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{ "1": { "exist": true, "char_ranges": [ [ 239, 353 ] ], "word_ranges": [ [ 39, 64 ] ], "text": "If I am told that he has AF, it is because the atria are of size XL, and a VSD does not produce atrial dilatation." }, "2": { "exist": true, "char_ranges": [ [ 0, 178 ] ], "word_ranges": [ [ 0, 28 ] ], "text": "If he has a pediatric murmur, I'm thinking congenital. Hepatomegaly, malleolar edema and BRD, something that overloads the right heart. So we rule out aortic and mitral stenosis." }, "3": { "exist": true, "char_ranges": [ [ 0, 178 ] ], "word_ranges": [ [ 0, 28 ] ], "text": "If he has a pediatric murmur, I'm thinking congenital. Hepatomegaly, malleolar edema and BRD, something that overloads the right heart. So we rule out aortic and mitral stenosis." }, "4": { "exist": true, "char_ranges": [ [ 239, 353 ] ], "word_ranges": [ [ 39, 64 ] ], "text": "If I am told that he has AF, it is because the atria are of size XL, and a VSD does not produce atrial dilatation." }, "5": { "exist": true, "char_ranges": [ [ 179, 226 ] ], "word_ranges": [ [ 28, 36 ] ], "text": "A patent ductus would give cyanosis: ruled out." } }

{ "1": "Ventricular septal defect.", "2": "Aortic stenosis.", "3": "Mitral stenosis.", "4": "Atrial septal defect.", "5": "Patent ductus arteriosus." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0758_11903", "title": "Natural history of atrial septal defect in the sixth decade : study of 5 cases.", "score": 0.017908538535337384, "content": "Atrial septal defect (ASD) is one of the most common causes of congenital heart disease manifested in adulthood. To describe clinical and likelihood picture of adults over 60 years born with an ASD type II. We performed a retrospective study of adult'sASD referred toourinstitutionfrom 1985 through 2010. Clinical, electrocardiographic, echocardiographic and hemodynamic data were reviewed. On follow up study, patients were investigated by echocardiography, ECG and assessed for quality of life by a questionnaire Among forty ASD type II manifested in adulthood which were referred to our department of cardiology five cases of ASD manifested in the sixth decades (2 men and 3 women). Complaints were dyspnea and palpitations in 4 cases and chest pain in only one patient. Slight anterior chest deformity was present in the older patient. Systolic murmur was found in the 3rd left intercostals space and the pulmonary second heart sound was accentuated in all patients. Complete right bundle branch block and right ventricular hypertrophy were found in all cases. Three patients presented atrial fibrillation. There was marked cardiomegaly in four patients. The pulmonary arteries were markedly enlarged and the peripheral vascular markings were increased. Echocardiographic data revealed large secundum ASD (mean 20 mm, ranged between 10 and 30mm), severe systolic pulmonary pressure in two cases (&gt;5O mmhg). MeanQP/QS was 2.2 and contrast revealed bidirectional shunt in one patient. All patients were studied by venous cardiac catheterization. They showed a significant increase in the oxygen content of right atrial blood. Three patients underwent surgical atrial septal defect closure under general anesthesia. There were no operative or peri operative deaths. At mean follow up of 50±75 months, there was one late death from heart failure in a patient with advanced preoperative heart failure. The oldest patient is in the medical group and he is 75years old. Most survival patients remain in good clinical condition. Some of them were symptomatic at the last follow up and complained of shortness of breath on effort and palpitations in two cases. Two patients were in chronic atrial fibrillation developed during follow up. However, chest RX showed reduction in cardiothoracic ratio postoperatively. Echocardiographic examination confirmed that there was no residual shunt in across the atrial septum in any patient. Systolic pulmonary pressure felled only in 2 patients in the surgery group. To our knowledge, thesepatients havealongue life span, although survivors with ASD described in the world. There is a lack of evidence regarding treatment options for adults with an ASD aged more than 60years. Given the higher risks of surgery in advanced age, the defect should be repaired as early as possible to prevent hemodynamic complications." }, { "id": "pubmed23n0128_1121", "title": "[Right ventricular dysplasia: clinical characteristics of five patients].", "score": 0.017489400363416112, "content": "The purpose of this study was to elucidate the clinical features of right ventricular (RV) dysplasia, a recently described clinical entity characterized by RV myopathic changes and ventricular tachycardia of left bundle branch block morphology. Five cases were reported, in which the diagnosis was established according to the criteria of Marcus. Case 1, a 33-year-old man, was referred to us for evaluation of his paroxysmal ventricular tachycardia of five years duration. Case 2, a 38-year-old man, was admitted because of shock caused by ventricular tachycardia. In both cases, the QRS configurations during ventricular tachycardia were those of the left bundle branch block pattern, and electrocardiograms during sinus rhythm showed T wave inversions in the right precordial leads and late ventricular potentials. Two-dimensional echocardiography, radionuclide angiography and contrast angiography disclosed RV dilatation and dysfunction with normal left ventricular (LV) function. The biopsied myocardium from the right and left ventricles in Case 2 revealed myocytolysis, a paucity of myofibrils and proliferation of collagen fibers. Case 3, a 73-year-old woman began to experience exertional dyspnea since 16 years of age. Her treatment consisted of bed rest, diuretics and digitalis. In December 1983, her New York Heart Association functional class was III, and physical examinations disclosed a Levine III/VI systolic murmur suggestive of tricuspid regurgitation, jugular vein dilatation, hepatomegaly, and pretibial edema. Electrocardiogram showed atrial fibrillation, incomplete right bundle branch block and T wave inversions in the precordial leads. Chest radiograph revealed marked cardiomegaly (cardiothoracic ratio of 92%). Echocardiography, radionuclide angiography and contrast angiography revealed marked RV dilatation, depressed ejection fraction (RV end-diastolic volume index of 342 ml/m2, and RV ejection fraction of 28%). Case 4, a 20-year-old man, was admitted with a chief complaint of palpitation. Case 5, a 19-year-old man, was referred to us for the evaluation of asymptomatic cardiomegaly, and his cardiothoracic ratio was 54%. A 12-lead electrocardiogram showed right bundle branch block and T wave inversions in the right precordial leads. Ambulatory electrocardiography revealed frequent premature ventricular complexes of the left bundle branch block pattern. Echocardiography, radionuclide angiography, and contrast angiography disclosed RV dilatation and dysfunction in both cases, and mild LV dilatation and dysfunction (LV end-diastolic volume index of 149 ml/m2, LV ejection fraction of 48%) in Case 4.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0794_10742", "title": "Pentology of Fallot's presenting with complete heart block.", "score": 0.016666666666666666, "content": "A 17-year-old male patient presented with cyanosis, repeated squatting since childhood and haemoptysis since the past 1 month. He had central cyanosis with clubbing. Cardiovasular examination revealed ejection systolic murmur in the pulmonary area with single S2. ECG showed right ventricular hypertrophy (RVH) with right atrial enlargement and first-degree heart block. Two-dimensional echo showed ventricular septal defect, overriding aorta, RVH, right ventricular enlargement (RVE) and right atrial enlargement with infundibular and valvular pulmonary stenosis and 1.9 cm ostium secondum atrial septal defect. There was no evidence of atrioventricular canal defect. The patient was diagnosed with pentology of Fallots. Follow-up ECG showed complete heart block (CHB) that again reverted to first-degree heart block. A diagnosis of pentology of Fallot with intermittent CHB was made with an awake heart rate of 50/min. This case report shows association of CHB with tetralogy of Fallot." }, { "id": "pubmed23n0054_19685", "title": "[Combined heart defects: tetralogy of Fallot, common atrium and a single atrioventricular valve diagnosed by echocardiography].", "score": 0.014719748559455213, "content": "We present a case of the rare coincidence of three mechanisms leading to development of congenital heart disease in intrauterine life: intrinsic defect of the development of the cardiac loop (dextrocardia), failure of normal expansion of the subpulmonary infundibulum (Fallot syndrome) and endocardial cushion defect (common atrium and common atrioventricular valve ). It was associated with partial viscera inversion. A 31-year old man with congenital cyanotic heart disease, and Blalock-Taussig anastomosis was admitted to the hospital due to symptoms of severe cardiac failure. On physical examination: systolic murmur, hepatomegaly, ascites, leg's edema and cyanosis were found. In ECG--atrial fibrillation with 3-d degree a-v block. Standard echocardiography revealed: dextrocardia, a large single atrium with ostia of pulmonary and systemic veins, single atrio-ventricular valve , large ventricular, Fallot-like septal defect. The papillary muscles were not visible in the left ventricle. Aorta and pulmonary trunk arose from morphological right ventricle. The patient died on the 3-rd day of hospitalization in the course of cardiac and respiratory insufficiency. Postmorten examination confirmed the diagnosis." }, { "id": "pubmed23n0603_14029", "title": "Unoperated tetralogy of Fallot in a 68-year-old patient.", "score": 0.013911694946177704, "content": "Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, generally treated with total correction within the first two years of life. Occasionally, some unoperated cases can reach older ages. A 68-year-old woman with diabetes mellitus presented with swelling in legs and abdomen, weakness, exertional dyspnea, and orthopnea. On physical examination, she had mild cyanosis with clubbing. Her blood pressure was 110/60 mmHg and pulse rate was 79 beat/min. She had a systolic ejection murmur and bilateral rales on basal lung areas. Massive edema was noted in both lower limbs. Electrocardiography showed atrial fibrillation with normal ventricular response. Chest radiography showed an increased cardiothoracic ratio and bilateral minimal pleural effusion. Echocardiography showed biatrial dilatation (right atrium 62 mm, left atrium 49 mm) and thickening of left ventricular walls. There was right ventricular hypertrophy with decreased systolic function. A very large ventricular septal defect and severe pulmonary stenosis were noted. The patient did not accept any interventional procedure. To our knowledge, this is the oldest unoperated TOF case reported from our country." }, { "id": "pubmed23n0525_6218", "title": "Cor triatriatum sinistrum: a rare congenital cardiac anomaly presenting in an adult with chronic atrial fibrillation.", "score": 0.013378076062639821, "content": "Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium is divided into proximal (dorsal or upper) and distal (ventral or lower) chambers by a fibromuscular septum. The upper chamber receives the pulmonary veins and the lower chamber contains the atrial appendage and the mitral valve. The 2 chambers communicate through a defect in the membrane. Cor triatriatum is often associated with other congenital cardiac anomalies. Most frequently, the upper chamber communicates with the right atrium through a patent foramen ovale or atrial septal defect, and the clinical symptoms simulate anomalous pulmonary venous return. Less commonly, the foramen ovale communicates with the distal chamber and the clinical features mimic mitral stenosis. When cor triatriatum is the only abnormality, the clinical findings are also similar to mitral stenosis with development of pulmonary hypertension and subsequent right ventricular hypertrophy and atrial enlargement. The diagnosis is usually made in infancy or childhood, and the lack of treatment results in death in 75% of patients. We report the case of a woman who presented much later in life. The patient was a 57-year-old female with a clinical history of chronic atrial fibrillation who presented to the emergency department because of a \"funny sensation\" in her chest, though she denied chest pain, nausea, vomiting, or diaphoresis. EKG revealed atrial fibrillation with a rapid ventricular response and a tachycardic rate of 157. She had a therapeutic level of digoxin, and cardiac enzymes were normal. The patient was admitted and placed on Cardizem drip. Serial EKGs remained normal and heart rate control was achieved. On hospital day 2, the patient became dyspneic and cyanotic. She went into cardiac arrest and died.Autopsy revealed cardiomegaly (610 g) with 4-chamber dilatation. A septum divided the left atrium into 2 chambers. The defect in the dividing membrane measured 1 cm in diameter. No other congenital defects were noted. The large size of the defect in the membrane likely accounted for the late onset of symptoms that allowed this patient to survive into adulthood without previous diagnosis or surgical intervention (which is usually required in childhood)." }, { "id": "article-26551_14", "title": "Palpitation -- History and Physical", "score": 0.012646124425526664, "content": "Positive orthostatic vital signs may indicate dehydration or an electrolyte abnormality. A midsystolic click and murmur may indicate mitral valve prolapse.  A harsh holosystolic murmur best heard at the left sternal border which increases with Valsalva may indicate hypertrophic obstructive cardiomyopathy. Fixed splitting of the S2 throughout the cardiac cycle and a right ventricular heave are characteristic clinical features of the atrial septal defect. An irregular rhythm indicates atrial fibrillation or atrial flutter. Evidence of cardiomegaly and peripheral edema may indicate heart failure and ischemia or a valvular abnormality. [1] [2] [6]" }, { "id": "wiki20220301en011_153729", "title": "Heart sounds", "score": 0.012081825896645674, "content": "Splitting of S2, also known as physiological split, normally occurs during inhalation because the decrease in intrathoracic pressure increases the time needed for pulmonary pressure to exceed that of the right ventricular pressure. A widely split S2 can be associated with several different cardiovascular conditions, and the split is sometimes wide and variable whereas, sometimes wide and fixed. The wide and variable split occurs in Right bundle branch block, pulmonary stenosis, pulmonary hypertension and ventricular septal defects. The wide and fixed splitting of S2 occurs in atrial septal defect. Pulmonary S2 (P2) will be accentuated (loud P2) in pulmonary hypertension and pulmonary embolism. S2 becomes softer in aortic stenosis. Extra heart sounds The rarer extra heart sounds form gallop rhythms and are heard in both normal and abnormal situations." }, { "id": "wiki20220301en063_19522", "title": "Valvular heart disease", "score": 0.011317352237042565, "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": "article-26694_14", "title": "Paroxysmal Atrial Fibrillation -- History and Physical", "score": 0.011286734574405807, "content": "All patients presenting with the above symptoms should have a detailed history, including past medical/cardiac history. On physical examination, patients should be examined for an irregularly irregular pulse, signs of heart failure like jugular vein distension (JVD), pedal edema, and lung crackles. In valvular AF, mitral stenosis/regurgitation murmur can be heard. A history of prior investigation of underlying causes, anticoagulation choices, and previously attempted methods for rate/rhythm control is important." }, { "id": "wiki20220301en082_40255", "title": "List of ICD-9 codes 390–459: diseases of the circulatory system", "score": 0.011244377811094452, "content": "Secondary cardiomyopathy unspecified Conduction disorders Atrioventricular block, third degree Atrioventricular block, first degree Atrioventricular block, Mobitz II Atrioventricular block, Wenckebach's Bundle branch block, left Bundle branch block, right Sinoatrial heart block Atrioventricular excitation, anomalous Wolff-Parkinson-White syndrome Cardiac dysrhythmias Tachycardia, paroxysmal supraventricular Atrial fibrillation and flutter Atrial fibrillation Atrial flutter Ventricular fibrillation and flutter Ventricular fibrillation Cardiac arrest Premature beats, unspec. Other specified cardiac dysrhythmias Sick sinus syndrome Sinus bradycardia, NOS Cardiac dysrhythmia unspecified Gallop rhythm Heart failure Congestive heart failure unspecified Left heart failure Pulmonary edema, acute Systolic heart failure Diastolic heart failure Heart failure, combined, unspec." }, { "id": "pubmed23n0080_2252", "title": "[Mitral valve prolapse as an initial clinical feature of dilated cardiomyopathy: report of two cases].", "score": 0.011097000483792937, "content": "Two cases with mitral valve prolapse (MVP), without any other cardiac abnormalities at the initial evaluation, developed the clinical features mimic to dilated cardiomyopathy (DCM) during follow-up period. Case 1. A 40-year-old man visited our hospital in May 1982 to evaluate a heart murmur. A standard 12-lead electrocardiogram (ECG) showed an abnormal Q wave in lead III. Echocardiography revealed MVP, but neither dilatation nor wall motion abnormality of the left ventricle (LV) were observed. Thallium-201 scintigraphy revealed an abnormal thallium uptake at the apex and inferior wall. He had no episode of acute myocardial infarction or myocarditis, but complete right bundle branch block developed, thus, he was hospitalized in October 1984. He had no coronary artery lesions, and had only mild mitral regurgitation on left ventriculography. The motion of the interventricular septum and apex was reduced on echocardiogram and a persistent perfusion defect was observed at the inferior wall and the interventricular septum on Tl-201 scintigrams. In December 1985, he experienced an Adams-Stokes attack due to complete atrioventricular block. Echocardiographically, the left ventricle enlarged, and the wall motion abnormalities and a perfusion defect on Tl-201 scintigrams were relatively severe. Case 2. A 46-year-old woman occasionally experienced palpitation of short duration and chest oppression since 1977. She was admitted to our hospital because of cardiac symptoms in 1982. A heart murmur of Levine II was heard and a standard 12-lead ECG showed single supraventricular extrasystole and T wave inversion in lead III and aVF. Echocardiography revealed MVP and mild mitral regurgitation, but neither dilatation nor wall motion abnormality of the LV was observed. During 6-year follow-up period, permanent atrial fibrillation developed and LV developed dilatation and wall motion abnormalities progressed. Thus, during follow-up periods, DCM-like features developed in two cases who had had MVP as a sole echocardiographic abnormality with systolic murmur and non-specific ECG changes. We consider that these two may be important cases who may show a relation between cardiomyopathic process and MVP." }, { "id": "wiki20220301en024_39600", "title": "Mitral stenosis", "score": 0.01103061335657479, "content": "Almost all signs increase with exercise and pregnancy. Other peripheral signs include: Malar flush - due to back pressure and buildup of carbon dioxide (CO2). CO2 is a natural vasodilator. Atrial fibrillation - irregular pulse and loss of 'a' wave in jugular venous pressure Left parasternal heave - presence of right ventricular hypertrophy due to pulmonary hypertension Tapping apex beat that is not displaced Medical signs of atrial fibrillation include: Heart rate is about 100-150/min. Irregularly irregular pulse with a pulse deficit>10. Varying first heart sound intensity. Opening snap is not heard sometimes. Absent a waves in the neck veins. Presystolic accentuation of diastolic murmur disappears. Embolic manifestations may appear." }, { "id": "wiki20220301en002_19675", "title": "Pulse", "score": 0.010755290258395847, "content": "Rhythm A normal pulse is regular in rhythm and force. An irregular pulse may be due to sinus arrhythmia, ectopic beats, atrial fibrillation, paroxysmal atrial tachycardia, atrial flutter, partial heart block etc. Intermittent dropping out of beats at pulse is called \"intermittent pulse\". Examples of regular intermittent (regularly irregular) pulse include pulsus bigeminus, second-degree atrioventricular block. An example of irregular intermittent (irregularly irregular) pulse is atrial fibrillation. Volume The degree of expansion displayed by artery during diastolic and systolic state is called volume. It is also known as amplitude, expansion or size of pulse. Hypokinetic pulse A weak pulse signifies narrow pulse pressure. It may be due to low cardiac output (as seen in shock, congestive cardiac failure), hypovolemia, valvular heart disease (such as aortic outflow tract obstruction, mitral stenosis, aortic arch syndrome) etc." }, { "id": "article-142599_21", "title": "Cardiac Sarcoidosis -- History and Physical -- Physical examination", "score": 0.010650887573964497, "content": "General physical examination may reveal tachycardia, bradycardia, irregular pulse (atrial fibrillation or variable block), pedal edema, or raised jugular venous pulse. In addition, a third or fourth heart sound can indicate left ventricular dysfunction; systolic or diastolic murmurs at the apex can be found in mitral valve involvement; and a loud second heart sound can occur in pulmonary hypertension. [20]" }, { "id": "article-31090_14", "title": "Ventricular Septal Defect -- History and Physical", "score": 0.010164005179110919, "content": "The presentation of unrepaired VSDs is largely dependent on the presence of hemodynamically significant shunt; hence it is directly related to the size of the defect. Small VSDs only lead to the minimal left-to-right shunt without left ventricular (LV) fluid overload or PAH; they are usually asymptomatic or found incidentally on physical exam. Medium size VSDs result in a moderate LV volume overload and absent to mild PAH; they present late in childhood with mild congestive heart failure (CHF). Those with large defects develop CHF early in childhood due to the severe LV overload and severe PAH. The murmur of VSD is typically pan-systolic best heard in the left lower sternal border; it is harsh and loud in small defects but softer and less intense in large ones. Handgrips increase afterload, increasing the strength of the murmur. Infundibular defects are best heard in the pulmonic area. A diastolic decrescendo murmur and wide pulse pressure can be detected in the setting of aortic regurgitation. Increased LV flow may result in the mid-diastolic rumble in the lower left sternal border. A systolic click of a septal aneurysm can be appreciated sometimes in membranous defects. Eisenmenger syndrome manifests in cyanosis, desaturation, dyspnea, syncope, secondary erythrocytosis, and clubbing; in such cases, the typical murmur of VSD can be absent and accentuated pulmonic component of the second heart sound may be heard." }, { "id": "wiki20220301en011_153789", "title": "Heart murmur", "score": 0.009900990099009901, "content": "Harsh holosystolic (pansystolic) murmur at the left lower sternal border Classic for a ventricular septal defect. It is in these children that the delayed-onset cyanotic heart disease occurs known as Eisenmenger syndrome, which is a reversal of the left-to-right heart shunt as the right ventricle hypertrophies, causing a right-to-left shunt and resulting cyanosis. Widely split fixed S2 and systolic ejection murmur at the left upper sternal border Classically due to a patent foramen ovale or atrial septal defect, which is lack of closure of the foramen ovale. This produces a left-to-right shunt initially, thus does not produce cyanosis, but causes pulmonary hypertension. Longstanding uncorrected atrial septal defects can also result in Eisenmenger's syndrome with resultant cyanosis." }, { "id": "pubmed23n0303_21558", "title": "[Possible mechanisms of false positive results of averaged ECG].", "score": 0.009900990099009901, "content": "The objective of this retrospective study was to investigate the causes of high amplification (HA) ECG abnormalities detected in apparently healthy subjects. This study was based on 14 patients derived from a population of 167 admitted for assessment of malaise or supraventricular tachycardia and who had no apparent heart disease. The surface ECG showed fine QRS complexes (&lt; 120 ms) with no left hemiblock on ECG. All of these subjects underwent a complete electrophysiological study and high amplification ECG using a 40 Hertz high-pass filter. For these 14 patients, the amplitude of the last 40 milliseconds (ms) of the mean QRS (RMS 40) was less than or equal to 20 microvolts (microV). Eight of them also had a duration of the terminal part of the QRS complex less than 40 microV (LAS) greater than 40 ms and 6 others had and LAS greater than 35 ms. The mean QRS interval was normal in all patients (&lt; 120 ms). The usual causes for reduction of the RMS 40-were eliminated: programmed ventricular pacing using 3 extrastimuli under basal conditions and with isuprel remained negative. E chocardiography and the right ventricular angiography were normal. The surface ECG showed slight abnormalities: absence of Q wave in V6 without delay of the intrinsic-like deflection in 3 subjects, increased R wave in V1 in 2 subjects and especially deep S wave in V5-V6 with no left axis deviation in 10 patients. Programmed or increasing frequency atrial pacing induced RBB or LBB in 13 of these 14 subjects (RBB: 7, LBB : 3, RBB and LBB:3). Follow-up, ranging from 6 months to 3 years, did not reveal any cardiac events, but signs of RBB appeared in 3 patients and signs of LBB were observed in 1 patient. an abnormal high amplification ECG in apparently healthy subjects could be explained by minor conduction disorders essentially in the right branch. The presence of a deep S wave (&gt; 2 mm) in V5-V6 is the commonest ECG sign in these subjects. This diagnosis can only be proposed after exclusion of right ventricular dysplasia in symptomatic patients." }, { "id": "pubmed23n0091_1961", "title": "[A case of sick sinus syndrome, considered to develop to atrial standstill].", "score": 0.00980392156862745, "content": "A 25 year old man was admitted to our hospital because of dizziness and bradycardia. Physical examination was normal except for an irregular pulse of 90 beats/min. Chest X-ray film showed no cardiomegaly and no pulmonary congestive changes. ECG showed 2:1 or 3:1 atrial flutter on admission. After atrial flutter was terminated spontaneously, ECG revealed absent P waves, a QRS interval of 0.10 seconds, and A-V junctional rhythm with irregular R-R interval ranging from 1.20 to 2.12 seconds. At times, cardiac arrest was noted. Esophageal electrocardiogram also failed to demonstrate atrial activity while A-V junctional rhythm continued. Mitral valve echocardiogram lacked A point, and then ä waves were absent in both the right atrial and pulmonary capillary pressure recordings. Transient atrial standstill was suspected from these findings, so that electrophysiological study was performed. Right atrial electrogram revealed complete absence of atrial activity. His bundle electrogram revealed H-V prolongation [80-83 msec]. Right atrial pacing was attempted at several atrial sites, including the high lateral, middle lateral, low lateral right atrium, and low right atrial septum. Atrial activity could be elicited with stimulus strength of 3 to 5 volts. These atrial pacing thresholds were mild or moderately higher than usual. After the cessation of atrial pacing at 90 beats for two minutes, the recovery time of the first beat prolonged to 8.46 second. We considered that this case was sick sinus syndrome in young adult which revealed generalized disturbance of conduction system including the atrial muscle, and would develop to atrial standstill in the near future." }, { "id": "wiki20220301en061_69153", "title": "Tricuspid atresia", "score": 0.009708737864077669, "content": "A combined atrial septal defect (ASD) and a ventricular septal defect (VSD) can be present to maintain blood flow-from the right atrium, the blood must flow through the ASD to the left atrium to the left ventricle and through the VSD to the right ventricle to allow access to the lungs. Alternatively, an atrial septal defect (ASD) with a patent ductus arteriosus may also be present, thus causing blood flow from the right atrium to the left atrium to the left ventricle to the aorta and then to the pulmonary artery. In these cases, prostaglandin E1 is used to maintain patency of the ductus arteriosus until emergency corrective surgery can be completed. Presentation progressive cyanosis poor feeding tachypnea over the first 2 weeks of life holosystolic murmur due to the VSD left axis deviation on electrocardiography and left ventricular hypertrophy (since it must pump blood to both the pulmonary and systemic systems) Normal or mildly enlarged heart" }, { "id": "pubmed23n0236_871", "title": "[Bifascicular block: long-term follow-up. Report of 40 cases].", "score": 0.009708737864077669, "content": "A total of 14,500 E.C.G. tracings were reviewed to determine the incidence of bifascicular block and those patients were followed up to assess prognosis. Forty patients with bifascicular block (complete right bundle branch block associated with left anterior hemiblock), diagnosed with standard E.C.G., according to Medrano's criteria from January 1978 to September 1980 were studied in our Service. The incidence of this intraventricular conduction defect was 0.0033 (3.3 per thousand). Males predominated over females at a rate of 2.4 to 1. This block was more frequent from the sixth to the ninth decades of life. Thirty five percent of the patients had no evidence of cardiovascular pathology; 32.5 percent had high blood pressure, 2.5 percent had coronary heart disease, 2.5 percent rheumatic heart disease, 5 percent chronic pulmonale, and 37.5 percent had diabetes mellitus as an associated finding. During the follow up which covered 20.2 months/patient, only one patient developed junctional rhythm and periods of asystolia and syncope; this case was treated with a permanent pacemaker with good results. Two patients died, one from digitalis intoxication and the other at home, the cause was not determined. It is necessary to study this conduction defect with longer follow up periods and according to the underlying heart disease, in order to assess properly the prognosis and behavior of this conduction defect." }, { "id": "wiki20220301en293_12445", "title": "List of circulatory system conditions", "score": 0.009615384615384616, "content": "Congenital heart diseaseSee also :Category:Congenital heart defects Aortic coarctation (Aortic coarctation) Acyanotic heart defect Atrial septal defect Cor triatriatum Dextro-Transposition of the great arteries Double aortic arch Double inlet left ventricle Double outlet right ventricle Ebstein's anomaly GUCH Cyanotic heart defect Tetralogy of Fallot (ToF) Total anomalous pulmonary venous connection Hypoplastic left heart syndrome (HLHS) Transposition of the great arteries (d-TGA) Truncus arteriosus (Persistent) Tricuspid atresia Interrupted aortic arch Coarctation of aorta Pulmonary atresia (PA) Pulmonary stenosis (critical) Non-cyanotic heart defects Atrial septal defect Ventricular septal defect Patent ductus arteriosus and Coarctation of aorta (may cause cyanosis in some cases) Ischemic heart diseasesSee also :Category:Ischemic heart diseases Angina pectoris Acute coronary syndrome Acute myocardial infarction" }, { "id": "wiki20220301en293_12443", "title": "List of circulatory system conditions", "score": 0.009523809523809525, "content": "Cardiovascular Angina Acute coronary syndrome Anomic aphasia Aortic dissection Aortic regurgitation Aortic stenosis Apoplexy Apraxia Arrhythmias Asymmetric septal hypertrophy (ASH) Atherosclerosis Atrial flutter Atrial septal defect Atrioventricular canal defect Atrioventricular septal defect Avascular necrosis'Cardiac electrophysiologySee also :Category:Cardiac electrophysiology AV nodal reentrant tachycardia (Atrioventricular nodal reentrant tachycardia) Accelerated idioventricular rhythm Andersen–Tawil syndrome (Andersen cardiodysrhythmic periodic paralysis, Andersen syndrome, Long QT syndrome 7; Periodic paralysis, potassium-sensitive cardiodysrhythmic type) Ashman phenomenon (Ashman beats) Atrial fibrillation Atrial fibrillation with rapid ventricular response Atrial flutter Atrial tachycardia Bifascicular block Brugada syndrome (Sudden Unexpected Death Syndrome) Bundle branch block Cardiac dysrhythmia (Cardiac arrhythmia)" }, { "id": "pubmed23n1058_21312", "title": "Case 288.", "score": 0.009523809523809525, "content": "History A 46-year-old woman was admitted to our hospital with decompensated congestive heart failure and pericardial effusion diagnosed on echocardiography. She had no family history of sudden cardiac death. She was born at term and experienced no cardiac events until 4 years of age, at which point she was hospitalized because of three syncopal episodes that were not related to exercise. Over the next 10 years, she experienced two additional episodes of syncope not related to exercise. She had another hospital admission at 12 years of age. Clinical examination did not reveal cyanosis or clubbing, peripheral pulses were normal, and blood pressure was 90/60 mmHg. Her venous pressure was elevated, but the liver was not enlarged, and the lung fields were clear. Electrocardiography showed sinus rhythm, right bundle branch block, T-wave inversion in V6, and evidence of right atrial dilatation. Two-dimensional echocardiography showed normal intracardiac connections, with the tricuspid valve in the normal position and normal size of the left atrium and left ventricle with a normal ejection fraction. The right ventricle was dilated without evidence of right ventricular outflow tract obstruction. Implantation of an implantable cardioverter-defibrillator was considered but was ultimately contraindicated because of right ventricle anatomy. Thus, the patient received conservative care and was started on digoxin and diuretics. At 32 years of age, she experienced an episode of atrial flutter that was treated with electrical cardioversion. As stated earlier, at 46 years of age, she was admitted to our hospital with decompensated heart failure to be evaluated for a heart transplant. She underwent electrocardiography, echocardiography, cardiac MRI with and without administration of contrast media, and non-cardiac-gated multidetector CT with and without contrast media to rule out pulmonary embolism. The following quantitative results were obtained with MRI: Left ventricular end-diastolic volume (LVDV) was 40 mL (LVDV per body surface area [BSA], 25 mL/m<sup2</sup); left ventricular end-systolic volume (LVSV), 21 mL (LVSV/BSA, 13 mL/m<sup2</sup); stroke volume (SV), 19 mL (SV/BSA, 12 mL/m<sup2</sup); and ejection fraction, 47%. Right ventricular end-diastolic volume (RVDV) was 262 mL (RVDV/BSA, 164 mL/m<sup2</sup); right ventricular end-systolic volume (RVSV), 198 mL (RVSV/BSA, 124 mL/m<sup2</sup); stroke volume (SV), 64 mL (SV/BSA, 40 mL/m<sup2</sup); and ejection fraction, 24%. Phase contrast sequences in the aorta and pulmonary artery showed systemic output of 20 mL and pulmonary output of 18 mL. Tricuspid regurgitation was massive (46 mL) (Figs 1-4)." }, { "id": "pubmed23n0326_9210", "title": "[Complete D-transposition of the great vessels diagnosed late in a 10-month infant. Rashkind manoeuvre].", "score": 0.009439410092395167, "content": "We report a first documented case in Senegal with simple transposition of the great arteries diagnosed in a 2 months old girl treated by Rashkind atrioseptostomy. Our patient benefited from clinical examination, ECG (15 derivations), chest X ray and standard laboratory tests. Pulsed-Doppler, two dimensional and TM