anti-HBe became anti-HBe positive during follow-up. All 4 patients who were HBeAg positive at the time of liver biopsy cleared HBeAg 6 to 39 months thereafter. Two of them became anti-HBe positive. None of the patients initially HBeAg negative became positive for this antigen during follow-up. Significant increases of serum transaminases were observed in 5 patients; in one superinfection by delta agent was documented, the other 4 being constantly anti-delta negative. Three of the latter patients underwent repeat liver biopsy, which showed progression from minimal changes to chronic persistent hepatitis in one, and from minimal changes to chronic active hepatitis in another. In the third patient, repeat biopsy showed persistence of chronic persistent hepatitis. chronic hepatitis occurs in about 25% of chronic asymptomatic HBsAg carriers; clearance of HBsAg is a rare event among these patients; the HBe system has little diagnostic or prognostic value; delta superinfection is rare; however, deterioration of liver histology may occur even in the absence of delta superinfection." }, { "id": "pubmed23n0061_3726", "title": "Hepatitis B virus infection in Ethiopian immigrants to Israel.", "score": 0.009523809523809525, "content": "Two groups of immigrants from Ethiopia, one of 86 and the other of 165 individuals, aged 0-40, were examined for hepatitis B virus (HBV) infection in 1987-88, 3-7 years after their arrival in Israel. The results were compared with those obtained in the same age-group among Ethiopians who immigrated to Israel in 1980-82. The immigrants were found to be in good physical condition, their liver function tests were normal and no clinical evidence of chronic liver disease was found. Of the 22 children aged 0-4, 16 had anti-HBs as a result of vaccination at birth against HBV and they were excluded from the comparative study. In the age-groups 5-40 there was no significant change in the percentage of individuals positive for HBsAg, anti-HBs or anti-HBc only, compared with the group examined in 1980-82. There were two significant findings in this study: a) In 1987-88 [corrected], 8-9% of HBsAg-positive individuals had HBeAg and 64-81% had anti-HBe, while in 1980-82, 36% of those positive for HBsAg had HBeAg and only 25% had anti-HBe. b) At the time of arrival recent infection by HBV was indicated by the presence of IgM anti-HBc in 57% of those positive for HBsAg and 21% in whom anti-HBc was the sole serological HBV marker. In 1987-88 no IgM anti-HBc was found in HBsAg-positive persons or in those with anti-HBc only. These results indicate that most HBV infections in this population had occurred before their arrival in Israel. There is a profound change in the epidemiology of HBV infection in this Ethiopian population following immigration, which is probably due to environmental changes as well as to vaccination against HBV of all young children aged less than or equal to 3 years." }, { "id": "pubmed23n0049_12776", "title": "[Asymptomatic HBs antigenemia in pregnant women].", "score": 0.009523809523809525, "content": "The authors have dispensarized for more than ten years HBsAg carriers at the Second Medical Clinic of the Olomouc Faculty Hospital when antigenaemia was detected during blood donorship. Since 1990 the authors dispensarize also women where HBs antigenaemia was revealed during pregnancy. In the presented paper the authors analyze this group of women. In 1990-1991 the authors examined blood samples for HBsAg from 12,042 symptom-free pregnant women. HBsAg positivity was proved in 34 women (0.28%). Eleven women (32.3%) are regularly followed up since delivery. The authors know nothing about the fate of 10 women (29.4%), as they did not respond to repeated invitations to the surgery. It must be however mentioned that 6 of them are Vietnamese and probably left Czechoslovakia. Four women (11.7%) did not attend the clinic for examination but the authors know that they were delivered of their babies elsewhere. In the remainder, i.e. 8 women the delivery was normal, usually in term. The neonates were passively as well as actively immunized at the appropriate dates. Their umbilical blood (if collected) was HBsAg positive, while the venous blood was in all instances negative. All 20 women who attended examination were throughly examined (ultrasound, HBeAg, HBeAb etc.) and the clinical picture is that of a \"healthy\" HBsAg carrier (not verified by histological examination)." }, { "id": "InternalMed_Harrison_23525", "title": "InternalMed_Harrison", "score": 0.009435851785912986, "content": "Another important serologic marker in patients with hepatitis B is HBeAg. Its principal clinical usefulness is as an indicator of relative infectivity. Because HBeAg is invariably present during early acute hepatitis B, HBeAg testing is indicated primarily in chronic infection. In patients with hepatitis B surface antigenemia of unknown duration (e.g., blood donors found to be HBsAg-positive) testing for IgM anti-HBc may be useful to distinguish between acute or recent infection (IgM anti-HBc-positive) and chronic HBV infection (IgM antiHBc-negative, IgG anti-HBc-positive). A false-positive test for IgM anti-HBc may be encountered in patients with high-titer rheumatoid factor. Also, IgM anti-HBc may be reexpressed during acute reactivation of chronic hepatitis B." }, { "id": "pubmed23n0589_8432", "title": "[Polyclonal activation due to Epstein-Barr virus superinfection in a case with chronic hepatitis B].", "score": 0.009433962264150943, "content": "Primary infection with Epstein-Barr virus (EBV) often occurs subclinically during childhood, resulting in a latent infection of B lymphocytes. In this report, a chronic hepatitis B case who presented with a serologic profile mimicking acute hepatitis B virus (HBV) infection and exhibiting transient autoantibody positivities because of the polyclonal activation of B cells due to EBV reactivation has been presented. The test results of 56 years old male patient who suffered from fatigue and pain on the right upper quadrant, revealed high levels of liver enzymes (AST: 187 U/L, ALT: 569 U/L), positivity of HBsAg, anti-HBc IgG and anti-HBe, and negativity of anti-HBc IgM, HBeAg and anti-HBs. Since HBV-DNA level was found 405,974 copies/mL by quantitative real time polymerase chain reaction (PCR), the patient was taken into follow-up. At the 6th month AST and ALT levels further elevated (352 U/L and 609 U/L, respectively), and anti-HBc IgM and anti-HBs became positive in addition to the previous positive markers of HBV. With the suspicion of superinfection, further laboratory investigations yielded negative results in CMV-IgM and Paul Bunnel test, while positive results in EBV anti-VCA IgM and IgG, anti-EBNA IgM and IgG, anti-p22 IgM and IgG and anti-EA IgM. In the follow-up period high levels of autoantibody positivities [rheumatoid factor (42.200 U/ml), anti-nuclear antibody (1/100) and anti-Ro-52] together with increased levels of total IgG, IgM and IgA were detected. In the following months, the levels of transaminases, total immunoglobulins and HBV-DNA have distinctively decreased, and in the 20th month the previous HBV profile regained (HBsAg, anti-HBc IgG and anti-HBe positive, anti-HBc IgM and anti-HBs negative, HBV-DNA: 6984 copies/ml) and the other pathological test results returned to normal. As a result, ALT increases seen during the course of chronic hepatitis B should not always be considered as HBV manifestations and the unusual serologic patterns should be evaluated as a consequence of superinfection with various viral agents." }, { "id": "pubmed23n0932_25379", "title": "Occult Hepatitis B Virus Infection and Associated Genotypes among HBsAg-negative Subjects in Burkina Faso.", "score": 0.009433962264150943, "content": "The presence of HBV DNA in the liver (with detectable or undetectable HBV DNA in the serum) of individuals tested HBsAg negative by currently available assays is defined occult B Infection (OBI). It remains a potential transmission threat and risk to HBV chronic infection. The purpose of this study was to determine the OBI prevalence among HBsAg negative subjects and to characterize associated genotypes. Blood samples of 219 HBsAg-negative subjects tested by ELISA were collected. HBV DNA was investigated in all samples. Viral loads were determined using quantitative real-time PCR. All samples were screened for HBV markers (anti-HBc, anti-HBe, HBsAg). The Pre-S/S region of the HBV genome was sequenced. The database was analyzed using the SPSS and Epi info software. Phylogenetic analysis was performed using the BioEdit and MEGA software. Of the 219 samples, 20.1% were anti-HBc positive, 1.8% HBeAg and 22.8% were anti-HBe positive. Fifty-six (56) (25.6%) of the samples had a detectable HBV DNA and viral loads ranging from 4 IU/mL to 13.6 10<sup6</sup IU/mL. Sixteen of them (16/56) had a viral load &lt; 200 IU/mL, resulting in an OBI prevalence of 7.3% (16/219) in our study. The remaining 40 subjects had viral loads &gt; 200 IU/mL, resulting in a \"false OBI\" prevalence of 18.3% (40/219). HBV genotype E was predominant followed by the quasi-sub-genotype A3. A single \"false OBI\" strain had the characteristic mutation G145R. Other mutations were observed and all located in the major hydrophilic region (MHR) of the S gene. The study reported a prevalence of 7.3% of occult hepatitis B infection. It confirms the predominance of genotype E and the existence of a subgroup of quasi-sub-genotype A3 of HBV in Burkina Faso. It further provides information on the presence of \"false OBI.\" This study has found mutations in the major hydrophilic region (MHR) of the pre-S/S gene of HBV." }, { "id": "pubmed23n0238_1631", "title": "[Seven-year follow-up studies on asymptomatic HBs Ag carriers].", "score": 0.009345794392523364, "content": "This report covers 7-year follow-up studies on 35 HBs Ag carriers whose anti-HBc titer levels were 10 (log 2) or more and who had normal liver functions at the start of the studies, when 9 of them (25.7%) were HBe Ag positive, 24 (68.6%) anti-HBe positive and 2 (5.7%) negative to both. 1. There was no significant difference in the incidence of abnormal SGPT levels as a whole between HBe Ag positives and anti-HBe positives. But abnormally high SGPT levels of 100 KU or more were observed at a higher percentage among HBe Ag positives (4/9. 44.4%) than among anti-HBe positives (1/24. 4.2%. p less than 0.02). 2. Based on the results of the 7-year studies, all cases were classified into six clinical stages. HBe Ag positives were divided into three groups by the stage with different SGPT levels: 5 cases (15.2%) whose SGPT leves never rose above 50 KU were classified as Stage 1; 3 cases with chronic active hepatitis (9.6%) whose highest SGPT levels were over 200 KU (2 new cases and 1 case with a relapse of chronic inactive hepatitis) as Stage 2 and 1 case (3.0%) seroconverted to anti-HBe positive following an acute relapse of chronic inactive hepatitis as Stage 3. Anti-HBe positives were divided into another three groups similarly according to their mean HBs Ag titer levels: 6 cases (18.2%) whose mean HBs Ag titer levels ranged from 10 to 13 (log 2) were classified as Stage 4; 13 cases (39.4%) whose mean HBs Ag titer levels ranged from 6 to 9 as Stage 5 and 5 cases (15.2%), including 2 cases turned negative to HBs Ag, whose mean HBs Ag titer levels were below 5 as Stage 6. The average age of each group increased wth its clinical stage, namely, 32.6 in Stage 1, 34.3 in Stage 2, 33.0 in Stage 3, 34.5 in Stage 4 and 37.0 in Stage 5, but the average age in Stage 6 was 29.0. 3. All HBe Ag positives showed fluctuations in HBs Ag titer levels. The fluctuations were particularly noteworthy among cases with chronic active hepatitis in Stage 2 during an acute relapse. The HBs Ag titers rose just before the acute relapses in a case of chronic active hepatitis when SGPT levels went over 200 KU. This suggested a proliferation of the virus. On the other hand, in anti-HBe positives, a decrement of the virus was suggested by the fact that an increasing proportion of cases showed their HBs Ag titer levels to fluctuate or to become lower with the progress of stages (p less than 0.05) and two cases turned negative to HBs Ag as plotted in Stage 6. And the proportion of cases with abnormal SGPT levels decreased with the progress of stages (p less than 0.05). One case whose SGPT level was 125 KU, highest among anti-HBe positives, followed the clinical course of chronic inactive hepatitis and lowered in HBs Ag titer. 4. Between HBe Ag and anti-HBe cases, there were considerable differences in the occurrence of liver disturbances and their clinical courses..." }, { "id": "InternalMed_Harrison_23421", "title": "InternalMed_Harrison", "score": 0.009286791639732818, "content": "well as those with chronic HBV infection, anti-HBc is predominantly of the IgG class. Infrequently, in ≤1–5% of patients with acute HBV infection, levels of HBsAg are too low to be detected; in such cases, the presence of IgM anti-HBc establishes the diagnosis of acute hepatitis B. When isolated anti-HBc occurs in the rare patient with chronic hepatitis B whose HBsAg level is below the sensitivity threshold of contemporary immunoassays (a low-level carrier), anti-HBc is of the IgG class. Generally, in persons who have recovered from hepatitis B, anti-HBs and anti-HBc persist indefinitely." }, { "id": "pubmed23n0786_19285", "title": "Clinical, biochemical, virological and sonographic profile of incidentally detected asymptomatic HBsAg positive subjects, in Bangladesh.", "score": 0.009259259259259259, "content": "Chronic hepatitis B virus (HBV) is known to be the significant cause of Liver related morbidity and mortality, affecting 400 million people worldwide and a major public health problem in Bangladesh where carrier rates of HBV infection varies from 7.5 to 10%. In Bangladesh prevalence of asymptomatic HBV infection and incidentally detected HBsAg positive subjects were not well studied. The aim of this study is to evaluate the disease activity, replicative status of the virus and to find out the stages of chronic liver disease among incidentally detected asymptomatic HBsAg positive Bangladeshi subjects. Two hundred (200) incidentally detected healthy HBsAg positive subject were evaluated clinically, biochemically, serologically and ultrasonographically from January 2004 to June 2008. HBeAg was found positive in 17(8.5%), anti-HBe was positive in 174(87%), raised serum ALT (&gt;45iu/L) in 45(22.5%), prothrombine time (PT) &gt;3 sec of control in 33(16.5%). Ultrasonography showed coarse hepatic echotexture in 13(6.5%). Evidence of active viral replication and signs of chronic liver disease were observed among incidentally detected healthy HBsAg positive subjects. Such individuals should be followed up at regular interval to evaluate the replicative status of the virus and disease activity so that appropriate measures could be initiated in time. " }, { "id": "article-22784_47", "title": "Hepatitis -- Evaluation -- Chronic Infection", "score": 0.009216785592932382, "content": "Patients who have chronic hepatitis B infection can have positive HBsAg for life.  