echocardiography have been performed with an ATL MK 600 echocardiograph. Cardiac catheterism, angiocardiography and Rashkind procedure have been realized in our Department. These data are discussed and compared to the literature. At admission this patient presents with major cyanosis and polypnea. At examination, there is a 3/6 murmur at the left sternal border and a subclavicular continuous murmur. Laboratory tests showed metabolic acidosis and severe hypoxemia. Chest x-ray showed a cardio-thoracic ratio at 0.64 with increased pulmonary vascular markings. ECG showed right ventricular hypertrophy. Echocardiography-Doppler revealed ventriculo-arterial discordance with restrictive atrial septal defect and persistent ductus arteriosus. Rashkind procedure was followed by an increased aortic saturation. After 6 weeks there was an improvement of cyanosis and cardiac failure. Diagnosis of transposition of the great arteries is actually easier with development of ultrasonography which is useful when performed by experienced cardiologist. Spontaneous prognosis of this malformation is very poor. Rashkind atrioseptostomy is an important step for the initial treatment of transposition of the great arteries in terms of survival before open heart surgery." }, { "id": "article-22653_7", "title": "First-Degree Heart Block -- History and Physical", "score": 0.009433962264150943, "content": "First-degree AV block is almost universally without associated symptoms. Patients will frequently be unaware of the condition until it appears on routine electrocardiography. Upon recognition of the PR interval prolongation, a thorough history should be obtained, with a specific focus on any history of congenital or acquired heart disease, risk factors for heart disease, family history of cardiac disease, the presence of neuromuscular disease, or family history of neuromuscular disease. In higher-grade first-degree block (PR interval greater than 0.30 seconds), patients may develop symptoms similar to pacemaker syndrome: dyspnea, malaise, lightheadedness, chest pain, or even syncope due to poor synchronization of atrial and ventricular contractions. [8] With the delay in ventricular contraction, patients will experience discomfort as the atria contracts against closed atrioventricular valves. Similarly, the physical exam will typically be normal, and there are no common physical exam findings suggestive of first-degree AV block. It is sensible to conduct a general assessment for signs of cardiac diseases, such as auscultation for murmurs or additional heart sounds, palpation for JVD and peripheral edema, and a skin evaluation for cyanosis, clubbing, or other signs of chronic cardiac disease." }, { "id": "wiki20220301en043_18499", "title": "Alagille syndrome", "score": 0.009345794392523364, "content": "Heart Common signs of Alagille syndrome include congenital heart problems varying from heart murmurs to significant structural abnormalities, such as Tetralogy of Fallot. Pulmonary Stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy are common amongst Alagille patients. Patients may also present with Ventricular septal defect, Atrial septal defect, Patent ductus arteriosus, and Coarctation of the aorta. The mortality rate of Tetralogy of Fallot when untreated ranges from 70% by age 10 to 95% by age 40. However, complete surgical repair can significantly improve both longevity and quality of life in patients with Alagille syndrome." }, { "id": "wiki20220301en257_19839", "title": "Continuous murmurs", "score": 0.009259259259259259, "content": "Heart murmurs are most frequently organized by timing, into systolic heart murmurs and diastolic heart murmurs. However, continuous murmurs can not be directly placed into either category. These murmurs are due to blood flow from a high pressure chamber or vessel to a lower pressure system. Patent ductus arteriosus . Patent ductus arteriosus (PDA) is an abnormal connection between the aorta and the pulmonary artery, which normally should be closed in infancy. Since aortic pressure is higher than pulmonary pressure, a continuous murmur occurs. This murmur is often described as a machinery murmur, or Gibson's murmur. This is named for George Alexander Gibson, who characterised it in 1898. Aortopulmonary window. Shunts. Usually a left to right shunt through a small atrial septal defect in the presence of mitral valve obstruction. References Heart murmurs Turbulence" }, { "id": "pubmed23n1076_23501", "title": "Case 288: Uhl Anomaly.", "score": 0.009259259259259259, "content": "History A 46-year-old woman was admitted to our hospital with decompensated congestive heart failure and pericardial effusion diagnosed at echocardiography. She had no family history of sudden cardiac death. She was born at term and experienced no cardiac events until 4 years of age, at which point she was hospitalized because of three syncopal episodes that were not related to exercise. Over the next 10 years, she experienced two additional episodes of syncope not related to exercise. She had another hospital admission at 12 years of age. Clinical examination did not reveal cyanosis or clubbing, peripheral pulses were normal, and blood pressure was 90/60 mmHg. Her venous pressure was elevated, but the liver was not enlarged, and the lung fields were clear. Electrocardiography showed sinus rhythm, right bundle branch block, T-wave inversion in V6, and evidence of right atrial dilatation. Two-dimensional echocardiography showed normal intracardiac connections, with the tricuspid valve in the normal position and normal size of the left atrium and left ventricle with a normal ejection fraction. The right ventricle (RV) was dilated, without evidence of RV outflow tract obstruction. Implantation of an implantable cardioverter-defibrillator was considered but was ultimately contraindicated because of RV anatomy. Thus, the patient received conservative care and was started on digoxin and diuretics. At 32 years of age, she experienced an episode of atrial flutter that was treated with electrical cardioversion. As stated earlier, at 46 years of age, she was admitted to our hospital with decompensated heart failure to be evaluated for a heart transplant. She underwent electrocardiography, echocardiography, cardiac MRI with and without administration of contrast media, and non-cardiac-gated multidetector CT (MDCT) with and without contrast media to rule out pulmonary embolism. The following quantitative results were obtained with MRI: Left ventricular end-diastolic volume (LVDV) was 40 mL (LVDV per body surface area [BSA], 25 mL/m<sup2</sup); left ventricular end-systolic volume (LVSV), 21 mL (LVSV/BSA, 13 mL/m<sup2</sup); left ventricular stroke volume (SV), 19 mL (SV/BSA, 12 mL/m<sup2</sup); and left ventricular ejection fraction, 47%. RV end-diastolic volume (RVDV) was 262 mL (RVDV/BSA, 164 mL/m<sup2</sup); RV end-systolic volume (RVSV), 198 mL (RVSV/BSA, 124 mL/m<sup2</sup); RV stroke volume (SV), 64 mL (SV/BSA, 40 mL/m<sup2</sup); and RV ejection fraction, 24%. Phase contrast sequences in the aorta and pulmonary artery showed systemic output of 20 mL and pulmonary output of 18 mL. Tricuspid regurgitation was massive (46 mL)." }, { "id": "article-25199_10", "title": "Mitral Stenosis -- History and Physical", "score": 0.009184881243588731, "content": "Mitral stenosis presents 20 to 40 years after an episode of rheumatic fever. The most common symptoms are orthopnea and paroxysmal nocturnal dyspnea. Patients may have symptoms of palpitations, chest pain, hemoptysis, thromboembolism when the left atrial volume is increased, ascites, edema, and hepatomegaly (if right-side heart failure develops). There is also an increase in symptoms of fatigue and weakness with exercise and pregnancy. On auscultation, the first heart sound is usually loud and maybe palpable due to increased force in closing the mitral valve. The P2 (pulmonic) component of the second heart sound (S2) will be loud if severe pulmonary hypertension is due to mitral stenosis." }, { "id": "wiki20220301en029_13556", "title": "Congenital heart defect", "score": 0.009174311926605505, "content": "Defects Aortic stenosis Arrhythmogenic right ventricular cardiomyopathy Atrial septal defect (ASD) Atrioventricular septal defect (AVSD) Bicuspid aortic valve Cardiomyopathy Complete heart block (CHB) Dextrocardia Double inlet left ventricle (DILV) Double outlet right ventricle (DORV) Ebstein's anomaly Early Repolarization Syndrome Hypoplastic left heart syndrome (HLHS) Hypoplastic right heart syndrome (HRHS) Mitral stenosis Persistent truncus arteriosus Pulmonary atresia Pulmonary stenosis Rhabdomyomas (Tumors of the Heart) Transposition of the great vessels dextro-Transposition of the great arteries (d-TGA) levo-Transposition of the great arteries (l-TGA) Tricuspid atresia Ventricular septal defect (VSD) Wolff-Parkinson-White syndrome (WPW)" }, { "id": "pubmed23n0061_15586", "title": "[Electrocardiographic diagnosis of left ventricular hypertrophy accompanied by complete right bundle branch block].", "score": 0.009174311926605505, "content": "The new electrocardiographic criteria for diagnosing left ventricular hypertrophy (LVH) were evaluated in patients with complete right bundle branch block (CRBBB) based on the relationships between left ventricular mass and multiple electrocardiographic variables obtained from 12-lead electrocardiograms. The subjects consisted of 88 patients with CRBBB, whose ages ranged from 18 to 86 years. Patients with histories of myocardial infarction, moderate to severe pericardial effusion and an undetermined axis were excluded from the study. LVH was defined as left ventricular mass (LVmass) &gt; or = 215 g calculated from the Penn method using standard M-mode echo measurements. All electrocardiograms were interpreted by one investigator who had no knowledge of the echocardiographic results. Items calculated were the amplitude of Q, R, and S waves and their A/R, R/S, and S/A ratios, the mean frontal QRS axis, ventricular activation time in lead V5, the Morris' index, ST-T segment depression in leads V5,6, and negative U waves in leads V5,6. We selected 22 items for our criteria according to their sensitivity and specificity, and added to the 11 previously reported ones determined. LV wall thickness correlated best with R I (r = 0.57, p &lt; 0.01), LV diastolic dimension with RV5 (r = 0.48, p &lt; 0.01), and LV mass with R I+S III (r = 0.60, p &lt; 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 317, 357 ] ], "word_ranges": [ [ 54, 64 ] ], "text": "we do not want to put the patient to run" }, "2": { "exist": true, "char_ranges": [ [ 406, 501 ] ], "word_ranges": [ [ 73, 88 ] ], "text": "nor do we want to do a catheterization without having first performed another noninvasive test." }, "3": { "exist": true, "char_ranges": [ [ 361, 405 ] ], "word_ranges": [ [ 65, 73 ] ], "text": "overload him with dobuta and have a syncope," }, "4": { "exist": true, "char_ranges": [ [ 506, 622 ] ], "word_ranges": [ [ 89, 112 ] ], "text": "cardioTC, in someone 80 years old, is going to tell us what we already know: that he has calcium up to his eyebrows." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "A stress test.", "2": "Coronary angiography.", "3": "Exercise echocardiogram.", "4": "Coronary CT scan.", "5": "Doppler echocardiogram." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en015_15772", "title": "Echocardiography", "score": 0.014059514059514059, "content": "A stress echocardiogram, also known as a stress echo, uses ultrasound imaging of the heart to assess the wall motion in response to physical stress. First, images of the heart are taken \"at rest\" to acquire a baseline of the patient's wall motion at a resting heart rate. The patient then walks on a treadmill or uses another exercise modality to increase the heart rate to his or her target heart rate, or 85% of the age-predicted maximum heart rate (220 − patient's age). Finally, images of the heart are taken \"at stress\" to assess wall motion at the peak heart rate. A stress echo assesses wall motion of the heart; it does not, however, create an image of the coronary arteries directly. Ischemia of one or more coronary arteries could cause a wall motion abnormality, which could indicate coronary artery disease. The gold standard test to directly create an image of the coronary arteries and directly assess for stenosis or occlusion is a cardiac catheterization. A stress echo is not" }, { "id": "wiki20220301en245_7286", "title": "Coronary ischemia", "score": 0.013988021987037493, "content": "Some people may be unable to exercise in order to achieve a sufficient heart rate for a useful test. In these cases, high-dose dobutamine may be used to chemically increase heart rate. If dobutamine is insufficient for this purpose, atropine be added to reach goal heart rate. Dipyridamole is an alternative to dobutamine but it is less effective in detecting abnormalities. While exercise echocardiograms are more effective in detecting coronary artery disease, all forms of stress echocardiograms are more effective than exercise EKG in detecting coronary ischemia secondary to coronary artery disease. If stress echocardiography is normal, risk of future adverse cardiac events is low enough that invasive coronary angiography is not needed." }, { "id": "wiki20220301en000_84827", "title": "Coronary artery disease", "score": 0.01295191295191295, "content": "The diagnosis of \"Cardiac Syndrome X\" – the rare coronary artery disease that is more common in women, as mentioned, is a diagnosis of exclusion. Therefore, usually, the same tests are used as in any person with the suspected of having coronary artery disease: Baseline electrocardiography (ECG) Exercise ECG – Stress test Exercise radioisotope test (nuclear stress test, myocardial scintigraphy) Echocardiography (including stress echocardiography) Coronary angiography Intravascular ultrasound Magnetic resonance imaging (MRI) The diagnosis of coronary disease underlying particular symptoms depends largely on the nature of the symptoms. The first investigation is an electrocardiogram (ECG/EKG), both for \"stable\" angina and acute coronary syndrome. An X-ray of the chest and blood tests may be performed. Stable angina" }, { "id": "pubmed23n0501_7080", "title": "Prognostic value of exercise echocardiography in patients with classic angina pectoris.", "score": 0.012932468396540253, "content": "The role of stress echocardiography in the prognostic evaluation of patients with angina pectoris is not well defined. This study included 437 patients (241 men and 196 women) with angina pectoris and a pretest probability of coronary artery disease (CAD) of &gt; or = 0.7 who were referred for exercise echocardiography. No patient had a history of acute myocardial infarction or coronary revascularization. Mean age was 65 +/- 10 years. During a median follow-up of 2.7 years, hard cardiac events (cardiac death or nonfatal myocardial infarction) occurred in 19 patients and 53 patients underwent coronary revascularization. Event-free survival rates in patients with normal versus abnormal stress echocardiograms were 98% versus 83% at 1 year, 96% versus 75% at 3 years, and 87% versus 69% at 5 years, respectively. In a multivariate analysis of clinical, exercise stress, and echocardiographic parameters, independent predictors of hard cardiac events were Q waves on the electrocardiogram (chi-square 8.7, p = 0.003) and the presence of wall motion abnormalities during exercise in multivessel distribution (chi-square 5.3, p = 0.02). In an incremental model of clinical, exercise, and echocardiographic variables for the prediction of all cardiac events, the addition of echocardiographic data increased the chi-square of the model from 62 to 78 (p = 0.0003). Exercise echocardiography provides useful information in the risk stratification of patients with suspected CAD and a high pretest probability of CAD. Patients with normal exercise echocardiograms have a low event rate and therefore can be exempted from invasive procedures during the 3 years after a normal exercise echocardiogram." }, { "id": "pubmed23n0313_4125", "title": "Outcome after normal exercise echocardiography and predictors of subsequent cardiac events: follow-up of 1,325 patients.", "score": 0.012762995049504951, "content": "This study sought to examine the outcome of a large group of patients after normal exercise echocardiography and to identify potential predictors of subsequent cardiac events. Earlier studies suggested that prognosis after normal exercise echocardiography is favorable, with a low subsequent cardiac event rate. These studies involved a small number of patients and did not have sufficient statistical power to stratify risk. The outcomes of 1,325 patients who had normal exercise echocardiograms were examined. End points were overall and cardiac event-free survival. Cardiac events were defined as cardiac death, nonfatal myocardial infarction and coronary revascularization. Patient characteristics were analyzed in relation to time to first cardiac event in a univariate and multivariate manner to determine which, if any, were associated with an increased hazard of subsequent cardiac events. Overall survival of the study group was significantly better than that of an age- and gender-matched group obtained from life tables (p &lt; 0.0001). The cardiac event-free survival rates at 1, 2 and 3 years were 99.2%, 97.8% and 97.4%, respectively. The cardiac event rate per person-year of follow-up was 0.9%. Subgroups with an intermediate or high pretest probability of having coronary artery disease also had low cardiac event rates. Multivariate predictors of subsequent cardiac events were angina during treadmill exercise testing (risk ratio [RR] 4.1, 95% confidence interval [CI] 1.5 to 11.0), low work load (defined as &lt; 7 metabolic equivalents [METs] for men and &lt; 5 METs for women; RR 3.2, 95% CI 1.4 to 7.6), echocardiographic left ventricular hypertrophy (RR 2.6, 95% CI 1.1 to 6.3) and advancing age (RR 1.04/year, 95% CI 1.0 to 1.1). The outcome after normal exercise echocardiography is excellent. Subgroups with an intermediate or high pretest probability of having coronary artery disease also have a favorable prognosis after a normal exercise echocardiogram. Characteristics predictive of subsequent cardiac events (i.e., patient age, work load, angina during exercise testing and echocardiographic left ventricular hypertrophy) should be considered in the clinical interpretation of a normal exercise echocardiogram." }, { "id": "wiki20220301en026_53737", "title": "Cardiac stress test", "score": 0.012023552678892484, "content": "Stress echocardiography A stress test may be accompanied by echocardiography. The echocardiography is performed both before and after the exercise so that structural differences can be compared. A resting echocardiogram is obtained prior to stress. The images obtained are similar to the ones obtained during a full surface echocardiogram, commonly referred to as transthoracic echocardiogram. The patient is subjected to stress in the form of exercise or chemically (usually dobutamine). After the target heart rate is achieved, 'stress' echocardiogram images are obtained. The two echocardiogram images are then compared to assess for any abnormalities in wall motion of the heart. This is used to detect obstructive coronary artery disease. Cardiopulmonary exercise test" }, { "id": "wiki20220301en000_84828", "title": "Coronary artery disease", "score": 0.01162931556632344, "content": "Stable angina In \"stable\" angina, chest pain with typical features occurring at predictable levels of exertion, various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), echocardiography (using ultrasound of the heart) or scintigraphy (using uptake of radionuclide by the heart muscle). If part of the heart seems to receive an insufficient blood supply, coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery. Stable coronary artery disease (SCAD) is also often called stable ischemic heart disease (SIHD). A 2015 monograph explains that \"Regardless of the nomenclature, stable angina is the chief manifestation of SIHD or SCAD.\" There are U.S. and European clinical practice guidelines for SIHD/SCAD. Acute coronary syndrome" }, { "id": "wiki20220301en347_19564", "title": "Coronary CT angiography", "score": 0.011390772757665488, "content": "The positive predictive value of cardiac CTA is approximately 82% and the negative predictive value is around 93%. This means for every 100 patients who appear to have coronary artery disease after CT angiography, 18 of them actually won't have it, and that for every 100 patients who have a negative CT angio test result (i.e. the test says they do not have coronary artery disease), 7 will actually have the disease as defined by the reference standard of invasive coronary angiography via cardiac catheterization. Both coronary CT angiography and invasive angiography via cardiac catheterization yield similar diagnostic accuracy when both are being compared to a third reference standard such as intravascular ultrasound or fractional flow reserve." }, { "id": "pubmed23n0120_13075", "title": "[Two-dimensional exercise echocardiography. Comparison with electrocardiography, myocardial scintigraphy with thallium 201 and coronary angiography].", "score": 0.010980531813865147, "content": "Biapical two-dimensional echocardiograms were obtained immediately before and after a bicycle exercise test in 54 patients referred for coronary angiography. Images of adequate quality were recorded in 47 cases (87%), 39 of whom had significant coronary artery disease. All patients also underwent a stress electrocardiogram. In 22 subjects echocardiography and bicycle stress test in the supine position were combined. 23 patients underwent scintigraphy with thallium-201. The sensitivity of rest and exercise echocardiography for the diagnosis of coronary artery disease was 90% and the specificity 63%, compared to 82% and 75% respectively for the electrocardiogram. The sensitivity for the detection of jeopardized myocardium, defined by angiographic criteria, was 75% for the exercise echocardiogram and 65% for the exercise electrocardiogram in the 28 patients without myocardial infarction. In 19 patients with infarction echocardiography detected jeopardized myocardium with a sensitivity of 73%, compared to 53% for the electrocardiogram. In the subgroup of 23 patients studied by thallium-201 scintigraphy, sensitivity for identification of multivessel disease (8 patients) was comparable for both rest and exercise scintigraphy (6/8) and echocardiography (7/8). The specificities were 88% and 94% respectively. Jeopardized myocardium was detected in this subgroup with a sensitivity of 82% by echocardiography, 76% by thallium scintigraphy and 65% by electrocardiography. In conclusion, this study demonstrates that two-dimensional echocardiography can be combined with exercise electrocardiography in one stress test. This improves the diagnosis of coronary artery disease, detection of jeopardized myocardium and identification of patients with multivessel disease." }, { "id": "InternalMed_Harrison_19103", "title": "InternalMed_Harrison", "score": 0.010084718149234277, "content": "CHAPTER 293 Ischemic Heart DiseaseAEvaluation of the patient with known or suspected IHD Can patient exercise adequately? Are confounding features present on resting ECG? Perform treadmill exercise test An imaging study should be performed Yes No Possible indications for stress testing of patient: 1. Dx of IHD uncertain 2. Assess functional capacity of patient 3. Assess adequacy of treatment program for IHD 4. Markedly abnormal calcium score on EBCT 2-D Echo Nuclear perfusion scan Cardiac MR scan Cardiac PET scan ECHOECG MIBI CMR PET No Yes" }, { "id": "pubmed23n0909_10224", "title": "Dyspnoea on exertion in a 53-year-old woman.", "score": 0.009900990099009901, "content": "A 53-year-old woman with no previous medical history complained of easy fatigue over the last 6 months. She had a positive family history for coronary artery disease but no other risk factors. On physical examination, a 3/6 pansystolic murmur was heard over the apex, and the lung auscultation was unremarkable. Her ECG showed a left anterior fascicular block, with poor R wave progression in the anterior leads (see online supplementary image A). A subsequent echocardiogram revealed a slightly dilated for the patient's body surface area (BSA) (1.73 m<sup2</sup) left ventricle (55/35 mm), with preserved systolic function and a moderate functional mitral regurgitation. The estimated pulmonary artery pressure was 45 mm Hg. During treadmill radionuclide scintigraphy, her exercise tolerance was normal, with good inotropic response, and 96% oxygen saturation at rest and at peak exercise. A 2 mm ST segment depression was noted at peak effort, which persisted well into recovery (see online supplementary image B). The scintigraphy scan showed extensive reversible anteroapical wall ischaemia (see online supplementary image C). At this point she was referred to us for right and left heart catheterisation. Intracardiac pressures and saturations were: right atrium (RA)RA=3 mm Hg, right ventricle (RV)=26/3 mm Hg, Pulmonary artery (PA)=26/10/mean 16 mm Hg, pulmonary capillary wedge pressure (PCWP)=11 mm Hg, left ventricle (LV)=110/10 mm Hg, Aorta (Ao)=110/60/mean 80 mm Hg, Superior vena cava saturation (SVCsat)=62%, RAsat=62%, PAsat=78%, Aosat=96% and estimated pulmonary to systematic flow ratio (Qp/Qs)=1.8. Her coronary angiography and CT angiography are shown in figure 1A,B.DC1SP110.1136/heartjnl-2017-311256.supp1Supplementary material 1 DC2SP210.1136/heartjnl-2017-311256.supp2Supplementary material 2 DC3SP310.1136/heartjnl-2017-311256.supp3Supplementary material 3 heartjnl;103/17/1390/F1F1F1Figure 1Coronary and CT angiograms. What is the most likely diagnosis?Right coronary fistula to right ventricleKawasaki disease with fistulaAnomalous origin of the left coronary artery from the pulmonary arteryPersistent truncus arteriosus." }, { "id": "pubmed23n0315_17600", "title": "Head-to-head comparison of exercise stress testing, pharmacologic stress echocardiography, and perfusion tomography as first-line examination for chest pain in patients without history of coronary artery disease.", "score": 0.009900990099009901, "content": "To overcome the relatively low accuracy of exercise stress testing (EST) in detecting coronary artery disease (CAD), both echocardiography and perfusion scintigraphy have been evaluated in conjunction with pharmacologic stress, but there is still uncertainty of the relative value of these tests as possible first-line examinations for suspected CAD. This study evaluated the accuracy of EST, dipyridamole and dobutamine stress echocardiography (DIP-ECHO, DOB-ECHO), and dipyridamole and dobutamine technetium 99m sestamibi tomography (DIP-MIBI, DOB-MIBI) for the detection of CAD in patients evaluated for the first time because of chest pain. Sixty patients underwent EST, DIP-ECHO, DOB-ECHO, DIP-MIBI, and DOB-MIBI. Echocardiographic images were acquired simultaneously with sestamibi injections, and the scintigraphic images were collected 1 hour later. Coronary angiography was performed within 15 days. Out of 33 patients with significant (&gt;70%) coronary stenoses, 19 (58%) were correctly identified by EST, 18 (55%) by DIP-ECHO, 20 (61%) by DOB-ECHO, 32 (97%) by DIP-MIBI, and 30 (91%) by DOB-MIBI (p &lt; 0.005 for MIBI vs EST and ECHO). The specificity of EST was 67% (p &lt; 0.05 vs ECHO and MIBI), 96%, 96%, 89%, and 81%, respectively. Of the 62 stenotic coronary arteries, 20 (32%) were correctly identified by DIP-ECHO, 24 (39%) by DOB-ECHO, 48 (77%) by DIP-MIBI, and 45 (73%) by DOB-MIBI. The sensitivity of the imaging techniques in predicting the presence of multivessel disease was 14% and 29% for DIP and DOB-ECHO compared with 48% and 57% for DIP and DOB-MIBI. Our results confirm the limited reliability of EST in detecting CAD and the good diagnostic value of DIP and DOB-MIBI. Conversely, the lower sensitivity and the poorer capability to recognize multivessel CAD do not support the role of either DIP or DOB-ECHO as first-line examination for suspected CAD." }, { "id": "article-92338_11", "title": "Multivessel Disease -- Evaluation", "score": 0.009884134146543032, "content": "Intermediate pretest probability is defined as between 10% and 25% to 75% and 90%, respectively, pretest probability of CAD. It must be determined if the patient has baseline EKG abnormalities, which would preclude the interpretation of the EKG and whether the patient has the capacity to exercise. If able to exercise without baseline EKG changes, then the patient can undergo treadmill exercise stress testing. If unable to exercise and baseline EKG abnormalities are present, then they should undergo pharmacological stress echocardiography. If the patient has baseline EKG changes and is able to exercise, then stress nuclear or treadmill stress echocardiography can be performed. If any test returns markedly positive, then the next step would be to perform coronary angiography. [8] Low pretest probability is defined as a lower than 25% or 10% pretest probability of CAD. No additional testing is required." }, { "id": "pubmed23n0549_1558", "title": "[Value of various criteria of assessment of a test in stress echocardiography in diagnosis of ischemic heart disease].", "score": 0.00980392156862745, "content": "Aim of investigation was to study significance of electrocardiographical and echocardiographical criteria of development of angina attack, and their combination in assessment of results of stress echocardiographical tests (stress-echo) with various stress-agents. Stress echocardiography, coronary angiography and left ventriculography were carried out in 928 patients (805 men and 123 women) aged 31 - 72 years with suspected ischemic heart disease (IHD). Attack of angina (AA) was registered in 324 cases, 1.5 mm ST-segment depression (Scapital TE, Cyrillic) -- in 448 tests, disturbances of local myocardial contractility (DLC) at piece exercise -- in 625 patients. Coronaro-ventriculography did not reveal hemodynamically significant coronary artery lesions in 235 patients. Accuracy, sensitivity, and specificity of assessment of stress-echo result were for criterion \"ST\" 62.1, 56.9, 77.4%, respectively, for criterion \"AA\" - 50.0, 40.7, 87.0%, respectively, for criterion DLC - 90.7%, 88.9%, 96.2%, respectively, for combinations of criteria \"ST+DLC\" - 46.1, 30.6, 91.9%, \"ST+AA\" -- 66.7, 56.1, 97.8, respectively, for \"DLC+AA\" -- 54.9, 40.5, 97.4%, respectively. Echocardiographic criterion DLC appears to be determinant in assessment of results of stress-echo tests." }, { "id": "pubmed23n0392_10549", "title": "[Is application of electrocardiographic exercise test always usefull in the diagnosis of coronary artery disease? Advantages and limitations of this method].", "score": 0.009708737864077669, "content": "To determine the diagnostic value of the electrocardiographic exercise testing (EET) in 551 patients with chest pain regarded as definite or probable stable angina pectoris (CAD), results of performed EET were compared with coronary angiography. All patients underwent exercise testing according to the Bruce protocol. The criterion for a positive exercise ST-segment response was &gt; or = 1 mm of horizontal or down sloping depression 80 msec after J-point. The indications for cardiac catheterization in each patient were determined at the discretion of the attending physician. Clinically important coronary artery disease was defined as &gt; 50 per cent narrowing of the diameter of at least one major vessel or &gt; or = 50 per cent of the left main coronary artery. The sensitivity and specificity of EET for detection of CAD were for the entire group, in women and men respectively: 93%, 91%, 94% and 21%, 16%, 27%. 1. Indications for EET should be based on prior probability of coronary artery disease. 2. Application of higher than conventional ST depression criteria (&gt; or = 2 mm) lowers sensitivity but increases specificity of EET. 3. Variables determining false positive results are as follows: age, sex (female), low probability of CAD, ST-segment depression in leads: II, III, aVF and mitral valve prolapse. 4. Variables determining false negative results are as follows: high probability of CAD, sex (male) and one vessel disease." }, { "id": "wiki20220301en437_23399", "title": "Quadricuspid aortic valve", "score": 0.009615384615384616, "content": "Diagnosis Previously, diagnosis was usually done through autopsy. Advances in imaging technologies allow for early detection and thus ample treatment and monitoring of the affected patient. A short-axis ultrasound of the aortic valve allows for the best view of the aortic valve, and gives a clear indication of the adduction pattern of the aortic valves. If an “X” shape is seen, then the patient can be diagnosed with having a quadricuspid aortic valve. A transthoracic echocardiogram (TTE) indicates if there is an aortic regurgitation, but a 3-D transesophageal echocardiogram can give a better view of the aortic valve. Multidetector coronary CT angiography has been indicated as a single competent diagnostic imaging tool capable of delineating valvular anatomy, severity of regurgitation, and high risk coronary problems." }, { "id": "pubmed23n0307_1855", "title": "[A comparative study of 4 diagnostic strategies in coronary artery disease. A theoretical approach].", "score": 0.009615384615384616, "content": "The prognosis of patients with coronary artery disease is constantly improving mainly due to better control of risk factors, to improved methods of myocardial revascularisation and better follow-up. For effective management, the diagnosis of coronary disease has to be established. The authors used a statistical model to study the efficacy of 4 diagnostic strategies used in daily practice: (i) three investigations in two stages: exercise stress testing, stress echocardiography or stress scintigraphy followed by coronary angiography when positive (EE, ECHO, SCINTI): (ii) one stage investigation: coronary angiography of first indication (CORO). When the a priori probability is low or moderate (less than 0.5) the efficacy of EE, ECHO and SCINTI is excellent as there are few false negative results. When the a priori probability of coronary disease is high (0.7 or more), the percentage of false negative results (patients with undetected significant coronary disease) becomes very high. At this level of risk the CORO strategy avoids the false negatives without increasing the costs with respect to the other strategies. In conclusion, the choice of diagnostic strategy of coronary artery disease should take into account the \"a priori\" risk of the patient. When high (&gt; 0.7), coronary angiography of first intention seems to be statistically justified." }, { "id": "wiki20220301en024_105827", "title": "Microvascular angina", "score": 0.009523809523809525, "content": "This is a distinct diagnosis from variant angina. Signs and symptoms While there is no formal definition of microvascular angina, the general consensus is that it entails all of the following: Angina: This usually does not cause dysfunction on echocardiogram and can last longer than that of heart disease. Abnormal cardiac stress test: ST changes are typically similar to those of coronary artery disease, and the opposite of those of Prinzmetal's angina. Myocardial perfusion imaging can be abnormal in 30% of patients. Coronary angiogram: Normal Other causes of chest pain must be ruled out, including: Variant angina / Coronary artery spasm. Esophageal spasm Causes" }, { "id": "pubmed23n0493_9182", "title": "[Algorithm for diagnosing stable coronary artery disease].", "score": 0.009523809523809525, "content": "The aim of the study was to develop simple algorithm for non-invasive estimating probability of the presence of CAD to optimize indications for cardiac catheterization. A prospective collection of clinical, electrocardiography (ECG), exercise electrocardiography (EE), dobutamine stress echocardiography (SE) and catheterization data was performed. All patients (n = 551, 65% male) complaining of chest pain, without prior history of myocardial infarction undergone EE (regarded as positive on the basis of &gt; or = 1 mm ST-depression) SE (ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model) and coronary angiography (CA): CAD was defined as &gt; or = 50% narrowing of at least one major vessel. Two algorithms were developed with the use of probability analysis by computer program which employs Bayes' theory. They incorporated pretest variables: (age, gender, chest pain classification according to Diamond), ECG and results of one or two non-invasive test: EE and (or) SE. The studied population was divided into 3 groups on the basis of pretest likelihood of CAD: 1. low (&lt; 10%), 2. intermediate (10-70%, in man divided into intermediate--low.: 10-29% and intermediate--high: 30-70%) and 3. high (&gt; 70%). The prevalence of CAD in studied population was 61%. The sensitivity of the algorithm is 96% and specificity was 44%. Sensitivity and specificity of EE and SE was respectively: 93%, 21% and 85%, 69%). 1. An algorithm derived in our study is simple and may be useful in decision making that relates to CA. 2. We showed that when the likelihood of CAD is high on the basis of initial evaluation, diagnostic non-invasive testing is not indicated before CA, when the probability is intermediate or low, implementation of first choice test should be different in women (SE) and men (EE)." }, { "id": "wiki20220301en133_3500", "title": "Cardiac myxoma", "score": 0.009433962264150943, "content": "Diagnosis A doctor will listen to the heart with stethoscope. A \"tumor plop\" (a sound related to movement of the tumor), abnormal heart sounds, or a murmur similar to the mid-diastolic rumble of mitral stenosis may be heard. These sounds may change when the patient changes position. Right atrial myxomata rarely produce symptoms until they have grown to be at least 13 cm (about 5 inches) wide. Tests may include: Echocardiogram and Doppler study Chest x-ray CT scan of chest Heart MRI Left heart angiography Right heart angiography ECG—may show atrial fibrillation Blood tests: Blood tests: A FBC may show anemia and increased WBCs (white blood cells). The erythrocyte sedimentation rate (ESR) is usually increased. Blood tests: A FBC may show anemia and increased WBCs (white blood cells). The erythrocyte sedimentation rate (ESR) is usually increased." }, { "id": "pubmed23n0300_12480", "title": "[Cardiac evaluation in arteritis].", "score": 0.009433962264150943, "content": "Coronary artery disease is very frequent and responsible for half of the death in patients with peripheral arterial disease. Clinical and electrocardiographic cardiac check-up must be systematic. The choice of coronary investigations must be guided by the clinical context. Exercise stress testing, with upper limb if necessary, must be performed in patients with suspected coronary artery disease and before high risk surgery. Dobutamine echocardiography or dipyridamole myocardial scintigraphy are justified in patients unable to performed a satisfactory exercise stress testing. Coronary angiography must be limited to patients with angina and/or recent myocardial infarction, and to patients with known coronary artery disease and high risk surgery." }, { "id": "pubmed23n0962_6518", "title": "Case 262.", "score": 0.009345794392523364, "content": "History A 17-year-old white male adolescent was re-evaluated for a withheld cardiac condition initially detected during prenatal imaging at an outside institution. He had previously experienced intermittent episodes of shortness of breath, chest pain, and palpitations with exertion, but more recently he had been asymptomatic. He had no other comorbidities and no family history of congenital heart disease, cardiomyopathy, arrhythmia, or sudden cardiac death. At physical examination, the patient had a grade II/IV rumbling systolic murmur best heard at the left upper sternal border. Otherwise, cardiovascular and other physical examination findings were normal. An electrocardiogram showed sinus bradycardia and nonspecific T wave changes. A graded exercise stress test was normal. Cardiac MRI was performed without and with gadolinium-based contrast material ( Figs 1 - 3 ). Multiple echocardiograms obtained since birth, cardiac MR images obtained 2 and 4 years earlier ( Fig 4 ), and nongated CT images obtained with iodinated contrast material to evaluate trauma 8 years prior ( Fig 5 ) showed findings similar to those of the current examination. Prior chest radiographs (not shown) were normal, and angiography performed when the patient was 4 years old revealed normal coronary arteries. [Figure: see text][Figure: see text][Figure: see text][Figure: see text][Figure: see text][Figure: see text][Figure: see text]." }, { "id": "pubmed23n0132_8433", "title": "Is there an indication for coronary angiography in patients under 60 years of age with no or minimal angina pectoris after a first myocardial infarction?", "score": 0.009345794392523364, "content": "Coronary angiography and exercise stress tests were performed in 91 consecutive patients under 60 years of age having either no or only mild angina pectoris with or without medication after a first myocardial infarction. Nine (10%) patients had angiographic high risk coronary artery disease defined as three vessel disease, left main stenosis, or proximal stenosis of the left anterior descending artery. Eighteen patients had a positive electrocardiographic exercise stress test including eight of the nine patients with angiographic high risk coronary artery disease. It may be concluded therefore that coronary angiography to detect high risk coronary artery disease in this group can be restricted to patients with a positive exercise stress test. This policy would obviate the need for about 80% of coronary angiograms performed in this age group." }, { "id": "wiki20220301en024_29018", "title": "Dextro-Transposition of the great arteries", "score": 0.009259259259259259, "content": "An endovascular stent is sometimes placed in a stenotic vessel immediately following a balloon angioplasty to maintain the widened passage. Angiography involves using the catheter to release a contrast medium into the chambers and/or vessels of the heart; this process facilitates examining the flow of blood through the chambers during an echocardiogram, or shows the vessels clearly on a chest x-ray, MRI, or CT scan - this is of particular importance, as the coronary arteries must be carefully examined and \"mapped out\" prior to the corrective surgery. It is commonplace for any of these palliations to be performed on a d-TGA patient. Moderate Left anterior thoracotomy Isolated pulmonary artery banding (PAB) Left lateral thoracotomy PAB (when coarctation or aortic arch repair also required) Right lateral thoracotomy Blalock-Hanlon atrial septectomy" }, { "id": "pubmed23n0852_18786", "title": "What's the risk? Assessment of patients with stable chest pain.", "score": 0.009259259259259259, "content": "In 2010, the National Institute for Heath and Clinical Excellence published guidelines for the management of stable chest pain of recent onset. Implementation has occurred to various degrees throughout the NHS; however, its effectiveness has yet to be proved. A retrospective study was undertaken to assess the impact and relevance of this guideline, comparing the estimated risk of coronary artery disease (CAD) with angiographic outcomes. Findings were compared with the recently published equivalent European guideline. A total of 457 patients who attended a Rapid Access Chest Pain Clinic were retrospectively reviewed. CAD risk was assessed according to NICE guidelines and patients were separated into typical, atypical and non-anginal chest pain groups. Risk stratification using typicality of symptoms in conjunction with NICE risk scoring and exercise tolerance testing was used to determine the best clinical course for each patient. The results include non-anginal chest pain - 92% discharged without needing further testing; atypical angina - 15% discharged, 40% referred for stress echocardiography, 35% referred for angiogram and significant CAD revealed in 8%; typical angina - 4% discharged, 19% referred for stress echocardiography, 71% referred for angiogram and 40% demonstrated CAD. Both guidelines appear to overestimate the risk of CAD leading to an excessive number of coronary angiograms being undertaken to investigate patients with typical or atypical sounding angina, with a low pick up rate of CAD. Given the high negative predictive value of stress echocardiography and the confidence this brings, there is much scope for expanding its use and potentially reduce the numbers going for invasive angiography. " }, { "id": "wiki20220301en001_252452", "title": "Heart", "score": 0.009174311926605505, "content": "Several imaging methods can be used to assess the anatomy and function of the heart, including ultrasound (echocardiography), angiography, CT, MRI, and PET, scans. An echocardiogram is an ultrasound of the heart used to measure the heart's function, assess for valve disease, and look for any abnormalities. Echocardiography can be conducted by a probe on the chest (transthoracic), or by a probe in the esophagus (transesophageal). A typical echocardiography report will include information about the width of the valves noting any stenosis, whether there is any backflow of blood (regurgitation) and information about the blood volumes at the end of systole and diastole, including an ejection fraction, which describes how much blood is ejected from the left and right ventricles after systole. Ejection fraction can then be obtained by dividing the volume ejected by the heart (stroke volume) by the volume of the filled heart (end-diastolic volume). Echocardiograms can also be conducted under" }, { "id": "pubmed23n0272_10770", "title": "Abnormal exercise electrocardiogram in an asymptomatic person--what next?", "score": 0.009174311926605505, "content": "No reasonable guidelines exist for evaluating an asymptomatic individual (without evidence for ischemic heart disease on history or electrocardiography) with a positive exercise ECG. Available data indicate that persons with a strongly positive test should undergo a coronary angiography. In persons with mild to moderately positive results, cinefluoroscopy is indicated and those who show coronary calcification should have a coronary angiogram. Although stress thallium-201 is often done before coronary angiography, its role is limited. Scant data exist in women and suggest that the overall approach may not be markedly different. However, ST changes in women have a low specificity. Recent studies indicate a 95% specificity and sensitivity for positron emission tomography. Despite its high costs it may still be the most cost-effective modality by saving unwanted radionuclide studies and arteriographies." }, { "id": "pubmed23n0105_45", "title": "[Role of clinical manifestations, the exercise test and exertion angioscintigraphy in the diagnosis of coronary disease. A multivariate study].", "score": 0.00909090909090909, "content": "Data of clinical examination, exercise electrocardiography and stress radionuclide angiography in 102 patients referred for assessment of chest pain was included in a logistic regression to optimise the diagnosis of coronary artery disease with coronary angiography as the reference investigation. None of the patients had other cardiac problems nor previous myocardial infarction. In the absence of symptoms exercise testing was continued until at least 80 p. 100 of the theoretical maximal heart rate was attained. Each patient was characterised by the value of the logistic function or probability of coronary artery disease. A threshold value corresponding to 80 p. 100 sensitivity was determined by the technique of ROC graphs. The significant variables were: a clinical variable--the type of chest pain as assessed by the clinical history; two radionuclide angiographic variables--the ejection fraction at peak effort and the corrected variation of ejection fraction between rest and stress, that is not taking into account possible decreases at the last increment of exercise. Coronary patients can be identified with an 80 p. 100 sensitivity and 77 p. 100 specificity on these criteria. This specificity is greater than that obtained by clinical examination and exercise electrocardiography alone (65 p. 100). Stress radionuclide angiography may therefore reduce the number of unnecessary coronary angiographies." }, { "id": "pubmed23n0076_11946", "title": "[Against routine coronary angiography after myocardial infarction].", "score": 0.009009009009009009, "content": "Various arguments have been put forward to justify routine coronary arteriography after myocardial infarction. This investigation has been said to be essential to: 1) evaluate prognosis--while it has now been shown that combined data based upon coronary history, the initial clinical and electrocardiographic course and stress tests (electrocardiographic and/or isotope) carried out 10 to 20 days after the infarction have a predictive value superior to that of coronary arteriography regarding post-infarct mortality and the remaining functional capacity of the patient; 2) guide therapeutic indications--while patients evaluated as low risk on the basis of the above data, i.e. 50% of all infarction victims, would derive no benefit from myocardial revascularisation procedures; 3) obtain the best cost/efficacy ratio--while it has been shown that approaches based upon stress tests best fulfil this criterion. The authors plead for a reasoned approach in terms of the indication for post-infarction coronary arteriography, with the risk level of patients after the infarct being taken into account overall, and with case by case discussion of the usefulness of the investigation in terms of the patient's age (rarely indicated in the elderly, but also in the younger patient when free of ischemia during exercise), the coronary history (broad indications in recurrent infarctions), the initial clinical course (coronary arteriography indispensable where there is early recurrence of angina and/or severe left ventricular dysfunction with ejection fraction less than 0.45) and the results of stress tests performed 10 to 20 days after the infarct." }, { "id": "pubmed23n0976_17870", "title": "Case 262: Isolated Left Ventricular Apical Hypoplasia.", "score": 0.008928571428571428, "content": "History A 17-year-old white male adolescent was re-evaluated for a withheld cardiac condition initially detected during prenatal imaging at an outside institution. He had previously experienced intermittent episodes of shortness of breath, chest pain, and palpitations with exertion, but more recently he had been asymptomatic. He had no other comorbidities and no family history of congenital heart disease, cardiomyopathy, arrhythmia, or sudden cardiac death. At physical examination, the patient had a grade II/IV rumbling systolic murmur best heard at the left upper sternal border. Otherwise, cardiovascular and other physical examination findings were normal. An electrocardiogram showed sinus bradycardia and nonspecific T wave changes. A graded exercise stress test was normal. Cardiac MRI was performed without and with gadolinium-based contrast material. Multiple echocardiograms obtained since birth, cardiac MR images obtained 2 and 4 years earlier, and nongated CT images obtained with iodinated contrast material to evaluate trauma 8 years prior showed findings similar to those of the current examination. Prior chest radiographs (not shown) were normal, and angiography performed when the patient was 4 years old revealed normal coronary arteries." }, { "id": "pubmed23n0497_19496", "title": "[Implication of probability analysis for diagnosis of stable coronary diseases. Comparison of non-invasive diagnostic tests].", "score": 0.008928571428571428, "content": "A prospective collection of clinical (history), electrocardiography (ECG), exercise electrocardiography (EE), dobutamine stress echocardiography (SE) and catheterization data was performed in 551 patients with chest pain regarded as definite or probable stable angina pectoris. All patients (65% male) without prior history of myocardial infarction undergone clinical evaluation: chest pain classification according to Diamond, ECG, EE (regarded as positive on the basis of &gt; or = 1 mm ST-depression), SE (ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model) and coronary angiography (CA):CAD was defined as &gt; or = 50% narrowing of at least one major vessel. Sensitivity and specificity of ECG, EE, SE was calculated: and results are as follows respectively: 23% and 87%, 93% and 21%, 85% and 69%. On the basis of these results with implication of probability analysis two algorithms were developed by computer program. They incorporated pretest variables: age, gender, chest pain classification, ECG and results of one or two non-invasive tests: EE and (or) SE. The sensitivity and specificity of the algorithm is 96% and 44%. 1. Chest pain characteristics remains an effective tool for estimating probability of CAD. 2. The diagnostic value of resting electrocardiography in stable CAD is low. 3. SE has comparably sensitivity but significantly higher specificity than EE. 4. We demonstrated that when the likelihood of CAD is high on the basis of initial evaluation, diagnostic non-invasive testing is not indicated before CA. 5. When the probability is intermediate or low, implementation of first choice test should be different in women (SE) and men (EE)." }, { "id": "pubmed23n0920_22021", "title": "Exertional dyspnoea in a 28-year-old woman.", "score": 0.008849557522123894, "content": "A 28-year-old woman with a history of critical pulmonic stenosis, status postsurgical valvotomy and subsequent pulmonary valve replacement, presented to the cardiology clinic with 1 year of progressive exertional dyspnoea. She has a heart rate of 75 bpm and blood pressure of 110/55 mm Hg. Cardiac auscultation reveals a 1/6 systolic ejection murmur along the left sternum and an early 3/6 diastolic decrescendo murmur. A transthoracic echocardiogram is obtained (figure 1). Which of the following would be most likely found during right heart catheterisation?Ratio of pulmonary to systemic blood flow (Qp:Qs) &gt;1.5Pulmonary vascular resistance &gt;3 Wood unitsRight atrial pressure &gt;10mm HgPulmonary artery systolic pressure &gt;45mm Hg E. Pulmonary artery diastolic pressure &lt;10mm Hg." } ] } } }

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{ "1": "LDLc<15 mg/dL and Hb A1c <6.5%.", "2": "LDLc<100 mg/dL and Hb A1c <7%.", "3": "LDLc<70 mg/dL and Hb A1c <7%.", "4": "LDLc< 115mg/dL and Hb A1c <7%.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1035_8927", "title": "In patients with stable coronary heart disease, low-density lipoprotein-cholesterol levels &lt; 70 mg/dL and glycosylated hemoglobin A1c &lt; 7% are associated with lower major cardiovascular events.", "score": 0.0166459455725929, "content": "In patients with stable coronary heart disease, it is not known whether achievement of standard of care (SOC) targets in addition to evidence-based medicine (EBM) is associated with lower major adverse cardiovascular events (MACE): cardiovascular death, myocardial infarction, and stroke. EBM use was recommended in the STabilisation of Atherosclerotic plaque By Initiation of darapLadIb TherapY trial. SOC targets were blood pressure (BP) &lt;140/90 mm Hg and low-density lipoprotein-cholesterol (LDL-C) &lt;100 mg/dL and &lt;70 mg/dL. In patients with diabetes, glycosylated hemoglobin A1c (HbA1c) &lt; 7% and BP of &lt;130/80 mm Hg were recommended. Feedback to investigators about rates of EBM and SOC was provided regularly. In 13,623 patients, 1-year landmark analysis assessed the association between EBM, SOC targets, and MACE during follow-up of 2.7 years (median) after adjustment in a Cox proportional hazards model. At 1 year, aspirin was prescribed in 92.5% of patients, statins in 97.2%, β-blockers in 79.0%, and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers in 76.9%. MACE was lower with LDL-C &lt; 100 mg/dL (70-99 mg/dL) compared with LDL-C ≥ 100 mg/dL (hazard ratio [HR] 0.694, 95% CI 0.594-0.811) and lower with LDL-C &lt; 70 mg/dL compared with LDL-C &lt; 100 mg/dL (70-99 mg/dL) (HR 0.834, 95% CI 0.708-0.983). MACE was lower with HbA1c &lt; 7% compared with HbA1c ≥ 7% (HR 0.705, 95% CI 0.573-0.866). There was no effect of BP targets on MACE. MACE was lower with LDL-C &lt; 100 mg/dL (70-99 mg/dL) and even lower with LDL-C &lt; 70 mg/dL. MACE in patients with diabetes was lower with HbA1c &lt; 7%. Achievement of targets is associated with improved patient outcomes." }, { "id": "pubmed23n0916_9090", "title": "HEMOGLOBIN A1C, BLOOD PRESSURE, AND LDL-CHOLESTEROL CONTROL AMONG HISPANIC/LATINO ADULTS WITH DIABETES: RESULTS FROM THE HISPANIC COMMUNITY HEALTH STUDY/STUDY OF LATINOS (HCHS/SOL).", "score": 0.015595794392523364, "content": "To determine the prevalence of Hispanic/Latino adults with diabetes who meet target hemoglobin A1c, blood pressure (BP), and low-density-lipoprotein cholesterol (LDL-C) recommendations, and angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blocker (ARB) and statin medication use by heritage and sociodemographic and diabetes-related characteristics. Data were cross-sectional, collected between 2008 and 2011, and included adults age 18 to 74 years who reported a physician diagnosis of diabetes in the Hispanic Community Health Study/Study of Latinos (N = 2,148). Chi-square tests compared the prevalence of hemoglobin A1c, BP, and LDL-C targets and ACE/ARB and statin use across participant characteristics. Predictive margins regression was used to determine the prevalence adjusted for sociodemographic characteristics. The overall prevalence of A1c &lt;7.0% (53 mmol/mol), BP &lt;130/80 mm Hg, and LDL-C &lt;100 mg/dL was 43.0, 48.7, and 36.6%, respectively, with 8.4% meeting all three targets. Younger adults aged 18 to 39 years with diabetes were less likely to have A1c &lt;7.0% (53 mmol/mol) or LDL-C &lt;100 mg/dL compared to those aged 65 to 74 years; younger adults were more likely to have BP &lt;130/80 mm Hg (P&lt;.05 for all). Individuals of Mexican heritage were significantly less likely to have A1c &lt;7.0% (53 mmol/mol) compared to those with Cuban heritage, but they were more likely to have BP &lt;130/80 mm Hg compared to those with Dominican, Cuban, or Puerto Rican heritage (P&lt;.05 for all); there was no difference in LDL-C by heritage. Overall, 38.2% of adults with diabetes were taking a statin, and 50.5% were taking ACE/ARB medications. Hemoglobin A1c, BP, and LDL-C control are suboptimal among Hispanic/Latinos with diabetes living in the U.S. With 8.4% meeting all three recommendations, substantial opportunity exists to improve diabetes control in this population. A1c = hemoglobin A1c; ABC = hemoglobin A1c, blood pressure, low-density-lipoprotein cholesterol; ACE = angiotensin-converting enzyme; ADA = American Diabetes Association; ARB = angiotensin receptor blocker; BMI = body mass index; BP = blood pressure; CHD = coronary heart disease; CVD = cardiovascular disease; HCHS/SOL = Hispanic Community Health Study/Study of Latinos; LDL-C = low-density-lipoprotein cholesterol; NHANES = National Health and Nutrition Examination Survey; PAD = peripheral artery disease." }, { "id": "pubmed23n0748_5313", "title": "Independent contribution of A1C, systolic blood pressure, and LDL cholesterol control to risk of cardiovascular disease hospitalizations in type 2 diabetes: an observational cohort study.", "score": 0.013696715583508037, "content": "Cardiovascular disease (CVD) prevention in diabetes requires broad-based treatment of dyslipidemia, hypertension, and hyperglycemia. The independent contribution of all combinations of risk factor control to CVD risk has not been evaluated. To estimate the independent association of control of glycosylated hemoglobin (A1C), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) with risk of cardiovascular disease hospitalization. Non-concurrent longitudinal cohort study. The study included 26,636 patients with type 2 diabetes who were members of an integrated group model HMO with multiple A1C, SBP, and LDL-C measurements. Patients were followed for a mean (SD) of 5.6 (2.5) years until they died or disenrolled, or until 31 December 2010. The outcome was a first-observed CVD hospitalization. Using the mean of all A1C, SBP, and LDL-C measures during follow-up, we created dichotomous categories of A1C control (&lt; 7 %), SBP control (&lt; 130 mmHg), and LDL-C control (&lt; 100 mg/dL) to estimate the incidence rate of CVD hospitalization associated with all combinations of risk factor control adjusting for demographic and clinical characteristics. Patients with no controlled risk factors (18.2/1,000 person-years, 95 % CI 16.5-20.2) or with only A1C in control (16.9, 15.0-19.0) had the highest rate of CVD hospitalization, whereas those with all three risk factors controlled (7.2, 6.2-8.4) or with SBP and LDL-C in control (6.1, 5.1-7.2) had the lowest rates. Those with only SBP or LDL-C in control, A1C and SBP controlled, or A1C and LDL-C controlled had statistically similar incidence between the highest and lowest rates. Maintaining SBP &lt; 130 mmHg or LDL-C &lt; 100 mg/dL was significantly associated with reduced CVD hospitalization risk, especially when both risk factors were well controlled. Maintaining A1C &lt; 7 % was not independently associated with reduced CVD hospitalization risk." }, { "id": "InternalMed_Harrison_27840", "title": "InternalMed_Harrison", "score": 0.013680425265791121, "content": "<7.0%c 4.4–7.2 mmol/L (80–130 mg/dL) <10.0 mmol/L (<180 mg/dL) <2.6 mmol/L (100 mg/dL)g >1 mmol/L (40 mg/dL) in men >1.3 mmol/L (50 mg/dL) in women <1.7 mmol/L (150 mg/dL) aAs recommended by the American Diabetes Association; goals should be individualized for each patient (see text). Goals may be different for certain patient populations. bHbA1c is primary goal. cDiabetes Control and Complications Trial–based assay. d1–2 h after beginning of a meal. eGoal of <130/80 mmHg may be appropriate for younger individuals fIn decreasing order of priority. Recent guidelines from the American College of Cardiology and American Heart Association no longer advocate specific LDL and HDL goals (see Chaps. 291e and 419). gGoal of <1.8 mmol/L (70 mg/dL) may be appropriate for individuals with cardiovascular disease. Abbreviation: HbA1c, hemoglobin A1c. Source: Adapted from American Diabetes Association: Diabetes Care 38(Suppl 1):S1, 2015. PATIENT EDUCATION ABOUT DM, NUTRITION, AND EXERCISE" }, { "id": "pubmed23n0386_14431", "title": "Treatment of cardiac risk factors in diabetic patients: How well do we follow the guidelines?", "score": 0.013563218390804599, "content": "Diabetic patients are at increased risk for both macrovascular and microvascular disease compared with nondiabetic patients. We conducted a prospective observational study to assess the control of multiple predetermined cardiovascular risk factors in 235 treated diabetic patients undergoing elective cardiac catheterization at our institution between December 20, 1997, and February 15, 2000. The following parameters were used to define optimal treatment in these patients: hemoglobin (Hgb) A1c &lt;7%, low-density lipoprotein cholesterol (LDL-c) &lt;100 mg/dL, high-density lipoprotein cholesterol (HDL-c) &gt;/=45 mg/dL for men and &gt;/=55 mg/dL for women, triglyceride (TG) level &lt;200 mg/dL, blood pressure (BP) &lt;130/85 mm Hg, body mass index (BMI) &lt;25, daily aspirin therapy, and current nonsmoking status. The use of b-blockers and angiotensin-converting enzyme inhibitors was also evaluated. The average patient age was 64 +/- 11 years; 155 (65%) were male. One hundred ninety-one (81%) patients had documented coronary artery disease at cardiac catheterization. The mean Hgb A1c level for all diabetic patients was 8.2% +/- 1.6%. Overall, 49 (21%) had an Hgb A1c level &lt;7%. The fasting cholesterol panel for all patients revealed a mean LDL-c level of 103 +/- 41 mg/dL, a mean HDL level of 39 +/- 11 mg/dL, and a mean TG level of 164 +/- 128 mg/dL. One hundred sixteen (52%) patients had an LDL-c &lt;100 mg/dL. Only 32 of 147 (22%) male patients and 14 of 80 (18%) female patients achieved an HDL-c &gt;/=45 mg/dL or &gt;/=55 mg/dL, respectively. One hundred seventy-seven of 232 (76%) patients had a TG level &lt;200 mg/dL. Only 23 of 233 (10%) diabetics were controlled to a BP of &lt;130/85 mm Hg, and 25 (11%) achieved a BMI &lt;25. Only one patient (0.4%) had optimal control of all modifiable risk factors. These data demonstrate the poor control of numerous cardiovascular risk factors in treated diabetics undergoing elective cardiac catheterization." }, { "id": "wiki20220301en233_16744", "title": "Health coaching", "score": 0.012418764964348673, "content": "Efficacy Several studies have shown health coaching to be effective in improving various aspects of health. One study on type 2 diabetes concludes that after six months, individuals who were coached showed improvement in medication adherence. Coaching had a positive effect on patients' knowledge, skill, self-efficacy and behavior change while a non-coached control group did not show any improvement. Additionally, coached participants with a hemoglobin A1C over 7% showed significant improvement in A1C. A study on coronary heart disease indicated that patients in a coaching program achieved a significantly greater change in total cholesterol of 14 mg/dl than the non-coached patients, with a considerable reduction in LDL-C. Those involved in the coaching program showed improvements in secondary outcomes such as weight loss, increased exercise, improved quality of life, less anxiety, and improvement in overall health and mood." }, { "id": "wiki20220301en000_205020", "title": "Hemoglobin", "score": 0.012056162512803004, "content": "To a small extent, hemoglobin A slowly combines with glucose at the terminal valine (an alpha aminoacid) of each β chain. The resulting molecule is often referred to as Hb A1c, a glycated hemoglobin. The binding of glucose to amino acids in the hemoglobin takes place spontaneously (without the help of an enzyme) in many proteins, and is not known to serve a useful purpose. However, as the concentration of glucose in the blood increases, the percentage of Hb A that turns into Hb A1c increases. In diabetics whose glucose usually runs high, the percent Hb A1c also runs high. Because of the slow rate of Hb A combination with glucose, the Hb A1c percentage reflects a weighted average of blood glucose levels over the lifetime of red cells, which is approximately 120 days. The levels of glycated hemoglobin are therefore measured in order to monitor the long-term control of the chronic disease of type 2 diabetes mellitus (T2DM). Poor control of T2DM results in high levels of glycated" }, { "id": "wiki20220301en070_34864", "title": "Diabetes management", "score": 0.011383120594398933, "content": "\"Perfect glycemic control\" would mean that glucose levels were always normal (70–130 mg/dl, or 3.9–7.2 mmol/L) and indistinguishable from a person without diabetes. In reality, because of the imperfections of treatment measures, even \"good glycemic control\" describes blood glucose levels that average somewhat higher than normal much of the time. In addition, one survey of type 2 diabetics found that they rated the harm to their quality of life from intensive interventions to control their blood sugar to be just as severe as the harm resulting from intermediate levels of diabetic complications. In the 1990s the American Diabetes Association conducted a publicity campaign to persuade patients and physicians to strive for average glucose and hemoglobin A1c values below 200 mg/dl (11 mmol/l) and 8%. Currently, many patients and physicians attempt to do better than that." }, { "id": "wiki20220301en180_32358", "title": "Prediabetes", "score": 0.010653409090909092, "content": "Prediabetes Screening in a Dental Setting Screening The United States Preventative Services Task Force (USPSTF) recommends adults who are overweight/obese and aged 40–70 years old to get screened during visits to their regular physician. The American Diabetes Association (ADA) recommends normal testing repeated every three years and recommends a larger range of people get tested: anyone over the age of 45 regardless of risk; an adult of any age who is obese or overweight and has one or more risk factors, which includes hypertension, a first degree relative with diabetes, a physical inactivity, high risk race/ethnicity, Asian Americans with BMI of ≥23 kg/m2, HDL < 35 mg/dL or TG > 250 mg/dL, women who have delivered child >9 lbs or with gestational diabetes, A1c ≥ 5.7%, impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)." }, { "id": "pubmed23n0733_10778", "title": "Systematic analysis of risk factors for coronary heart disease in Japanese patients with type 2 diabetes: a matched case-control study.", "score": 0.009900990099009901, "content": "To identify predictors of coronary heart disease (CHD) in Japanese patients with type 2 diabetes (T2DM). A matched case-control study was performed using 800 patients with T2DM admitted for treatment of hyperglycemia from January 2002 to June 2010. Cases comprised 16 patients who had developed acute myocardial infarction and/or received a coronary artery bypass by June 2010, and controls comprised 48 age- and sex-matched patients without CHD events. The mean age, glycated hemoglobin (HbA1c), and body mass index (BMI) were 61.5 yrs, 9.7% and 24.4 kg/m(2), respectively. The relationship of baseline variables, including lipid values, HbA1c, BMI, blood pressure, fasting blood sugar, 2h-post-breakfast blood sugar, delta blood sugar(0-2h), urinary albumin excretion, estimated glomerular filtration rate and treatment modalities (insulin/sulfonylurea/biguanide), to CHD development was analyzed by conditional logistic regression analysis. Total cholesterol (TC) (OR 2.35, 95%CI 1.11-4.98, p=0.03), non-HDL-cholesterol (OR 3.07, 95%CI 1.33-7.10, p=0.009), LDL-cholesterol (OR 2.84, 95%CI 1.24-6.51, p=0.01), non-HDL-cholesterol/HDL-cholesterol (OR 2.07, 95%CI 1.10-3.90, p=0.02) and LDL-cholesterol/ HDL-cholesterol (OR 2.74, 95%CI 1.22-6.15, p=0.01) were significantly related to CHD. Fold risk increment per 1-SD increase in basal TC, non-HDL-cholesterol, LDL-cholesterol, non-HDL-cholesterol/HDL-cholesterol and LDL-cholesterol/HDL-cholesterol was 2.33, 2.89, 2.52, 2.37 and 2.60, respectively. Only non-HDL-cholesterol was an independent risk factor. From the receiver operating characteristic curve, 3.89 mmol/L non-HDL-C was the best cutoff value. None of the non-lipid variables were significantly related to CHD. Non-HDL-cholesterol was the most dominant predictor of the development of CHD in Japanese patients with T2DM." }, { "id": "pubmed23n0559_17795", "title": "[Compliance with the 2002 consensus document of the Spanish Society of Nephrology for the control of diabetic nephropathy in Catalonia (ECCODIAB)].", "score": 0.00980392156862745, "content": "To evaluate the level of compliance with the 2002 consensus document (Spanish Society of Nephrology) on guidelines for the detection, prevention and treatment of diabetic nephropathy in Catalonia. Multicenter (23 hospitals), observational, cross-sectional, descriptive study conducted in 413 diabetic patients (61.7% men, 38.3% women) with a median age of 66.2 +/-11.5 years (26-93 years). The ANOVA test (post-hoc analysis; p value&lt; 0.05) was used to study the relationships between the stages of diabetic nephropathyand different variables. 90.3% of the patients had type 2 DM. The following anthropometric parameters were observed: BMI 29.8 +/- 5 kg/m2 (BMI &gt; 30 kg/m2: 48.7%) and waist circumference 104.1 +/- 14 cm (48.6% men &gt; 102 cm and 78.9% women &gt; 88 cm). Serum creatinine 1.9 +/- 1.3 mg/dl and simplified MDRD equation 45.3 +/- 25.0 ml/min/1.73 m2 [65.8%with CKD stages 3 and 4]. 80% of patients had ophthalmologic examination and 52.8% antiplatelet treatment. Hb A1c was 7.3 +/- 1.3%, but the percentage of patients with glycated hemoglobin &gt; 7% and 8% was 54.9 and 28.6% [only 50.2% had been seen by an endocrinologist in the last 6 months]. 52.8% of patients were treated with insulin and 44.1% with anti-diabetic drugs, although only 19.6% used the new anti-diabetic drugs. 