These patients can be inactive carriers of the hepatitis B virus or may have active chronic hepatitis. All patients with chronic hepatitis B virus infection have the presence of anti-HBc. If HBeAg may or may not be present, but if it present in patients with active chronic hepatitis, it can indicate viral replication. Similarly, hepatitis B virus DNA may or may not be present, but high levels indicate active chronic hepatitis. Patients with chronic infection of hepatitis B usually have an absence of anti-HBs, but the presence of anti-HBs with positive HBsAg in patients with chronic infection with the hepatitis B virus means that the antibody was unsuccessful in inducing the viral clearance." }, { "id": "pubmed23n0236_11170", "title": "[2-year follow-up of a series of cases of asymptomatic carriers of HBsAg antigen].", "score": 0.009174311926605505, "content": "20 asymptomatic carriers of HBsAg antigen have been subjected to haemato-chemical examinations and liver biopsy and followed up after two years. The only altered serological test result regarded transaminases, except for one case where other liver function indices were irregular, and these were up in 13 cases at the first control and in 6 at the second. The histological changes observed in respectively 18 and 17 patients were in the majority of cases of persistent chronic hepatitis type. In one case the histopathological picture was related to active chronic hepatitis. It is therefore concluded that the term asymptomatic carrier is often inexact as the subjects are suffering from clinically silent chronic hepatitis." }, { "id": "wiki20220301en089_27823", "title": "Jade Ribbon Campaign", "score": 0.009145517657084658, "content": "Reasons for lack of diagnosis The danger of hepatitis B lies in its silent transmission and progression. Many chronic hepatitis B carriers are asymptomatic (have no symptoms) and feel perfectly healthy. Chronically infected individuals may exhibit normal blood tests for liver function and be granted a clean bill of health. The diagnosis cannot be made without a specific blood test for the presence of the hepatitis B surface antigen (HBsAg), a marker for chronic infection. Since the detection of hepatitis B is so easily missed, even by doctors, it is also up to the patient to specifically request the HBsAg test. Early detection not only benefits the person tested, but prevents infection from being passed silently from one child to another, and from one generation to another." }, { "id": "Pathology_Robbins_3888", "title": "Pathology_Robbins", "score": 0.00913318180870363, "content": "Anti-HBs antibody appears after the acute disease is over and usually is not detected until a few weeks to several months after HBsAg disappears. Anti-HBs may persist for life and confers protection, which is the rationale for current vaccines containing HBsAg. HBeAg and HBV DNA appear in serum soon after HBsAg and signify ongoing viral replication. Persistence of HBeAg is an indicator of progression to chronic hepatitis. The appearance of anti-HBe antibodies implies that an acute infection has peaked and is on the wane. IgM anti-HBc becomes detectable in serum shortly before the onset of symptoms, concurrent with the onset of elevated serum aminotransferase levels (indicative of hepatocyte destruction). Over a period of months, the IgM anti-HBc antibody is replaced by IgG anti-HBc. As in the case of anti-HAV, there is no direct assay for IgG anti-HBc; its presence is inferred from decline of IgM anti-HBc in the face of rising total anti-HBc." }, { "id": "pubmed23n0293_11196", "title": "[Basic and clinical aspects of hepatitis virus carriers].", "score": 0.00909090909090909, "content": "Among the six species of hepatitis viruses, HBV (hepatitis B virus) and HCV (hepatitis C virus) can induce persistent infection. HBV and HCV are transmitted parenterally, of which maternal transmission and transfusion-associated infection is a major route respectively. We opened the special clinic for carriers detected through blood donation, and followed them at regular intervals for their health care. The prevalence rate of HBV carriers decreased from 3.0% to 1.2% in these 10 years, and that of HCV decreased from 0.9 to 0.4% in these 4 years. Prevalence rate of HBV peaks at 50s and that of HCV peaks at 60s. Due to nearly complete screening of donated blood, post-transfusion hepatitis almost disappeared. HBV vaccine for neonates born from infected mothers reduced the new incidence of HBV carriers. In HBV carriers seroconversion of HBeAg to HBeAb occurs at teens with transient hepatitis and appearance of mutant virus. Ninety percent of the carriers remains healthy for the lifetime but some of them aggravate into chronic hepatitis leading to HCC (hepatocellular carcinoma). In HCV acute infection at adult age succeeds to chronic infection and eventually to liver cirrhosis with sporadic appearance of HCC. On the other hand, less than 50% of HCV carriers seem to be asymptomatic and do not lead to grave disease. In HBV carriers tendency to reject the virus occurs and eventually HBV is cleared in some percentage of the population. In contrast HCV does not tend to be cleared. HBsAb is a defensive antibody. In contrast HCVAb is not a defensive antibody but an infective antibody like HBcAb. DNA polymerase is a good marker of disease state in HBV, and HCV RNA is a good marker of HCV proliferation. Treatment with IFN is sometimes effective for seroconversion in HBV, and for eradication of virus in HCV." }, { "id": "pubmed23n0658_3520", "title": "Evidence of protection against clinical and chronic hepatitis B infection 20 years after infant vaccination in a high endemicity region.", "score": 0.009009009009009009, "content": "Vaccination against hepatitis B virus (HBV) immediately after birth prevents neonatal infection by vertical transmission from HBV carrier mothers. There is an ongoing debate whether infant vaccination is sufficient to protect against infection when exposed to HBV later in life. We studied 222 Thai infants born to HBsAg -/+ and HBeAg -/+ mothers who were vaccinated with recombinant hepatitis B vaccine at 0-1-2-12 months of age. A subset of 100 subjects received a booster dose at age 5 years. Blood samples collected yearly for 20 years were examined for anti-HBs antibodies and serological markers of hepatitis B infection (anti-HBc, HBsAg, and in selected cases HBeAg, anti-HBe, HBV DNA). During the 20-year follow-up, no subject acquired new chronic HBV infection or clinical hepatitis B disease. During the first decade, possible subclinical breakthrough HBV infection (anti-HBc seroconversion) was only observed in subjects born to HBsAg +/HBeAg + mothers (6/49 [12.2%]). During the second decade, breakthrough HBV infections were detected in all groups (18/140 [12.8%]). Increases in anti-HBs concentrations that were unrelated to additional HBV vaccination or infection were detected in approximately 10% of subjects in each decade. Primary infant vaccination with a recombinant hepatitis B vaccine confers long-term protection against clinical disease and new chronic hepatitis B infection despite confirmed hepatitis B exposure." }, { "id": "pubmed23n0083_6842", "title": "The etiology of acute hepatitis superimposed upon previously unrecognized asymptomatic HBsAg carriers.", "score": 0.009009009009009009, "content": "To study the etiology of acute hepatitis superimposed upon previously unrecognized asymptomatic HBsAg carriers, paired sera were collected in acute and convalescence phases for measurement of HBeAg, anti-HBe, hepatitis B virus DNA and anti-delta from 76 adult patients with acute hepatitis who were HBsAg positive but IgM anti-HBc negative or positive only at low titer. None of them were IgM anti-hepatitis A virus positive on admission. Of the 34 patients who were HBeAg positive initially, two (5.9%) were diagnosed as having delta superinfection, and another two (5.9%) were suspected to have non-A, non-B virus superinfection because of a transient decrease of serum hepatitis B virus DNA. The remaining 30 (88.2%) cases were hepatitis B virus DNA negative with or without anti-HBe seroconversion on follow-up. The episodes of acute hepatitis in these cases may represent \"immune clearance of HBeAg\" or \"immune clearance of hepatitis B virus with delayed anti-HBe seroconversion,\" respectively, in the natural course of chronic hepatitis B virus infection. Of the patients who were anti-HBe positive initially, 23 (54.8%) were diagnosed as having delta superinfection, including eight with de novo seroconversion of anti-delta and 15 with a rising titer of anti-delta; 10 (23.8%) were positive for hepatitis B virus DNA and were considered as reactivation of hepatitis B virus, and the other nine (21.4%) were suspected as having non-A, non-B virus superinfection.(ABSTRACT TRUNCATED AT 250 WORDS)" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 139, 603 ] ], "word_ranges": [ [ 21, 95 ] ], "text": "The clinical case is fairly typical. A young person with fever and neurological symptoms that make him go to the emergency department (he is on the run). Laboratory tests show anemia with evidence of hemolysis (increased LDH and retis, presence of schistocytes in peripheral blood) and severe thrombopenia. In addition, coagulation is normal. To distinguish it from the rest of things (although you should not hesitate...) it tells you that the coombs is negative." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Autoimmune hemolytic anemia.", "2": "Thrombotic thrombocytopenic purpura.", "3": "Evans syndrome (hemolytic anemia and immune thrombopenia).", "4": "Idiopathic immune thrombocytopenia.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0719_4304", "title": "Pseudo-thrombotic thrombocytopenic purpura: A rare presentation of pernicious anemia.", "score": 0.019142700128228614, "content": "Schistocytes are fragmented red blood cells due to the flow of blood through damaged capillaries and indicate endothelial injury. They are typical of microangiopathic hemolytic anemia seen in life threatening conditions like disseminated intravascular coagulation or thrombotic thrombocytopenic purpura/hemolytic uremic syndrome .We report a rare sub-acute presentation of pernicious anemia with hemolysis, thrombocytopenia and numerous schistocytes that was initially diagnosed as a more serious thrombotic thrombocytopenic purpura. A 31-year-old Caucasian woman presented with fatigue and paresthesia of both feet for 1 week. Past medical history included hypertension and gastro-esophageal reflux disease. Examination revealed scleral icterus and pallor. Examination of the abdomen did not show hepatosplenomegaly. Initial laboratory tests showed severe anemia, and low platelets. Indirect bilirubin and serum Lactate De Hydrogenase were elevated. Prothrombin time, partial thromboplastin time, serum fibrinogen, and serum fibrin degradation product levels were normal. Peripheral smear revealed numerous schistocytes, anisocytosis and macro-ovalocytes. Thrombotic thrombocytopenic purpura (TTP) was suspected due to the constellation of sub-acute onset of fatigue and paresthesia along with thrombocytopenia, schistocytes and an elevated LDH. Plasmapheresis was initiated for possible TTP. However, platelet count worsened despite plasmapheresis for 4 days. On re-evaluation, vitamin B(12) was found to be low. Treatment with intra-muscular vitamin B(12) led to symptomatic and hematologic improvement. Pernicious anemia was confirmed by the presence of anti-intrinsic factor antibodies, elevated serum gastrin level and atrophic gastritis. Clinicians must be aware of unusual clinical presentation of vitamin B(12) deficiency with schistocytes as the management is simple and effective." }, { "id": "pubmed23n0282_16640", "title": "[An elderly case of thrombotic thrombocytopenic purpura].", "score": 0.016993188680570183, "content": "A 78-year-old woman was admitted to our hospital because of disorientation and fever on January 21, 1992. Two days before admission she experienced vomiting, anorexia and general malaise. Laboratory examinations on admission disclosed a hemoglobin level of 11.1 g/dl and a platelet count of 8,000/microliters. The peripheral blood smear revealed anisocytosis with numerous schistocytes and poikilocytes. Polychromatophilic and nucleated red blood cells were also seen, and the reticulocyte count was 38/1000. Her serum lactate dehydrogenase (LDH) value was 2,977 WU and the total serum bilirubin level was 3.5 mg/dl with 2.7 mg/dl indirect reacting fraction. Serum creatinine was 4.7 mg/dl. Her consciousness became semicomatose after a systemic seizure which lasted approximately 15 seconds and her hemoglobin level decreased to 8.5 g/dl on hospital day 2. Therefore, we diagnosed her as having thrombotic thrombocytopenic purpura (TTP) because of the presence of all 5 features, that is, thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurologic abnormalities, renal dysfunction and fever. A plasmapheresis with fresh frozen plasma (FFP) replacement was begun on that day. She was also treated with anti-platelet agents, 80 mg/day aspirin, and 300 mg/day dipyridamole. Moreover, packed red blood cells (PRC) were infused. While also receiving diphenylhydantoin and phenobarbital to prevent convulsions, status epilepticus developed on day 3. Because of inhibited spontaneous respiration which was an adverse effect derived from diazepam and sodium thiamylal administered intravenously to treat the status epilepticus, an artificial respiration was initiated.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0681_21394", "title": "[Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure, mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case].", "score": 0.016151866151866152, "content": "Disseminated intravascular coagulopathy (DIC) is characterized as activation of the clotting system resulting in fibrin thrombi, gradually diminishing levels of clotting factors with increased risk of bleeding. Basically two types of DIC are distinguished: (1) chronic (compensated) - with alteration of laboratory values and (2) acute (non-compensated) - with severe clinical manifestations: bleeding, shock, acute renal failure (ARF), transient focal neurologic deficit, delirium or coma. Chronic DIC related to metastatic neoplasia is caused by pancreatic, gastric or prostatic carcinoma in most of the cases. Incidence rate of DIC is 13-30% in prostate cancer, among those only 0.4-1.65% of patients had clinical signs and symptoms of DIC. In other words, chronic DIC is developed in one of eight patients with prostate cancer. DIC is considered as a poor prognostic factor in prostatic carcinoma. The similar clinical and laboratory findings of TTP-HUS (thrombotic thrombocytopenic purpura - hemolytic uremic syndrome) and DIC makes it difficult to differentiate between them. A 71 years old male patient with known chronic obstructive pulmonary disease, benign prostatic hyperplasia, significant carotid artery stenosis, gastric ulcer and alcoholic liver disease was admitted to another hospital with melena. Gastroscopy revealed intact gastric mucosa and actually non-bleeding duodenal ulcer covered by clots. Laboratory results showed hyperkalemia, elevated kidney function tests, indirect hyperbilirubinemia, increased liver function tests, leukocytosis, anemia, thrombocytopenia and elevated international normalized ratio (INR). He was treated with saline infusions, four units of red blood cells and one unit of fresh frozen plasma transfusions. Four days later he was transported to our Institution with ARF. Physical examination revealed dyspnoe, petechiae, hemoptoe, oliguria, chest-wall pain and aggressive behavior. Thrombocytopenia, signs of MAHA (fragmentocytes and helmet cells in the peripheral blood), normal INR, elevated lactate dehydrogenase (LDH) and ARF suggested TTP-HUS. Hemodialysis and six plasmaferesis (PF) were carried out. After the fifth PF, skin manifestations of thrombotic microangiopathy occurred on the feet. Clotting analysis revealed elevated D-dimer (&gt;5 μg/mL), normal fibrinogen (3.2 g/L), a slightly raised INR (1.36) and activated partial prothrombin time (APTT) (45.8 sec), normal reticulocyte (57 G/L) and a slightly low platelet count (123 G/L), which proved to be chronic DIC. Therapeutic dose of low-molecular-weight heparin (LMWH) was started. Elevated prostate-specific antigen (PSA) (109.6 ng/mL) suggested prostatic carcinoma. Prostate biopsy revealed adenocarcinoma (Gleason: 4+4 for left lobe and 3+3 for right lobe). Elevated alkaline phosphatase suggested metastases in the bone, which were confirmed by bone scintigraphy. Combined androgen blockade (CAB) was started. After three months follow-up our patient's status is satisfactory. PSA is in the normal range (4.6 ng/mL). Thrombocytopenia of uncertain origin with normal or raised INR, APTT, elevated D-dimer, normal fibrinogen and reticulocyte count prove the diagnosis of chronic DIC. This process warrants searching for metastatic neoplasia. Due to the relatively low serum levels of circulating procoagulant factors (e.g. tissue factor), therapeutic dose of LMWH can be used with good efficiency in chronic DIC with low risk of bleeding. Severe DIC as a complication of metastatic prostate cancer can be treated by androgen deprivation therapy (ADT) or CAB in combination with ketokonazole and concomitant use of supportive treatment. Deme D, Ragán M, Kovács L, Kalmár K, Varga E, Varga T, Rakonczai E. Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case." }, { "id": "pubmed23n0322_1104", "title": "[Hemolytic anemia and thrombocytopenia associated with anti-omeprazole antibody].", "score": 0.015516224188790562, "content": "An 80-year-old woman was admitted with anemia, jaundice and a bleeding tendency about 5 weeks after starting omeprazole. On admission, the hemoglobin was 6.4 g/dl, platelets 0.1 x 10(4)/microliter, leukocyte count 7,500/microliter, and reticulocyte count 325/1000. The total bilirubin was 1.9 mg/dl, indirect bilirubin 0.6 mg/dl, lactate dehydrogenase 572 IU/l, and haptoglobin &lt; 10 mg/dl. Both the direct and the indirect Coombs' tests were positive. The platelet-associated IgG (PAIgG) was 1,100.0 ng/10(7) cells. A decrease in the complement value was observed. There was an increase in the number of megakaryocytes and erythroblasts in the marrow film. After omeprazole administration was halted, her hemoglobin and platelet levels gradually returned to normal. On the 27th hospital day, the direct Coombs' test was positive but the indirect Coombs' test became negative. The PAIgG value also returned to normal, and she was discharged on the 59th hospital day. The acute phase of the drug-induced lymphocyte stimulation test was negative, however, we detected the IgG antibody to omeprazole. In the recovery phase, the IgG value decreased. Forty days after discharge, the direct Coombs' test had become negative. This is apparently the first report of a patient with acute hemolytic anemia and thrombocytopenia due to omeprazole through an immune complex mechanism." }, { "id": "pubmed23n0297_3204", "title": "[Autoimmune hemolytic anemia with eosinophilia in elderly patient].", "score": 0.015169525103299938, "content": "A 70-year-old woman was admitted to our hospital in November 1992 for evaluation of anemia. Physical examination revealed anemia, jaundice, swelling of axial and inguinal lymph nodes, and splenomegaly. Abnormal hematological findings were as follows: Hb of 3.9 g/dl, reticulocyte count of 58.2% (61.7 x 10(4)/microliters), hyperplasia of normal erythroblasts in bone marrow, and eosinophilia (21.0%, 2352/microliters) in peripheral blood. Routine laboratory examinations revealed polycolonal hypergammaglobulinemia 3.0 g/dl, a high level of serum LDH (797 IU/I) and a total bilirubin of 2.4 mg/dl (indirect, 1.6 mg/dl). The serum haptoglobin level was very low (&lt; 5 mg/dl). Results of serological examinations were as follows: IgG of 3366 mg/dl, CH50 of 16.0 U/ml, positive Coombs test 2+, and positive tests for antinuclear antibody, rheumatoid factor, and cold agglutinin. CRP was negative. PHA-stimulated lymphocyte blast formation, NK activity, and ADCC activity were found to be suppressed, and the percentage of CD4-positive lymphocytes in peripheral blood was also low. An axillary lymph node biopsy revealed reactive lymphadenitis. No signs or history suggested allergy, collagen disease, or parasitic infection. Autoimmune hemolytic anemia (AIHA) complicated by immunologic abnormalities and eosinophilia was diagnosed. Oral prednisolone markedly reduced the hemolytic anemia, eosinophilia, lymph node swelling, and splenomegaly, but NK activity remained low." }, { "id": "pubmed23n1041_14942", "title": "Et Tu, B12? Cobalamin Deficiency Masquerading As Pseudo-Thrombotic Microangiopathy.", "score": 0.015043290043290043, "content": "Vitamin B12 deficiency is classically associated with megaloblastic anemia. Possible cobalamin deficiency is not investigated once hemolysis is seen. Around 2.5% of cases can present as pseudo-thrombotic microangiopathy (TMA). A swift identification of this means the difference between an easy solution and a protracted one for the patient. A 74-year-old man with no past medical history presented with exertional dyspnea, fatigue, and increasing anorexia over two weeks. Physical examination including a neurological examination was normal. Laboratory tests revealed pancytopenia, unconjugated hyperbilirubinemia, elevated LDH (lactate dehydrogenase), low haptoglobin, and fragmented red blood cells (RBCs) on the peripheral smear, but normal FDP (fibrinogen degradation product) and fibrinogen. The absolute reticulocyte count was reduced as opposed to the expected elevation. Vitamin B12 levels were undetectable, and severe cobalamin deficiency from pernicious anemia was found to be the paramount etiology. Cobalamin deficiency causing pseudo-TMA baffles most physicians. Advanced pernicious anemia is thought to cause intramedullary hemolysis, resulting in peripheral pancytopenia. The fragile RBCs are easily sheared, producing schistocytosis without platelet microthrombi. In contrast to hemolytic anemias, reticulocyte count is low given the unavailability of B12 for erythropoiesis. Reticulocytopenia is a universal finding in cases of pseudo-TMA. Around 38.8% of cases with pseudo-TMA are misdiagnosed as thrombotic thrombocytopenic purpura and treated with plasma product therapy. Keeping an eye out for reticulocytopenia in cases of hemolysis could mean a world of difference for the patient." }, { "id": "wiki20220301en085_21868", "title": "Thrombotic microangiopathy", "score": 0.014718614718614718, "content": "Diagnosis CBC and blood film: decreased platelets and schistocytes PT, aPTT, fibrinogen: normal markers of hemolysis: increased unconjugated bilirubin, increased LDH, decreased haptoglobin negative Coombs test. Creatinine, urea, to follow renal function ADAMSTS-13 gene, activity or inhibitor testing (TTP)." }, { "id": "wiki20220301en046_51369", "title": "Schistocyte", "score": 0.01436752224153799, "content": "Schistocyte count A normal schistocyte count for a healthy individual is <0.5% although usual values are found to be <0.2%. A schistocyte count of >1% is most often found in thrombotic thrombocytopenic purpura, although they are more often seen within the range of 3–10% for this condition. A schistocyte count of <1% but greater than the normal value is suggestive of disseminated intravascular coagulation, but is not an absolute diagnosis. The standard for a schistocyte count is a microscopic examination of a peripheral blood smear." }, { "id": "pubmed23n0709_10292", "title": "[Hemolytic anemias in adults].", "score": 0.014265621860558568, "content": "The erythrocyte lifespan in haemolytic anemia is shortened while erythropoesis is increased. Important labaratory findings are increased reticulocytes, LDH, indirect bilirubin and a decreased haptoglobin level. The most important diagnostic tool for further work up of hemolytic anemia is the direct antiglobulin test (DAT, Coombs test) to differentiate autoimmune hemolytic anemia (AIHA) from other causes. Another important group are fragmentation syndroms (hemolytic uremic syndrome and thrombotic thrombocytopenic purpura). In these forms of haemolytic anemia fragmented red blood cells can be found in the blood smear together with thrombocytopenia. A severe problem in paroxysmal nocturnal hematuria is the incidence of thrombosis. The following review describes the most important forms of hemolytic anemia in the adult and the diagnostic and therapeutic strategies." }, { "id": "pubmed23n1042_13774", "title": "Thrombotic Thrombocytopenic Purpura: Revisiting a Miss and an Inevitable Consequence.", "score": 0.014256722475900558, "content": "Thrombotic thrombocytopenic purpura (TTP) is typically characterized by the symptomatic pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, and renal failure. Atypical TTP is the diagnosis used to describe the subset of patients with TTP who present with symptoms that deviate from the classic pentad. We report a case an 86-year-old woman who presented to the emergency department complaining of chest pain for one day. She was reportedly on antibiotics for sinus infection. Physical examination revealed multiple bilateral superficial hematomas, predominantly on her extremities. On admission, her lab values were as follows: platelet count of 6,000/cubic millimeter, hemoglobin of 10.4 grams/deciliter, leukocyte count of 5100 cells/cubic millimeter, total bilirubin of 2.3 milligrams/deciliter, and troponin-I of 5.190 nanograms/milliliter. Peripheral blood smear was normal and did not reveal any schistocytes. The patient was admitted to the intensive care unit with a diagnosis of a non-ST-elevation myocardial infarction and a presumed diagnosis of immune thrombocytopenic purpura from antibiotic use. She was treated with intravenous solumedrol and a high-intensity statin. On the third day of her admission, the patient's mental functioning deteriorated and was intubated to protect her airway. A second peripheral smear revealed schistocytes, and subsequent laboratory studies supported the diagnosis of TTP. Plasma exchange therapy was planned. However, the patient succumbed to cardiac arrest before it could be initiated. The diagnosis was later confirmed with an ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) assay.  This case serves as an example of one of the many ways in which TTP can present, and emphasizes the importance of considering TTP as a differential diagnosis." }, { "id": "pubmed23n0282_20398", "title": "[Emergency blood picture].", "score": 0.014146815751093826, "content": "Assessment of peripheral blood counts and blood film analysis are frequently performed as diagnostic procedures in emergency medicine. Far fewer situations exist, however, in which these analyses are the main clue in establishing an emergency diagnosis. Artifacts can lead to wrong diagnosis, e.g. pseudo-thrombocytopenia, which is defined as a low platelet count resulting from a laboratory artifact. Severe neutropenia (agranulocytosis) and extreme hyperleukocytosis, as well as suspicion of acute leukemia, require a rapid diagnostic work-up. A newly detected anemia should not necessarily be treated by packed red cell transfusions. The decision whether an anemic patient ought to receive transfusions should be based on the speed with which the anemia has developed, as well as on clinical judgement. As a rule a chronic anemia patient with hemoglobin above 70 g/l does not need transfusions. An uncritical transfusion policy can even cause emergencies, e.g. in patients with megaloblastic anemia or in anemic multiple myeloma patients with a hyperviscosity syndrome. An elevated hematocrit requires prompt further investigations. This is of utmost importance if one considers the diagnosis of polycythemia vera rubra, a disease in which patients are particularly prone to thrombotic complications. Fragmented red cells (schistocytes) on peripheral blood smears constitute a cardinal diagnostic clue for the detection of microangiopathic hemolytic anemias (MAHA), in particular for the diagnosis of the life-threatening thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Malaria is another example for a chief role of blood smears examination in achieving a rapid diagnosis. If one encounters an unexpected severe thrombocytopenia, a marrow examination reveals whether it is due to rapid peripheral destruction, or due to a marrow failure. Furthermore, in any patients with an unanticipated thrombocytopenia, a disseminated intravascular coagulation and a MAHA should be ruled out. Heparin-induced thrombocytopenia is a rare, but possibly fatal complication of therapy with heparins." }, { "id": "pubmed23n0516_2225", "title": "Thrombotic thrombocytopenic purpura without schistocytes on the peripheral blood smear.", "score": 0.01412512218963832, "content": "A hallmark of the clinical syndrome of thrombotic thrombocytopenic purpura (TTP) is evidence of microangiopathic hemolytic anemia. The presence of schistocytes on the peripheral blood smear, elevated plasma lactic dehydrogenase, and decreased haptoglobin concentration are used as evidence of microangiopathic hemolytic anemia to make a diagnosis of TTP. This report describes a case of recurrence of TTP in the absence of schistocytes in the peripheral blood smear during the recurrent episode. Although careful attention should be paid to microscopic examination of a blood smear in any patient presenting with acute renal failure and thrombocytopenia, this case emphasizes the need to consider TTP-hemolytic uremic syndrome in the differential diagnosis, even in the absence of peripheral schistocytosis." }, { "id": "pubmed23n0059_11730", "title": "[Thrombotic thrombocytopenic pupura (TTP)--remission following treatment with high-dose immunoglobulin].", "score": 0.013938805245264693, "content": "A 60-year-old man was admitted to our hospital because of fever, hemorrhagic tendency, anemia and neurological abnormality. A blood count revealed that the hemoglobin was 6.8 g/dl, the reticulocyte was 17.3 percent with 2 erythroblasts per 100 white cells, the white cell count was 7,100/microliters and the platelet count was 0.8 x 10(4)/microliters. Peripheral blood smear demonstrated marked fragmentation of red cells. Bone marrow