61% of patients had an LDLc &gt; 100 mg/dl (61% treated) and 44% had triglycerides (TG) &gt; 150 mg/dl (72% treated). 95% of patients presented with hypertension (BP &gt; or = 130/80 mmHg),91% were undergoing antihypertensive treatment (79.7% with angiotensin-converting enzyme inhibitors and / or angiotensin receptor blockers). 81% with microalbuminuria and 78%with established proteinuria were receiving anti-proteinuric treatment. Of the patients considered to be refractory to BP (&gt;3 drugs), only 28.9% underwent ambulatory BP monitoring. Significant differences were observed between stages of diabetic nephropathy and glycated hemoglobin (HBA1c; p = 0.048), systolic blood pressure (SBP; p = 0.024), lipidic control (HDLc; p = 0.015 and TG; p = 0.034), anemia (Hb; p = 0.010) and CKD (creatinine and sMDRD; p = 0.000). The levels of compliance with the therapeutic objectives regarding lipid control (LDL &lt; or = 100 mg/dl and TG&lt; or = 150 mg/dl), BP &lt; or = 130/80 mmHg and HbA1c &lt; or =7% were 1 objective: 68%, 2 objectives: 21.8% and 3 objectives: only 4% of patients. According to the results of our study, only a reduced proportion of patients fulfilled the different therapeutic end-points indicated. Future measures will be directed at improving physician-patient relationships with the main aim of intensifying the therapeutic measures to attain better metabolic and blood pressure control, nephroprotection and prevention in the appearance of cardiovascular events." }, { "id": "pubmed23n0826_10992", "title": "The ABC of diabetes. How many patients are able to achieve the goal laid down by American Diabetes Association?", "score": 0.00980392156862745, "content": "To study the number of patients with Type 2 Diabetes Mellitus who achieve the glycemic, blood pressure and LDL-Cholesterol targets as per American Diabetes Association, Standard of Care for Management of Diabetes. Hundred patients of Type 2 Diabetes mellitus were recruited from December 2008 to January 2009 from an Endocrinology OPD of tertiary care hospital and followed up for six months. Glycosylated hemoglobin (HbA1c), blood pressure (BP) and LDL-Cholesterol (LDL) were estimated at baseline and prevalence of those at target (HbA1c &lt;7%, BP &lt; 130/80 mm Hg, LDL &lt; 100 mg/dl) was documented and repeated at three and six months to monitor improvement in the number of patients at target and trend in improvement of individual parameters. The percentage of patients at target at baseline and six months for HbA1c was (45% vs. 55% p = 0.101), BP &lt; 130/80 mm Hg (27% vs. 25%) and LDL &lt;100 mg/dl (37% vs. 40% p = 0.386). All three parameters were at target in one patient and three patients at six months period. Mean values at baseline and six months of HbA1c 7.46% (95% CI 7.17-7.75) vs 7.21% (95% CI 6.9-7.52), Systolic BP 138 mm Hg (95% CI 135-141), Diastolic BP 86 mm Hg (95% CI 84-86) and LDL 114 mg/dl (95%CI 107-121) vs. 110 mg/dl (95%CI 105-116) did not show significant improvement (p for trend). Standards of care for HbA1c, blood pressure and LDL remains to be achieved in majority of the diabetic patients." }, { "id": "pubmed23n0917_1768", "title": "[Trends in the level of control of patients with type 2 diabetes from 2010 to 2015].", "score": 0.009708737864077669, "content": "Aim: To examine the trend in the level of control of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL-cholesterol (LDL) in patients with type 2 diabetes mellitus between 2010 and 2015. Setting: 3 cut-offs in the years 2010, 2013, and 2015. Southeast area of Madrid. Descriptive and cross-sectional epidemiological study. Patients diagnosed and registered with type 2 diabetes. N=41,096 (2010), n=49,658 (2013), n=6,674 (2015) MAIN MEASUREMENTS: Measurement or not in the last year of HbA1c, BP, and LDL. Control of HbA1c (&lt;7% individual targeting), BP (&lt;140/90mmHg), and LDL (&lt;100mg/dL, if cardiovascular disease &lt;70mg/dL). Data were collected from electronic records of clinical history. The Chi-square test was used. The percentages of patients with each parameter measured in 2010, 2013 and 2015 were: HbA1c: 36.4%, 37.0%, 62.0% (P&lt;.001); BP: 33.2%, 43.3%, 65.0% (P&lt;.001); LDL: 32.9%, 33.2%, 43.5% (P&lt;.001). The percentages of patients with each parameter measured and controlled in 2010, 2013, and 2015 were: HbA1c: 59.6%, 59.1%, 79.6% (P&lt;.001); BP: 74.9%, 67.4%, 79.2% (P&lt;.001); LDL: 41.8%, 58.3%, 58.8% (P&lt;.001) CONCLUSION: In the 2010-2015 period, a sustained but insufficient trend of better control of HbA1c, BP and LDL was observed in patients with diabetes. The frequency of the measurements of these parameters improved more than the control of them. It seems that efforts to improve care for the patient with diabetes pay off, but they still have to be maintained." }, { "id": "article-36052_24", "title": "Type 2 Diabetes -- Evaluation -- Glycated Hemoglobin (Hb) A1C", "score": 0.009678577561310667, "content": "Anemia due to deficiency of iron or vitamin B12 leads to spurious elevation of Hb A1C, limiting its use in countries with a high prevalence of anemia. Also, in children and the elderly, the relation between Hb A1C and FPG is suboptimal. For all of the above tests, if the person is asymptomatic, testing should be repeated later to make a diagnosis of diabetes mellitus. In patients with classic symptoms of hyperglycemia (increased thirst, increased hunger, increased urination), random plasma glucose more than 200 mg/dL is also sufficient to diagnose DM. FPG, 2-hour PG during 75-g GTT, and Hb A1C are equally appropriate for the diagnosis of DM. There is no concordance between the results of these tests." }, { "id": "wiki20220301en000_205027", "title": "Hemoglobin", "score": 0.009615384615384616, "content": "Long-term control of blood sugar concentration can be measured by the concentration of Hb A1c. Measuring it directly would require many samples because blood sugar levels vary widely through the day. Hb A1c is the product of the irreversible reaction of hemoglobin A with glucose. A higher glucose concentration results in more Hb A1c. Because the reaction is slow, the Hb A1c proportion represents glucose level in blood averaged over the half-life of red blood cells, is typically ~120 days. An Hb A1c proportion of 6.0% or less show good long-term glucose control, while values above 7.0% are elevated. This test is especially useful for diabetics. The functional magnetic resonance imaging (fMRI) machine uses the signal from deoxyhemoglobin, which is sensitive to magnetic fields since it is paramagnetic. Combined measurement with NIRS shows good correlation with both the oxy- and deoxyhemoglobin signal compared to the BOLD signal." }, { "id": "pubmed23n0362_22336", "title": "Revisiting the oral glucose tolerance test criterion for the diagnosis of diabetes.", "score": 0.009523809523809525, "content": "The Expert Committee on the Diagnosis and Classification of Diabetes retained the 2-hour glucose concentration on an oral glucose tolerance test of &gt;/=11.1 mmol/L (200 mg/dL) as a criterion to diagnose diabetes. Since glycated hemoglobin levels have emerged as the best measure of long-term glycemia and an important predictor of microvascular and neuropathic complications, we evaluated the distribution of hemoglobin A1C (Hb A1C) levels in individuals who had undergone an oral glucose tolerance test to determine how well 2-hour values could identify those with normal versus increased Hb A1C levels. A cross-sectional analysis of 2 large data sets was performed. We cross-tabulated 2-hour glucose concentrations on an oral glucose tolerance test separated into 4 intervals (&lt;7.8 mmol/L [140 mg/dL], 7.8-11.0 mmol/L [140-199 mg/dL], 11.1-13.3 mmol/L [200-239 mg/dL], and &gt;/=13.3 mmol/L [240 mg/dL]) with Hb A1C levels separated into 3 intervals (normal; &lt;1% above the upper limit of normal; and greater than or equal to the upper limit of normal + 1%). Approximately two thirds of patients in both data sets with 2-hour glucose concentrations of 11.1 to 13.3 mmol/L (200-239 mg/dL) had normal Hb A1C levels. In contrast, 60% to 80% of patients in both data sets with 2-hour glucose concentrations &gt;/=13.3 mmol/L (240 mg/dL) had elevated Hb A1C levels. Since Hb A1C levels are the best measures presently available that reflect long-term glycemia, we conclude that the 2-hour glucose concentration criterion on an oral glucose tolerance test for the diagnosis of diabetes should be raised from &gt;/= 11.1 mmol/L (200 mg/dL) to &gt;/= 13.3 mmol/L (240 mg/dL) to remain faithful to the concept that diagnostic concentrations of glucose should predict the subsequent development of specific diabetic complications (e.g., retinopathy)." }, { "id": "pubmed23n0810_9863", "title": "All-cause mortality in patients with type 2 diabetes in association with achieved hemoglobin A(1c), systolic blood pressure, and low-density lipoprotein cholesterol levels.", "score": 0.009523809523809525, "content": "To identify the ranges of hemoglobin A(1c) (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels which are associated with the lowest all-cause mortality. A retrospective cohort of 12,643 type 2 diabetic patients (aged ≥18 years) were generated from 2002 to 2010, in Far-Eastern Memorial Hospital, New Taipei city, Taiwan. Patients were identified to include any outpatient diabetes diagnosis (ICD-9: 250), and drug prescriptions that included any oral hypoglycemic agents or insulin prescribed during the 6 months following their first outpatient visit for diabetes. HbA1c, SBP, and LDL-C levels were assessed by the mean value of all available data, from index date to death or censor date. Deaths were ascertained by matching patient records with the Taiwan National Register of Deaths. Our results showed general U-shaped associations, where the lowest hazard ratios occurred at HbA1c 7.0-8.0%, SBP 130-140 mmHg, and LDL-C 100-130 mg/dL. The risk of mortality gradually increases if the patient's mean HbA1c, SBP, or LDL-C during the follow-up period was higher or lower than these ranges. In comparison to the whole population, the adjusted hazard ratio (95% CI) for patients with HbA1c 7.0-8.0%, SBP 130-140 mmHg, and LDL-C 100-130 mg/dL were 0.69 (0.62-0.77), 0.80 (0.72-0.90), and 0.68 (0.61-0.75), respectively. In our type 2 diabetic cohort, the patients with HbA1c 7.0-8.0%, SBP 130-140 mmHg, or LDL-C 100-130 mg/dL had the lowest all-cause mortality. Additional research is needed to confirm these associations and to further investigate their detailed mechanisms." }, { "id": "wiki20220301en012_132177", "title": "Green tea", "score": 0.009433962264150943, "content": "Glycemic control Green tea consumption lowers fasting blood sugar but in clinical studies the beverage's effect on hemoglobin A1c and fasting insulin levels was inconsistent. Hyperlipidemia Drinking green tea or taking green tea supplements decreases the blood concentration of total cholesterol (about 3–7 mg/dL), LDL cholesterol (about 2 mg/dL), and does not affect the concentration of HDL cholesterol or triglycerides. A 2013 Cochrane meta-analysis of longer-term randomized controlled trials (>3 months duration) concluded that green tea consumption lowers total and LDL cholesterol concentrations in the blood. Inflammation A 2015 systematic review and meta-analysis of 11 randomized controlled trials found that green tea consumption was not significantly associated with lower plasma levels of C-reactive protein levels (a marker of inflammation). Weight loss There is no good evidence that green tea aids in weight loss or weight maintenance." }, { "id": "pubmed23n0762_9046", "title": "Clinical and economic benefits associated with the achievement of both HbA1c and LDL cholesterol goals in veterans with type 2 diabetes.", "score": 0.009433962264150943, "content": "This study compared the clinical and economic benefits associated with dual-goal achievement, glycated hemoglobin (HbA1c)&lt;7% (53 mmol/mol) and LDL cholesterol (LDL-C)&lt;100 mg/dL, with achievement of only the LDL-C goal or only the HbA1c goal in veterans with type 2 diabetes mellitus (T2DM). This retrospective cohort analysis evaluated electronic medical records (Veterans Integrated Service Network 16) in adult T2DM patients with two or more measurements of LDL-C and HbA1c between 1 January 2004 and 30 June 2010 (N=75,646). Cox proportional hazards models were used to compare microvascular and cardiovascular outcomes by goal achievement status; generalized linear regression models were used to assess diabetes-related resource utilization (hospitalization days and number of outpatient visits) and medical service costs. Relative to achievement of only the LDL-C goal, dual-goal achievement was associated with lower risk of microvascular complications (adjusted hazard ratio [aHR] 0.79), acute coronary syndrome (0.88), percutaneous coronary intervention (0.78), and coronary artery bypass graft (CABG) (0.74); it was also associated with fewer hospitalization days (adjusted incidence rate ratio [aIRR] 0.93) and outpatient visits (0.88), as well as lower diabetes-related annual medical costs (-$130.89). Compared with achievement of only the HbA1c goal, dual-goal achievement was associated with lower risk of the composite cardiovascular-related end point (aHR 0.87) and CABG (aHR 0.62), as well as fewer outpatient visits (aIRR 0.98). Achieving both HbA1c and LDL-C goals in diabetes care is associated with additional clinical and economic benefits, as compared with the achievement of either goal alone." }, { "id": "pubmed23n1120_24133", "title": "Glycated Albumin for the Diagnosis of Diabetes in US Adults.", "score": 0.009345794392523364, "content": "There is growing interest in using glycated albumin for the diagnosis of diabetes, especially when standard tests (glucose and hemoglobin A1c [Hb A1c]) are unavailable. However, it is unknown how well glycated albumin identifies diabetes in the general population. We measured glycated albumin in stored serum samples from the 1999-2004 National Health and Nutrition Examination Survey. We evaluated the ability of glycated albumin to identify undiagnosed diabetes in US adults aged ≥20 (n = 4785), overall and at thresholds corresponding to clinical cut points for Hb A1c and fasting plasma glucose (FPG). We assessed 4 reference definitions for undiagnosed diabetes: increased FPG (≥126 mg/dL) [≥6.99 mmol/L), increased Hb A1c (≥6.5%), either FPG or Hb A1c increased, or both FPG and Hb A1c increased. Among US adults, glycated albumin had excellent diagnostic accuracy across all 4 definitions of undiagnosed diabetes, with the area under the receiver operating characteristic curve (AUC) ranging from 0.824 to 0.951. Performance was generally consistent across patient demographic and clinical characteristics. Glycated albumin cut points of 16.5% and 17.8% were equivalent to an FPG of 126 mg/dL (6.99 mmol/L; 97th percentile) and Hb A1c of 6.5% (98th percentile) and had low to moderate sensitivity (0.273 to 0.707) but high specificity (0.980 to 0.992) for detecting undiagnosed diabetes. The excellent diagnostic performance of glycated albumin to identify diabetes defined by either FPG or Hb A1c suggests that glycated albumin may be useful for identifying adults with undiagnosed diabetes when standard tests are unavailable." }, { "id": "pubmed23n0701_21905", "title": "Screening for diabetes using monitoring guidance in schizophrenia patients treated with second-generation antipsychotics: a 1-year follow-up study.", "score": 0.009259259259259259, "content": "Second-generation antipsychotics (SGAs) tend to induce weight gain, dyslipidemia and diabetes mellitus. For those reasons, patients treated with SGAs should receive appropriate monitoring to avoid morbidity and mortality associated with cardiovascular disease. We conducted a one-year follow-up study using Japanese blood glucose monitoring guidance in schizophrenia patients treated with SGAs to evaluate the detection capability of the guidance in real clinical settings and to assess the importance of longitudinal monitoring. This retrospective cohort study included schizophrenia patients receiving at least one SGA, who were enrolled during June 2008-January 2009 at multiple sites and who had both baseline data and follow-up monitoring data at month 12. After one-year follow-up, the probable diabetes type (fasting blood glucose is higher than 125 mg/dL, casual blood glucose is higher than 179 mg/dL, or glycosylated hemoglobin (Hb(A1c)) is greater than 6.4%) was detected in 30 (8%) of the patients, and the pre-diabetes type (fasting blood glucose is 110-125 mg/dL, or casual blood glucose is 140-179 mg/dL, or Hb(A1c) is 6.0-6.4%) in 65 (17.4%) out of the total of 374 patients. During the follow-up period, 1.5% of patients had advanced from the normal (fasting blood glucose is less than 110 mg/dL, casual blood glucose is less than 140 mg/dL, or Hb(A1c) is less than 6.0%) to probable diabetes type and 42.4% had progressed from the pre-diabetes to probable diabetes type. Predictive factors for worsening of the diabetic state were a family history of diabetes, and high serum total-cholesterol and triglyceride levels at baseline. Not only cross-sectional baseline screening but also longitudinal follow-up screening is important to detect glucose abnormalities in patients treated with SGAs." }, { "id": "pubmed23n0802_14602", "title": "Association of glycemic control with mortality in patients with diabetes mellitus undergoing percutaneous coronary intervention.", "score": 0.009259259259259259, "content": "Diabetes mellitus adversely affects outcomes in patients undergoing percutaneous coronary intervention. The association of baseline hemoglobin A1c (HbA1c) at the time of percutaneous coronary intervention with long-term mortality is unknown. Consecutive patients with diabetes mellitus undergoing percutaneous coronary intervention between 1998 and 2008 were identified from our institutional database. Characteristics and outcomes of patients were compared based on HbA1c categories (≤7%, 7.1%-8.0%, 8.1%-9.0%, 9.1%-10.0%, and &gt;10.0%). Among 3008 patients, 1321 had HbA1c ≤7%, 782 with HbA1c 7.1% to 8.0%, 401 with HbA1c 8.1% to 9.0%, 229 with HbA1c 9.1% to 10.0%, and 275 with HbA1c &gt;10%. Compared with low HbA1c (≤7%), those with highest HbA1c (&gt;10%) were younger (56.5 versus 67.5 years), had higher total cholesterol (188 versus 157 mg/dL), more insulin use (54% versus 26%), and presented more often with ST-segment-elevation myocardial infarction (10.9% versus 5.6%). Those with lower HbA1c (≤7%) more often had other comorbidities (more hypertension [90.4% versus 82.5%] and chronic renal failure [14.4% versus 7.6%]). On multivariable Cox proportional hazards modeling, survival analysis demonstrated a trend toward higher mortality with higher HbA1c. Compared with the reference group of patients with HbA1c ≤7%, patients with HbA1c &gt;10% had a significantly higher mortality on follow-up (hazard ratio [95% confidence interval], 1.52 [1.17-1.99]; P=0.002). This difference was primarily seen among noninsulin users; however, insulin users had no significant differences in mortality among HbA1c categories. Patients with diabetes mellitus who were not on insulin and had poor glycemic control (HbA1c &gt;10%) had significantly higher long-term mortality after percutaneous coronary intervention as compared with those with well-controlled diabetes mellitus, evidenced by HbA1c ≤7%. Insulin users, however, had similar rates of mortality among different HbA1c categories." }, { "id": "pubmed23n0524_2841", "title": "The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus.", "score": 0.009174311926605505, "content": "To compare the effects of a 4-month strength training (ST) versus aerobic endurance training (ET) program on metabolic control, muscle strength, and cardiovascular endurance in subjects with type 2 diabetes mellitus (T2D). Randomized controlled trial. Large public tertiary hospital. Twenty-two T2D participants (11 men, 11 women; mean age +/- standard error, 56.2+/-1.1 y; diabetes duration, 8.8+/-3.5 y) were randomized into a 4-month ST program and 17 T2D participants (9 men, 8 women; mean age, 57.9+/-1.4 y; diabetes duration, 9.2+/-1.7 y) into a 4-month ET program. ST (up to 6 sets per muscle group per week) and ET (with an intensity of maximal oxygen consumption of 60% and a volume beginning at 15 min and advancing to a maximum of 30 min 3x/wk) for 4 months. Laboratory tests included determinations of blood glucose, glycosylated hemoglobin (Hb A1c), insulin, and lipid assays. A significant decline in Hb A1c was only observed in the ST group (8.3%+/-1.7% to 7.1%+/-0.2%, P=.001). Blood glucose (204+/-16 mg/dL to 147+/-8 mg/dL, P&lt;.001) and insulin resistance (9.11+/-1.51 to 7.15+/-1.15, P=.04) improved significantly in the ST group, whereas no significant changes were observed in the ET group. Baseline levels of total cholesterol (207+/-8 mg/dL to 184+/-7 mg/dL, P&lt;.001), low-density lipoprotein cholesterol (120+/-8 mg/dL to 106+/-8 mg/dL, P=.001), and triglyceride levels (229+/-25 mg/dL to 150+/-15 mg/dL, P=.001) were significantly reduced and high-density lipoprotein cholesterol (43+/-3 mg/dL to 48+/-2 mg/dL, P=.004) was significantly increased in the ST group; in contrast, no such changes were seen in the ET group. ST was more effective than ET in improving glycemic control. With the added advantage of an improved lipid profile, we conclude that ST may play an important role in the treatment of T2D." }, { "id": "pubmed23n0577_2013", "title": "Clinical significance of HbA1c as a marker of circulating lipids in male and female type 2 diabetic patients.", "score": 0.009174311926605505, "content": "Diabetic patients with accompanied (but often unnoticed) dyslipidemia are soft targets of cardiovascular deaths. An early intervention to normalize circulating lipids has been shown to reduce cardiovascular complications and mortality. Glycated hemoglobin (HbA(1c)) is a routinely used marker for long-term glycemic control. This investigation is an attempt to evaluate the diagnostic value of HbA(1c) in predicting diabetic dyslipidemia. Venous blood samples were collected from 2,220 type 2 diabetic patients (ages, 35-91 years; male/female ratio, 1.07). The sera were analyzed for HbA(1c), fasting blood glucose (FBG), total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL). The levels of HbA(1c) did not differ significantly between males (8.33 +/- 0.06%) and females (8.47 +/- 0.07%), whereas female patients had significantly higher FBG (10.01 +/- 0.13 mmol/l) than males (9.31 +/- 0.11 mmol/l). HbA(1c) showed direct and significant correlations with cholesterol, triglycerides and LDL and inverse correlation with HDL. Female diabetic patients had significantly higher levels of serum cholesterol (5.42 +/- 0.03 vs. 5.18 +/- 0.03 mmol/l) and HDL (1.32 +/- 0.01 vs. 1.12 +/- 0.01 mmol/l) as compared to males. There was no significant difference in triglycerides and LDL between the two genders. Older patients (&gt;70 years) had significantly lower FBG, cholesterol, triglycerides and LDL. There was a linear and significant increase in triglycerides in the patients of both genders with impaired glycemic control. Both male and female patients with worse glycemic control (HbA(1c) &gt; 9%) had significantly high cholesterol and LDL levels. Serum HDL showed a significant and inverse relationship with uncontrolled hyperglycemia in females but not in males. These findings clearly suggest that HbA(1c) can provide valuable supplementary information about the extent of circulating lipids besides its primary role in monitoring long-term glycemic control. Further studies are warranted to reinforce the potential of HbA(1c) as a biomarker for screening of high-risk diabetic patients." }, { "id": "pubmed23n0839_7213", "title": "Obese Nondiabetic Pregnancies and High Maternal Glycated Hemoglobin at Delivery as an Indicator of Offspring and Maternal Postpartum Risks: The Prospective PEACHES Mother-Child Cohort.", "score": 0.00909090909090909, "content": "We investigated whether obese pregnant women negative for gestational diabetes (GDM) still experience dysglycemia, as indicated by high glycated hemoglobin (Hb A1c) at delivery, and whether this impacts offspring and long-term maternal outcomes. Data of 462 mother-child pairs of our prospective Programming of Enhanced Adiposity Risk in Childhood - Early Screening (PEACHES) cohort study were analyzed. Of 885 obese and normal-weight pregnancies prospectively enrolled after GDM testing according to the International Association of Diabetes and Pregnancy Study Groups criteria, 462 GDM-negative mothers and their offspring were investigated. We assessed associations of maternal Hb A1c at delivery with large-for-gestational-age (LGA) birth weights, cord-blood C-peptide, and biomarkers of glucose metabolism and inflammation in obese mothers followed for 2.9 years (median) postpartum (n = 42). Cumulative distribution analysis in GDM-negative normal-weight women (n = 155) revealed that 12% had Hb A1c ≥5.7% at delivery (high Hb A1c). Among obese GDM-negative women (n = 307), 31.9% (95% CI, 26.7%-37.4%) equaled or exceeded this cutoff. In obese GDM-negative women with Hb A1c ≥5.7% (n = 98) vs &lt;5.7% (n = 209) at delivery, newborns were more likely to be born LGA [adjusted odds ratio 3.56 (95% CI, 1.64-8.02)], and mean cordblood serum C-peptide was increased by 0.09 ng/mL (95% CI, 0.01-0.17 ng/mL). In the mothers at follow-up, mean postpartum Hb A1c, fasting glucose, high-sensitivity C-reactive protein, and fibrinogen concentrations were higher by 0.3% (95% CI, 0.1%-0.5%), 6.0 mg/dL (95% CI, 2.4-9.5 mg/dL), 6.8 mg/L (95% CI, 1.4-12.3 mg/L), and 74.9 mg/dL (95% CI, 13.6-136.2 mg/dL), respectively. Increased Hb A1c in obese GDM-negative women at delivery indicates gestational dysglycemia, potentially conferring offspring and long-term maternal health risks. These findings should raise awareness as to careful monitoring of obese pregnancies. Measurement of Hb A1c at delivery could help select women who may need closer postpartum health checks." }, { "id": "pubmed23n0613_7707", "title": "Distribution and cardiovascular risk correlates of hemoglobin A(1c) in nondiabetic younger adults: the Bogalusa Heart Study.", "score": 0.00909090909090909, "content": "Excess glycated hemoglobin (HbA(1c)), an indicator of long-term glucose homeostasis, is recognized as a risk factor for cardiovascular (CV) disease and mortality even among persons without diabetes. However, information is scant regarding its distribution and correlates of CV risk in nondiabetic younger adults. This aspect was examined in a biracial (black-white) community-based sample of 1111 younger adults (mean age: 36.2 years; 71% white, 43% male) enrolled in the Bogalusa Heart Study. Blacks vs whites and women vs men had higher HbA(1c) values (P &lt; .0001). In bivariate analysis adjusted for age, race, sex, and smoking status, significant adverse trends were noted for body mass index, waist circumference, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), total cholesterol to HDL-C ratio, insulin, glucose, and homeostasis model assessment of insulin resistance across HbA(1c) quartiles; trends were not significant for mean arterial blood pressure, triglycerides, C-reactive protein, adiponectin, and estimated glomerular filtration rate. In multivariate analysis, besides race and sex, total cholesterol to HDL-C ratio and waist circumference were independent correlates of HbA(1c). Furthermore, the prevalence of excess (top decile) HbA(1c) was 1.6-fold (P &lt; .05) higher among those with metabolic syndrome defined by the National Cholesterol Education Program Adult Treatment Panel III and 2.1-fold (P &lt; .01) and 1.5-fold (P &lt; .05) higher, respectively, among those with positive parental history of CV disease and type 2 diabetes mellitus. These findings underscore the potential value of HbA(1c) in risk assessments of CV disease and type 2 diabetes mellitus in nondiabetic, apparently \"healthy\" younger adults." }, { "id": "pubmed23n0689_23160", "title": "Prevalence and effect of hemoglobin E disorders on Hba1c and lipid profile of diabetic patients at Surin Hospital.", "score": 0.009009009009009009, "content": "To evaluate the prevalence of hemoglobin E disorders (HbE) and their characteristics in diabetic patients at Surin Hospital. Effects of HbE on HbA1c measurement and other variables in diabetic patients were also studied. A cross-sectional study was performed. One thousand nine hundred seventy eight patients were recruited randomly using a systemic random sampling method HbE screening test and Hb typing was performed HbA lc was measured by turbidimetric inhibition immunoassay. The prevalence of homozygous HbE (HbEE) and HbE trait were 7.9% and 35.3% respectively. When compared with the negative screening group, the variables that were significantly higher in the HbEE group were hemoglobin A1c (HbA1c) &lt; 6.5% (p &lt; 0.010), HbA1c &lt; 7% (p &lt; 0.010), serum cholesterol level (CHOL) &lt; 200 mg/dl (p &lt; 0.010), low density lipoprotein (LDL) &lt; 100 mg/dl (p = 0.021), and anemia by Hb measurement (p &lt; 0.010). The adjusted odds ratio and 95% confidence interval (CI) of HbA1c &lt; 6.5% and &lt; 7% in HbEE when compared with the negative screening group were 5.16 (3.55-7.50) and 4.60 (3.04-6.97) respectively The means of HbA1c, Hb, CHOL, and LDL in HbEE were significantly lower than the other groups (p &lt; 0.010 in all variables). The adjusted odds ratio and 95% CI of HbA1c &lt; 6.5% and &lt; 7% in HbE trait when compared with the negative screening group were 1.12 (1.01-1.24) and 1.17 (1.06-1.29) respectively. Hemoglobin E disorders are highly prevalent in diabetes patients at Surin Hospital. HbA1c, CHOL, and LDL were significantly lower in diabetic patients with HbEE." }, { "id": "pubmed23n0639_2985", "title": "Characteristics of patients with type 2 diabetes of short duration in Poland: Rationale, design and preliminary results of the ARETAEUS1 study.", "score": 0.009009009009009009, "content": "There is a paucity of Polish data describing the characteristics of and assessing treatment goals in patients with relatively newly diagnosed type 2 diabetes. The aim of the study was to describe the baseline characteristics of patients with newly diagnosed type 2 diabetes, who participated in the ARETAEUS1 study, and to assess to what degree diabetic control criteria recommended by the Polish Diabetes Association clinical practice guidelines are met. This cross-sectional questionnaire-based study was conducted from January to April 2009. It involved patients of any age and gender, diagnosed with type 2 diabetes after January 1, 2007, and recruited by randomly selected physicians, both diabetologists and non-diabetologists. We analyzed 1714 valid questionnaires from 333 physicians: 1150 from non-diabetologists and 564 from diabetologists. Mean age of patients was 60 years, mean body mass index -- 30.6 kg/m2, proportion of females -- 50%. The levels of median glycated hemoglobin (HbA1c), total cholesterol and triglycerides, mean low-density lipoprotein (LDL) cholesterol, as well as blood pressure were above the thresholds recommended in the guidelines (i.e., &lt;6.5% for HbA1c, &lt;4.5 mmol/l for total cholesterol, &lt;2.6 mmol/l [or &lt;1.8 mmol/l in patients with coronary heart disease (CHD)] for LDL cholesterol, &lt;1.7 mmol/l for triglycerides, and &lt;130/80 mmHg for blood pressure). Cardiovascular disease risk factors were common: hypertension was reported in over 75% of patients, lipid disorders in nearly 75%, CHD in 27% (previous acute coronary syndrome or stable CHD), previous stroke in 4%, and previous transient ischemic attack in 5.5%. Diabetic foot was reported in 1.7% of patients, nephropathy in 7%, retinopathy in 9% (in the group of diabetologists) and in 21% of patients (in the group of non-diabetologists). We observed a relatively high prevalence of cardiovascular disease risk factors and late diabetes complications in patients with diabetes diagnosed within the previous 2 years." }, { "id": "pubmed23n0399_18221", "title": "Niacin treatment of the atherogenic lipid profile and Lp(a) in diabetes.", "score": 0.008928571428571428, "content": "We tested the hypotheses that niacin is effective for the separate treatments of abnormalities of LDL particle size, HDL2 percentage and Lp(a) without potential negative effects on glycated haemoglobin. The atherogenic lipid profile lipids, such as triglycerides, small, dense LDL cholesterol (LDLc) particle mass, LDL particle size, total HDLc and HDL2 percentage as well as Lp(a), were measured in 42 diabetic patients with abnormalities of LDL particle size, HDL2 percentage and/or Lp(a) levels before and after niacin treatment. LDL particle size and HDL2 were measured using polyacrylamide gradient gel electrophoreses and Lp(a) was measured by enzyme-linked immunoabsorbance assay (ELISA). After niacin treatment, LDL peak particle diameter increased from 252 +/- 7 A to 263 +/- 7 (p &lt; 0.0001), small, dense LDLc particle mass decreased from 27 +/- 11 mg/dL to 15 +/- 4 (p &lt; 0.0001), total HDLc increased from 39 +/- 7 mg/dL to 51 +/- 11 (p &lt; 0.0001), HDL2 as the percentage of total HDLc mass increased from 29 +/- 8% to 45 +/- 10 (p &lt; 0.0001) and Lp(a) decreased from 43 +/- 17 mg/dL to 25 +/- 10 (p &lt; 0.0001). Mean haemoglobin A1c level was improved during treatment from 7.6 +/- 1.8% to 6.5 +/- 1.0 (p &lt; 0.0001) using increased oral agent and insulin treatment doses in more than 90% of the patients. A total of 21% of the patients were unable to tolerate niacin owing to reversible side-effects, and 14% were unable to adhere to the niacin dosing regimen of three times daily. These data indicate that in diabetic patients, niacin (i) is effective for treating diabetic dyslipidaemias associated with both the atherogenic lipid profile and Lp(a); (ii) must be used with modern and aggressive oral hypoglycaemic agents or insulin treatment; and (iii) is an important drug to treat diabetes dyslipidaemias because of its broad spectrum of effectiveness." }, { "id": "pubmed23n0917_22125", "title": "Effect of Multifactorial Treatment Targets and Relative Importance of Hemoglobin A1c, Blood Pressure, and Low-Density Lipoprotein-Cholesterol on Cardiovascular Diseases in Chinese Primary Care Patients With Type 2 Diabetes Mellitus: A Population-Based Retrospective Cohort Study.", "score": 0.008928571428571428, "content": "The relative effect of hemoglobin A1c, blood pressure, and low-density lipoprotein-cholesterol (LDL-C) (\"ABC\" factors) on the prevention of cardiovascular diseases (CVD) among patients with type 2 diabetes mellitus is poorly understood. This study aimed to evaluate the association of key clinical parameters on CVD risk using a multifactorial optimal control approach in Chinese primary care patients with type 2 diabetes mellitus. A population-based retrospective cohort study was conducted on 144 271 Chinese type 2 diabetes mellitus primary care patients, aged 18 to 79 and without prior clinical diagnosis of CVD in 2008-2011. Cox regressions were conducted to examine the association between the combinations of ABC targets (hemoglobin A1c &lt;7%, blood pressure &lt;130/90 mm Hg, and LDL-C &lt;2.6 mmol/L) and risks of CVD (overall), coronary heart disease, stroke, and heart failure. Achieving more ABC targets incrementally reduced the incidence of total CVD and individual disease including coronary heart disease, stroke, and heart failure, irrespective of other patient characteristics. Compared with suboptimal control in all ABC levels, achieving any 1, 2, and all 3 ABC targets reduced the relative risk of CVD by 13% to 42%, 31% to 52%, and 55%, respectively. Among those achieving only 1 ABC target, LDL-C reduction was associated with the greatest CVD risk reduction (42%), followed by blood pressure reduction (18%), and hemoglobin A1c reduction (13%). To achieve the greatest risk reduction for the incidence of CVD, the ultimate goal of treatment should be to achieve target control of hemoglobin A1c, blood pressure, and LDL-C. If it is not possible to achieve all 3 targets, efforts should be prioritized on treating the LDL-C to minimize CVD risk." }, { "id": "pubmed23n0640_3167", "title": "Comparison of A1C and fasting glucose criteria to diagnose diabetes among U.S. adults.", "score": 0.008849557522123894, "content": "To compare A1C and fasting glucose for the diagnosis of diabetes among U.S. adults. This study included 6,890 adults (&gt; or =20 years of age) from the 1999-2006 National Health and Nutrition Examination Survey without a self-reported history of diabetes who had fasted &gt; or =9 h. A1C &gt; or =6.5% and fasting glucose &gt; or =126 mg/dl were used, separately, to define diabetes. Overall, 1.8% of U.S. adults had A1C &gt; or =6.5% and fasting glucose &gt; or =126 mg/dl, 0.5% had A1C &gt; or =6.5% and fasting glucose &lt;126 mg/dl, and 1.8% had A1C &lt;6.5% and fasting glucose &gt; or =126 mg/dl. Compared with individuals with A1C &lt;6.5% and fasting glucose &gt; or =126 mg/dl, individuals with A1C &gt; or =6.5% and fasting glucose &lt;126 mg/dl were younger, more likely to be non-Hispanic black, had lower Hb levels, and had higher C-reactive protein. A1C &gt; or =6.5% demonstrates reasonable agreement with fasting glucose for diagnosing diabetes among U.S. adults." }, { "id": "pubmed23n0556_8470", "title": "Undertreatment of cardiovascular risk factors among persons with diabetes in the United States.", "score": 0.008849557522123894, "content": "We examined the extent of control of cardiovascular risk factors and distance from goal for those with uncontrolled levels in a recent sample of U.S. adults with diabetes. In the cross-sectional National Health and Nutrition Examination Survey 2001-2002, 532 (projected to 15.2 million) or 7.3% of adults aged &gt;/=18 years had diabetes. Use of antihypertensive, antidiabetic and antidyslipidemic medications was examined. We determined the proportion of subjects not at goal for blood pressure (BP), lipids and glycosylated hemoglobin (A1C) and examined the distance from goal for those not under control. Overall, 50.2% of subjects with diabetes were not at goal for A1C, 64.6% for low density lipoprotein-cholesterol (LDL-C), 52.3% for high density lipoprotein-cholesterol (HDL-C), 48.6% for triglycerides and 53.0% BP. Only 5.3% of men and 12.7% of women with diabetes were simultaneously at goal for A1C, LDL-C and BP. Even among those on treatment, most were not at goal for these parameters. Women were more likely to have LDL-C and HDL-C not at goal than men. Non-Hispanic Blacks were more often not at goal for BP and LDL-C. Mean distances from targets were 36mg/dL for LDL-C, 18mmHg for systolic BP, 6mmHg for diastolic BP and 2.0% for A1C in patients not at goal. Many U.S. adults with diabetes have sub-optimal control of cardiovascular risk factors and remain far from target goals for BP, lipids and A1C, even if on treatment." } ] } } }