examination disclosed the marked erythroid hyperplasia. Although the bleeding time was prolonged (14 minutes 30 seconds), the other hemostatic data were within normal limits. The serum bilirubin level was 1.57 mg/dl; LDH level, 1,437 U/l; creatinine level, 0.92 mg/dl; BUN level 14.7 mg/dl. Haptoglobin was below 10 mg/dl. Results of immunological tests were all negative except the result of PAIgG (576.6 ng/10(7) cells). The urinalysis showed proteinuria, microhematuria and trace granular and hyaline casts. A diagnosis of thrombotic thrombocytopenic purpura was made. The patient was initially treated with prednisolone (60 mg), aspirin (1,000 mg), dipyridamole (150 mg), gabexate mesilate (1.5 g), sodium oxagrel (80 mg) daily with little response. The thirty days after admission, infusion of gamma globulin (20 g, daily) was given for 3 days. The clinical state and laboratory findings became dramatically improved shortly after the administration of gamma globulin and the laboratory data came to be normalized after 1 month. After ten months of this treatment, the patient is remained asymptomatic and the hematological data are within normal range without using any drug. A trial seems justified to confirm the value of this mode of therapy." }, { "id": "pubmed23n0509_8196", "title": "Frequency and significance of schistocytes in TTP/HUS patients at the discontinuation of plasma exchange therapy.", "score": 0.013800523952095809, "content": "Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) is characterized by thrombocytopenia, a microangiopathic hemolytic anemia (presence of schistocytes) and elevated LDH without another likely explanation. Standard of care is daily plasma exchange, which is typically discontinued when the platelet count exceeds 100-150 x 10(9)/L for 2 days. However, residual schistocytosis, the presence of schistocytes at the time of discontinuation of plasma exchange therapy, is often disconcerting. We evaluated the frequency and significance of residual schistocytosis in TTP/HUS patients when the patients' platelet counts returned to normal levels (e.g., 100-150 x 10(9)/L). Retrospective review in our institution from 01/1999-03/2004 of all patients treated with plasma exchange for TTP/HUS with at least 2 months of follow-up for relapse was completed. Patients were excluded if the clinical course was complicated by HIV, stem cell/bone marrow and solid organ transplant, pregnancy and auto-immune disease. Schistocytes were documented on day of presentation and on the day the platelet count reached 150 x 10(9)/L. Grading scale (using 100 x objective-a high power field, with approximately 100 red blood cells per field) for schistocytes was as follows: rare for 1 schistocyte per every other other field, 1+ for 1-5%, 2+ for 6-15%, and 3+ for &gt;15%. The frequency of schistocytes was compared to frequency of relapse within 2 months, using Fisher's exact test. We identified 57 patients with TTP/HUS who received plasma exchange therapy. Of these patients, 12 did not have a follow-up microscopic examination of a peripheral blood smear at discontinuation of plasma exchange therapy and were excluded from further analysis. Of the remaining 45 patients, 16 had residual schistocytosis (35.6%). There was no statistically significant difference in relapse rate with or without residual schistocytosis (P = 1.00, Fisher's Exact test, 2 sided). In this study, we found that the presence of residual schistocytosis is common (35.6%). The presence of residual schistocytosis, however, was not predictive of relapse." }, { "id": "pubmed23n1108_5666", "title": "Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19.", "score": 0.013541666666666667, "content": "In this case report, we report a pediatric patient with COVID-19 and atypical hemolytic uremic syndrome (aHUS). A 3-year-old girl with fever and respiratory distress was admitted to the hospital. The patient tested positive for COVID-19 by a PCR test. As her respiratory distress increased and blood gas indicated deep respiratory acidosis on the third day of the pediatric intensive care unit follow-up, the patient was intubated and ventilated. Thorax computerized tomography (CT) showed bilateral effusion and atelectasis. During her follow-up, the pleural effusion resolved but there were marked consolidation areas and ground glass opacities compatible with COVID-19 on the follow-up CT. On the 10th day, she became anuric and developed progressive thrombocytopenia and persistent microangiopathic hemolytic anemia, which were suggestive of HUS given a high creatinine level (1.9 mg/dl), an undetectable haptoglobin level, reticulocytosis (8%), and an LDH level of 2540 U/l. Direct Coombs test returned negative. Examination of a peripheral blood smear revealed schistocytes. Disseminated intravascular coagulation was ruled out by normal INR and PTT. In the light of the available findings, we considered the patient to have thrombotic microangiopathy (TMA) triggered by COVID-19. It was not a TTP-form of TMA but rather an aHUS type, based on an ADAMTS13 activity level &gt;5%. Hence, plasmapheresis was performed with fresh frozen plasma (FFP). After 4 weeks, she became completely asymptomatic, and her hemodynamic parameters normalized. COVID-19 induced uncontrolled complement activation leading to the development of aHUS. Early diagnosis and treatment may reduce morbidity and mortality since its treatment options." }, { "id": "wiki20220301en435_34729", "title": "Upshaw–Schulman syndrome", "score": 0.013485219489690906, "content": "Diagnosis A diagnosis of TTP is based on the clinical symptoms with the concomitant presence of thrombocytopenia (platelet count below 100×109/L) and microangiopathic hemolytic anemia with schistocytes on the blood smear, a negative direct antiglobulin test (Coombs test), elevated levels of hemolysis markers (such as total bilirubin, LDH, free hemoglobin, and an unmeasurable haptoglobin), after exclusion of any other apparent cause. USS can present similar to the following diseases, which have to be excluded: fulminant infections, disseminated intravascular coagulation, autoimmune hemolytic anemia, Evans syndrome, the typical and atypical form of hemolytic uremic syndrome, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, pre-eclampsia, heparin-induced thrombocytopenia, cancer that is often accompanied with metastasis, kidney injury, antiphospholipid antibody syndrome, and side effects from hematopoietic stem cell transplantation." }, { "id": "pubmed23n1085_17745", "title": "[Recurrent thrombocytopenia with hemolytic anemia in a boy aged 3 years].", "score": 0.013312852022529442, "content": "A boy, aged 3 years and 8 months, had recurrent thrombocytopenia with hemolytic anemia for more than 3 years. The physical examination showed no enlargement of the liver, spleen, and lymph nodes or finger deformities. Laboratory results showed a negative result of the direct antiglobulin test, normal coagulation function, and increases in bilirubin, lactate dehydrogenase and reticulocytes. The results of von Willebrand factor-cleaving protease ADAMTS13 activity assay showed extreme deficiency, and antibody assay showed negative ADAMTS13 inhibitory autoantibodies. Next-generation sequence showed compound heterozygous mutation in the <iADAMTS13</i gene. The boy was diagnosed with congenital thrombotic thrombocytopenic purpura. This disease may be easily misdiagnosed as Evans syndrome and is difficult to diagnose in clinical practice. The child had developed the disease since birth, but it took 3 years to make a confirmed diagnosis. Therefore, congenital thrombotic thrombocytopenic purpura should be considered for children with jaundice at birth, recurrent thrombocytopenia with hemolytic anemia, and negative results of the direct antiglobulin test. The detection of ADAMTS13 activity and ADAMTS13 inhibitory autoantibodies should be performed as soon as possible for a definite diagnosis, and gene detection should be performed to make a confirmed diagnosis when necessary." }, { "id": "pubmed23n0736_22209", "title": "[Successful delivery following treatment with plasma exchange in a female patient with thrombotic thrombocytopenic purpura].", "score": 0.012805016242350985, "content": "We report here on a case of a 27-year-old woman in her first pregnancy. She was diagnosed with idiopathic thrombocytopenic purpura (ITP) at the age of 14 years. At 36 weeks of gestation, she was admitted to our hospital due to thrombocytopenia. We initially suspected ITP exacerbated by pregnancy. Laboratory results revealed mild anemia, thrombocytopenia (5.0×10(9)/l), and slightly elevated liver enzymes and lactate dehydrogenase. The next day, hemoglobin fell to 6.6 g/dl. Thrombotic thrombocytopenic purpura (TTP) was suspected on the basis of hemolytic anemia with schistocytes and a negative Coombs' test. Plasma exchange and methylprednisolone were initiated immediately. ADAMTS13 analysis showed a severe deficiency in ADAMTS13 activity but no inhibitors. At Day 6, the platelet count rose to 223×10(9)/l and she delivered a live baby by cesarean section. Currently, the patient receives fresh frozen plasma infusions every 2 weeks due to suspected Upshaw-Schulman syndrome." }, { "id": "pubmed23n0905_8690", "title": "Acquired Thrombotic Thrombocytopenic Purpura in a Patient with Pernicious Anemia.", "score": 0.012802327695944717, "content": "<iIntroduction</i. Acquired thrombotic thrombocytopenic purpura (TTP) has been associated with different autoimmune disorders. However, its association with pernicious anemia is rarely reported. <iCase Report</i. A 46-year-old male presented with blood in sputum and urine for one day. The vitals were stable. The physical examination was significant for icterus. Lab tests' results revealed leukocytosis, macrocytic anemia, severe thrombocytopenia, renal dysfunction, and unconjugated hyperbilirubinemia. He had an elevated LDH, low haptoglobin levels with many schistocytes, nucleated RBCs, and reticulocytes on peripheral smear. Low ADAMTS13 activity (&lt;10%) with elevated ADAMTS13 antibody clinched the diagnosis of severe acquired TTP, and plasmapheresis was started. There was an initial improvement in his hematological markers, which were however not sustained on discontinuation of plasmapheresis. For his refractory TTP, he was resumed on daily plasmapheresis and Rituximab was started. Furthermore, the initial serum Vitamin B12 and reticulocyte index were low in the presence of anti-intrinsic factor antibody. So with the concomitant diagnosis of pernicious anemia, Vitamin B12 was supplemented. The rest of the immunological workups were negative. Subsequently, his symptoms resolved and his hematological parameters improved. <iDiscussion</i. While pernicious anemia can masquerade as TTP, an actual association between the two can also occur and needs further evaluation and characterization." }, { "id": "InternalMed_Harrison_9159", "title": "InternalMed_Harrison", "score": 0.012797933544675354, "content": "TTP is a devastating disease if not diagnosed and treated promptly. In patients presenting with new thrombocytopenia, with or without evidence of renal insufficiency and other elements of classic TTP, laboratory data should be obtained to rule out DIC and to evaluate for evidence of microangiopathic hemolytic anemia. Findings to support the TTP diagnosis include an increased lactate dehydrogenase and indirect bilirubin, decreased haptoglobin, and increased reticulocyte count, with a negative direct antiglobulin test. The peripheral smear should be examined for evidence of schistocytes (Fig. 140-1D). Polychromasia is usually also present due to the increased number of young red blood cells, and nucleated RBCs are often present, which is thought to be due to infarction in the micro-circulatory system of the bone marrow." }, { "id": "InternalMed_Harrison_9127", "title": "InternalMed_Harrison", "score": 0.012698412698412698, "content": "Platelet count < 150,000/˜L Hemoglobin and white blood count Normal Abnormal Bone marrow examination Peripheral blood smear Platelets clumped: Redraw in sodium citrate or heparin Fragmented red blood cells Normal RBC morphology; platelets normal or increased in size Microangiopathic hemolytic anemias (e.g., DIC, TTP) Consider: Drug-induced thrombocytopenia Infection-induced thrombocytopenia Idiopathic immune thrombocytopenia Congenital thrombocytopenia first appear in areas of increased venous pressure, the ankles and feet in an ambulatory patient. Petechiae are pinpoint, nonblanching hemorrhages and are usually a sign of a decreased platelet number and not platelet dysfunction. Wet purpura, blood blisters that form on the oral mucosa, are thought to denote an increased risk of life-threatening hemorrhage in the thrombocytopenic patient. Excessive bruising is seen in disorders of both platelet number and function." }, { "id": "pubmed23n0319_6679", "title": "[Idiopathic thrombocytopenic purpura in children].", "score": 0.012620192307692308, "content": "Idiopathic (immune) thrombocytopenic purpura (ITP) is the most frequent hemorrhagic disease in children. It represents the acquired megakaryocytic thrombocytopenia with the shortened life of platelets because of immunologic damage (antibodies absorbed by platelets). In the case of this acquired hemorrhagic disorder, in spite of compensatory increased function of the bone marrow, there is a reduced number of platelets because of their increased destruction by the reticuloendothelial system (destructive thrombocytopenia). There are three forms of ITP: acute, chronic and intermittent. The acute form occurs in 80-90% of cases with bleeding episodes lasting a few days or weeks, but no longer than 6 months. The chronic form occurs in 10-15% of children, while the rarest-intermittent form is characterized by periods of normalization in regard to the number of platelets but also with relapse in intervals of 1-3 months. The disease is caused by an immunological disorder in the sense of an imbalanced immune response. Immunologic damages of platelets cause shortening of the opsonized platelets life span. The most frequent platelet opsonins are the immumoglobulin G (IgG) antibodies directed at the platelet membrane in the form of autoantibodies, alloantibodies or possibly absorbed antigen caused by microorganism infection or drug intake. It is typical for the phenomenon of bleeding that it starts suddenly and without any other sign of illness. The most frequent acute form appears between the second and fourth year, and is characterized by seasonal occurrence usually after acute viral infections. Children older than 10 years of age, like adults, often have the chronic form associated with other immunologic disorders. The disease affects girls more often than boys (about three times more often) with moderate and constant increase of antiplatelet antibodies. Hemorrhagic manifestations include: petechiae, purpura, epistaxis, gastrointestinal and genitourinary bleeding. They depend on the grade of thrombocytopenia, although there is no strict correlation between the number of platelets and volume of bleeding. Low mortality of the acute ITP is almost exclusively due to intracranial hemorrhage. LABORATORY STUDIES: Thrombocytopenia represents a decrease in the number of blood platelets being a basic abnormality of the blood count. The half-life of platelets in ITP is shortened. Detection of antiplatelet antibodies is connected with technical difficulties, so they are established in about 30% of cases. Bleeding time is prolonged and so is the coagulum retraction which may be completely missed. The Rumpel-Leede test is positive. Clinical differentiation of drug-induced thrombocytopenia is not possible. However, other differential diagnostic possibilities are thrombotic-thrombocytopenic purpura and hemolytic-uremic syndrome. A child with aplastic anemia or acute leukemia, beside thrombocytopenia, has a characteristic finding of white and red blood cell count. Thrombocytopenia with absent radii syndrome is associated with skeletal system abnormalities. New knowledge about the role of the immune system in ITP determines the modern therapeutic modalities. In cases of acute ITP in children, there are two therapeutic options or therapies of choice: corticosteroids and high doses of intravenous immunoglobulin. Immunosupressive therapy means anti Rh(D) immunoglobulin, cyclosporine, cytostatics, danazol, loaded platelets. In cases of distinctive hemorrhagic syndrome there are also indications for platelet transfusion. Nowadays splenectomy is more restricted, because one third of cases is unsuccessful, whereas plasmapheresis is rarely used in children because of possible complications. ITP is the most frequent hemorrhagic disease in children. The disease is basically caused by an immunologic disorder with platelet destruction due to increased immunoglobulin on their membrane. (ABSTRACT TRUNCATED)" }, { "id": "wiki20220301en022_67051", "title": "Hemolytic anemia", "score": 0.012441769624721506, "content": "suggest paroxysmal nocturnal haemoglobinuria. Direct examination of blood under a microscope in a peripheral blood smear may demonstrate red blood cell fragments called schistocytes, red blood cells that look like spheres (spherocytes), and/or red blood cells missing small pieces (bite cells). An increased number of newly made red blood cells (reticulocytes) may also be a sign of bone marrow compensation for anemia. Laboratory studies commonly used to investigate hemolytic anemia include blood tests for breakdown products of red blood cells, bilirubin and lactate dehydrogenase, a test for the free hemoglobin binding protein haptoglobin, and the direct Coombs test to evaluate antibody binding to red blood cells suggesting autoimmune hemolytic anemia." }, { "id": "First_Aid_Step2_372", "title": "First_Aid_Step2", "score": 0.012338868888630821, "content": "A clinical syndrome characterized by f ve signs/symptoms: low platelet count, microangiopathic hemolytic anemia, neurologic changes (delirium, seizure, stroke), impaired renal function, and fever. Diagnosis is largely clinical. It is rare for all signs to be present, but the presence of schistocytes (broken RBCs) on peripheral smear with low platelets and rising creatinine is highly suggestive. Nucleated RBCs are also often seen in the peripheral smear. Hemolytic anemia labs include elevated indirect bilirubin, LDH, and AST along with low haptoglobin. Coagulation factors are normal. TABLE 2.7-3. Laboratory Values in DIC Overlapping conditions are HUS, HELLP syndrome, and DIC. HUS: Characterized by renal failure, hemolytic anemia, and low platelets. Severe elevations in creatinine are more typical of HUS than of TTP. HELLP syndrome: Affects pregnant women, often occurring in conjunction with preeclampsia (see the Obstetrics chapter)." }, { "id": "pubmed23n1041_19599", "title": "Immune Thrombocytopenia Purpura Secondary to COVID-19.", "score": 0.012278353964536635, "content": "A 73-year-old female with past medical history of essential hypertension, hyperlipidemia, seasonal allergies, and chronic back pain presented to the hospital with complaints of headaches, fevers, fatigue, generalized body aches, shortness of breath, and diarrhea. Initial complete blood count was remarkable for leukopenia with an absolute lymph count of 0.60 K/µL and severe thrombocytopenia (platelet count &lt; 3 K/µL). She was tested for COVID-19 via nasopharyngeal swab polymerase chain reaction (PCR) testing and found positive. Additional labs showed an elevated D-dimer, C-reactive protein, fibrinogen, and lactate dehydrogenase. Vitamin B12 and folate levels were obtained and found to be normal. Peripheral smear showed no schistocytes or additional hematologic abnormalities apart from thrombocytopenia. The patient was transfused one unit of platelets with no improvement in platelet count. Fibrinogen count was obtained and found in normal range at 458 mg/dL. Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) were all found to be normal. Immune thrombocytopenia purpura (ITP) was suspected and intravenous immunoglobulin (IVIG) was administered at a dose of 1 g/kg/day for two doses. By day 4, the patient had marked response to treatment with platelet recovery to 105 K/µL and subsequently discharged by day 5 with complete resolution of symptoms and platelet count of 146 K/µL. Twenty-eight days after discharge, she presented to hematology clinic with platelet count of 8 K/µL. Repeat nasopharyngeal swab PCR COVID testing was negative and she was treated with IVIG and pulse dexamethasone with prompt response, confirming suspicion of underlying, undiagnosed ITP prior to COVID infection." }, { "id": "InternalMed_Harrison_9154", "title": "InternalMed_Harrison", "score": 0.011765343743222727, "content": "Thrombotic thrombocytopenic microangiopathies are a group of disorders characterized by thrombocytopenia, a microangiopathic hemolytic anemia evident by fragmented RBCs (Fig. 140-1D) and laboratory evidence of hemolysis, and microvascular thrombosis. They include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS), as well as syndromes complicating bone marrow transplantation, certain medications and infections, pregnancy, and vasculitis. In DIC, although thrombocytopenia and microangiopathy are seen, a coagulopathy predominates, with consumption of clotting factors and fibrinogen resulting in an elevated prothrombin time (PT) and often activated partial thromboplastin time (aPTT). The PT and aPTT are characteristically normal in TTP or HUS." }, { "id": "article-23385_13", "title": "Immune Thrombocytopenic Purpura -- Evaluation -- Initial Evaluation", "score": 0.01156957928802589, "content": "In ITP, the white blood count, hemoglobin concentration, red cell indices, and differential are usually normal, and the only abnormality seen is a platelet count of less than 100,000/microL. [15] If considerable blood loss has occurred, microcytic anemia can be seen on the CBC. If a patient had a recent infection, the white cell count could be high or low depending on the cause of the infection (i.e., bacterial cause showing high WBC vs. viral cause showing low WBC). The reticulocyte count is usually normal unless the patient presents with significant acute blood loss anemia. [15] On the peripheral blood smear, white and red blood cells typically have a normal appearance with a decreased number of platelets, and the platelets will be normal to increased size. [15]" }, { "id": "article-30097_9", "title": "Thrombotic Thrombocytopenic Purpura -- Evaluation", "score": 0.011199371911513416, "content": "Laboratory evaluation plays a critically important role in diagnosing TTP because signs and symptoms are variable, and end-organ damage can be delayed. For diagnosis, the laboratory data must show anemia and thrombocytopenia along with an indication of active hemolysis, such as the presence of schistocytes, increased unconjugated bilirubin, increased reticulocyte count and increased lactate dehydrogenase. [23] [24] [25] As with any hemolysis in general, the serum haptoglobin decreases as it combines with the free hemoglobin released from the destroyed erythrocytes." }, { "id": "wiki20220301en019_45579", "title": "Thrombotic thrombocytopenic purpura", "score": 0.011182959300114112, "content": "TTP is characterized by thrombotic microangiopathy (TMA), the formation of blood clots in small blood vessels throughout the body, which can lead to microangiopathic hemolytic anemia and thrombocytopenia. This characteristic is shared by two related syndromes, hemolytic-uremic syndrome (HUS) and atypical hemolytic uremic syndrome (aHUS). Consequently, differential diagnosis of these TMA-causing diseases is essential. In addition to TMA, one or more of the following symptoms may be present in each of these diseases: neurological symptoms (e.g. confusion, cerebral convulsions seizures,); kidney impairment (e.g. elevated creatinine, decreased estimated glomerular filtration rate [eGFR], abnormal urinalysis); and gastrointestinal (GI) symptoms (e.g. diarrhea nausea/vomiting, abdominal pain, gastroenteritis. Unlike HUS and aHUS, TTP is known to be caused by an acquired defect in the ADAMTS13 protein, so a lab test showing ≤5% of normal ADAMTS13 levels is indicative of TTP. ADAMTS13 levels" }, { "id": "article-17530_18", "title": "Acute Anemia -- Histopathology", "score": 0.011008811986276009, "content": "When examining a peripheral blood smear under a microscope, specific findings can provide valuable information about the underlying condition. The following are some observations related to certain types of anemia: Microangiopathic Hemolysis (TTP, ITP, HUS, DIC): In conditions characterized by microangiopathic hemolysis, such as thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenic purpura (ITP), hemolytic-uremic syndrome (HUS), and disseminated intravascular coagulation (DIC), several abnormal RBC shapes may be observed. These include helmet cells (schistocytes), fragmented RBCs, and other RBC fragments. Spherocytes (small, round RBCs lacking central pallor) can also be seen in some cases." }, { "id": "wiki20220301en218_13342", "title": "Hematologic disease", "score": 0.010868365883261613, "content": "Direct physical damage to RBCs Microangiopathic hemolytic anemia Secondary to artificial heart valve(s) Aplastic anemia Fanconi anemia Diamond–Blackfan anemia (inherited pure red cell aplasia) Acquired pure red cell aplasia Decreased numbers of cells Myelodysplastic syndrome Myelofibrosis Neutropenia (decrease in the number of neutrophils) Agranulocytosis Glanzmann's thrombasthenia Thrombocytopenia (decrease in the number of platelets) Idiopathic thrombocytopenic purpura (ITP) Thrombotic thrombocytopenic purpura (TTP) Heparin-induced thrombocytopenia (HIT) Myeloproliferative disorders (Increased numbers of cells) Polycythemia vera (increase in the number of cells in general) Erythrocytosis (increase in the number of red blood cells) Leukocytosis (increase in the number of white blood cells) Thrombocytosis (increase in the number of platelets) Myeloproliferative disorder Transient myeloproliferative disease Coagulopathies (disorders of bleeding and coagulation)" }, { "id": "InternalMed_Harrison_12756", "title": "InternalMed_Harrison", "score": 0.010734231076082488, "content": "Shiga toxin produced by S. dysenteriae type 1 has been linked countries, where enterohemorrhagic E. coli (EHEC) predominates as the etiologic agent of this syndrome. HUS is an early complication that most often develops after several days of diarrhea. Clinical examination shows pallor, asthenia, and irritability and, in some cases, bleeding of the nose and gums, oliguria, and increasing edema. HUS is a nonimmune (Coombs test–negative) hemolytic anemia defined by a diagnostic triad: microangiopathic hemolytic anemia (hemoglobin level typically <80 g/L [<8 g/dL]), thrombocytopenia (mild to moderate in severity; typically <60,000 platelets/μL), and acute renal failure due to thrombosis of the glomerular capillaries (with markedly elevated creatinine levels). Anemia is severe, with fragmented red blood cells (schizocytes) in the peripheral smear, high serum concentrations of lactate dehydrogenase and free circulating hemoglobin, and elevated reticulocyte counts. Acute renal failure occurs" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 231 ] ], "word_ranges": [ [ 0, 27 ] ], "text": "The patient presents criteria for Thrombotic Thrombocytopenic Purpura (TTP): 1. Neurological alteration. 2. Febrile syndrome (fever). 3. Coombs negative migroangiopathic hemolytic anemia (presence of schistocytes). 4. Thrombopenia." }, "3": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Autoimmune hemolytic anemia.", "2": "Thrombotic thrombocytopenic purpura.", "3": "Evans syndrome (hemolytic anemia and immune thrombopenia).", "4": "Idiopathic immune thrombocytopenia.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0719_4304", "title": "Pseudo-thrombotic thrombocytopenic purpura: A rare presentation of pernicious anemia.", "score": 0.019232547387887194, "content": "Schistocytes are fragmented red blood cells due to the flow of blood through damaged capillaries and indicate endothelial injury. They are typical of microangiopathic hemolytic anemia seen in life threatening conditions like disseminated intravascular coagulation or thrombotic thrombocytopenic purpura/hemolytic uremic syndrome .We report a rare sub-acute presentation of pernicious anemia with hemolysis, thrombocytopenia and numerous schistocytes that was initially diagnosed as a more serious thrombotic thrombocytopenic purpura. A 31-year-old Caucasian woman presented with fatigue and paresthesia of both feet for 1 week. Past medical history included hypertension and gastro-esophageal reflux disease. Examination revealed scleral icterus and pallor. Examination of the abdomen did not show hepatosplenomegaly. Initial laboratory tests showed severe anemia, and low platelets. Indirect bilirubin and serum Lactate De Hydrogenase were elevated. Prothrombin time, partial thromboplastin time, serum fibrinogen, and serum fibrin degradation product levels were normal. Peripheral smear revealed numerous schistocytes, anisocytosis and macro-ovalocytes. Thrombotic thrombocytopenic purpura (TTP) was suspected due to the constellation of sub-acute onset of fatigue and paresthesia along with thrombocytopenia, schistocytes and an elevated LDH. Plasmapheresis was initiated for possible TTP. However, platelet count worsened despite plasmapheresis for 4 days. On re-evaluation, vitamin B(12) was found to be low. Treatment with intra-muscular vitamin B(12) led to symptomatic and hematologic improvement. Pernicious anemia was confirmed by the presence of anti-intrinsic factor antibodies, elevated serum gastrin level and atrophic gastritis. Clinicians must be aware of unusual clinical presentation of vitamin B(12) deficiency with schistocytes as the management is simple and effective." }, { "id": "pubmed23n0282_16640", "title": "[An elderly case of thrombotic thrombocytopenic purpura].", "score": 0.016993188680570183, "content": "A 78-year-old woman was admitted to our hospital because of disorientation and fever on January 21, 1992. Two days before admission she experienced vomiting, anorexia and general malaise. Laboratory examinations on admission disclosed a hemoglobin level of 11.1 g/dl and a platelet count of 8,000/microliters. The peripheral blood smear revealed anisocytosis with numerous schistocytes and poikilocytes. Polychromatophilic and nucleated red blood cells were also seen, and the reticulocyte count was 38/1000. Her serum lactate dehydrogenase (LDH) value was 2,977 WU and the total serum bilirubin level was 3.5 mg/dl with 2.7 mg/dl indirect reacting fraction. Serum creatinine was 4.7 mg/dl. Her consciousness became semicomatose after a systemic seizure which lasted approximately 15 seconds and her hemoglobin level decreased to 8.5 g/dl on hospital day 2. Therefore, we diagnosed her as having thrombotic thrombocytopenic purpura (TTP) because of the presence of all 5 features, that is, thrombocytopenia, microangiopathic hemolytic anemia, fluctuating neurologic abnormalities, renal dysfunction and fever. A plasmapheresis with fresh frozen plasma (FFP) replacement was begun on that day. She was also treated with anti-platelet agents, 80 mg/day aspirin, and 300 mg/day dipyridamole. Moreover, packed red blood cells (PRC) were infused. While also receiving diphenylhydantoin and phenobarbital to prevent convulsions, status epilepticus developed on day 3. Because of inhibited spontaneous respiration which was an adverse effect derived from diazepam and sodium thiamylal administered intravenously to treat the status epilepticus, an artificial respiration was initiated.