{ "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": [ [ 80, 254 ] ], "word_ranges": [ [ 17, 40 ] ], "text": "the levels of complement fractions C3 and C4 are low. Of the options given, only membranoproliferative glomerulonephritis presents with hypocomplementemia (option 4 correct)." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Membranous glomerulonephritis.", "2": "Glomerulonephritis with minimal changes.", "3": "Mesangial IgA glomerulonephritis.", "4": "Membranoproliferative glomerulonephritis.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0497_11164", "title": "[Rapidly progressive glomerulonephritis in a 68-year-old man].", "score": 0.01637840670859539, "content": "A 68-year-old male with macroscopic hematuria and constitutional symptoms as fever and weight loss. There was nothing interesting in the anamnesis or in the physical exploration. The laboratory test had an elevation of creatinine of 4 mg/dL and ten days before it had been 1.4 mg/dL. In the urine analysis: proteinuria of 1.5 G/24 h, and hematuria. On the second day we made a renal biopsy where we could seen segmental glomerular necrosis and crescent fromation in 80% of the glomeruli. In the immune study c-ANCA anti-PR3 was positive. In the complementary studies we didn't find other organs affected. With the diagnosis of pauci-immune glomerulonephritis limited to the kidney we began treatment with corticosteroids and cyclophosphamide. As the renal function was severely affected the patient needed one dialysis session. We began with 1 g intravenous methylprednisolone daily for 3 days followed by oral prednisone 60 mg daily tapering to 10 mg daily by 3 months. This was combined with 150 mg oral cyclophosphamide daily. Seven plasma exchanges were performed. At the beginning of treatment creatinine was 7 mg/dL, it was decreasing rapidly and three week after cretinine was 3 mg/Dl and he was asymptomatic. One year after treatment, creatinine is 1.4 mg/dL and the urine analysis is normal, C-ANCA are negative." }, { "id": "pubmed23n0844_9194", "title": "When Coke Is Not Hydrating: Cocaine-Induced Acute Interstitial Nephritis.", "score": 0.01422170270796805, "content": "A 47-year-old African American man was admitted with 4 days of back pain, nausea and vomiting, and low urine output. There was no history of fever, dysuria, frequency, hesitancy, viral symptoms, trauma, rash, or constipation. Despite his past medical history of hypertension, diabetes mellitus, and hyperlipidemia he denied taking any medications for 18 months, including nonsteroidal anti-inflammatory drugs, acetaminophen, or antacids. He denied smoking and alcohol but admitted to cocaine use. No significant FH. Physical examination results were as follows: BP 235/125 mm Hg, heart rate 90 beats/min, temperature 98°F, O2 saturation normal; lungs and heart normal, abdomen soft but bilateral costovertebral angle tenderness. Neurological examination was normal. Laboratory tests yielded the following results: creatinine (Cr) 10.5 mg/dL (1.2 mg/dL in 2010), blood urea nitrogen 63 mg/dL, glucose 151 mg/dL, Ca 9.4 mg/dL, PO4 6.1 mg/dL, Hgb 15 g/dL, white blood cells (WBC) 9100, platelets 167 000, amylase/lipase normal, aspartate aminotransferase/alanine aminotransferase (AST/ALT) normal, bilirubin 1.4 mg/dL, alkaline phosphatase 39 IU/L, creatine phosphokinase 127 µg/L. Hepatic panel, C- and P-ANCA (cytoplasmic- and perinuclear-antineutrophil cytoplasm antibodies, respectively), anti-GBM (anti-glomerular basement membrane), antimyeloperoxidase, antinuclear antibody, and Helicobacter pylori were all negative. C3, C4 normal, urinalysis: 2+ blood, no white blood cells or eosinophils, no casts, no albumin, negative for nitrate/leukocyte esterase and bacteria. Imaging: chest radiograph, abdominal radiograph, computed tomography of the abdomen, electrocardiography, and transthoracic echocardiography were all normal. Course. The patient's urine output declined from 700 to 400 cm(3)/d and the on third day he required hemodialysis with Cr 14 mg/dL. Renal biopsy showed typical findings of interstitial nephritis. The patient was dialyzed for 10 days and responded to steroids and went home with an improving Cr of 3.5 mg/dL, back to baseline of 1.5 in 8 weeks. Discussion. Internists encounter patients with acute kidney injury (AKI) on a daily basis, most of which can be explained by prerenal azotemia, acute tubular necrosis (ATN), obstruction, or rhabdomyolysis among other etiologies. Cocaine is only rarely implicated as an etiology of AKI and if it is, usually the injury is due to ATN or pigment effects. Acute interstitial nephritis (AIN) caused by cocaine, on the other hand, has only been described in a handful of cases. AIN is a renal lesion that causes a decline in creatinine clearance and is characterized by an inflammatory infiltrate in the kidney interstitium and is most often associated with drug therapy. AIN can also be seen in autoimmune disorders like systemic lupus erythematosus, Sjögren's syndrome, or sarcoidosis; or with infections remote to the kidney like Legionella, leptospirosis, and streptococcal disease. Our case was very similar to the other reported cases of AIN due to cocaine in that all have occurred in middle-aged African American males and all have responded to steroids. This case reminds clinicians to consider AIN in patients with AKI and a history of cocaine abuse. " }, { "id": "pubmed23n0049_11777", "title": "[A case of anti-GBM nephritis (crescentic glomerulonephritis) associated with membranous nephropathy].", "score": 0.014153439153439154, "content": "We report a case of endstage renal disease due to simultaneous occurrence of membranous nephropathy and crescentic glomerulonephritis associated with anti-GBM antibodies. The patient was a 60-year-old male and was hospitalized for prolonged anorexia and general malaise. On admission, his body temperature was 38.5 degrees C. Urinalysis revealed 3+ proteinuria and the sediment contained abundant erythrocytes. The urea nitrogen was 142.4 mg/dl, the creatinine 19.5 mg/dl, the potassium 6.47 mEq/dl and CRP 10.1 mg/dl. Anti-GBM antibodies were 1000EU/ml. Immediately after initiating hemodialysis, pulse steroid therapy, plasma exchange and continuous heparinization were performed. However, renal function had been impaired and maintenance hemodialysis was required. Histological examination of the renal specimen revealed marked epithelial crescent formation, whereas thickening of basement membrane and mesangial proliferation were not observed. By immunofluorescent staining, both bright linear and fine granular fixation of IgG and fine granular fixations of C3 along the glomerular capillary walls were observed. Electron microscopy showed subepithelial electron lucent deposits and thickening of the glomerular basement membrane, diagnostic of the advanced membranous nephropathy (stage IV)." }, { "id": "InternalMed_Harrison_3650", "title": "InternalMed_Harrison", "score": 0.013057592004960426, "content": "A 44-year-old woman was referred from a local hospital after presenting with flaccid paralysis. Severe hypokalemia was documented (2.0 meq/L), and an infusion containing KCl was initiated. PART 2 Cardinal Manifestations and Presentation of Diseases Sodium 140 meq/L Potassium 2.6 meq/L Chloride 115 meq/L Bicarbonate 15 meq/L Anion gap 10 meq/L BUN 22 mg/dL Creatinine 1.4 mg/dL pH 7.32 U PaCO2 30 mmHg HCO3− 15 meq/L Rheumatoid factor positive, anti-Ro/SS-A positive, and anti-La/SS-B positive pH = 6.0, normal sediment without white or red blood cell casts and no bacteria. The urine protein-to-creatinine ratio was 0.150 g/g. Urinary electrolyte values were: Na+ 35, K+ 40, Cl− 18 meq/L. Therefore, the urine anion gap was positive, indicating low urine NH4+ excretion." }, { "id": "pubmed23n0534_4424", "title": "[A case of anti-GBM-antibody positive rapidly progressive glomerulonephritis who was weaned from hemodialysis after combination therapy with steroid and plasmapheresis].", "score": 0.011577760084925691, "content": "We report an anti-GBM antibody-positive crescentic glomerulonephritis patient who benefitted from maintenance hemodialysis 4 months after the initial treatment, which included steroid pulse therapy and plasma exchange. A-29-year-old male was referred to our hospital because of high fever, abnormal urinary findings (leukocytes 3+, protein 2+, occult blood 3+) and a moderate degree of azotemia(S-Cr 2.9 mg/dl). C-reactive protein (CRP) was 18.9 mg/dl and antibiotics were administered intravenously for 7 days under the diagnosis of pyelonephritis. High fever persisted, however, and S-Cr increased to 9.2 mg/dl even though a sufficient volume of urine was maintained. Blood and urine cultures were negative for bacteria. A kidney biopsy was performed and cellular crescents were observed around the glomeruli. No abnormal finding was observed in the lung and the nasopharyngeal region. To treat the crescentic glomerulonephritis, steroid and cyclophosphamide were administered while hemodialysis was carried out simultaneously. Although P-ANCA and C-ANCA were negative, anti-GBM antibody was proven to be positive thereafter (169 U) and six sessions of plasmapheresis were additionally performed to remove the antibody. Two months after the last plasmapheresis, the reduced urine volume (300 ml/day) gradually returned to normal. Hemodialysis was terminated because the S-Cr concentration reached a plateau at 4 mg/dl. Repeated biopsy revealed marked glomerulosclerosis, hence hypertension treatment and a low protein diet were ordered. In conclusion, residual renal function might improve even after 4 months of hemodialysis in cases of intensively treated anti-GBM-positive crescentic glomerulonephritis, though consecutive renoprotective therapy is required." }, { "id": "InternalMed_Harrison_3384", "title": "InternalMed_Harrison", "score": 0.011282647546454794, "content": "PROTEINURIA ON URINE DIPSTICK Quantify by 24-h urinary excretion of protein and albumin or first morning spot albumin-to-creatinine ratio RBCs or RBC casts on urinalysis In addition to disorders listed under microalbuminuria consider Myeloma-associated kidney disease (check UPEP) Intermittent proteinuria Postural proteinuria Congestive heart failure Fever Exercise Go to Fig. 61-2 Macroalbuminuria 300-3500 mg/d or 300-3500 mg/g Microalbuminuria 30-300 mg/d or 30-300 mg/g Nephrotic range > 3500 mg/d or > 3500 mg/g + Consider Early diabetes Essential hypertension Early stages of glomerulonephritis (especially with RBCs, RBC casts)Consider Early diabetes Essential hypertension Early stages of glomerulonephritis (especially with RBCs, RBC casts) Nephrotic syndrome Diabetes Amyloidosis Minimal change disease FSGS Membranous glomerulopathy IgA nephropathy" }, { "id": "wiki20220301en012_140488", "title": "Nephrotic syndrome", "score": 0.011273783049172226, "content": "Along with obtaining a complete medical history, a series of biochemical tests are required in order to arrive at an accurate diagnosis that verifies the presence of the illness. In addition, imaging of the kidneys (for structure and presence of two kidneys) is sometimes carried out, and/or a biopsy of the kidneys. The first test will be a urinalysis to test for high levels of proteins, as a healthy subject excretes an insignificant amount of protein in their urine. The test will involve a 24-hour bedside urinary total protein estimation. The urine sample is tested for proteinuria (>3.5 g per 1.73 m2 per 24 hours). It is also examined for urinary casts, which are more a feature of active nephritis. Next a blood screen, comprehensive metabolic panel (CMP) will look for hypoalbuminemia: albumin levels of ≤2.5 g/dL (normal=3.5-5 g/dL). Then a Creatinine Clearance CCr test will evaluate kidney function particularly the glomerular filtration capacity. Creatinine formation is a result of" }, { "id": "wiki20220301en002_229984", "title": "Albuminuria", "score": 0.010995670995670996, "content": "Causes of albuminuria can be discriminated between by the amount of protein excreted. The nephrotic syndrome usually results in the excretion of about 3.0 to 3.5 grams per 24 hours. Nephritic syndrome results in far less albuminuria. Microalbuminuria (between 30 and 300 mg/24h, mg/l of urine or μg/mg of creatinine) can be a forerunner of diabetic nephropathy. The term albuminuria is now preferred in Nephrology since there is not a \"small albumin\" (microalbuminuria) or a \"big albumin\" (macroalbuminuria). A1 represents normal to mildly increased urinary albumin/creatinine ratio (<30 mg/g or < 3 mg/mmmol); A2 represents moderately increased urinary albumin/creatinine ratio (30–300 mg/g or 3–30 mg/mmmol, previously known as microalbuminuria); and A3 reflects severely increased urinary albumin/creatinine ratio >300 mg/g or > 30 mg/mmol)." }, { "id": "article-22283_9", "title": "Diffuse Proliferative Glomerulonephritis -- Evaluation", "score": 0.009936920504635963, "content": "A complete blood count showing possible anemia and low platelet count followed by renal function tests with elevated serum creatinine (0.4 mg/dl above the upper limit), blood urea nitrogen levels, and urine analysis positive for urine sediments: red blood cells and casts, white blood cells, granular casts are indicative of a glomerular pathology. For further confirmation, a 24 hours urine protein to creatinine ratio and 24 hours urine sample for protein levels can be done. A protein count of greater than 3.5 g/day is suggestive of nephrotic range proteinuria, which is associated with a worse prognosis. A 24-hour urine sample can be used to calculate creatinine clearance to estimate the eGFR. Renal ultrasound can be done to see the size and confirm the presence of two kidneys and the absence of any obstructive pathology resulting in hydronephrosis. Serum complement (C3 and C4) levels help determine the etiology; low levels are associated with the presence of SLE, cryoglobulinemia, and infectious etiology. [12]" }, { "id": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009900990099009901, "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": "pubmed23n0820_14586", "title": "Renal biopsy findings and clinical indicators of patients with hematuria without overt proteinuria.", "score": 0.009900990099009901, "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": "wiki20220301en033_21958", "title": "Acute pancreatitis", "score": 0.00980392156862745, "content": "At admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11.1 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall >10% Oxygen (hypoxemia PO2 < 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 The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis. Alternatively, pancreatitis can be diagnosed by meeting any of the following:[2] Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)" }, { "id": "article-25173_15", "title": "Minimal Change Disease -- Evaluation -- Basic labs:", "score": 0.00980392156862745, "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": "pubmed23n0696_21547", "title": "[Chronic renal failure: unexpected late sequela of pulmonary tuberculosis after 30 years].", "score": 0.009708737864077669, "content": "Tuberculosis-related chronic granulomatous tubulointerstitial nephritis (GTN) and chronic renal dysfunction as a consequence of GTN is a rarely seen clinical condition, with a few case reports in the literature. In this report, a case with end stage renal failure as an unexpected late extrapulmonary sequela of tuberculosis has been presented. A 60 years old female patient was admitted to hospital with the complaints of fever, malaise and nausea. Her history revealed that she had pulmonary tuberculosis 30 years ago and received antituberculosis therapy for nine months. The laboratory results on admission were as follows: blood urea nitrogen 90 mg/dl, serum creatinine 9 mg/dl, sodium 116 mEq/L, potassium 6.6 mEq/L, albumine 2.9 g/dl, hemoglobin, 8.4 g/dl, white blood cell count 10.800/mm3, C-reactive protein 187 mg/L and erythrocyte sedimentation rate 110 mm/hour. Urinalysis showed 8.1 g/L protein, 10-12 leukocytes, 1-2 erythrocytes, while 24-hours urinalysis yielded proteinuria with 8 ml/minutes creatinine clearance value. Urine and blood cultures of the patient revealed neither bacteria or mycobacteria. PPD skin test was negative. Acid-resistant bacilli (ARB) were not detected in sequential urine samples obtained on three consecutive days. Since sputum samples could not be obtained, diagnostic procedures for sputum were not performed. Abdomen ultrasonography yielded bilateral edema and grade II echogenity in kidneys. Computed tomography of the chest showed bilateral pulmonary nodules, chronic sequela lesions, pleural scarring and calcifications, as well as minimal interstitial infiltrate. Transthoracic lung biopsy showed chronic inflammation and fibrosis, while amyloid was negative. Renal biopsy showed GTN with central caseified necrosis and granulomas, multinuclear giant cells, tubular atrophy and interstitial fibrosis. Amyloid was negative and ARB were not detected in renal biopsy sample. Definitive diagnosis was achieved by the demonstration of Mycobacterium tuberculosis nucleic acid in kidney biopsy by polymerase chain reaction (PCR). Antituberculosis therapy was not initiated since there were no signs of active tuberculosis. The patient became clinically stable following dialysis and was discharged, however, she has been undergoing hemodialysis three times a week. The aim of this case presentation was to emphasize that renal tuberculosis should be considered in the differential diagnosis of patients with end stage renal failure, especially in countries like Turkey where tuberculosis incidence is high." }, { "id": "pubmed23n0047_1231", "title": "[Clinical studies of the prognosis in cases of chance proteinuria and/or hematuria].", "score": 0.009708737864077669, "content": "A total of 174 cases that consulted due to chance proteinuria and/or hematuria (CPH) were studied as to its clinical course, in particular patients' prognosis. They were selected from 311 patients on whom renal biopsy was performed from December, 1975 to December, 1985 in our institute. Furthermore, IgA nephropathy which occupied the major part of the CPH group was also studied as a prognostic factor. The CPH group showed 81% of disease stabilizing rate in 10 years' follow-up. In various data such as chemical analysis of blood and urine, immunoglobulin levels, and renal function at the time of biopsy, daily urinary protein excretion (greater than 1 g/day) statistically showed a significant correlation to deterioration of the renal function during the follow up. However, hematuria was not found correlated. Of CPH group, 48% was diagnosed to be with IgA nephropathy. The patients with IgA nephropathy with CPH, comparing with the cases without CPH, were younger and had better renal function and milder change of renal mesangial proliferation. The 10 years-disease stabilizing rates of the disease were 81% in CPH and 63% in non CHP group. In conclusion, prognostic factors affecting renal function in the CPH group was found to be daily urinary protein excretion and, if diagnosed as IgA nephropathy by biopsy, pathological changes were also shown to be prognostic factors. Therefore, CPH patients having proteinuria over 1 g/day must be examined by renal biopsy and when IgA nephropathy is diagnosed, long time follow-up is necessary and re-biopsy for examination of pathological change during the interval is recommended." }, { "id": "pubmed23n0563_16706", "title": "Blood and urine physiological values in farm-cultured Rana catesbeiana (Anura: Ranidae) in Argentina.", "score": 0.009615384615384616, "content": "A total of 302 samples of healthy farm-cultured Rana catesbeiana specimens (9-21 months-old, 50-350 g liveweight, 50% each sex) from the north-east of Argentina, were analyzed through spectrophotometry, electrophoresis, densitometry, refractometry and microscopy in order to obtain blood and urine normal values. Confidence intervals (p&lt;0.05) for PCV (28.6-31.6%), RBC (0.40-0.44 T/L), MCV (686-732 fL), hemoglobin (6.41-7.20 g/dL), MCH (151-164 pg), MCHC (22.6-24.0%), WBC (18.7-22.3 G/L), neutrophils (58.4-63.4%), lymphocytes (23.9-29.8%), monocytes (2.1-3.8%), eosinophils (4.6-7.0%), basophils (2.9-4.1%), bleeding time (289-393s), coagulation time (452-696s), prothrombin time (76-128s), urinary density (1.0061-1.0089 g/mL), urinary pH (6,38-6.96)., fibrinogen (0.59-0.99 g/dL), total protein (4.19-4.49 g/dL), albumin (1.49-1.67 g/dL), alpha-1 globulin (0.20-0.24 g/dL), alpha-2 globulin (0.48-0.54 g/dL), beta globulin (0.68-0.77 g/dL), gamma globulin (1.28-1.42 g/dL), albumin/globulin ratio (0.50-0.58), creatinine (4.09-5.56 mg/L). urea (76.1-92.4 mg/L), uric acid (11.5-15.4 mg/L), triglycerides (0.34-0.52 g/L), total cholesterol (0.56-0.67 g/L), HDL-C (0.03-0.05 g/L), LDL-C (0.34-0.44 g/L), alpha lipoprotein (6.01-8.67%). beta lipoprotein (91.3-93.9%), glucose (0.45-0.54 g/L), Na (116-121 meq/L), K (3.42-3.81 meq/L), Cl (100-116 meq/L), Ca (7.98-8.61 mg/dL). P (8.319.36 mg/dL), Mg (2.26-2.55 mg/dL), Fe (105-178 ug/dL), ALP (144-170 [U/L), ALT (10.0-14.8 IU/L), AST (42.8-53.4 IU/L), GGT (7.8-10.6 IU/L), LDH (99-135 IU/L), CHE (151-185 lU/L) and CPK (365-500 IU/L), were obtained. Some parameter ranges were similar to those obtained in amphibians, birds or mammals; others were very different. These parameters are useful to evaluate sanitary, metabolic and nutritional state on captive bullfrogs." }, { "id": "article-23357_25", "title": "IgA Nephropathy (Berger Disease) -- History and Physical", "score": 0.009615384615384616, "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": "wiki20220301en086_257", "title": "Hyperosmolar hyperglycemic state", "score": 0.009523809523809525, "content": "Management Intravenous fluids Treatment of HHS begins with reestablishing tissue perfusion using intravenous fluids. People with HHS can be dehydrated by 8 to 12 liters. Attempts to correct this usually take place over 24 hours with initial rates of normal saline often in the range of 1 L/h for the first few hours or until the condition stabilizes. Electrolyte replacement Potassium replacement is often required as the metabolic problems are corrected. It is generally replaced at a rate 10 mEq per hour as long as there is adequate urinary output. Insulin Insulin is given to reduce blood glucose concentration; however, as it also causes the movement of potassium into cells, serum potassium levels must be sufficiently high or dangerously low blood potassium levels may result. Once potassium levels have been verified to be greater than 3.3 mEq/l, then an insulin infusion of 0.1 units/kg/hr is started. The goal for resolution is a blood glucose of less than 200 mg/dL. References" }, { "id": "pubmed23n0291_4596", "title": "A long-term follow-up study of asymptomatic hematuria and/or proteinuria in adults.", "score": 0.009433962264150943, "content": "Between January 1, 1983 and December 31, 1992, 805 patients with asymptomatic proteinuria and/or hematuria were selected in the mass screening of 56,269 adults. We conducted prospective long-term follow-up studies of these patients and evaluated their clinical findings and renal histology. They were divided into three groups according to the first dipstick urinalysis findings: 478 patients with pure hematuria (H), 150 patients with concomitant hematuria and proteinuria (H &amp; P), and 177 patients with proteinuria (P). The mean follow-up period was 5.80 +/- 4.42 years. Of the 478 patients with H, a specific cause of hematuria was found in 46 (9.6%), the remaining 432 (90.4%) patients were diagnosed as having asymptomatic hematuria (ASH). During the follow-up period, in the ASH patients, hematuria disappeared in 44.2%, 43.7% had persistent microhematuria without proteinuria, and 10.6% manifested proteinuria, none of the patients showed renal insufficiency. Of the 150 patients with H &amp; P, 134 were diagnosed as having asymptomatic H &amp; P. During the follow-up period, the hematuria and proteinuria disappeared in 16.4% of these patients, the proteinuria disappeared in 8.2%, and 14.9% of the patients showed renal insufficiency. Of the 177 patients with P, 151 were diagnosed has having asymptomatic P. During the follow-up period, proteinuria disappeared in 23.2%, and 10.6% showed renal insufficiency. Renal biopsy was performed in 151 patients in the study population who had a moderate degree of proteinuria; 68.2% of these patients had IgA nephropathy, 12.6% had non-IgA mesangial proliferative GN, 6.0% had membranous nephropathy, 5.3% had minimal change, and 2.6% had focal and segmental glomerular sclerosis. This study of the mass screening of urinalysis in asymptomatic adults showed that although the patients with pure hematuria did not exhibit renal insufficiency, 10.6% of these patients were proteinuric during the follow-up period. Therefore, careful observation and management are needed in these patients." }, { "id": "pubmed23n0362_21085", "title": "Effects of high-dose furosemide and small-volume hypertonic saline solution infusion in comparison with a high dose of furosemide as a bolus, in refractory congestive heart failure.", "score": 0.009345794392523364, "content": "Diuretics, have been accepted as first-line treatment in refractory heart failure, but a lack of response is a frequent event. A randomised single blind study was performed to evaluate the effects of the combination of high-dose furosemide and small-volume hypertonic saline solution (HSS) infusion in the treatment of refractory NYHA class IV congestive heart failure (CHF). Sixty patients (21 F/39 M) with refractory CHF (NYHA class IV) of different etiologies, unresponsive to high oral doses of furosemide, ACE-inhibitors, digitalis, and nitrates, aged 65-90 years, were enrolled. They had to have an ejection fraction (EF) &lt;35%, serum creatinine &lt;2 mg/dl, BUN &lt;/=60 mg/dl, a reduced urinary volume and a low natriuresis. The patients were randomised in two groups (single blind): group 1 (11 F/19 M) received an i.v. infusion of furosemide (500-1000 mg) plus HSS (150 ml of 1.4-4.6% NaCl) b.i.d. in 30 min. Group 2 (10 F/20 M) received an i.v. bolus of furosemide (500-1000 mg) b.i.d., without HSS, during a period lasting 6-12 days. Both groups received KCl (20-40 mEq.) i.v. to prevent hypokalemia. All patients underwent at entry a physical examination, measurement of body weight (BW), blood pressure (BP), heart rate (HR), evaluation of signs of CHF, and controls of serum Na, K, Cl, bicarbonate, albumin, uric acid, creatinine, urea and glycemia and daily during hospitalization, as well as the daily output of urine for, Na, K and Cl measurements. Chest X-ray, ECG and echocardiogram were obtained at entry during and at the discharge. During the treatment and after discharge the daily dietary Na intake was 120 mmol with a drink fluid intake of 1000 ml daily. An assessment of BW and 24-h urinary volume, serum and urinary laboratory parameters, until reaching a compensated state, were performed daily, when i.v. furosemide was replaced with oral administration (250-500 mg/day). After discharge, patients were followed as outpatients weekly for the first 3 months and subsequently once per month. The groups were similar for age, sex, EF, risk factors, treatment and etiology of CHF. All patients showed a clinical improvement. Six patients in both groups had hyponatremia (from 120 to 128 mEq./l) at entry. A significant increase in daily diuresis in both groups was observed (from 390+/-155 to 2100+/-626, and from 433+/-141 to 1650+/-537 ml/24 h, P&lt;0.05). Natriuresis (from 49+/-15 to 198+/-28 mEq./24 h) was higher in group 1 vs. group 2 (from 53.83+/-12 to 129+/-39 mEq./24 h, P&lt;0.05). Serum Na (from 135.9+/-6.8 to 142.2+/-3. 8 mEq./l, P&lt;0.05) increased in the group 1 and decreased in the group 2 (from 134.7+/-7.9 to 130.1+/-4.3 mEq./l). Serum K was decreased (from 4.4+/-0.6 to 3.9+/-0.6, and 4.6+/-9 to 3.6+/-0.5 mEq. /l, P&lt;0. 05) in both groups. BW was reduced (from 73.8+/-9.1 to 63. 8+/-8.8, and from 72.9+/-10.2 to 64.5+/-7.5 kg, P&lt;0. 05) in both groups. Group 2 showed more patients in NYHA class III than group 1 (18 vs. 2 patients, P&lt;0.05). Group 2 showed an increase of serum creatinine. Serum uric acid increased in both groups. BP values decreased, and HR was corrected to normal values in both groups. Group 2 showed a longer hospitalization time than group receiving HHS infusion (11.67+/-1.8 vs. 8.57+/-2.3 days, P&lt;0.001). In the follow-up (6-12 months), none of the patients from group 1 were readmitted to the hospital and they maintained the NYHA class achieved at the discharge. Group 2 showed 12 patients readmitted to hospital and a higher class than at discharge. Our data suggest that the combination of furosemide with HSS is feasible and it appears that this combination produces an improvement of hemodynamic and clinical parameters, reduces the hospitalization time and maintains the obtained results over time in comparison with those receiving high-dose furosemide as bolus." }, { "id": "pubmed23n1081_6442", "title": "C3 glomerulonephritis associated with ANCA positivity: a case report.", "score": 0.009345794392523364, "content": "C3 glomerulopathy (C3G) is a recent disease classification that is characterized by the presence of glomerular deposits (composed of C3) in the absence of significant amounts of immunoglobulin and comprises dense deposit disease and C3 glomerulonephritis (C3GN). Most C3GN manifests as membranoproliferative, mesangial proliferative glomerulonephritis patterns via light microscopy. Pure membranous nephropathy (MN)-like glomerular lesions are rare manifestations of C3GN. Anti-neutrophil cytoplasmic antibodies (ANCAs) are also seldomly reported to be positive in C3GN. Herein, we report the case of a C3GN patient presenting with an MN-like glomerular pattern with ANCA positivity. A 68-year-old woman was admitted to a local hospital with elevated serum creatinine for two weeks. Laboratory tests showed a hemoglobin level of 85 g/L. Urinalysis was positive for 2 + protein and 360 RBCs/HPF. Blood biochemistry analysis revealed the following concentrations: albumin, 30.3 g/L; globulin, 46.2 g/L; blood urea nitrogen, 19.9 mmol/L; and serum creatinine, 234 µmol/L. The serum C3 level was 0.4950 g/L, and the serum C4 level was 0.1050 g/L. The direct Coombs test was positive. Serologic testing for ANCA revealed the presence of p-ANCA (1:10) by indirect immunofluorescence microscopy assay, as well as the presence of PR3 1.2 (normal range &lt; 1) and MPO 3.5 (normal range &lt; 1) by enzyme immunoassay. Renal biopsy sample pathology showed 2/6 cellular crescents and thickened glomerular basement membranes. Immunofluorescence testing revealed only diffuse, finely granular depositions of C3 along the glomerular capillary walls in frozen and paraffin-embedded tissue sections. Electron microscopy demonstrated the presence of subepithelial electron-dense deposits, similar to those that are observed in membranous nephropathy. Corticosteroid and cyclophosphamide were administered, with a subsequent improvement in renal function. We present the rare case of a patient with MN-like C3GN with ANCA positivity. C3GN with ANCA positivity may be represented by more crescents, severe renal dysfunction and more extrarenal manifestations. More cases are needed to elucidate the clinicopathologic features and optimal treatments of these patients." }, { "id": "wiki20220301en086_255", "title": "Hyperosmolar hyperglycemic state", "score": 0.009259259259259259, "content": "Diagnosis Criteria According to the American Diabetes Association, diagnostic features include: Plasma glucose level >30 mmol/L (>600 mg/dL) Serum osmolality >320 mOsm/kg Profound dehydration, up to an average of 9L (and therefore substantial thirst (polydipsia)) Serum pH >7.30 Bicarbonate >15 mEq/L Small ketonuria (~+ on dipstick) and absent-to-low ketonemia (<3 mmol/L) Some alteration in consciousness BUN > 30 mg/dL (increased) Creatinine > 1.5 mg/dL (increased) Imaging Cranial imaging is not used for diagnosis of this condition. However, if MRI is performed, it may show cortical restricted diffusion with unusual characteristics of reversible T2 hypointensity in the subcortical white matter." }, { "id": "pubmed23n0289_15595", "title": "[Microalbuminuria in patients with glomerulonephritis in remission].", "score": 0.009259259259259259, "content": "The authors focused their attention on residual changes in patients with glomerulonephritis who have a zero or only \"physiological\" proteinuria (under 0.15 g/24 hours), normal or slightly elevated s-creatinine and who do not suffer from hypertension. In these patients microalbuminuria in urine per 24 hours was assessed. Patients with albuminuria under 20 micrograms/min were included in the group with normal albuminuria (13 patients) and patients with albuminuria of more than 20 micrograms/min in the microalbuminuric group (11 patients). The two groups did not differ significantly as to age, sex, duration of the disease, maximum levels of proteinuria and s-creatinine values at the onset of the disease. S-creatinine and blood pressure values at the time of investigation were also comparable. The groups differed, however, significantly as to the period of \"absolute\" remission which the authors defined as the period during which proteinuria did not exceed the \"physiological\" limit. This period was in the normoalbuminuric group significantly longer--on average 5.1 years--while in the microalbuminuric group it was 2.1 years (difference at the 1% level of significance)." }, { "id": "pubmed23n1162_751", "title": "Cyclosporine therapy could be considered for membranoproliferative glomerulonephritis with immunoglobulin A deposits: a