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0681_21394", "title": "[Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure, mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case].", "score": 0.01625538582060321, "content": "Disseminated intravascular coagulopathy (DIC) is characterized as activation of the clotting system resulting in fibrin thrombi, gradually diminishing levels of clotting factors with increased risk of bleeding. Basically two types of DIC are distinguished: (1) chronic (compensated) - with alteration of laboratory values and (2) acute (non-compensated) - with severe clinical manifestations: bleeding, shock, acute renal failure (ARF), transient focal neurologic deficit, delirium or coma. Chronic DIC related to metastatic neoplasia is caused by pancreatic, gastric or prostatic carcinoma in most of the cases. Incidence rate of DIC is 13-30% in prostate cancer, among those only 0.4-1.65% of patients had clinical signs and symptoms of DIC. In other words, chronic DIC is developed in one of eight patients with prostate cancer. DIC is considered as a poor prognostic factor in prostatic carcinoma. The similar clinical and laboratory findings of TTP-HUS (thrombotic thrombocytopenic purpura - hemolytic uremic syndrome) and DIC makes it difficult to differentiate between them. A 71 years old male patient with known chronic obstructive pulmonary disease, benign prostatic hyperplasia, significant carotid artery stenosis, gastric ulcer and alcoholic liver disease was admitted to another hospital with melena. Gastroscopy revealed intact gastric mucosa and actually non-bleeding duodenal ulcer covered by clots. Laboratory results showed hyperkalemia, elevated kidney function tests, indirect hyperbilirubinemia, increased liver function tests, leukocytosis, anemia, thrombocytopenia and elevated international normalized ratio (INR). He was treated with saline infusions, four units of red blood cells and one unit of fresh frozen plasma transfusions. Four days later he was transported to our Institution with ARF. Physical examination revealed dyspnoe, petechiae, hemoptoe, oliguria, chest-wall pain and aggressive behavior. Thrombocytopenia, signs of MAHA (fragmentocytes and helmet cells in the peripheral blood), normal INR, elevated lactate dehydrogenase (LDH) and ARF suggested TTP-HUS. Hemodialysis and six plasmaferesis (PF) were carried out. After the fifth PF, skin manifestations of thrombotic microangiopathy occurred on the feet. Clotting analysis revealed elevated D-dimer (&gt;5 μg/mL), normal fibrinogen (3.2 g/L), a slightly raised INR (1.36) and activated partial prothrombin time (APTT) (45.8 sec), normal reticulocyte (57 G/L) and a slightly low platelet count (123 G/L), which proved to be chronic DIC. Therapeutic dose of low-molecular-weight heparin (LMWH) was started. Elevated prostate-specific antigen (PSA) (109.6 ng/mL) suggested prostatic carcinoma. Prostate biopsy revealed adenocarcinoma (Gleason: 4+4 for left lobe and 3+3 for right lobe). Elevated alkaline phosphatase suggested metastases in the bone, which were confirmed by bone scintigraphy. Combined androgen blockade (CAB) was started. After three months follow-up our patient's status is satisfactory. PSA is in the normal range (4.6 ng/mL). Thrombocytopenia of uncertain origin with normal or raised INR, APTT, elevated D-dimer, normal fibrinogen and reticulocyte count prove the diagnosis of chronic DIC. This process warrants searching for metastatic neoplasia. Due to the relatively low serum levels of circulating procoagulant factors (e.g. tissue factor), therapeutic dose of LMWH can be used with good efficiency in chronic DIC with low risk of bleeding. Severe DIC as a complication of metastatic prostate cancer can be treated by androgen deprivation therapy (ADT) or CAB in combination with ketokonazole and concomitant use of supportive treatment. Deme D, Ragán M, Kovács L, Kalmár K, Varga E, Varga T, Rakonczai E. Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case." }, { "id": "pubmed23n0322_1104", "title": "[Hemolytic anemia and thrombocytopenia associated with anti-omeprazole antibody].", "score": 0.01560631427888065, "content": "An 80-year-old woman was admitted with anemia, jaundice and a bleeding tendency about 5 weeks after starting omeprazole. On admission, the hemoglobin was 6.4 g/dl, platelets 0.1 x 10(4)/microliter, leukocyte count 7,500/microliter, and reticulocyte count 325/1000. The total bilirubin was 1.9 mg/dl, indirect bilirubin 0.6 mg/dl, lactate dehydrogenase 572 IU/l, and haptoglobin &lt; 10 mg/dl. Both the direct and the indirect Coombs' tests were positive. The platelet-associated IgG (PAIgG) was 1,100.0 ng/10(7) cells. A decrease in the complement value was observed. There was an increase in the number of megakaryocytes and erythroblasts in the marrow film. After omeprazole administration was halted, her hemoglobin and platelet levels gradually returned to normal. On the 27th hospital day, the direct Coombs' test was positive but the indirect Coombs' test became negative. The PAIgG value also returned to normal, and she was discharged on the 59th hospital day. The acute phase of the drug-induced lymphocyte stimulation test was negative, however, we detected the IgG antibody to omeprazole. In the recovery phase, the IgG value decreased. Forty days after discharge, the direct Coombs' test had become negative. This is apparently the first report of a patient with acute hemolytic anemia and thrombocytopenia due to omeprazole through an immune complex mechanism." }, { "id": "pubmed23n0297_3204", "title": "[Autoimmune hemolytic anemia with eosinophilia in elderly patient].", "score": 0.015169525103299938, "content": "A 70-year-old woman was admitted to our hospital in November 1992 for evaluation of anemia. Physical examination revealed anemia, jaundice, swelling of axial and inguinal lymph nodes, and splenomegaly. Abnormal hematological findings were as follows: Hb of 3.9 g/dl, reticulocyte count of 58.2% (61.7 x 10(4)/microliters), hyperplasia of normal erythroblasts in bone marrow, and eosinophilia (21.0%, 2352/microliters) in peripheral blood. Routine laboratory examinations revealed polycolonal hypergammaglobulinemia 3.0 g/dl, a high level of serum LDH (797 IU/I) and a total bilirubin of 2.4 mg/dl (indirect, 1.6 mg/dl). The serum haptoglobin level was very low (&lt; 5 mg/dl). Results of serological examinations were as follows: IgG of 3366 mg/dl, CH50 of 16.0 U/ml, positive Coombs test 2+, and positive tests for antinuclear antibody, rheumatoid factor, and cold agglutinin. CRP was negative. PHA-stimulated lymphocyte blast formation, NK activity, and ADCC activity were found to be suppressed, and the percentage of CD4-positive lymphocytes in peripheral blood was also low. An axillary lymph node biopsy revealed reactive lymphadenitis. No signs or history suggested allergy, collagen disease, or parasitic infection. Autoimmune hemolytic anemia (AIHA) complicated by immunologic abnormalities and eosinophilia was diagnosed. Oral prednisolone markedly reduced the hemolytic anemia, eosinophilia, lymph node swelling, and splenomegaly, but NK activity remained low." }, { "id": "pubmed23n1041_14942", "title": "Et Tu, B12? Cobalamin Deficiency Masquerading As Pseudo-Thrombotic Microangiopathy.", "score": 0.015043290043290043, "content": "Vitamin B12 deficiency is classically associated with megaloblastic anemia. Possible cobalamin deficiency is not investigated once hemolysis is seen. Around 2.5% of cases can present as pseudo-thrombotic microangiopathy (TMA). A swift identification of this means the difference between an easy solution and a protracted one for the patient. A 74-year-old man with no past medical history presented with exertional dyspnea, fatigue, and increasing anorexia over two weeks. Physical examination including a neurological examination was normal. Laboratory tests revealed pancytopenia, unconjugated hyperbilirubinemia, elevated LDH (lactate dehydrogenase), low haptoglobin, and fragmented red blood cells (RBCs) on the peripheral smear, but normal FDP (fibrinogen degradation product) and fibrinogen. The absolute reticulocyte count was reduced as opposed to the expected elevation. Vitamin B12 levels were undetectable, and severe cobalamin deficiency from pernicious anemia was found to be the paramount etiology. Cobalamin deficiency causing pseudo-TMA baffles most physicians. Advanced pernicious anemia is thought to cause intramedullary hemolysis, resulting in peripheral pancytopenia. The fragile RBCs are easily sheared, producing schistocytosis without platelet microthrombi. In contrast to hemolytic anemias, reticulocyte count is low given the unavailability of B12 for erythropoiesis. Reticulocytopenia is a universal finding in cases of pseudo-TMA. Around 38.8% of cases with pseudo-TMA are misdiagnosed as thrombotic thrombocytopenic purpura and treated with plasma product therapy. Keeping an eye out for reticulocytopenia in cases of hemolysis could mean a world of difference for the patient." }, { "id": "wiki20220301en085_21868", "title": "Thrombotic microangiopathy", "score": 0.014718614718614718, "content": "Diagnosis CBC and blood film: decreased platelets and schistocytes PT, aPTT, fibrinogen: normal markers of hemolysis: increased unconjugated bilirubin, increased LDH, decreased haptoglobin negative Coombs test. Creatinine, urea, to follow renal function ADAMSTS-13 gene, activity or inhibitor testing (TTP)." }, { "id": "wiki20220301en046_51369", "title": "Schistocyte", "score": 0.014284272158287906, "content": "Schistocyte count A normal schistocyte count for a healthy individual is <0.5% although usual values are found to be <0.2%. A schistocyte count of >1% is most often found in thrombotic thrombocytopenic purpura, although they are more often seen within the range of 3–10% for this condition. A schistocyte count of <1% but greater than the normal value is suggestive of disseminated intravascular coagulation, but is not an absolute diagnosis. The standard for a schistocyte count is a microscopic examination of a peripheral blood smear." }, { "id": "pubmed23n1042_13774", "title": "Thrombotic Thrombocytopenic Purpura: Revisiting a Miss and an Inevitable Consequence.", "score": 0.014256722475900558, "content": "Thrombotic thrombocytopenic purpura (TTP) is typically characterized by the symptomatic pentad of fever, thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, and renal failure. Atypical TTP is the diagnosis used to describe the subset of patients with TTP who present with symptoms that deviate from the classic pentad. We report a case an 86-year-old woman who presented to the emergency department complaining of chest pain for one day. She was reportedly on antibiotics for sinus infection. Physical examination revealed multiple bilateral superficial hematomas, predominantly on her extremities. On admission, her lab values were as follows: platelet count of 6,000/cubic millimeter, hemoglobin of 10.4 grams/deciliter, leukocyte count of 5100 cells/cubic millimeter, total bilirubin of 2.3 milligrams/deciliter, and troponin-I of 5.190 nanograms/milliliter. Peripheral blood smear was normal and did not reveal any schistocytes. The patient was admitted to the intensive care unit with a diagnosis of a non-ST-elevation myocardial infarction and a presumed diagnosis of immune thrombocytopenic purpura from antibiotic use. She was treated with intravenous solumedrol and a high-intensity statin. On the third day of her admission, the patient's mental functioning deteriorated and was intubated to protect her airway. A second peripheral smear revealed schistocytes, and subsequent laboratory studies supported the diagnosis of TTP. Plasma exchange therapy was planned. However, the patient succumbed to cardiac arrest before it could be initiated. The diagnosis was later confirmed with an ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) assay.  This case serves as an example of one of the many ways in which TTP can present, and emphasizes the importance of considering TTP as a differential diagnosis." }, { "id": "pubmed23n0709_10292", "title": "[Hemolytic anemias in adults].", "score": 0.014225816112608565, "content": "The erythrocyte lifespan in haemolytic anemia is shortened while erythropoesis is increased. Important labaratory findings are increased reticulocytes, LDH, indirect bilirubin and a decreased haptoglobin level. The most important diagnostic tool for further work up of hemolytic anemia is the direct antiglobulin test (DAT, Coombs test) to differentiate autoimmune hemolytic anemia (AIHA) from other causes. Another important group are fragmentation syndroms (hemolytic uremic syndrome and thrombotic thrombocytopenic purpura). In these forms of haemolytic anemia fragmented red blood cells can be found in the blood smear together with thrombocytopenia. A severe problem in paroxysmal nocturnal hematuria is the incidence of thrombosis. The following review describes the most important forms of hemolytic anemia in the adult and the diagnostic and therapeutic strategies." }, { "id": "pubmed23n0516_2225", "title": "Thrombotic thrombocytopenic purpura without schistocytes on the peripheral blood smear.", "score": 0.01412512218963832, "content": "A hallmark of the clinical syndrome of thrombotic thrombocytopenic purpura (TTP) is evidence of microangiopathic hemolytic anemia. The presence of schistocytes on the peripheral blood smear, elevated plasma lactic dehydrogenase, and decreased haptoglobin concentration are used as evidence of microangiopathic hemolytic anemia to make a diagnosis of TTP. This report describes a case of recurrence of TTP in the absence of schistocytes in the peripheral blood smear during the recurrent episode. Although careful attention should be paid to microscopic examination of a blood smear in any patient presenting with acute renal failure and thrombocytopenia, this case emphasizes the need to consider TTP-hemolytic uremic syndrome in the differential diagnosis, even in the absence of peripheral schistocytosis." }, { "id": "pubmed23n0282_20398", "title": "[Emergency blood picture].", "score": 0.01401243424198948, "content": "Assessment of peripheral blood counts and blood film analysis are frequently performed as diagnostic procedures in emergency medicine. Far fewer situations exist, however, in which these analyses are the main clue in establishing an emergency diagnosis. Artifacts can lead to wrong diagnosis, e.g. pseudo-thrombocytopenia, which is defined as a low platelet count resulting from a laboratory artifact. Severe neutropenia (agranulocytosis) and extreme hyperleukocytosis, as well as suspicion of acute leukemia, require a rapid diagnostic work-up. A newly detected anemia should not necessarily be treated by packed red cell transfusions. The decision whether an anemic patient ought to receive transfusions should be based on the speed with which the anemia has developed, as well as on clinical judgement. As a rule a chronic anemia patient with hemoglobin above 70 g/l does not need transfusions. An uncritical transfusion policy can even cause emergencies, e.g. in patients with megaloblastic anemia or in anemic multiple myeloma patients with a hyperviscosity syndrome. An elevated hematocrit requires prompt further investigations. This is of utmost importance if one considers the diagnosis of polycythemia vera rubra, a disease in which patients are particularly prone to thrombotic complications. Fragmented red cells (schistocytes) on peripheral blood smears constitute a cardinal diagnostic clue for the detection of microangiopathic hemolytic anemias (MAHA), in particular for the diagnosis of the life-threatening thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Malaria is another example for a chief role of blood smears examination in achieving a rapid diagnosis. If one encounters an unexpected severe thrombocytopenia, a marrow examination reveals whether it is due to rapid peripheral destruction, or due to a marrow failure. Furthermore, in any patients with an unanticipated thrombocytopenia, a disseminated intravascular coagulation and a MAHA should be ruled out. Heparin-induced thrombocytopenia is a rare, but possibly fatal complication of therapy with heparins." }, { "id": "pubmed23n0059_11730", "title": "[Thrombotic thrombocytopenic pupura (TTP)--remission following treatment with high-dose immunoglobulin].", "score": 0.013844974609562135, "content": "A 60-year-old man was admitted to our hospital because of fever, hemorrhagic tendency, anemia and neurological abnormality. A blood count revealed that the hemoglobin was 6.8 g/dl, the reticulocyte was 17.3 percent with 2 erythroblasts per 100 white cells, the white cell count was 7,100/microliters and the platelet count was 0.8 x 10(4)/microliters. Peripheral blood smear demonstrated marked fragmentation of red cells. Bone marrow examination disclosed the marked erythroid hyperplasia. Although the bleeding time was prolonged (14 minutes 30 seconds), the other hemostatic data were within normal limits. The serum bilirubin level was 1.57 mg/dl; LDH level, 1,437 U/l; creatinine level, 0.92 mg/dl; BUN level 14.7 mg/dl. Haptoglobin was below 10 mg/dl. Results of immunological tests were all negative except the result of PAIgG (576.6 ng/10(7) cells). The urinalysis showed proteinuria, microhematuria and trace granular and hyaline casts. A diagnosis of thrombotic thrombocytopenic purpura was made. The patient was initially treated with prednisolone (60 mg), aspirin (1,000 mg), dipyridamole (150 mg), gabexate mesilate (1.5 g), sodium oxagrel (80 mg) daily with little response. The thirty days after admission, infusion of gamma globulin (20 g, daily) was given for 3 days. The clinical state and laboratory findings became dramatically improved shortly after the administration of gamma globulin and the laboratory data came to be normalized after 1 month. After ten months of this treatment, the patient is remained asymptomatic and the hematological data are within normal range without using any drug. A trial seems justified to confirm the value of this mode of therapy." }, { "id": "pubmed23n0509_8196", "title": "Frequency and significance of schistocytes in TTP/HUS patients at the discontinuation of plasma exchange therapy.", "score": 0.013836596385542169, "content": "Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) is characterized by thrombocytopenia, a microangiopathic hemolytic anemia (presence of schistocytes) and elevated LDH without another likely explanation. Standard of care is daily plasma exchange, which is typically discontinued when the platelet count exceeds 100-150 x 10(9)/L for 2 days. However, residual schistocytosis, the presence of schistocytes at the time of discontinuation of plasma exchange therapy, is often disconcerting. We evaluated the frequency and significance of residual schistocytosis in TTP/HUS patients when the patients' platelet counts returned to normal levels (e.g., 100-150 x 10(9)/L). Retrospective review in our institution from 01/1999-03/2004 of all patients treated with plasma exchange for TTP/HUS with at least 2 months of follow-up for relapse was completed. Patients were excluded if the clinical course was complicated by HIV, stem cell/bone marrow and solid organ transplant, pregnancy and auto-immune disease. Schistocytes were documented on day of presentation and on the day the platelet count reached 150 x 10(9)/L. Grading scale (using 100 x objective-a high power field, with approximately 100 red blood cells per field) for schistocytes was as follows: rare for 1 schistocyte per every other other field, 1+ for 1-5%, 2+ for 6-15%, and 3+ for &gt;15%. The frequency of schistocytes was compared to frequency of relapse within 2 months, using Fisher's exact test. We identified 57 patients with TTP/HUS who received plasma exchange therapy. Of these patients, 12 did not have a follow-up microscopic examination of a peripheral blood smear at discontinuation of plasma exchange therapy and were excluded from further analysis. Of the remaining 45 patients, 16 had residual schistocytosis (35.6%). There was no statistically significant difference in relapse rate with or without residual schistocytosis (P = 1.00, Fisher's Exact test, 2 sided). In this study, we found that the presence of residual schistocytosis is common (35.6%). The presence of residual schistocytosis, however, was not predictive of relapse." }, { "id": "pubmed23n1108_5666", "title": "Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19.", "score": 0.013680926916221033, "content": "In this case report, we report a pediatric patient with COVID-19 and atypical hemolytic uremic syndrome (aHUS). A 3-year-old girl with fever and respiratory distress was admitted to the hospital. The patient tested positive for COVID-19 by a PCR test. As her respiratory distress increased and blood gas indicated deep respiratory acidosis on the third day of the pediatric intensive care unit follow-up, the patient was intubated and ventilated. Thorax computerized tomography (CT) showed bilateral effusion and atelectasis. During her follow-up, the pleural effusion resolved but there were marked consolidation areas and ground glass opacities compatible with COVID-19 on the follow-up CT. On the 10th day, she became anuric and developed progressive thrombocytopenia and persistent microangiopathic hemolytic anemia, which were suggestive of HUS given a high creatinine level (1.9 mg/dl), an undetectable haptoglobin level, reticulocytosis (8%), and an LDH level of 2540 U/l. Direct Coombs test returned negative. Examination of a peripheral blood smear revealed schistocytes. Disseminated intravascular coagulation was ruled out by normal INR and PTT. In the light of the available findings, we considered the patient to have thrombotic microangiopathy (TMA) triggered by COVID-19. It was not a TTP-form of TMA but rather an aHUS type, based on an ADAMTS13 activity level &gt;5%. Hence, plasmapheresis was performed with fresh frozen plasma (FFP). After 4 weeks, she became completely asymptomatic, and her hemodynamic parameters normalized. COVID-19 induced uncontrolled complement activation leading to the development of aHUS. Early diagnosis and treatment may reduce morbidity and mortality since its treatment options." }, { "id": "wiki20220301en435_34729", "title": "Upshaw–Schulman syndrome", "score": 0.013498112401168175, "content": "Diagnosis A diagnosis of TTP is based on the clinical symptoms with the concomitant presence of thrombocytopenia (platelet count below 100×109/L) and microangiopathic hemolytic anemia with schistocytes on the blood smear, a negative direct antiglobulin test (Coombs test), elevated levels of hemolysis markers (such as total bilirubin, LDH, free hemoglobin, and an unmeasurable haptoglobin), after exclusion of any other apparent cause. USS can present similar to the following diseases, which have to be excluded: fulminant infections, disseminated intravascular coagulation, autoimmune hemolytic anemia, Evans syndrome, the typical and atypical form of hemolytic uremic syndrome, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, pre-eclampsia, heparin-induced thrombocytopenia, cancer that is often accompanied with metastasis, kidney injury, antiphospholipid antibody syndrome, and side effects from hematopoietic stem cell transplantation." }, { "id": "pubmed23n1085_17745", "title": "[Recurrent thrombocytopenia with hemolytic anemia in a boy aged 3 years].", "score": 0.013312852022529442, "content": "A boy, aged 3 years and 8 months, had recurrent thrombocytopenia with hemolytic anemia for more than 3 years. The physical examination showed no enlargement of the liver, spleen, and lymph nodes or finger deformities. Laboratory results showed a negative result of the direct antiglobulin test, normal coagulation function, and increases in bilirubin, lactate dehydrogenase and reticulocytes. The results of von Willebrand factor-cleaving protease ADAMTS13 activity assay showed extreme deficiency, and antibody assay showed negative ADAMTS13 inhibitory autoantibodies. Next-generation sequence showed compound heterozygous mutation in the <iADAMTS13</i gene. The boy was diagnosed with congenital thrombotic thrombocytopenic purpura. This disease may be easily misdiagnosed as Evans syndrome and is difficult to diagnose in clinical practice. The child had developed the disease since birth, but it took 3 years to make a confirmed diagnosis. Therefore, congenital thrombotic thrombocytopenic purpura should be considered for children with jaundice at birth, recurrent thrombocytopenia with hemolytic anemia, and negative results of the direct antiglobulin test. The detection of ADAMTS13 activity and ADAMTS13 inhibitory autoantibodies should be performed as soon as possible for a definite diagnosis, and gene detection should be performed to make a confirmed diagnosis when necessary." }, { "id": "pubmed23n0736_22209", "title": "[Successful delivery following treatment with plasma exchange in a female patient with thrombotic thrombocytopenic purpura].", "score": 0.012891556992226584, "content": "We report here on a case of a 27-year-old woman in her first pregnancy. She was diagnosed with idiopathic thrombocytopenic purpura (ITP) at the age of 14 years. At 36 weeks of gestation, she was admitted to our hospital due to thrombocytopenia. We initially suspected ITP exacerbated by pregnancy. Laboratory results revealed mild anemia, thrombocytopenia (5.0×10(9)/l), and slightly elevated liver enzymes and lactate dehydrogenase. The next day, hemoglobin fell to 6.6 g/dl. Thrombotic thrombocytopenic purpura (TTP) was suspected on the basis of hemolytic anemia with schistocytes and a negative Coombs' test. Plasma exchange and methylprednisolone were initiated immediately. ADAMTS13 analysis showed a severe deficiency in ADAMTS13 activity but no inhibitors. At Day 6, the platelet count rose to 223×10(9)/l and she delivered a live baby by cesarean section. Currently, the patient receives fresh frozen plasma infusions every 2 weeks due to suspected Upshaw-Schulman syndrome." }, { "id": "pubmed23n0905_8690", "title": "Acquired Thrombotic Thrombocytopenic Purpura in a Patient with Pernicious Anemia.", "score": 0.012802327695944717, "content": "<iIntroduction</i. Acquired thrombotic thrombocytopenic purpura (TTP) has been associated with different autoimmune disorders. However, its association with pernicious anemia is rarely reported. <iCase Report</i. A 46-year-old male presented with blood in sputum and urine for one day. The vitals were stable. The physical examination was significant for icterus. Lab tests' results revealed leukocytosis, macrocytic anemia, severe thrombocytopenia, renal dysfunction, and unconjugated hyperbilirubinemia. He had an elevated LDH, low haptoglobin levels with many schistocytes, nucleated RBCs, and reticulocytes on peripheral smear. Low ADAMTS13 activity (&lt;10%) with elevated ADAMTS13 antibody clinched the diagnosis of severe acquired TTP, and plasmapheresis was started. There was an initial improvement in his hematological markers, which were however not sustained on discontinuation of plasmapheresis. For his refractory TTP, he was resumed on daily plasmapheresis and Rituximab was started. Furthermore, the initial serum Vitamin B12 and reticulocyte index were low in the presence of anti-intrinsic factor antibody. So with the concomitant diagnosis of pernicious anemia, Vitamin B12 was supplemented. The rest of the immunological workups were negative. Subsequently, his symptoms resolved and his hematological parameters improved. <iDiscussion</i. While pernicious anemia can masquerade as TTP, an actual association between the two can also occur and needs further evaluation and characterization." }, { "id": "InternalMed_Harrison_9159", "title": "InternalMed_Harrison", "score": 0.012797933544675354, "content": "TTP is a devastating disease if not diagnosed and treated promptly. In patients presenting with new thrombocytopenia, with or without evidence of renal insufficiency and other elements of classic TTP, laboratory data should be obtained to rule out DIC and to evaluate for evidence of microangiopathic hemolytic anemia. Findings to support the TTP diagnosis include an increased lactate dehydrogenase and indirect bilirubin, decreased haptoglobin, and increased reticulocyte count, with a negative direct antiglobulin test. The peripheral smear should be examined for evidence of schistocytes (Fig. 140-1D). Polychromasia is usually also present due to the increased number of young red blood cells, and nucleated RBCs are often present, which is thought to be due to infarction in the micro-circulatory system of the bone marrow." }, { "id": "InternalMed_Harrison_9127", "title": "InternalMed_Harrison", "score": 0.012608565438754119, "content": "Platelet count < 150,000/˜L Hemoglobin and white blood count Normal Abnormal Bone marrow examination Peripheral blood smear Platelets clumped: Redraw in sodium citrate or heparin