case report.", "score": 0.009174311926605505, "content": "Membranoproliferative glomerulonephritis (MPGN), a rare glomerulonephritis that causes nephrotic syndrome in children, is often difficult to treat. Typical immunofluorescence findings include strong C3 staining in a granular pattern along the glomerular capillary wall and negative IgA staining. IgA-dominant MPGN without hypocomplementemia has been reported. Herein, we report a rare case of MPGN with hypocomplementemia and predominant IgA subclass 2 deposits. An 11-year-old girl showed proteinuria on a school urinalysis screening and presented with upper eyelid edema. The urinalysis showed elevated urinary protein levels and hematuria. Laboratory examinations revealed the following: serum albumin, 1.3 g/dL; serum creatinine, 0.54 mg/dL; and C3c, 67 mg/dL (normal range: 73-138 mg/dL). The physical and laboratory findings did not suggest autoimmune diseases. A renal biopsy was then performed. Specimen examination under a light microscope showed mesangial cell proliferation, increased mesangial matrix with lobulation, and some double contours of the glomerular basement membrane in almost all glomeruli, which are characteristic findings of MPGN. Immunofluorescent studies showed IgA deposits not only in the mesangial regions but also along the capillary walls, which were more strongly stained than C3. IgA subclass staining showed a stronger immunoreactivity for IgA2 than IgA1. Electron microscopic studies showed electron-dense deposits in the subendothelial, subepithelial, and paramesangial regions. Based on these findings, the patient was diagnosed with IgA-dominant MPGN. Accordingly, she was treated with three courses of methylprednisolone pulse therapy (MPT), followed by prednisolone, mizoribine, and lisinopril. Although hypocomplementemia improved after three courses of MPT, nephrotic-range proteinuria and hypoalbuminemia remained; therefore, two courses of MPT were additionally administered, and the immunosuppressant was changed from mizoribine to cyclosporine (CsA). Finally, the urinary protein level decreased, and a subsequent renal biopsy, two years later, showed improvement in the lesions. We report an atypical case of MPGN with IgA2 dominant deposits along the glomerular capillary wall and in the mesangial region. The case was refractory to standard therapy but sensitive to CsA, which resulted in remission. Our findings suggest that CsA may be useful as an immunosuppressant to treat refractory MPGN." }, { "id": "pubmed23n0563_23247", "title": "Useful indicators for performing renal biopsy in adult patients with isolated microscopic haematuria.", "score": 0.009174311926605505, "content": "Among adult patients with isolated microscopic haematuria (IMH) which is defined as persistent microscopic haematuria but without proteinura, hypertension, renal insufficiency, urinary tract infection or structural abnormality of the urinary tract, some patients have chronic glomerulonephritis (CGN), in whom early diagnosis by renal biopsy is beneficial to timely intervention. Nevertheless, a considerable number of patients with optimistic prognosis [e.g. thin basement membrane nephropathy (TBMN)] undergo invasive and needless renal biopsy. Indicators for weighing the necessity of renal biopsy would be clinically significant. To investigate the value of urinary albumin/creatinine ratio (UACR), serum IgA level, serum C3 level and serum IgA to C3 ratio in predicting the necessity of renal biopsy for adult patients with IMH, 216 patients were studied retrospectively. Patients were divided into: (CGN group, n=137), (TBMN group, n=56) and normal biopsy (normal group, n=23). Of all patients, 131 (61%) evidenced microalbuminuria (UACR=30-299 mg/g) and 85 (39%) had normoalbuminuria (UACR&lt;30 mg/g). The mean value of UACR in CGN group was higher (96+/-17 mg/g) compared with that in TBMN (20+/-4 mg/g, p&lt;0.01) or normal (18+/-3 mg/g, p&lt;0.01) group. The mean values of serum IgA and serum IgA/C3 ratio in patients with IgA nephropathy (IgAN) were significantly higher than those with non-IgAN (380+/-103:217+/-99 mg/dl, p&lt;0.01; 4.5+/-1.2 : 2.4+/-0.9, p&lt;0.01). The odds ratio for distinguishing IgAN from non-IgAN was significantly correlated with serum IgA level and serum IgA to C3 ratio. For adult patients with IMH, UACR, serum IgA level and serum IgA to C3 ratio are non-invasive markers for predicting the necessity of renal biopsy." }, { "id": "pubmed23n0577_1624", "title": "Efonidipine reduces proteinuria and plasma aldosterone in patients with chronic glomerulonephritis.", "score": 0.00909090909090909, "content": "Efonidipine, a dihydropirydine calcium channel blocker, has been shown to dilate the efferent glomerular arterioles as effectively as the afferent arterioles. The present study compared the chronic effects of efonidipine and amlodipine on proteinuria in patients with chronic glomerulonephritis. The study subjects were 21 chronic glomerulonephritis patients presenting with spot proteinuria greater than 30 mg/dL and serum creatinine concentrations of &lt;or=1.3 mg/dL in men or &lt;or=1.1 mg/dL in women. All patients were receiving antihypertensive medication or had a blood pressure &gt;or=130/85 mmHg. Efonidipine 20-60 mg twice daily and amlodipine 2.5-7.5 mg once daily were given for 4 months each in a random crossover manner. In both periods, calcium channel blockers were titrated when the BP exceeded 130/85 mmHg. Blood sampling and urinalysis were performed at the end of each treatment period. The average blood pressure was comparable between the efonidipine and the amlodipine periods (133+/-10/86+/-5 vs. 132+/-8/86+/-5 mmHg). Urinary protein excretion was significantly less in the efonidipine period than in the amlodipine period (1.7+/-1.5 vs. 2.0+/-1.6 g/g creatinine, p=0.04). Serum albumin was significantly higher in the efonidipine period than the amlodipine period (4.0+/-0.5 vs. 3.8+/-0.5 mEq/L, p=0.03). Glomerular filtration rate was not significantly different between the two periods. Plasma aldosterone was lower in the efonidipine period than in the amlodipine period (52+/-46 vs. 72+/-48 pg/mL, p=0.009). It may be concluded that efonidipine results in a greater reduction of plasma aldosterone and proteinuria than amlodipine, and that these effects occur by a mechanism independent of blood pressure reduction. A further large-scale clinical trial will be needed in order to apply the findings of this study to the treatment of patients with renal disease." }, { "id": "pubmed23n0124_1256", "title": "[Incidence and early detection of glomerulonephritis].", "score": 0.00909090909090909, "content": "Within of a for the first time performed aimed study of the early recognition and frequency of the glomerulonephritis in 1,425 males the findings of an \"asymptomatic proteinuria\" were proved in 5.26% of the affected persons. As a result of a comprehensive investigation, the close of which was in every case the biopsy of the kidney with the histological examination of the renipuncture cylinder, a frequency of glomerulonephritis of 2.8% was found. Within this investigation the findings of an \"asymptomatic proteinuria\" proved to be the decisive parameter independent of the size of excretion and the reproducibility. The serological investigations did not show any specifity and proved to be insignificant for the early recognition. The results confirm that the diagnosis of \"physiological proteinuria\" may be made only then when there is an inconspicuous histological finding. In lacking renal histology every form of the proteinuria should at first be attributed to glomerular process." }, { "id": "pubmed23n0569_21470", "title": "The Pisa experience of renal biopsies, 1977-2005.", "score": 0.009009009009009009, "content": "Although several registries collecting data of patients with kidney diseases exist, only a few specifically collect data relating to renal biopsy. Kidney biopsy has been performed routinely in Pisa since 1977; the aim of this study was to report the relative frequency of nephropathies according to gender, age at time of biopsy, clinical presentation and renal function, based on histological diagnoses during the years 1977 through 2005. During this time, 3,810 kidney biopsies were performed, of which 89.3% were from native (n=3,446) and 10.7% from transplant kidneys. Throughout this period, 5% of renal biopsies were not diagnostic, so in this paper we report data regarding 3,269 native kidney nephropathies. During the years 1977 through 2005, data for renal biopsies were collected on specific registers filled out by clinicians. Information collected in the database included a variety of indicators, such as clinical anamnesis, creatinine clearance, daily proteinuria, hemoglobin levels, blood pressure, height and weight, clinical presentation, and current medications. Clinical presentation was defined as urinary abnormalities (UA), nephrotic syndrome (NS) and acute nephritic syndrome (ANS). Renal diseases were divided into 4 major categories: primary glomerulonephritis (GN), secondary GN, tubulointerstitial nephropathies (TIN) and vascular nephropathies (VN). From 1977 up to 1987, a mean of 95 +/- 18 renal biopsies/year were performed; this number significantly increased to 185 +/- 22 renal biopsies/year (range 138-200) (p&lt;0.001) in the following period (1988-2005). Renal biopsy was more frequently performed in males (59%) compared with females (41%). Of all diseases of the native kidney, primary GN was the most frequent (66%), followed by secondary GN (25.6%), TIN (4.2%) and VN (4.2%). The type of primary GN with the highest frequency was mesangial GN (both IgA and non-IgA) (45.7%), followed by membranous GN (23%), focal segmental glomerulosclerosis (19.8%), minimal change disease (5.3%), crescentic GN (4.2%) and postinfectious GN (2%). In terms of age, renal biopsy was more frequently performed in patients aged 20 to 60 years, and nearly 60% of patients presented a glomerular filtration rate (GFR) &gt;60 ml/min at the time of biopsy. The main clinical reason for performing renal biopsy was UA, in all the types of nephropathies. We confirm data that renal diseases are more frequent in men, with the exception of secondary GN. The mean age at diagnosis was 42 years resulting from the tendency not to perform renal biopsies in children and in elderly patients. Renal biopsy was mainly performed in patients with GFR &gt;60 ml/min and asymptomatic urinary abnormalities suggesting concern on the part of clinicians regarding glomerular diseases. The tendency to perform renal biopsies has been significantly increasing throughout our follow-up period." }, { "id": "pubmed23n0941_12213", "title": "A Case of Crescentic Glomerulonephritis Complicated with Hypocomplementemic Urticarial Vasculitis Syndrome and ANCA-Associated Vasculitis.", "score": 0.008928571428571428, "content": "Systemic urticaria in a 64-year-old woman was diagnosed as leukocytoclastic vasculitis by a punch biopsy of the skin. Her physical findings improved after prescription of prednisolone at a dose of 20 mg/day, but the skin rash relapsed with renal dysfunction, proteinuria, and hematuria when the dose of prednisolone was reduced over a period of 9 months to 1 mg/day. She was admitted to our institute for further examination, when urinary protein and plasma creatinine levels were 0.8 g/day and 1.7 mg/dL, respectively. Complement analysis showed that levels of total hemolytic component, component C3 fraction, and component C4 fraction were 30∼60% of normal values and the titer of anti-neutrophil cytoplasmic antibody for myeloperoxidase (MPO-ANCA) was 89 EU (normal range, &lt;10 EU), though there were no immunologic disorders such as systemic lupus erythematosus. Cellular crescentic glomerulonephritis was observed by light microscopy, and immunofluorescent studies showed positive staining for IgG, IgM, C3, C4, and C1q. Electron microscopy showed mesangial and subendothelial deposits with circumferential mesangial interposition. She fulfilled the diagnostic criteria for hypocomplementemic urticarial vasculitis syndrome (HUV), and ANCA-associated vasculitis (AAV) was also indicated by small vessel vasculitis and positive MPO-ANCA. Steroid pulse therapy with methylprednisolone followed by oral prednisolone improved her general condition and hypocomplementemia, and MPO-ANCA became negative. HUV and AAV are distinct clinical disorders, though both affect small blood vessels. Here we report a case of AAV-complicated HUV with crescentic glomerulonephritis." }, { "id": "pubmed23n0791_5001", "title": "Comparison of laboratory findings in patients with glomerulonephritis classified according to histopathologic diagnosis.", "score": 0.008928571428571428, "content": "The aim of the present study was to assess whether laboratory investigations have predictional values for histopathological diagnosis of glomerulonephritis before performing renal biopsy. The study enrolled 452 patients, who underwent kidney biopsy and were examined retrospectively; 128 patients with the histopathological diagnosis of glomerulonephritis were included in the study. Serum CRP, albumin, uric acid levels, 24 hour urine protein presence, leucocyte count, C3, C4, IgG, IgA and IgM levels were assessed. The most common diagnosis of glomerulonephritis was IgAN with the percentage of 29.7% within the groups. Male gender was predominant except lupus group. Only the ones with crescentic glomerulonephritis had higher CRP levels. In 20% of patients with IgAN, in 8.3% of the ones with MN, in 35% of crescentic group, in 42% of FSGS group, in 30% of patients with MPGN and in 33% of the ones with lupus nephritis uric acid levels were found as elevated. In IgAN, FSGS and lupus nephritis normoalbuminemia and nephritic proteinuria, in MN and crescentic glomerulonephritis hypoalbuminemia, nephrotic proteinuria, in MPGN hypoalbuminemia, nephritic proteinuria were established. Serum Ig G levels were lower in MN and MPGN. Serum IgA levels were found as elevated in IgAN. Serum C4 levels were found as lower in lupus nephritis and MPGN. In patients admitted in clinical picture of glomerulopathy, since measurements of serum CRP, albumin, uric acid, C3, C4,IgG, IgA, IgM levels, leucocyte count and 24 hour urine protein amount can lead to predict the histopathological diagnosis, their significance in routine investigations has been suggested also in our study." }, { "id": "pubmed23n0392_19300", "title": "Aristolochic acid-induced Fanconi's syndrome and nephropathy presenting as hypokalemic paralysis.", "score": 0.008849557522123894, "content": "Hypokalemic paralysis rarely is seen as the presenting feature in patients with Fanconi's syndrome. We describe a 60-year-old man who presented with the inability to ambulate on awakening in the morning. The pertinent history revealed he had consumed Chinese herbs for leg edema for 5 months. Physical examination was unremarkable except for extracellular fluid volume depletion and total paralysis of both lower extremities. Laboratory investigation showed hypokalemia (1.8 mEq/L), hyperchloremic metabolic acidosis (Cl-, 111 mEq/L, and HCO3-, 14.0 mEq/L), hypophosphatemia (0.9 mg/dL) with hyperphosphaturia, hypouricemia (1.3 mg/dL) with hyperuricosuria, and glycosuria, consistent with Fanconi's syndrome. Mild renal insufficiency (serum creatinine, 1.7 mg/dL) also was noticed. Blood and urine screens for heavy metals, autoantibodies, and monoclonal gammopathy were negative. A renal biopsy specimen revealed typical findings of aristolochic acid-associated nephropathy. Aristolochic acids were detected in the consumed Chinese herbs. This case highlights that consumption of Chinese herbs containing aristolochic acids may cause Fanconi's syndrome and should be considered as a cause of hypokalemic paralysis." }, { "id": "pubmed23n1110_3651", "title": "Something Out of Nothing: A Rare Case of Pulmonary Renal Syndrome With Pauci-Immune Glomerulonephritis and Diffuse Alveolar Hemorrhage With Negative Serologies.", "score": 0.008771929824561403, "content": "Pauci-immune crescentic glomerulonephritis (CrGN) is one of the most common etiologies of rapidly progressive glomerulonephritis. This condition presents with crescentic glomerulonephritis with little or no immunoglobulin staining and negative serological workup aside from a positive antineutrophil cytoplasmic autoantibody (ANCA). Typically, patients with pauci-immune CrGN have an underlying systemic small vessel vasculitis, but in rare cases, it presents without any known vasculitis or ANCA. Pauci-immune ANCA negative CrGN is often strictly isolated to the kidneys. In this case, we present a patient with ANCA negative, pauci-immune CrGN with severe diffuse alveolar hemorrhage. A 66-year-old Hispanic woman with a past medical history of controlled hypertension presented with fatigue and dysphagia. On admission, her vital signs were significant for hypoxia on room air, and her physical exam was remarkable for crackles bilaterally. The initial laboratory results revealed anemia (hemoglobin 5.2 g/dL), hyperkalemia (6.3 mmol/L), elevated creatinine (4.50 mg/dL, with a baseline of 0.9mg/dL). Urinalysis showed moderate blood and urine protein (200 mg/dL). Urine microscopic examination showed 25-50 RBCs seen/high power field. The patient was admitted to ICU due to hypoxia, a computed tomography scan of the chest/abdomen/pelvis was obtained and revealed multifocal pulmonary consolidations. A blood transfusion was ordered. The patient began to have hemoptysis and subsequent bronchoscopy showed diffuse alveolar hemorrhage. ICU team proceeded to intubate her as the hemorrhage continued to worsen. Further workup revealed a positive anti-nuclear antibodies (ANA) of 1:40, but otherwise negative serologies including myeloperoxidase (MPO)-ANCA, glomerular basement membrane antibody, and anti-double stranded DNA. Kidney biopsy showed necrotizing glomerulonephritis with crescents and negative immunofluorescence. She was diagnosed with pauci-immune ANCA-negative vasculitis with associated diffuse alveolar hemorrhage and nephritis based on these results and was started on pulse-dose steroids. The patient was started on intravenous (IV) high-dose cyclophosphamide, which helped improved the overall clinical condition significantly. After creatinine began trending down and urine output improved, the patient was discharged on a regimen of daily oral cyclophosphamide and steroid taper. Patient oxygen requirements decreased and she was sent home with supplemental oxygen while requiring 3L/min of oxygen. Pauci-immune and ANCA-negative glomerulonephritis with concurrent diffuse alveolar hemorrhage is exceptionally rare. In this situation, medical management relied on clinical evidence from similar populations in the use of steroids and cyclophosphamide. This case report aims to shed more light on the clinical progression and management of this condition. Here we present a case of pulmonary-renal syndrome with biopsy-proven glomerulonephritis but without ANCA positive serologies." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 684, 858 ] ], "word_ranges": [ [ 119, 147 ] ], "text": "A history of stroke (presumably ischemic) 4 months ago is a relative contraindication for fibrinolysis (if the time is less than 3 months it is an absolute contraindication)," }, "2": { "exist": true, "char_ranges": [ [ 543, 683 ] ], "word_ranges": [ [ 92, 119 ] ], "text": "Option 2 does not make much sense, since in the event that fibrinolysis is indicated, it would only be a waste of time to make the transfer." }, "3": { "exist": true, "char_ranges": [ [ 863, 1004 ] ], "word_ranges": [ [ 148, 173 ] ], "text": "the definitive factor that tips the balance towards PCI is the extent of AMI and the presence of shock, which are indications for urgent PCI." }, "4": { "exist": true, "char_ranges": [ [ 240, 374 ] ], "word_ranges": [ [ 42, 63 ] ], "text": "It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5." }, "5": { "exist": true, "char_ranges": [ [ 240, 374 ] ], "word_ranges": [ [ 42, 63 ] ], "text": "It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5." } }

{ "1": "Immediate systemic fibrinolysis at the regional hospital.", "2": "Immediate transfer to a tertiary center for treatment with fibrinolysis.", "3": "Immediate transfer to a tertiary center for percutaneous coronary revascularization procedure.", "4": "Hemodynamic stabilization and deferred revascularization procedure.", "5": "Immediate treatment with fondaparinux and abciximab." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0547_14526", "title": "[Coronary angioplasty for primary cardiogenic shock following acute myocardial infarction].", "score": 0.018108816781383152, "content": "In the setting of acute myocardial infarction (AMI), several investigators have demonstrated that emergency coronary angioplasty (PTCA) reduces in-hospital mortality of primary cardiogenic shock (CS) from 90% to less than 50% ; however, few studies have focused on the current outcome of non selected patients in whom the onset of AMI is immediately complicated by CS. To evaluate in-hospital mortality of the patients admitted to our institution for Q wave AMI presented in CS. Between 05/93 and 05/03, 30 consecutive pts, 26 men and 4 women, in CS following AMI were treated with direct PTCA, 26 without thrombolysis and 4 as rescue after failed streptokinase. AMI was defined by prolonged chest pain and &gt; or =1 mm ST segment elevation in &gt; or =2 contiguous peripheral leads or &gt; or =2 mm for precordial leads on the admission ECG. The diagnosis of CS was based on the combination of systolic blood pressure of &lt;90 mm Hg, unresponsive to volume expansion, signs of acute circulatory failure (cyanosis, cold extremities, restlessness, mental confusion or coma) and congestive heart failure secondary to myocardial dysfunction. In 40% of cases the diagnosis of CS was only clinical and in 60% of cases was confirmed by a Swan Ganz catheter. Mean age was 62.3 +/- 12.3 years, 7 had triple vessel disease, 14 a double vessel disease, 8 a single vessel disease and in one case a left main disease. The AMI was anterior in 22 pts (73%), inferior in 8 (27%). Intraaortic balloon was used in 3 pts, CPR in 16 (47%), transitory pacemaker in 1 pt, inotropes in 25 pts, emergency coronary artery bypass grafting (CABG) in 1 pt. Success for PTCA with a residual stenosis &lt; 50% and a TIMI flow III was obtained in 26 pts (87%). Mean time between CS and revascularization was 219 +/- 302 minutes. 19 pts (63%) survived and 11 pts (37%) died while at the hospital, 6 from intractable shock, 4 from multiple organ failure and in 1 case from pulmonary hemorrhage. Mean time of revascularization for the surviving was 190 +/- 329 min, and for the dead 295 +/- 212 min. Hospital mortality for inferior infarction is 12.5% after successful angioplasty. Comparison of surviving and non surviving number of patients according to revascularization time showed a significant difference of these groups whether the revascularization was accomplished before or after 120 minutes. [table: see text] Direct PTCA for AMI immediately complicated by CS, can be achieved with a high success rate, and can significantly reduce in-hospital mortality; this improvement of survival is most evident if revascularizarion is performed early." }, { "id": "pubmed23n0974_20947", "title": "Sequential development of cardiac tamponade and subacute stent thrombosis after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: A case report.", "score": 0.01670843776106934, "content": "A 42-year-old male suffered from ST elevation myocardial infarction and underwent successful percutaneous coronary intervention (PCI) of the left anterior descending coronary artery (LAD) with drug-eluting stent using intravenous glycoprotein IIB/IIIa inhibitor (Clotinab<sup®</sup, Isu Abxis). Five hours after PCI, the patient developed cold sweating and went into a stupor. Urgent 2D-echocardiography showed a large amount of pericardial effusion and akinesia in the LAD territory. A repeat emergent angiography (CAG) was done to ascertain whether acute stent thrombosis or coronary perforation had occurred after PCI. The CAG showed, however, no leakage of dye or thrombus in any coronary arteries with a patent stent in the middle LAD. Approximately 200 cm<sup3</sup of bloody pericardial effusion was drained, and his blood pressure returned to normal immediately after pericardiocentesis. Seven days later, he again developed sudden hypotension, bradycardia, and loss of consciousness. The ECG showed ST elevation in V1-V6 and 2D-echocardiography showed scanty pericardial effusion. Emergent CAG showed total occlusion of the LAD due to subacute stent thrombosis. He was successfully treated with balloon angioplasty and was discharged with dual anti-platelet therapy. A follow-up CAG after 9 months showed good flow without residual stenosis across the stented segment." }, { "id": "pubmed23n0686_7064", "title": "Glucose-6-phosphate dehydrogenase (G6PDH) deficiency in a patient with ST-segment elevation acute myocardial infarction successfully treated by simple thrombectomy.", "score": 0.015109890109890112, "content": "We report the case of an 82-year-old Sardinian woman affected by \"favism\" (i.e. intolerance to fava beans) with chest pain associated with persistent massive ST elevation in V2-V6 leads, admitted to our department after transfer from a rural hospital without catheterization facilities. On immediate transfer to the catheterization laboratory for primary percutaneous intervention (PCI), coronary angiogram showed proximal left anterior descending (LAD) thrombotic occlusion. In consideration of her history of glucose-6 phosphate dehydrogenase deficiency and \"loss of consciousness\" at a young age after taking aspirin, which contraindicated aspirin therapy, we treated this patient using a new, two-step strategy, with an emergency minimalist intervention using manual thrombectomy and intracoronary glycoprotein IIb/IIIa (GPIIbIIIa) inhibition with abciximab. Subsequent angiography control confirmed the persistence of Thrombolysis in Myocardial Infarction Trial (TIMI) grade 3 flow and the presence of an intermediate proximal LAD coronary lesion, which was not treated, also due to the persisting contraindication to aspirin. In our opinion, minimalist intervention with a thrombectomy device (especially in patients characterized by a high intracoronary thrombus burden) and/or with the use of a small balloon or gentle dilation, sustained by maximized antithrombotic therapy may represent an interesting and rational approach, allowing interventionalists to postpone stenting in the setting of primary PCI in special cases." }, { "id": "pubmed23n0398_13261", "title": "[Direct percutaneous transluminal coronary angioplasty in patients with acute myocardial infarct treated at the Cardiac Center of the General Medical School Hospital in Prague: a 1-year retrospective study].", "score": 0.014433962264150942, "content": "Direct percutaneous transluminal coronary angioplasty (d-PTCA) in patients with acute myocardial infarctions (AIM) has become an alternative of thrombolytic treatment. If the involved department has adequate experience the success rate of the procedure is high and the immediate and long-term results are better than those of thrombolysis. Moreover contrary to thrombolytic treatment successful percutaneous coronary intervention in AIM is more beneficial for patients also later than 6 hours after the development of infarction pain. In the Cardiocentre of the General Faculty Hospital (GFH) patients with AIM are constantly attended, i.e. those indicated for reperfusion therapy are treated solely by the d-PTCA method. Retrospective analysis of d-PTCA in AIM made during the annual period from Jan. 1 2000 to Dec. 31 2000. Into the observation study patients were included with clinical and/or ECG signs of AIM when the period from the onset of pain to the beginning of intervention did not exceed 12 hours. All patients were given before the procedures 500 mg of acetylsalicylic acid and 10,000 u. heparin. Cardiac catheterization was implemented by the percutaneous Seldinger technique via the a. femoralis l.dx., in exceptional cases from the left femoral artery. An approach via the a. radialis and/or a. brachialis was not used in any of the patients. From the investigation patients were excluded who had before the percutaneous coronary intervention (PCI) a thrombolytic preparation (so-called rescue-PTCA). During the mentioned period in the Cardiocentre of the GFH a total of 673 PTCA were performed, incl. 127 (18.9%) d-PTCA in patients with AIM. In the mentioned group of 127 patients subjected to intervention were 87 (68.5%) men and 40 (31.5%) women. The mean age of the men was 59.1 +/- 12 years and the mean age of the women 68.2 +/- 12 years. As to the main risk factors of coronary atherosclerosis arterial hypertension was present in 48%, smoking in 42%, diabetes in 23% and hyperlipoproteinaemia in 31% of the treated patients. More than one third of the patients had a history of myocardial infarction (38%). The infarcted artery was the r. interventricularis anterior (LAD) in 51 (40.2%), the right coronary artery (RCA) in 54 (42.5%), the r. circumflex (LCX) in 16 (12.6%), the left main coronary artery in 2 (1.6%) and the bypass in 4 (3.1%). Multiple coronary affections were recorded in 80 (63%) patients, affections of one artery in 47 (37%). Primary procedural success (flow TIMI 3/2) was achieved in 121 patients (95.3%). Normal flow through the infarcted artery TIMI 3 was achieved in 118/127 (85.8%) patients. In 91 (71.7%) into the infarcted artery a coronary stent was implanted, during hospitalization no subacute stenosis of the stent developed. The mean period between the onset of infarction pain--injection was 4.4 +/- 2.3 hours. The mean period of the entire procedures was 48 +/- 14.5 minutes. As contrast material only non-ionic contrast substances were used (Iomeron 350) with a mean consumption of 150 ml per patient. The mean skiascopic time was 13.6 +/- 1.8 min. A total of 9 (7.1%) patients were treated with GP IIb/IIIa receptor blockers (abciximab). The total hospitalization mortality of the intervened group was 7.1% (9 patients). In a sub-group of 9 patients who at the onset of the procedure were in cardiogenic shock 3 (33%) died. The hospitalization mortality of the sub-group of patients with AIM without cardiogenic shock, treated with d-PTCA was 5.1% (6/118). During hospitalization the authors did not observe any intracranial haemorrhage. The group of subjects with AIM subjected to catheterization who are treated by d-PTCA is relatively numerous in our department. According to a number of clinical studies successful d-PTCA in AIM gives better short-term and long-term results as compared with thrombolytic therapy. The primary success rate of d-PTCA was high and the hospital mortality was low and comparable with contemporary data in the literature. Direct PTCA is effective treatment in patients with acute myocardial infarction. The authors results confirm the high procedural success rate and acceptable hospital mortality. These favourable results of an invasive approach to treatment of AIM must be compared in future with bolus thrombolytic treatment by new types of thrombolytic preparations in combination with anti-platelet treatment with blockers of platelet glycoprotein receptors IIb/IIIa with/or without subsequent percutaneous coronary intervention." }, { "id": "pubmed23n0592_21267", "title": "Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial.", "score": 0.0134975035965135, "content": "Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be done within 90 min. However, the best subsequent management of patients after thrombolytic therapy remains unclear. To assess the best management, we randomised patients with STEMI treated by thrombolysis and abciximab at a non-interventional hospital to immediate transfer for PCI, or to standard medical therapy with transfer for rescue angioplasty. 