Fragmented red blood cells Normal RBC morphology; platelets normal or increased in size Microangiopathic hemolytic anemias (e.g., DIC, TTP) Consider: Drug-induced thrombocytopenia Infection-induced thrombocytopenia Idiopathic immune thrombocytopenia Congenital thrombocytopenia first appear in areas of increased venous pressure, the ankles and feet in an ambulatory patient. Petechiae are pinpoint, nonblanching hemorrhages and are usually a sign of a decreased platelet number and not platelet dysfunction. Wet purpura, blood blisters that form on the oral mucosa, are thought to denote an increased risk of life-threatening hemorrhage in the thrombocytopenic patient. Excessive bruising is seen in disorders of both platelet number and function." }, { "id": "pubmed23n0319_6679", "title": "[Idiopathic thrombocytopenic purpura in children].", "score": 0.012559630292188432, "content": "Idiopathic (immune) thrombocytopenic purpura (ITP) is the most frequent hemorrhagic disease in children. It represents the acquired megakaryocytic thrombocytopenia with the shortened life of platelets because of immunologic damage (antibodies absorbed by platelets). In the case of this acquired hemorrhagic disorder, in spite of compensatory increased function of the bone marrow, there is a reduced number of platelets because of their increased destruction by the reticuloendothelial system (destructive thrombocytopenia). There are three forms of ITP: acute, chronic and intermittent. The acute form occurs in 80-90% of cases with bleeding episodes lasting a few days or weeks, but no longer than 6 months. The chronic form occurs in 10-15% of children, while the rarest-intermittent form is characterized by periods of normalization in regard to the number of platelets but also with relapse in intervals of 1-3 months. The disease is caused by an immunological disorder in the sense of an imbalanced immune response. Immunologic damages of platelets cause shortening of the opsonized platelets life span. The most frequent platelet opsonins are the immumoglobulin G (IgG) antibodies directed at the platelet membrane in the form of autoantibodies, alloantibodies or possibly absorbed antigen caused by microorganism infection or drug intake. It is typical for the phenomenon of bleeding that it starts suddenly and without any other sign of illness. The most frequent acute form appears between the second and fourth year, and is characterized by seasonal occurrence usually after acute viral infections. Children older than 10 years of age, like adults, often have the chronic form associated with other immunologic disorders. The disease affects girls more often than boys (about three times more often) with moderate and constant increase of antiplatelet antibodies. Hemorrhagic manifestations include: petechiae, purpura, epistaxis, gastrointestinal and genitourinary bleeding. They depend on the grade of thrombocytopenia, although there is no strict correlation between the number of platelets and volume of bleeding. Low mortality of the acute ITP is almost exclusively due to intracranial hemorrhage. LABORATORY STUDIES: Thrombocytopenia represents a decrease in the number of blood platelets being a basic abnormality of the blood count. The half-life of platelets in ITP is shortened. Detection of antiplatelet antibodies is connected with technical difficulties, so they are established in about 30% of cases. Bleeding time is prolonged and so is the coagulum retraction which may be completely missed. The Rumpel-Leede test is positive. Clinical differentiation of drug-induced thrombocytopenia is not possible. However, other differential diagnostic possibilities are thrombotic-thrombocytopenic purpura and hemolytic-uremic syndrome. A child with aplastic anemia or acute leukemia, beside thrombocytopenia, has a characteristic finding of white and red blood cell count. Thrombocytopenia with absent radii syndrome is associated with skeletal system abnormalities. New knowledge about the role of the immune system in ITP determines the modern therapeutic modalities. In cases of acute ITP in children, there are two therapeutic options or therapies of choice: corticosteroids and high doses of intravenous immunoglobulin. Immunosupressive therapy means anti Rh(D) immunoglobulin, cyclosporine, cytostatics, danazol, loaded platelets. In cases of distinctive hemorrhagic syndrome there are also indications for platelet transfusion. Nowadays splenectomy is more restricted, because one third of cases is unsuccessful, whereas plasmapheresis is rarely used in children because of possible complications. ITP is the most frequent hemorrhagic disease in children. The disease is basically caused by an immunologic disorder with platelet destruction due to increased immunoglobulin on their membrane. (ABSTRACT TRUNCATED)" }, { "id": "wiki20220301en022_67051", "title": "Hemolytic anemia", "score": 0.01242271746944644, "content": "suggest paroxysmal nocturnal haemoglobinuria. Direct examination of blood under a microscope in a peripheral blood smear may demonstrate red blood cell fragments called schistocytes, red blood cells that look like spheres (spherocytes), and/or red blood cells missing small pieces (bite cells). An increased number of newly made red blood cells (reticulocytes) may also be a sign of bone marrow compensation for anemia. Laboratory studies commonly used to investigate hemolytic anemia include blood tests for breakdown products of red blood cells, bilirubin and lactate dehydrogenase, a test for the free hemoglobin binding protein haptoglobin, and the direct Coombs test to evaluate antibody binding to red blood cells suggesting autoimmune hemolytic anemia." }, { "id": "pubmed23n1041_19599", "title": "Immune Thrombocytopenia Purpura Secondary to COVID-19.", "score": 0.01234609546297858, "content": "A 73-year-old female with past medical history of essential hypertension, hyperlipidemia, seasonal allergies, and chronic back pain presented to the hospital with complaints of headaches, fevers, fatigue, generalized body aches, shortness of breath, and diarrhea. Initial complete blood count was remarkable for leukopenia with an absolute lymph count of 0.60 K/µL and severe thrombocytopenia (platelet count &lt; 3 K/µL). She was tested for COVID-19 via nasopharyngeal swab polymerase chain reaction (PCR) testing and found positive. Additional labs showed an elevated D-dimer, C-reactive protein, fibrinogen, and lactate dehydrogenase. Vitamin B12 and folate levels were obtained and found to be normal. Peripheral smear showed no schistocytes or additional hematologic abnormalities apart from thrombocytopenia. The patient was transfused one unit of platelets with no improvement in platelet count. Fibrinogen count was obtained and found in normal range at 458 mg/dL. Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) were all found to be normal. Immune thrombocytopenia purpura (ITP) was suspected and intravenous immunoglobulin (IVIG) was administered at a dose of 1 g/kg/day for two doses. By day 4, the patient had marked response to treatment with platelet recovery to 105 K/µL and subsequently discharged by day 5 with complete resolution of symptoms and platelet count of 146 K/µL. Twenty-eight days after discharge, she presented to hematology clinic with platelet count of 8 K/µL. Repeat nasopharyngeal swab PCR COVID testing was negative and she was treated with IVIG and pulse dexamethasone with prompt response, confirming suspicion of underlying, undiagnosed ITP prior to COVID infection." }, { "id": "First_Aid_Step2_372", "title": "First_Aid_Step2", "score": 0.012338868888630821, "content": "A clinical syndrome characterized by f ve signs/symptoms: low platelet count, microangiopathic hemolytic anemia, neurologic changes (delirium, seizure, stroke), impaired renal function, and fever. Diagnosis is largely clinical. It is rare for all signs to be present, but the presence of schistocytes (broken RBCs) on peripheral smear with low platelets and rising creatinine is highly suggestive. Nucleated RBCs are also often seen in the peripheral smear. Hemolytic anemia labs include elevated indirect bilirubin, LDH, and AST along with low haptoglobin. Coagulation factors are normal. TABLE 2.7-3. Laboratory Values in DIC Overlapping conditions are HUS, HELLP syndrome, and DIC. HUS: Characterized by renal failure, hemolytic anemia, and low platelets. Severe elevations in creatinine are more typical of HUS than of TTP. HELLP syndrome: Affects pregnant women, often occurring in conjunction with preeclampsia (see the Obstetrics chapter)." }, { "id": "InternalMed_Harrison_9154", "title": "InternalMed_Harrison", "score": 0.011765343743222727, "content": "Thrombotic thrombocytopenic microangiopathies are a group of disorders characterized by thrombocytopenia, a microangiopathic hemolytic anemia evident by fragmented RBCs (Fig. 140-1D) and laboratory evidence of hemolysis, and microvascular thrombosis. They include thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS), as well as syndromes complicating bone marrow transplantation, certain medications and infections, pregnancy, and vasculitis. In DIC, although thrombocytopenia and microangiopathy are seen, a coagulopathy predominates, with consumption of clotting factors and fibrinogen resulting in an elevated prothrombin time (PT) and often activated partial thromboplastin time (aPTT). The PT and aPTT are characteristically normal in TTP or HUS." }, { "id": "article-23385_13", "title": "Immune Thrombocytopenic Purpura -- Evaluation -- Initial Evaluation", "score": 0.01156957928802589, "content": "In ITP, the white blood count, hemoglobin concentration, red cell indices, and differential are usually normal, and the only abnormality seen is a platelet count of less than 100,000/microL. [15] If considerable blood loss has occurred, microcytic anemia can be seen on the CBC. If a patient had a recent infection, the white cell count could be high or low depending on the cause of the infection (i.e., bacterial cause showing high WBC vs. viral cause showing low WBC). The reticulocyte count is usually normal unless the patient presents with significant acute blood loss anemia. [15] On the peripheral blood smear, white and red blood cells typically have a normal appearance with a decreased number of platelets, and the platelets will be normal to increased size. [15]" }, { "id": "article-30097_9", "title": "Thrombotic Thrombocytopenic Purpura -- Evaluation", "score": 0.011199371911513416, "content": "Laboratory evaluation plays a critically important role in diagnosing TTP because signs and symptoms are variable, and end-organ damage can be delayed. For diagnosis, the laboratory data must show anemia and thrombocytopenia along with an indication of active hemolysis, such as the presence of schistocytes, increased unconjugated bilirubin, increased reticulocyte count and increased lactate dehydrogenase. [23] [24] [25] As with any hemolysis in general, the serum haptoglobin decreases as it combines with the free hemoglobin released from the destroyed erythrocytes." }, { "id": "wiki20220301en019_45579", "title": "Thrombotic thrombocytopenic purpura", "score": 0.0111873451496093, "content": "TTP is characterized by thrombotic microangiopathy (TMA), the formation of blood clots in small blood vessels throughout the body, which can lead to microangiopathic hemolytic anemia and thrombocytopenia. This characteristic is shared by two related syndromes, hemolytic-uremic syndrome (HUS) and atypical hemolytic uremic syndrome (aHUS). Consequently, differential diagnosis of these TMA-causing diseases is essential. In addition to TMA, one or more of the following symptoms may be present in each of these diseases: neurological symptoms (e.g. confusion, cerebral convulsions seizures,); kidney impairment (e.g. elevated creatinine, decreased estimated glomerular filtration rate [eGFR], abnormal urinalysis); and gastrointestinal (GI) symptoms (e.g. diarrhea nausea/vomiting, abdominal pain, gastroenteritis. Unlike HUS and aHUS, TTP is known to be caused by an acquired defect in the ADAMTS13 protein, so a lab test showing ≤5% of normal ADAMTS13 levels is indicative of TTP. ADAMTS13 levels" }, { "id": "article-17530_18", "title": "Acute Anemia -- Histopathology", "score": 0.011008811986276009, "content": "When examining a peripheral blood smear under a microscope, specific findings can provide valuable information about the underlying condition. The following are some observations related to certain types of anemia: Microangiopathic Hemolysis (TTP, ITP, HUS, DIC): In conditions characterized by microangiopathic hemolysis, such as thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenic purpura (ITP), hemolytic-uremic syndrome (HUS), and disseminated intravascular coagulation (DIC), several abnormal RBC shapes may be observed. These include helmet cells (schistocytes), fragmented RBCs, and other RBC fragments. Spherocytes (small, round RBCs lacking central pallor) can also be seen in some cases." }, { "id": "wiki20220301en218_13342", "title": "Hematologic disease", "score": 0.01087719298245614, "content": "Direct physical damage to RBCs Microangiopathic hemolytic anemia Secondary to artificial heart valve(s) Aplastic anemia Fanconi anemia Diamond–Blackfan anemia (inherited pure red cell aplasia) Acquired pure red cell aplasia Decreased numbers of cells Myelodysplastic syndrome Myelofibrosis Neutropenia (decrease in the number of neutrophils) Agranulocytosis Glanzmann's thrombasthenia Thrombocytopenia (decrease in the number of platelets) Idiopathic thrombocytopenic purpura (ITP) Thrombotic thrombocytopenic purpura (TTP) Heparin-induced thrombocytopenia (HIT) Myeloproliferative disorders (Increased numbers of cells) Polycythemia vera (increase in the number of cells in general) Erythrocytosis (increase in the number of red blood cells) Leukocytosis (increase in the number of white blood cells) Thrombocytosis (increase in the number of platelets) Myeloproliferative disorder Transient myeloproliferative disease Coagulopathies (disorders of bleeding and coagulation)" }, { "id": "InternalMed_Harrison_12756", "title": "InternalMed_Harrison", "score": 0.010678120650765465, "content": "Shiga toxin produced by S. dysenteriae type 1 has been linked countries, where enterohemorrhagic E. coli (EHEC) predominates as the etiologic agent of this syndrome. HUS is an early complication that most often develops after several days of diarrhea. Clinical examination shows pallor, asthenia, and irritability and, in some cases, bleeding of the nose and gums, oliguria, and increasing edema. HUS is a nonimmune (Coombs test–negative) hemolytic anemia defined by a diagnostic triad: microangiopathic hemolytic anemia (hemoglobin level typically <80 g/L [<8 g/dL]), thrombocytopenia (mild to moderate in severity; typically <60,000 platelets/μL), and acute renal failure due to thrombosis of the glomerular capillaries (with markedly elevated creatinine levels). Anemia is severe, with fragmented red blood cells (schizocytes) in the peripheral smear, high serum concentrations of lactate dehydrogenase and free circulating hemoglobin, and elevated reticulocyte counts. Acute renal failure occurs" } ] } } }