600 patients aged 75 years or younger with one or more high-risk features (extensive ST-segment elevation, new-onset left bundle branch block, previous myocardial infarction, Killip class &gt;2, or left ventricular ejection fraction &lt; or =35%) in hospitals in France, Italy, and Poland were treated with half-dose reteplase, abciximab, heparin, and aspirin, and randomly assigned to immediate transfer to the nearest interventional centre for PCI, or to management in the local hospital with transfer only in case of persistent ST-segment elevation or clinical deterioration. The primary outcome was a composite of death, reinfarction, or refractory ischaemia at 30 days, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number 00220571. Of the 299 patients assigned to immediate PCI, 289 (97.0%) underwent angiography, and 255 (85.6%) received PCI. Rescue PCI was done in 91 patients (30.3%) in the standard care/rescue PCI group. The primary outcome occurred in 13 patients (4.4%) in the immediate PCI group compared with 32 (10.7%) in the standard care/rescue PCI group (hazard ratio 0.40; 95% CI 0.21-0.76, log rank p=0.004). Major bleeding was seen in ten patients in the immediate group and seven in the standard care/rescue group (3.4%vs 2.3%, p=0.47). Strokes occurred in two patients in the immediate group and four in the standard care/rescue group (0.7%vs 1.3%, p=0.50). Immediate transfer for PCI improves outcome in high-risk patients with STEMI treated at a non-interventional centre with half-dose reteplase and abciximab." }, { "id": "pubmed23n0350_14784", "title": "[Pre-hospitalization treatment with Abciximab in the preparation of patients for primary angioplasty in the acute phase of myocardial infarct. Immediate and long-term (one month) results].", "score": 0.012780853142298926, "content": "Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p &lt; 0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies." }, { "id": "pubmed23n1094_2769", "title": "The Young Heart Tears Easily Apart: A Case Report of Spontaneous Coronary Artery Dissection.", "score": 0.012462006079027355, "content": "Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS), seen mostly in young females. The rarity and limited knowledge of the disease make its management challenging. Prompt diagnosis of the condition is extremely important to decrease both long- and short-term complications. Treatment options depend on hemodynamic stability and the location of the dissection- with more distal lesions treated more conservatively as opposed to proximal lesions which are treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The following are the two cases with different presentation, management and outcomes. Our first patient was a 35-year-old woman with no medical history who presented with acute, anginal pain, diaphoresis and palpitations. She was hemodynamically stable on presentation, with work-up significant for electrocardiogram (ECG) with sinus bradycardia, ST elevation in leads V1-V6, and elevated troponin level of 4 ng/ml. There was no evidence of a pulmonary embolism on computed tomography (CT) of the chest. A coronary angiogram showed 100% dissection of the proximal to mid-left anterior descending (LAD) artery. Attempts to place a stent in the proximal to mid LAD were unsuccessful as the true lumen of the LAD was not accessible. The patient became hemodynamically unstable, and an emergent CABG was done, restoring blood flow. The patient recovered during her hospital stay and was discharged with dual antiplatelet therapy (DAPT), beta-blockers, and atorvastatin. The second patient was a 28-year-old woman, with a history of hypertension who presented with anginal chest pain. Workup showed ECG with minimal ST elevations in anteroseptal leads, with elevated troponin level to 0.71 ng/ml. Coronary angiogram showed 40-50% stenosis of the mid LAD with an aneurysmal segment. An echocardiogram showed no evidence of wall motion abnormalities, and she had a normal left ventricular ejection fraction (LVEF). She was discharged home the next day, on medical management. After two days, she returned to the hospital with similar complaints, with work-up significant for ECG with non-specific ST-T abnormality, and troponin level which peaked at 2.22 ng/ml. She was started on a heparin drip, and a repeat left heart catheterization revealed type 2 dissection of the mid to distal LAD, with intravascular ultrasound showing a fractional flow reserve of 0.76. She was discharged home on DAPT, beta-blocker, calcium channel blocker (CCB), and atorvastatin, with close cardiology follow up. These two cases highlight the importance of keeping in mind the possibility of SCAD, especially when relatively healthy young women present with anginal symptoms. Early diagnosis of the condition and prompt management are extremely important to ensure favourable outcomes. The two cases also describe the coronary angiogram findings in SCAD, and the different strategies employed in the management of this condition." }, { "id": "InternalMed_Harrison_19297", "title": "InternalMed_Harrison", "score": 0.012078034829681833, "content": "Cardiac catheterization and coronary angiography should be carried out after fibrinolytic therapy if there is evidence of either (1) failure of reperfusion (persistent chest pain and ST-segment elevation >90 min), in which case a rescue PCI should be considered; or (2) coronary artery reocclusion (re-elevation of ST segments and/or recurrent chest pain) or the development of recurrent ischemia (such as recurrent angina in the early hospital course or a positive exercise stress test before discharge), in which case an urgent PCI should be considered. Routine angiography and elective PCI even in asymptomatic patients following administration of fibrinolytic therapy are used with less frequency, given the numerous technologic advances that have occurred in the catheterization laboratory and the increasing number of skilled interventionalists. Coronary artery bypass surgery should be reserved for patients whose coronary anatomy is unsuited to PCI but in whom revascularization appears to" }, { "id": "article-178_5", "title": "Selecting a Treatment Modality in Acute Coronary Syndrome -- Function", "score": 0.01046894803548796, "content": "Fibrinolysis should be a consideration if the patient first presents to a non-PCI capable facility and the anticipated time from first medical contact to the performance of primary PCI exceeds 120 minutes (this 120-minute duration usually accounts for a 30-minute door in-door out time (DIDO) time goal at the non-PCI capable facility). Upon deciding about whether or not to use fibrinolysis, it should preferably occur within the first 30 minutes of the first medical contact. This strategy can be achieved either as prehospital fibrinolysis by the emergency medical service (EMS) provider or within 30 minutes of arriving at a non-PCI capable facility (door to needle time). Contraindications to fibrinolysis require prompt review if this strategy is an option. Absolute contraindications are any previous intracranial hemorrhage, ischemic stroke in the past 3 months, central nervous system neoplasm or arteriovenous malformation, major head trauma or surgery within the past month, known active bleeding or bleeding diathesis (with the exception of menses), suspected aortic dissection, severe uncontrolled hypertension unresponsive to emergent medical therapy and use of streptokinase in the last 6 months. [7] Some relative contraindications include a history of chronic poorly controlled hypertension, surgery in the last 3 months, ischemic stroke more than 3 months ago, traumatic or prolonged cardiopulmonary resuscitation (CPR), and any other unspecified intracranial pathology. Some factors merit consideration when considering fibrinolysis based on the available evidence from the recent clinical studies. Mortality reduction in patients with STEMI who are undergoing fibrinolysis is the highest within the first 4 hours, being around 80% after 2 hours and less than 20% after 4 hours of symptom onset. [13] Patients with developed collateral circulation may have more significant benefits beyond the 2-hour timeframe when compared to patients without collateral circulation. The CAPTIM trial compared prehospital fibrinolysis with PCI in patients with STEMI and found that patients who received treatment with pre-hospital fibrinolysis within 2 hours of symptoms onset had better survival when compared to PCI strategy. [14] Based on the STREAM trial, prehospital fibrinolysis provides similar efficacy when compared to PCI in patients with STEMI who presented within 3 hours and were unable to get PCI within 1 hour but with a higher rate of intracranial bleeding. [15] [16] An overview of nine randomized trials published by the Fibrinolytic Therapy Trialist collaborative group suggests that characteristics of patients who derive the least benefit from fibrinolysis are those with a delayed presentation (over 13 to 24 hours of symptom onset), elderly (age greater than 75 years), inferior ST elevations, and uncontrolled hypertension (systolic blood pressure (BP) more than 175 mmHg). [17] Thus, as a general framework, it seems that patients who present with early onset of symptoms but with a significant anticipated delay in transportation to a PCI-capable facility should get fibrinolytic treatment in the absence of absolute contraindications. While on the other hand, patients who present with onset of symptoms longer than 12 hours and absence of hemodynamic instability and evidence of ongoing ischemia of a large amount of myocardium should not receive fibrinolysis due to a likely lack of significant benefit. Other cases require evaluation on a case-by-case basis with careful consideration of risks and benefits. Upon deciding for a fibrinolytic strategy, agents that are fibrin-specific and given as a bolus (such as tenecteplase and reteplase) are preferred to other agents due to demonstrated lower risk of intracerebral bleeding and are more convenient to use. [18] [19]" }, { "id": "First_Aid_Step2_44", "title": "First_Aid_Step2", "score": 0.010167253521126761, "content": "T AB LE 2.1 -1 0. TIMI Risk Score for Unstable Angina/NSTEMI DEATH, MI, OR URGENT CHARACTERISTICS POINT RISK SCORE DEATH OR MI REVASCULARIZATION History Age ≥ 65 years 1 0/1 3 5 ≥ 3 CAD risk factors (family history, DM, tobacco, hypertension, ↑ cholesterol) 1 2 3 8 Known CAD (stenosis > 50%) 1 3 5 13 ASA use in past seven days 1 4 7 20 Presentation 5 12 26 Severe angina (≥ 2 episodes within 24 hours) 1 6/7 19 41 ST deviation ≥ 0.5 mm 1 + cardiac marker 1 Risk score—total points (0–7) Higher-risk patients (risk score ≥ 3) beneft more from enoxaparin (vs. unfractionated heparin), glycoprotein IIb/IIIa inhibitors, and early angiography. Defined as ST-segment elevations and cardiac enzyme release 2° to prolonged cardiac ischemia and necrosis. Presents with acute-onset substernal chest pain, commonly described as a pressure or tightness that can radiate to the left arm, neck, or jaw." }, { "id": "First_Aid_Step2_43", "title": "First_Aid_Step2", "score": 0.010050778463217088, "content": "Unstable angina is not associated with elevated cardiac markers, but ST changes may be seen on ECG and are indicative of high-risk occlusions. NSTEMI is diagnosed by serial cardiac enzymes and ECG. Acute treatment of symptoms is the same as that for stable angina. Clopidogrel, unfractionated heparin or enoxaparin, and glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide, tirofiban, abciximab) should also be considered. Patients with chest pain refractory to medical therapy, a TIMI score of ≥ 3, a troponin elevation, or ST changes > 1 mm should be given heparin and scheduled for angiography and possible revascularization (percutaneous coronary intervention [PCI] or CABG). Think unstable angina if chest pain is new onset, accelerating, or occurring at rest. T AB LE 2.1 -1 0. TIMI Risk Score for Unstable Angina/NSTEMI DEATH, MI, OR URGENT CHARACTERISTICS POINT RISK SCORE DEATH OR MI REVASCULARIZATION" }, { "id": "pubmed23n0911_1103", "title": "Fibromuscular Dysplasia with Spontaneous Coronary Artery Disease Presenting as Acute Myocardial Infarction.", "score": 0.009900990099009901, "content": "A 40-year-old female presented to a rural hospital with crushing substernal chest pain. An initial electrocardiogram showed ST elevation in lead II and aVF with elevated troponin I. She was immediately transferred to a tertiary care hospital. An emergent coronary angiogram did not show any significant coronary artery disease. On the second day, the patient experienced recurrence of severe chest pain with ST elevations in leads I, aVL, V5-V6, ST depressions in V1-V3, T-wave inversion over V2-V5. The troponin I level increased to &gt; 40 ng/ml (normal 0.0 to 0.04 ng/ml). An emergent angiogram was performed revealing local dissection of the mid to distal left main coronary artery and a totally occluded diagonal artery. It was deemed unsafe to perform percutaneous coronary intervention because it was a non-flow limiting left main coronary artery dissection and was difficult to cannulate with the guide catheter. Subsequently, an elective angiogram was performed after a 48-hour interval to evaluate the progression of dissection and to make a definitive decision for revascularization versus medical management. On the third angiogram, stenosis seen in the diagonal branch on the previous angiogram progressed to dissection, and local dissection of the left main coronary artery seen on the previous angiogram spontaneously resolved. The patient was symptom-free and hemodynamically stable. It was decided to manage the patient conservatively due to the spontaneous resolution of occlusion in the diagonal artery and dissection of the left main coronary artery. The patient was started on conservative medical treatment. A magnetic resonance angiography of the right internal carotid artery revealed a \"string of beads\" appearance, which confirmed the diagnosis of fibromuscular dysplasia. She was followed closely in the clinic and has remained asymptomatic for the past one year." }, { "id": "pubmed23n0538_19008", "title": "[Disseminated coronary occlusions and massive pulmonary embolism in a 40-year-old woman].", "score": 0.009900990099009901, "content": "A 40-year-old woman was admitted to the emergency room because of severe angina pectoris and dyspnoe at rest. She developed ventricular fibrillation a few minutes later from which she had to be resuscitated . After intubation and controlled ventilation immediate angiocardiography was performed while she was still in cardiogenic shock. Coronary angiography ten days before had been unremarkable. The second coronary angiogram revealed severe thrombotic lesion at the origin of the left anterior descending branch (LAD) and total occlusions of the peripheral LAD and of the first marginal branch. After intracoronary application of 10 mg abciximab and coronary stent implantation in the origin of the LAD the patient had good clinical improvement. Massive pulmonary embolism two days later, despite of effective heparinization and inhibition of platelet aggregation (as measured by partial thromboplastin time), was treated successfully by regional injection of 100 mg tissue plasminogen activator (t-PA). Tests for possible hypercoagulability showed no detectable changes in the clotting and fibrinolytic system with a normal platelet count. In a standardized aggregation test of platelets hyperaggregation in response to ADP and epinephrine, also at low test doses, revealed the presence of a sticky platelet syndrome. This case history suggests that enhanced platelet aggregation associated with sticky platelet syndrome may provoke myocardial infarction even in angiographically normal coronary arteries." }, { "id": "pubmed23n1097_2190", "title": "Impact of Percutaneous Coronary Intervention and Implantation of Intra-Aortic Balloon Pump on the Outcome of an Acute Total Obstruction of the Left Main Coronary Artery.", "score": 0.00980392156862745, "content": "Acute total occlusion of the left main coronary artery (LMCA) is a fatal event; most patients die before reaching hospitals. Few of them reach the hospital alive. Revascularization of the LMCA can be achieved by surgical intervention or percutaneous coronary intervention with unknown optimal modality. However, mortality of those patients is very high even with either; few cases reported successful management of acute total occlusion of the LMCA including our patient. <iCase Presentation</i. A 56-year-old male patient who is a smoker presented with typical chest pain worsened 2 hours prior to admission. He was hemodynamically stable, but he had respiratory failure due to pulmonary edema. An electrocardiogram showed anterior ST-elevation myocardial infarction. He was given loading doses of dual antiplatelet agents, in addition to respiratory support, then transferred immediately to the cardiac catheterization laboratory. Urgent cardiac catheterization showed total occlusion of the LMCA. Recanalization was done successfully, and a stent was inserted in the LMCA and left anterior descending artery. The patient developed cardiogenic shock during the procedure. An intra-aortic balloon pump (IABP) was applied which improved his hemodynamic status and enhanced his coronary flow. He is clinically improved, there was resolution of ST elevation, and cardiogenic shock gradually resolved. IABP was removed, and the patient was discharged in good general condition. Survival after acute total occlusion of the LMCA is very rare. The good outcome in this patient is attributed to early recognition and timely successful intervention, with good respiratory and hemodynamic support. The surgical and anaesthesia team should be on stand-by until complete revascularization and stabilization of the patient are achieved." }, { "id": "pubmed23n0329_6276", "title": "[Initial experience with the use of abciximab in the salvage treatment of acute coronary thrombosis in the Hemodynamics Laboratory].", "score": 0.00980392156862745, "content": "The optimal treatment of acute thrombotic complications in the Catheterization Laboratory has not been defined yet, due to the limited efficacy shown by various pharmacological regimens, even when associated to coronary angioplasty (PTCA). The aim of our study was therefore to evaluate the effects of abciximab (ReoPro), a new potent inhibitor of the platelet glycoprotein IIb/IIIa, when administered as a \"rescue\" treatment for acute thrombotic coronary occlusion during diagnostic or interventional procedures. Sixteen patients (12 males, 4 females, mean age 59.3 +/- 9.2 years, range 43-77 years), with unstable angina and consecutively treated with abciximab due to clinical instability attributable to coronary thrombosis angiographically proven during PTCA (9 cases) or diagnostic angiography (7 cases), were identified. The individual angiographic films and medical records were then reviewed in order to evaluate the effects of treatment on coronary flow, thrombus size and occurrence of in-hospital adverse events: death, non-fatal acute myocardial infarction (AMI), need for urgent myocardial revascularization and hemorrhage. The administration of abciximab, in association with PTCA (associated in turn with stent implantation in 8 cases), induced a significant increase of coronary TIMI flow grade (0.3 +/- 0.6 vs 2.4 +/- 0.9; p &lt; 0.05) and a significant decrease of thrombus \"score\" (size) 2.4 +/- 0.9 vs 1.3 +/- 0.6; p &lt; 0.01). No deaths nor need for urgent myocardial revascularization were observed; in 31% of cases (5 patients) evolution towards AMI occurred, while however 94% of cases (15 patients) had a coronary occlusion before treatment. No major hemorrhagic complications were observed, while in 12% of cases (2 patients) a groin hematoma associated with moderate hemoglobin drop, developed. In conclusion, the administration of abciximab, associated with the common \"rescue\" interventional procedures, in patients with acute thrombotic coronary occlusion in the Catheterization Laboratory, appears to be effective in restoring adequate coronary flow and reducing the thrombus size (limiting therefore the evolution towards AMI), and safe, not having been associated with significant hemorrhagic complications." }, { "id": "pubmed23n1016_4294", "title": "Pseudo-Wellens syndrome, acute pancreatitis, and an anomalous coronary artery: a case report.", "score": 0.009708737864077669, "content": "Chest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies. A 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features. Clinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis." }, { "id": "pubmed23n0403_20779", "title": "[Prognostic factors in unstable angina with dynamic electrocardiographic changes. Value of fibrinogen].", "score": 0.009708737864077669, "content": "The prognosis of unstable angina varies between series depending on the inclusion criteria and management protocol used. The aim of this study was to analyze in-hospital events and their predictors in a homogeneous single-center series of patients with unstable angina. A total of 246 patients with the following inclusion criteria were studied: 1) resting anginal pain, 2) transient electrocardiographic changes during anginal pain, 3) normal CK-MB levels and 4) exclusion of postinfarction angina. All patients were treated with aspirin and enoxaparin (1 mg/kg/12 h). Coronary angiography was performed in the case of recurrent angina or ischemia in Bruce I-II stage during the predischarge effort stress test. The variables recorded were risk factors, history of ischemic heart disease, history of coronary surgery, ECG upon admission, and fibrinogen. During the hospital stay the following events were recorded: 36% recurrent angina, 58% cardiac catheterization, and 5,7% major events (infarction or death). Multivariate analysis found recurrent angina to be more frequent in patients with a history of coronary bypass surgery (p = 0.004. OR = 22; CI 95%, 3-182), ST-segment changes (p = 0.01. OR = 4.7, CI 95%; 1.4-15.9) and higher fibrinogen (p = 0.002. OR = 1,4, CI 95%; 1.1-1.7). Fibrinogen was the only variable related to cardiac catheterization (p = 0,009. OR = 1.3. CI 95%, 1.1-1.6) and major events (p = 0.001. OR = 2.0. CI 95%, 1.4-3.1). 1) Unstable angina with electrocardiographic changes was associated to a high rate of in-hospital events. 2) Fibrinogen was related to any event, and previous by-pass surgery and ST changes were related to recurrent angina." }, { "id": "pubmed23n1135_15840", "title": "Acute myocardial infarction with simultaneous total occlusion of the left anterior descending artery and right coronary artery successfully treated with percutaneous coronary intervention.", "score": 0.009615384615384616, "content": "Simultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required. We report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1-V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital. Acute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease." }, { "id": "pubmed23n0930_11083", "title": "Acute myocardial infarction due to simultaneous spasm of 3 coronary arteries that worsened over time.", "score": 0.009523809523809525, "content": "Coronary artery spasm (CAS) rarely worsens from single-vessel to simultaneous multivessel CAS naturally, and simultaneous multivessel CAS leads to serious conditions such as cardiopulmonary arrest (CPA). A 77-year-old Japanese man who took medications for CAS was transferred to our hospital due to persistent chest pain. On arrival, his vital signs were stable, but his electrocardiogram (ECG) showed ST-segment elevation in leads II, III and aVF. Ventricular fibrillation developed suddenly. Although routine cardiopulmonary resuscitation (CPR) including intravenous administration of epinephrine was performed immediately, he could not be resuscitated. After initiation of percutaneous cardiopulmonary support (PCPS), there was a return of spontaneous circulation. His ECG showed exacerbation of myocardial ischemia with ST-segment elevation in leads I, II, III, aVL, aVF and V3-V6. Emergency coronary angiography revealed severe CAS of the right and left coronary arteries, which was relieved completely by intracoronary administration of nitrates. He was diagnosed with acute myocardial infarction due to simultaneous 3-vessel CAS that progressed over time. About 6h after arrival, he developed hemodynamic instability and died. CAS worsened from single-vessel to simultaneous 3-vessel spasm, and intracoronary administration of nitrates was effective in relieving CAS, which was documented by the ECG and coronary angiogram. Since CAS can progress over time, nitrates must be administered immediately. When CAS leads to CPA, epinephrine may be ineffective in CPR because of its vasoconstrictive effect on coronary arteries; therefore, PCPS should be initiated, and intracoronary nitrates should be administered." }, { "id": "pubmed23n0086_20387", "title": "[A case of myocardial infarction due to the left main trunk lesion, in which percutaneous coronary recanalization and emergency coronary-aorto bypass graft, and subsequent percutaneous coronary angioplasty were effective not only from a viewpoint of survival but from comeback to social life].", "score": 0.009523809523809525, "content": "A case of acute myocardial infarction due to the lesion in the left main coronary artery was reported. A 50-year male was referred to our department for suspected acute myocardial infarction. Physical examination on admission revealed slight cyanosis with cold sweating due to severe chest pain. Pulse was irregular and heart rate was 78 beats/min. Blood pressure was 100/80 mmHg. A series of electrocardiograms (ECG) and laboratory data provided the diagnosis of wide-ranged anterolateral infarction in the left ventricle. Emergency coronary angiograms taken without delay showed a subtotal occlusion (99% stenosis) of the left main coronary trunk (LMT) before the initiation of intracoronary thrombolysis (PTCR). Following the intracoronary infusion of urokinase of 1,200,000 units, symptoms and ECG changes transiently improved but worsened later, and LMT stenotic lesion and delayed filling of myocardium were similar with before PTCR. Emergency coronary-aorto bypass graft (CABG) was undertaken without a significant delay to both the left anterior descending artery (LAD) and left circumflex coronary artery (LCX). With these treatments, the patient could survive despite the wide area of infarction due to LMT lesion. Coronary angiograms performed 37 days after the CABG showed that the graft to LAD was completely occluded and the LCX graft was patent with partial stenosis. Treadmill test at this time induced an anginal episode with ischemic ECG changes on moderate exercise, indicating the presence of significant area of ischemic myocardium. For salvage of the ischemic myocardium, percutaneous transluminal coronary angioplasty (PTCA) was successfully performed for the LMT stenosis, resulting in no episode of angina nor ischemic ECG changes during exercise loading.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "First_Aid_Step2_49", "title": "First_Aid_Step2", "score": 0.009457228461365999, "content": "FIGURE 2.1-6. Anterior wall MI. This patient presented with acute chest pain. The ECG showed acute ST-segment elevation in leads aVL and V1–V6, and hyperacute T waves. (Reproduced, with permission, from Stobo J et al. The Principles and Practice of Medicine, 23rd ed. Stamford, CT: Appleton & Lange, 1996: 19.) If the patient presents within three hours, PCI cannot be performed within 90 minutes, and there are no contraindications to thrombolysis (e.g., a history of hemorrhagic stroke or recent ischemic stroke, severe heart failure, or cardiogenic shock), thrombolysis with tPA, reteplase, or streptokinase should be performed instead of PCI. In the setting of three-vessel disease, left main coronary artery disease, discrete lesions not amenable to PCI, or diffuse disease with good target vessels, PCI should be attempted immediately for the lesion thought to be responsible for STEMI; the patient is a candidate for CABG afterward." }, { "id": "wiki20220301en027_33224", "title": "Abciximab", "score": 0.009433962264150943, "content": "Indications for use Abciximab is indicated for use in individuals undergoing percutaneous coronary intervention (angioplasty with or without stent placement). The use of abciximab in this setting is associated with a decreased incidence of ischemic complications due to the procedure and a decreased need for repeated coronary artery revascularization in the first month following the procedure. Research also shows that this drug can be of use for patients with diabetes and chronic kidney disease. It is not the appropriate drug of choice if a patient is scheduled for an emergency surgery (i.e., heart surgery) because bleeding time may take about 12 hours to normalize. Pediatric uses include treatment of Kawasaki disease." }, { "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": "pubmed23n0643_22852", "title": "Simultaneous thromboses of double coronary arteries in a young male with antithrombin III deficiency.", "score": 0.009259259259259259, "content": "In most acute ST-segment elevation myocardial infarction, a single culprit vessel is often found; however, multivessel occlusion, although uncommon, can occur and usually with a poor prognosis, including mortality. We reported a 22-year-old young male who presented to our emergency department because of chest pain after exercise. On physical examination, the cardiac auscultation revealed gallop rhythm without murmur, and the pulmonary auscultation revealed minimal basal moist rales. Other physical examinations were unremarkable. Twelve-lead electrocardiography showed normal sinus rhythm with rate of 96 beats per minute, hyperacute T wave in V1 to V6 and II, III, aVF with reciprocal change in lead I, aVL. He underwent immediate coronary angiography that revealed simultaneous total occlusion of proximal portion of right coronary artery and left anterior descending coronary artery. Successful percutaneous coronary intervention with angioplasty was performed with optimal angiographic result. Although simultaneous total occlusion of double coronary arteries is a rare condition, especially in young group with antithrombin III deficiency, percutaneous coronary intervention and long-term anticoagulant agent are still one of the standard treatments, but the operator should be aware of the hemodynamic change and the importance of mechanical support." }, { "id": "pubmed23n0303_14448", "title": "[Successful treatment of intraoperative myocardial ischemia with nicorandil].", "score": 0.009174311926605505, "content": "We report five patients who developed intraoperative myocardial ischemia but were treated successfully with nicorandil. Case 1; An 84 year-old male underwent emergent laparotomy and ileolysis under inhalational plus thoracic epidural anesthesia. During his emergence from anesthesia, arterial pressure and heart rate increased abruptly due to excitement, leading to ST-T depression on V5 lead. Bradycardia and hypotension developed subsequently. Immediately after i.v. injections of nicorandil 4 mg and atropine 0.3 mg, ST-T change and hemodynamics improved dramatically. Case 2; A 67 year-old male underwent esophagectomy under inhalational plus thoracic epidural anesthesia. Following the completion of surgery, elevation of ST-T developed suddenly on lead II, though hemodynamics were not compromised. ST-T elevation disappeared immediately after nicorandil 6 mg and continuous infusion of nitroglycerin (TNG) was initiated. Case 3; A 71 year-old female underwent aortic valve replacement under high-dose fentanyl anesthesia. Shortly after starting cardiopulmonary bypass (CPB), ST-T segment on leads II and V5 was elevated suddenly. This was accompanied by severe pulmonary hypertension suggestive of severe left ventricular failure. Shortly after nicorandil 4 mg via a pulmonary artery (PA) catheter, ST-T segment returned to the baseline and pulmonary arterial pressure was normalized. Case 4; A 61 year-old male underwent coronary revascularization under high-dose fentanyl anesthesia. During weaning from CPB, elevation of ST-T segment occurred on leads II and V5. ST change improved, responding to nicorandil 6 mg en bolus via a PA catheter. Case 5; A 67 year-old male underwent coronary revascularization under high-dose fentanyl anesthesia. He was unable to be weaned from CPB for several hours because of frequent and repeated attacks of ventricular tachycardia and ventricular fibrillation. The arrhythmia did not respond to various kinds of treatments including intra-aortic balloon pumping and continuous infusions of inotropes, anti-arrhythmic drugs and anti-anginal drugs. In spite of repeated intracoronary injections of TNG, graft flow to the left anterior descending branch remained low at 40 ml.min-1. After an intracoronary injection of nicorandil 1 mg, however, blood flow increased to 100 ml.min-1, resulting in a marked reduction in frequency of ventricular arrhythmia. The patient came off bypass successfully. In each case, intraoperative myocardial ischemia was treated successfully with nicorandil. Neither hypotension nor arrhythmia resulted from its bolus injection. Nicorandil might be a useful therapeutic tool for myocardial ischemia during anesthesia." }, { "id": "pubmed23n0355_19904", "title": "[The best of thrombosis and thromboembolic disease in 1999].", "score": 0.009174311926605505, "content": "1999 has been a good year in the field of innovation in thrombosis. In coronary syndrome without ST elevation: low molecular weight heparin has been confirmed to be more effective than non-fractionated heparin (enoxaparin) and to improve the prognosis of non-revascularised patients (dalteparin) after the hospital phase; hirudin has been shown to be more effective in terms of incidence of myocardial infarction and recurrence of angina than non-fractionated heparin without a higher incidence of bleeding complications; the anti-GP IIb-IIIa (abciximab) has confirmed all its advantages at 6 months and 1 year after a coronary event. The association of heparin and aspirin, which has been the mainstay of antithrombotic treatment of acute coronary syndromes without ST elevation, will soon be improved upon at the beginning of the third millennium. In myocardial infarction, medical thrombolysis has probably reached a turning point in its history. The association of half doses of rt-Pa and anti-GP IIb-IIIa has been shown to be more effective in obtaining good reflow than the thrombolytic agent alone at conventional doses. These results were obtained without any increase in bleeding complication. The same anti-GP IIb-IIIa also improve mechanical revascularisation by optimising reperfusion after the 24th hour. This benefit is rapidly transformed into reduced left ventricular dysfunction. Pulmonary embolism remains a critical illness as the ICOPER registry reports a 3 year mortality of nearly 16%. This emphasises the importance of early diagnosis which is usually possible without resorting to invasive procedures and by modulating all the results of paraclinical investigations with respect to the pretest clinical probability." }, { "id": "pubmed23n0918_2470", "title": "Myocardial infarction during anaphylaxis in a young healthy male with normal coronary arteries- is epinephrine the culprit?", "score": 0.00909090909090909, "content": "Anaphylaxis is an acute, potentially fatal medical emergency. Myocardial injury or infarction in the setting of an anaphylaxis can be due the anaphylaxis itself, when it is known as Kounis syndrome or it can also be due to the effect of epinephrine treatment. Epinephrine is considered as the cornerstone in management of anaphylaxis. Myocardial infarction secondary to therapeutic doses of adrenaline is a rare occurrence and only a few cases have been reported in literature. The mechanism of myocardial injury was considered to be due to coronary vasospasm secondary to epinephrine as the coronary angiograms were normal on these occasions. A 21-year- old previously healthy male got admitted to the local hospital with an urticarial rash and difficulty in breathing, one hour after ingestion of prawns for which he was known to be allergic. He was treated with 0.5 ml of intramuscular adrenaline (1:1000) which was administered to the lateral side of the thigh, following which he developed palpitations and tightening type central chest pain. Electrocardiogram showed ST segment depressions in leads III, aVF and V1 to V5 and he was transferred to a tertiary care hospital. The second electrocardiogram, done 2 h later, showed resolution of ST segment depressions but new T inversions in leads I and aVL. Troponin I was elevated with a titer of 2.15 ng/ml. He was treated with sublingual GTN in the emergency treatment unit and the symptoms resolved. Transthoracic 2D echocardiogram and stress testing with treadmill was normal and CT coronary angiogram revealed normal coronary arteries. Here we present a case of a young healthy adult with no significant risk factors for coronary artery disease who developed myocardial infarction following intramuscular administration of therapeutic dose of adrenalin for an anaphylactic reaction. The postulated mechanism is most likely an alpha receptor mediated coronary vascular spasm. However the use of adrenaline in the setting of life threatening anaphylaxis is life saving and the benefits far outweigh the risks of adverse effects. Therefore the purpose of reporting this case is not to discourage the use of adrenaline in anaphylaxis but to make aware of this potential adverse effect which can occur in the acute setting." }, { "id": "pubmed23n0275_41", "title": "[Reinfarction after thrombolytic therapy. Results obtained with readministration of thrombolytic agent in 3 patients].", "score": 0.00909090909090909, "content": "From 1985 to 1990, 120 patients within 6h after the onset of acute myocardial infarction were submitted to thrombolytic treatment. In 4 patients, there were clinical and electrocardiographic (ECG) changes of reinfarction. Three of them were undergone to a second thrombolytic therapy with streptokinase (SK). Two had infarction of the inferior wall, and one on the anterior wall. The patients were managed with the same SK dosage as in the first episode and the same protocol of infusion. All 3 patients, after new SK infusion showed evidence of myocardial reperfusion with relief of pain and improvement of the ECG. One patient, 24h after retreatment, had another reinfarction treated with emergency angioplasty of the right coronary artery, which was totally occluded. One patient (case n. 2), presented haematoma of right arm after punction of the subclavian vein and the other two patients did not show any serious intecorrence related to the new thrombolytic treatment. All of them were found alive over one year of follow-up." }, { "id": "pubmed23n0616_449", "title": "Successful treatment of cardiogenic shock by stenting of the left main coronary artery in acute myocardial infarction.", "score": 0.009009009009009009, "content": "Patients with non-ST elevation acute coronary syndromes (NSTE-ACS) are sometimes severely hemodynamicly compromised. Urgent coronary angiography should be performed in these patients in percutaneous coronary intervention (PCI) centers according to the ESC NSTE-ACS guidelines to determine suitabilty for percutaneous or surgical revascularization. We reported a 62-year-old male with chest pain admitted to the Coronary Care Unit. ST segment depression of 2 mm in leads I, L and V4-6 was revealed at electrocardiogram. After following 6 hours the patient had chest pain and signs of cardiogenic shock despite of the therapy. Chest xray showed pulmonary edema. Echocardiographic examination showed dyskinetic medium and apical segments of septum. The patient underwent coronary angiography immediately which revealed 75% stenosis of the left main coronary artery with thrombus. The use of a GPIIb/III inhibitor-tirofiban and stent implantation resulted in TIMI III flow. After that the patient had no chest pain and acute heart failure subsided in the following days Echocardiography done at the fourth day from PCI showed only hypokinesis medium and apical segment of septum. The patient was discharged at day 11 from admission in a stable condition. Stenting of left main coronary artery stenosis in patients with cardiogenic shock and non-ST segment elevation acute coronary syndromes may be a life saving procedure." }, { "id": "pubmed23n0314_3008", "title": "[Successful direct percutaneous transluminal coronary angioplasty in a 91-year-old male with acute myocardial infarction complicating cardiogenic shock].", "score": 0.009009009009009009, "content": "A 91-year-old male patient was admitted to hospital with acute myocardial infarction complicating cardiogenic shock. An emergency coronary arteriogram showed 99% stenosis at the mid-section of the right coronary artery, and in order to achieve an early recovery direct percutaneous transluminal angioplasty (PTCA) was performed through the brachial artery using a 6 french catheter. The lesion was successfully dilated up to 25% residual stenosis. Hypointention had been sustained during the admission; however, it gradually improved and he was discharged on the 31st hospital day. He has been followed up for 6 months after discharge at the out-patient clinic and has not recurrent ischemic episodes. According to other reports on the use of direct PTCA in the elderly, the postdischarge mortality rate is lower than that with medical therapy or thrombolysis. When cardiogenic shock occurs even in the elderly, direct PTCA should be selected as the first choice of treatment." }, { "id": "pubmed23n0646_4190", "title": "No fate but what we make: a case of full recovery after out-of-hospital cardiac arrest.", "score": 0.008928571428571428, "content": "An 80 years old man suffered a cardiac arrest shortly after arrival to his local health department. Basic Life Support was started promptly and nine minutes later, on evaluation by an Advanced Life Support team, the victim was defibrillated with a 200J shock. When orotracheal intubation was attempted, masseter muscle contraction was noticed: on reevaluation, the victim had pulse and spontaneous breathing.Thirty minutes later, the patient had been transferred to an emergency department. As he complained of chest pain, the ECG showed a ST segment depression in leads V4 to V6 and laboratory tests showed cardiac troponine I slightly elevated. A coronary angiography was performed urgently: significant left main plus three vessel coronary artery disease was disclosed.Eighteen hours after the cardiac arrest, a quadruple coronary artery bypass grafting operation was undertaken. During surgery, a fresh thrombus was removed from the middle left anterior descendent artery. Post-operative course was uneventful and the patient was discharged seven days after the procedure. Twenty four months later, he remains asymptomatic.In this case, the immediate call for the Advanced Life Support team, prompt basic life support and the successful defibrillation, altogether, contributed for the full recovery. Furthermore, the swiftness in the detection and treatment of the acute reversible cause (myocardial ischemia in this case) was crucial for long-term prognosis." }, { "id": "pubmed23n0424_17020", "title": "[Facilitated revascularisation in myocardial infarction with ST-segment elevation].", "score": 0.008928571428571428, "content": "The authors performed urgent coronarography and revascularisation after administering a combined half dose of alteplase (tissue plazminogen activator) and eptifibatide (glycoprotein II/bIIIa receptor blocking agent) to patients suffering from acute coronary syndromes with persistent ST-segment elevation. During the period between 01 April to 15 December, 2001. 20 patients (16 men and 4 women, mean age: 55.6 years) were treated. The localization of infarction on the basis of ST-segment elevation was: 9 cases inferior, 10 cases anterior and patient with left bundle branch block in 1 cases. The mean time between the infarct related angina and hospital admission was 158 (30-600) minutes. The combined medical therapy was initiated after 34 (15-150) minutes on the average admission, and 123 (71-210) minutes later the patients were in the catheter laboratory. Coronarography showed TIMI-0 flow in 4 cases, TIMI-2 flow in 3 cases and TIMI-3 flow in 13 cases. Acute percutan coronary intervention was done in 14 cases, aorto-coronary bypass surgery was performed in 4 cases (2 of them were emergency operations, the other 2 were done electively). Besides postpunctional haematomas, hemorrhagic complications in the form of haematemesis were observed in 2 cases, but there was no need for transfusion. The mean CK-MB release (between 14 patients) was 230.4 (30-1176) U/l. One patient died after the emergency bypass surgery. On the basis of initial results the authors emphasize the importance of working out the optimal revascularisation strategy for acute coronary syndrome patients with ST-segment elevation in every Hungarian catheter centre. The authors find this method--in their case the catheter laboratory is 60 kms away, time of transport is approximately 70-90 minutes--an effective and safe alternative therapy in patients under the age of 75 years with acute myocardial infarction." } ] } } }

{ "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": [ [ 22, 84 ] ], "word_ranges": [ [ 3, 12 ] ], "text": "is the definition of delirium. Altered state of consciousness." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "The presence of visual hallucinations.", "2": "Cognitive symptoms.", "3": "Psychomotor agitation.", "4": "Fluctuation of the alert level.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0950_15602", "title": "Visual Hallucinations and Paranoid Delusions.", "score": 0.015566323440339189, "content": "Visual well-formed hallucinations, fluctuations in the level of cognition, and alertness and extrapyramidal signs are core features of dementia with Lewy bodies. Some patients realize that what they are seeing or hearing are just hallucinations and learn to accept them. Others, however experience these hallucinations as quite real and cannot be dissuaded from the firm belief that they are. In fact, efforts to dissuade them often serve only to confirm the often associated paranoid delusions and this may lead to a catastrophic ending. Hence, it is best not to contradict the patient. Instead, attempts should be made to distract the patient and change the focus of her or his attention. In this case scenario, we present a 68-year-old man who has been diagnosed with dementia with Lewy bodies. He lives with his daughter. He has visual hallucinations and paranoid delusions that worsen at night: He thinks there are people outside the house plotting to kill him. We discuss what went wrong in the patient/caregiver interaction and how the catastrophic ending could have been avoided or averted." }, { "id": "article-17289_25", "title": "Agitation -- Differential Diagnosis", "score": 0.013679890560875513, "content": "Dementia leads to gradual, or rarely, sudden changes in memory, intellectual abilities, and cognition, leading to increased confusion and agitation. Ongoing medical causes leading to delirium can complicate this. In most cases, the course is progressive, and accurate history from collaterals can be useful. It is helpful to do a mental status exam on a regular basis, and in some cases where dementia or delirium is severe, doing these mental exams 2 to 3 times a day as a patient's cognition tends to vary throughout the day. Having multiple data sets from mental exams will give clinicians a better picture of how the patient is doing." }, { "id": "pubmed23n0955_4309", "title": "Probable Lewy Body Dementia with a Predilection for Auditory Hallucinations.", "score": 0.013116424182611188, "content": "The patient was a 60-year-old male who initially presented to the emergency room with extreme agitation aggravated by internal stimuli as well as visual hallucinations, paranoia, and grandiose delusions. He was diagnosed with nonspecific schizophrenia and treated with risperidone, trazodone, and lithium. Approximately 16 months later, he was readmitted to the hospital trying to enter a stranger's car that he thought was his. He was confused and was unable to give an accurate history. His psychomotor retardation and confusion were thought to be due to risperidone. When his dose was decreased, he displayed involuntary movements of the mouth and extremities, restlessness, and a patting of his head. The risperidone was switched to zyprexa in an effort to decrease extrapyramidal symptoms. About two months later, he was found unresponsive and catatonic in his car. During his stay, the patient had a fluctuation in the latency of his responses on a daily basis. He would be aware of where he was but was unable to explain why or for how long. He had a difficult time remembering names and was still exhibiting abnormal involuntary movements around the mouth and extremities. The patient's course of initial predominantly auditory and visual hallucinations that progressed to extrapyramidal symptoms and fluctuating cognition one year later may suggest Lewy body dementia." }, { "id": "wiki20220301en269_20182", "title": "Agitation (dementia)", "score": 0.01219209640262272, "content": "Agitation in predementia and dementia is distressed affect that leads to poor moods and often aggression toward other people, such as family members and other caregivers. Agitation is often part of dementia and often precedes the diagnosis of common age-related disorders of cognition such as Alzheimer's disease (AD). More than 80% of people who develop AD eventually become agitated or aggressive. Agitation in dementia overlaps with psychomotor agitation but is not always equal to it, depending on whose definition is used. Although some authorities consider them synonymous, psychomotor agitation by definition (\"-motor\") involves maladaptive movements, whereas agitation in predementia and dementia often involves distress, fear, and aggression even when repetitive purposeless movements (such as pacing) are absent. The synonymy viewpoint views the whole topic as a single spectrum in which repetitive purposeless movements may arise or not, or recede, at various times. Evaluation" }, { "id": "InternalMed_Harrison_866", "title": "InternalMed_Harrison", "score": 0.011343323108158807, "content": "delirium (See also Chap. 34) Delirium is an acute disorder of disturbed attention that fluctuates with time. It affects 15–55% of hospitalized older patients. Delirium has previously been considered to be transient and reversible and a normal consequence of surgery, chronic disease, or infections in older people. Delirium may be associated with a substantially increased risk for dementia and is an independent risk factor for morbidity, prolonged hospitalization, and death. These associations are particularly strong in the oldest old. Fig. 11-16 shows an algorithm for assessment and management of delirium in hospitalized older patients. The clinical presentation of delirium is heterogeneous, but frequent features are (1) a rapid decline in the level of consciousness, with difficulty focusing, shifting, or sustaining attention; (2) cognitive change (rumbling incoherent speech, memory gaps, disorientation, hallucinations) not explained by dementia; and (3) a medical history suggestive of" }, { "id": "wiki20220301en047_29653", "title": "Psychomotor agitation", "score": 0.010485384821668008, "content": "Psychomotor agitation overlaps with agitation generally, such as agitation in predementia and dementia; see Agitation (dementia) for details. Signs and symptoms People experiencing psychomotor agitation may feel the following emotions or do the following actions. Some of these actions are not inherently bad or maladaptive, but they can have maladaptively excessive versions. For example, self-hugging can be therapeutically advisable, but self-hugging as a component of a set of motor agitation movements is a sign of psychomotor agitation." }, { "id": "Neurology_Adams_3536", "title": "Neurology_Adams", "score": 0.010451612903225806, "content": "Questions asked by the patient’s family must be answered patiently and sensitively by the physician. Common questions are “Should I correct or argue with the patient?” (No.) Orientation as to date, circumstances, and planned appointments is, however, helpful in preparing the patient for the day activities. “Can the patient be left alone?” “Must I be there constantly?” (Depends on specific circumstances and the severity of dementia.) “Should the patient manage his own money?” (Generally not.) “Will a change of environment or a trip help?” (Generally not; often the disruption in daily routine worsens behavior and orientation.) “Can he drive?” (Best to advise against driving in most instances.) “What shall we do about the patient’s fears at night and his hallucinations?” (Medication under supervision may help.) “When is a nursing home appropriate?” “How will the condition worsen? What should the family expect, and when?” (Uncertain, but usually a 5to 10-year course.) Many families have" }, { "id": "Neurology_Adams_8461", "title": "Neurology_Adams", "score": 0.010249165168250706, "content": "4. Paranoia and personality changes Occasionally, at some point in the development of Alzheimer dementia, paranoia or bizarre behavior assumes prominence. This may appear before the more obvious memory or language defects announce themselves. The patient becomes convinced that relatives are stealing his possessions or that an elderly and even infirm spouse is guilty of infidelity. He may hide his belongings, even relatively worthless ones, and go about spying on family members. Hostilities arise, and wills may be altered irrationally. Many of these patients are constantly worried, tense, and agitated. Of course, paranoid delusions may be part of a depressive psychosis and of other dementias, but most of the elderly patients in whom paranoia is the presenting problem, seem not to be depressed, and their cognitive functions are for a time relatively well preserved. Social indiscretions, rejection of old friends, embarking on imprudent financial ventures, or an amorous pursuit that is" }, { "id": "Neurology_Adams_3329", "title": "Neurology_Adams", "score": 0.01014566828520317, "content": "These initial symptoms rapidly give way to a clinical picture that is one of the most colorful in medicine. The patient is inattentive and unable to perceive the elements of his situation. He may talk incessantly and incoherently, and look distressed and perplexed; his expression may be in keeping with vague notions of being annoyed or threatened by someone. From his manner and the content of speech, it is evident that he misinterprets the meaning of ordinary objects and sounds, misidentifies the people around him, and is experiencing vivid visual, auditory, and tactile hallucinations, often of a most unpleasant type. At first the patient can be brought into touch with reality and may identify the examiner and answer other questions correctly; but almost at once he relapses into a preoccupied, confused state, giving incorrect answers and being unable to think coherently. As the process evolves, the patient cannot shake off his hallucinations and is unable to make meaningful responses" }, { "id": "pubmed23n0208_17284", "title": "[Agitation in the elderly (author's transl)].", "score": 0.009900990099009901, "content": "Agitation in the elderly is a common behaviour disorder. The clinical picture is quite variable: aggressive reactions, anxious agitation, agitation associated with confusion: sometimes, the agitation occurs in episodes, especially during the night. These types of agitation have two basic causes: confusion and dementia. In some cases, they are the clinical expression of an angry, hostile or excited state. In agitation associated with confusion, one must eliminate an intoxication, a neurological disorder, an infection, and notably a past head injury which may have gone undetected. Therapeutic measures are discussed." }, { "id": "pubmed23n0573_15273", "title": "[Cerebral hydatic cyst and psychiatric disorders. Two cases].", "score": 0.00980392156862745, "content": "The hydatidosis is an endemic illness in regions of the Middle Orient, Mediterranean, south of America, north Africa and the Australia. The preferential localization of cyst hydatic is the liver (48%), the lung (36%) and in 6% of cases it localizes in unaccustomed place as the brain. Intracerebral localization is relatively rare, its impact is 1 to 5% of all cases of hydatidose. This localization is the child's appendage with a masculine predominance. The cyst hydatic intracranien is often lone, of localization usually supratentorielle, sometimes infratentorielle. Symptoms are especially the diffuse headache associated to various neurological signs in relation with sits of the tumor. The psychiatrics symptoms depends on its localization, sides, intracranial hypertension, and the previous personality. In 15 to 20% of cases these tumors can appear in the beginning of their evolution by the isolated psychiatric symptoms. We report the case of two patients that have been hospitalized first in the Academic Psychiatric Unit of Marrakech for isolates psychiatric disorders and whose scanning revealed the presence of cerebral hydatic cyst and that required a surgical intervention in neurosurgery. Case 1 - Patient 29 years old, bachelor, uneducated, leaving in country outside, fermar, in permanent contact with dogs. No particular medical history. The patient has been brought by his family to the psychiatric emergencies after behavior disorders. The beginning of his symptomatology was one year ago by behavior disorders: instability, violence, isolation, and a corporo-sartorial carelessness. His symptomatology worsened and the patient became very aggressive. In psychiatric unit, he was disregarded, sad, anguished, indifferent to his state, very dissonant, completely detached, depersonalized. He brought back some visual and auditory hallucinations with attitude of monitoring. He was raving with delirium of persecution, of ideas of reference and delirium of bewithment. He was unconscious of his disorders. The patient has first been put under classical neuroleptic 9 mg/day of Haloperidol and 200 mg/day of chlorpromazine. The diagnosis of schizophrenia has been kept according to criteria of DSM IV. The PANSS (Positive and Negative Syndrome Scale) was to 137 (score on a positive scale was to 34, score on a negative scale was to 35 and the general psychopathologie scale was to 58). One week after his hospitalization, he developed headache with subconfusion, a cerebral scanning has been made in emergency and showed a voluminous cyst in oval foramen compressing the mesencephalon strongly. The cyst was well limited, hypodense, not taking the contrast, and without intracerebral oedema, the diagnosis of cerebral hydatic cyst has been made. The complementary exploration didn't show any other localizations, and biologic exam results didn't show any particular anomalies. The patient has been operated in neurosurgery. The immediate evolution was favorable with disappearance of confusion and absence of complications. The patient was lost of view. Six months after, the patient has been readmitted to the psychiatric emergency. He dropped his neuroleptic treatment. He was aggressive, raving, hallucinated and depersonalized. The global score to the PANSS was 63. He has been put back under neuroleptics. Three weeks after improvement and passage of the PANSS to 30, the patient went out. We couldn't have a cerebral scanner of control because the patient had no medical assurance and no money for cerebral scanner. Case 2 - Patient aged of 53 years, father of four children, uneducated, native and resident of Marrakech, confectioner as profession. He is in contact with dogs since 12 years. He has been brought to the psychiatric emergencies by his family after an agitation. The history of his illness seemed to go back at eight months ago, by the progressive apparition of an instability, sleep disorders, hostility, associated with an emotional lability. To the interview he was agitated and had a delirium of persecution. He was convinced that his wife and his children plotted against him. He had sad mood. He was anguished and had auditory and visual hallucinations. The patient was not confused but it had a hypoproxie, an fixing amnesia, a disorders of judgment and a light left hemiparesia. Cerebral scanner revealed three cerebral cyst. The first measuring 42 x 40 mm, sitting at the level parietal right, to the contact of the occipital horn, dragging his/her/its amputation and an effect of mass on ventricle homolateral, the median line and ventricle controlateral. The two other, at the level of the center semi oval, behind the first, measuring 23 mm and 15 mm on the big axis. The patient has been addressed in neurosurgery. He had a completeray exploration to search other localizations. The thoracic x-ray showed 2 pulmonary cyts. The abdominal scan and imagery by magnetic resonance showed liver cyst, peri-heart cyst and mediastinal cyst. The patient has been operated for these three cysts with good recuperation on the psychiatric and neurological symptoms. He has been addressed in heart surgery for the heart localization. The hydatidose is an endemic illness in Morocco and constitute a public health problem. The cerebral localization is rare and appear by signs of cerebral hypertension and signs of focusing. The psychiatric demonstrations are rare but preserve a major interest, by the therapeutic measure specificity that they impose. Of course, the surgical ablation of the tumor can be sufficient to attenuate the psychiatric symptoms but the recourse to a specific treatment can prove to be necessary to act on the precise targets. We are conscious of the methodological difficulties that present these 2 cases but there are unfortunately due to the financial difficulties of our patients." }, { "id": "wiki20220301en034_52837", "title": "Agitation", "score": 0.009732306884786983, "content": "Agitation may refer to: Agitation (action), putting into motion by shaking or stirring, often to achieve mixing An emotional state of excitement or restlessness Psychomotor agitation, an extreme form of the above, which can be part of a mental illness or a side effect of anti-psychotic medication Agitation (dementia), a symptom of dementia Political agitation or demonstration (protest), political activities in which an agitator urges people to do something Agitation and Propaganda against the State, a former criminal offence in communist Albania Anti-Soviet agitation, a former criminal offence in the Soviet Union Music Agitations (album) \"Agitation\", a Miles Davis song on his album E.S.P. \"Agitated\", a Devo song on their album Total Devo \"Agitated\", a song by the band Muse See also Agitator (disambiguation) Excitation (disambiguation) Mix (disambiguation) Restless (disambiguation) Majority–minority relations" }, { "id": "pubmed23n0763_14041", "title": "History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).", "score": 0.009708737864077669, "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": "pubmed23n0264_14072", "title": "[Delirium or acute confusional state in elderly persons].", "score": 0.009708737864077669, "content": "Delirium or acute confusional state is a common neuropsychiatric syndrome in later life. Failure to recognise delirium and treat the underlying organic condition may have fatal consequences. In delirium the main aspects of cognition, thinking, perception and memory are all disordered to some degree. A global disorder of attention is invariably present and may include illusions and hallucinations. Disturbances in the sleep-wake cycle and abnormalities of the psychomotor activity are essential features. Hypoactive and hyperactive states are reported. Some patients have a mixed picture, with swing back and forth between apathy and agitation. Its onset is acute and its duration is brief (less than one month). Typically, the severity of the symptoms fluctuates during the daytime with peaks at night. The adequate treatment of delirium presupposes that the syndrome has been diagnosed and that its underlying causes have been identified." }, { "id": "pubmed23n0273_1486", "title": "[A 75-year-old man with parkinsonism and delirium].", "score": 0.009615384615384616, "content": "We report a 75-year-old man with a ten-year history of parkinsonism, who developed acute delirium. He was well until 65 years of age, when there was an onset of tremor in his left hand. He had been treated with levodopa and trihexyphenidyl with marked improvement. He was doing well until July of 1991 at his age of 75-year-old, when he noted backache; he was found to have a compression fracture of the third lumbar spine. He had to use a wheel-chair most of the time since then. In December 1991, he started to have visual hallucinations and difficulty in swallowing. On December 25 of that year, he developed fever and delirium, and was admitted to our hospital on December 30. On admission, general physical examination was unremarkable except for low grade fever (37.3 degrees C). Neurologic examination revealed an alert but chronically ill patient. Apparently he had visual hallucinations. He was disoriented to all spheres; he could respond only to simple questions. Apparently he was demented. Cranial nerves were intact except for mumbling speech disturbance and masked face. He was unable to stand or walk. He had flexion contracture in his both knee joints. He had paratonic rigidity in all his limbs and marked bradykinesia. Once in a while, myoclonic jerks were seen in both upper and lower extremities. Deep reflexes were diminished bilaterally, and the plantar reflex was not elicited on either side. On laboratory examination, BUN was increased to 72 mg/dl, creatinine to 3.0 mg/dl, and WBC 16,000/microliter. Cranial CT scans were unremarkable.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "InternalMed_Harrison_1970", "title": "InternalMed_Harrison", "score": 0.009615384615384616, "content": "It may be difficult to elicit an accurate history in delirious patients who have altered levels of consciousness or impaired attention. Information from a collateral source such as a spouse or another The diagnosis of delirium requires the presence of features 1 and 2 and of either feature 3 or 4. Feature 1. Acute onset and fluctuating course This feature is satisfied by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or did it increase and decrease in severity? Feature 2. Inattention This feature is satisfied by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or have difficulty keeping track of what was being said? Feature 3. Disorganized thinking" }, { "id": "pubmed23n0796_16550", "title": "Attention deficit hyperactivity, fetal alcohol spectrum disorder, or something else: the broad differential of kindergarten suspension.", "score": 0.009523809523809525, "content": "Thomas is a 5-year 6-month-old boy whose parents requested an urgent care appointment because he has recently been suspended from kindergarten stating \"and his doctor must see him before he can come back.\" His suspension from kindergarten was due to kicking and biting his classmates, but he has also become increasingly aggressive at home. His teacher reported that he has always had a high activity level and difficulty shifting attention between tasks, as well as noncompliance with rules and directions. He is noted to have learning challenges and is showing difficulties in the concept of numbers and letter sounds. The practice has followed Thomas since his healthy birth. He has a history of delayed language development, and he received early intervention services from 2 years of age. He spoke his first word at 2 years 6 months. He started a half-day preschool program at 3 years of age. He had difficulty acclimating to preschool, interacting with peers, and was described as \"hyperactive\" by his teachers. His program was modified to decrease his time having to sit in a circle time, and he often required the support of the paraprofessional in the classroom. His parents have always described him as a \"difficult child.\" He gets frustrated easily and can tantrum for up to 2 hours multiple times in a week when his immediate needs or requests are not met. He has difficulty falling asleep, has frequent night awakenings, and often has trouble getting back to sleep. His self-help skills are poor, and he has difficulty with activities such as brushing his teeth and dressing. His parents report that he does not seem to remember rules from day to day. He was evaluated at 5 years of age and diagnosed with Attention Deficit Hyperactivity Disorder, but his response to stimulants has been limited. Thomas is an only child. His parents are college educated and professionally employed. They deny drug use, domestic violence, and guns in the home. They reported that prior to the pregnancy, they enjoyed \"partying\" with friends on the weekends, but Thomas's mother reported that she stopped drinking as soon as she realized she was pregnant. All are wondering whether this child might have a fetal alcohol spectrum disorder, although he seems to have no clear facial dysmorphology. It is unsure what the next step might be and if there is value added in pursuing this diagnosis. What do you do next?" }, { "id": "pubmed23n0056_1931", "title": "Agitation and other noncognitive abnormalities in Alzheimer's disease.", "score": 0.009523809523809525, "content": "Agitation and other noncognitive abnormalities in patients with Alzheimer's disease are present in at least 50% of patients and are a serious problem for caregivers. Agitation can be divided into aggressive agitation, physically nonaggressive agitation, and verbal agitation. Persecutory delusions of suspiciousness and stealing are the most common psychotic symptoms. Auditory and visual hallucinations are also associated with delusions. Similar to delusions are misidentifications, which are false beliefs probably secondary to agnosia. They occur in one third of patients with dementia of the Alzheimer type in the form of the belief that strangers are living in the home and misidentification of the patient's home and reflection in the mirror. Passive personality changes are present early in the disease, whereas agitation and psychotic symptoms occur with disease progression and predict a more rapid rate of cognitive decline. Agitation and wandering are related to more severe cognitive impairment and psychosocial variables, and neurochemical variables that may be related to behavior disturbance require further study. There are few systematic studies of behavioral or environmental interventions for behavioral symptoms in patients with Alzheimer's disease. Current treatment emphasizes education of families, the formation of Alzheimer units in the nursing home, and adjunctive psychotropic agents to treat well-defined target symptoms." }, { "id": "Neurology_Adams_3319", "title": "Neurology_Adams", "score": 0.009449019983400371, "content": "Characteristically, the confusional states fluctuate in severity, typically being worse at night (“sundowning”). In the mildest form, the patient appears alert and may even pass for normal; only the failure to recollect and accurately reproduce happenings of the past few hours or days reveals the subtle inadequacy of his mental function. The more obviously confused patient spends much of his time in idleness, and what he does may be inappropriate and annoying to others. Only the more automatic acts and verbal responses are performed properly, but these may permit the examiner to obtain a number of relevant replies to questions about age, occupation, and residence. Orientation to the date, day of the week, and place is imprecise, often with the date being off by several days, the year being given as several years or one decade previous, or with the last two numbers transposed, for example, 2015 given as 2051. Such patients may, before answering, repeat every question that is put to" }, { "id": "pubmed23n0392_10544", "title": "[Psychiatric manifestations of lupus erythematosus systemic and Sjogren's syndrome].", "score": 0.009433962264150943, "content": "We present one case of Sjögren's syndrome (SS) secondary to systemic lupus erythematosus (SLE) with predominant psychiatric manifestations, treated with success by cyclophosphamide. From this case, we review the psychiatric aspects of these two autoimmune diseases as described in the literature and we present the etiopathogenic hypothesis and treatment of the psychiatric disorders. Case report--In August 1996, a 38 year old man was admitted in our psychiatric department for agitation. Primary SS had been diagnosed in July 1996. He had previously attempted to suicide but was never hospitalized in a psychiatric department. During the hospitalization in our department, the patient had auditive hallucinations and felt persecuted. He received loxapine 400 mg/day and was remitted in a few days. He was discharged to a convalescent home with the diagnosis of brief psychotic disorder. In October 1996, he was readmitted to our department for agitation. He had shown agitated behavior and aggression in the convalescent home. There were no hallucinations and no affective disorders. He became calm rapidly and was discharged home a few days later. In November 1996, he was found in a coma by a neighbor. He was admitted to an intensive care unit. The lumbar punction revealed blood cells. Cerebral computer tomography showed subarachnoid hemorrhage. The diagnosis was meningeal hemorrhage due to vasculitis. After regaining consciousness, the patient complained of reduced visual acuity. This was believed to be due to retrobulbar neuritis and the patient's vision improved slightly with corticosteroids. The third hospitalization in our department occurred in February 1997 for depression. The patient had shut himself away for days in his apartment. He had suicidal ideas. His mood improved progressively under fluoxetine 40 mg/day. He was discharged to a convalescent home with the diagnosis of major depressive disorder. The fourth and last admission in our department occurred in June 1997. There were disturbances of memory and orientation. He felt sad and guilty about accusation of sexual abuse on his daughter. He presented typical histrionic symptoms: he had catatonic attitudes only in public areas such as the corridors. Cerebral computer tomography and electroencephalogram were normal. There was no biological abnormality. Signs of confusion rapidly disappeared. He felt better after reintroduction of fluoxetine 40 mg/day. Diagnosis was non-specified depressive disorder, but this episode could be retrospectively seen as delirium. After being hospitalized on these four occasions in one year in our psychiatric department, the diagnosis of his systemic disease was revised by rheumatologists. The patient was diagnosed as suffering from systemic lupus erythematosus associated with secondary Sjögren's syndrome. From September 1997, he received cyclophosphamide 2 g intraveinously per month during 6 months. His vision improved dramatically. His ocular dryness became milder. His mood is now stable. He has not suffered from hallucinations or delusion since. Psychiatric disorders in SLE--During the course of SLE, the occurrence of psychiatric manifestations varies widely from 5 to 83%. They include psychotic disorders, major depressive disorders, subtle cognitive disorders and personality disorders of histrionic type. Etiopathogenic hypothesis are: direct activity of the disease on the central nervous system by autoantibodies (antiphospholipide and antiribosome P autoantibodies) (18, 19) or cytokines (interleukin 2, interleukin 6, alpha interferon) (38, 59), side-effects of glucocorticosteroids and hydroxychloroquine (16) or anxious reaction to a chronic and potentially lethal illness (43, 54). Nevertheless, immunologic and cerebral imagery research suggests that psychiatric disorders are related to vasculitis and non-inflammatory vasculopathy of the small cerebral blood vessels. The management of the patients should include treatment of the disease itself and specific psychotropic treatment. Glucocorticosteroids and especially intravenous infusions of immunosuppressive agents, such as cyclophosphamide, are effective. Psychotropic drugs must be used, making sure to avoid SLE-inducing drugs, like chlorpromazine, carbamazepine and lithium carbonate (19, 20, 45). In addition, psychologic care is essential. Psychiatric disorders in SS--During the course of the primary SS, the occurrence of psychiatric disorders is large as well: from 20 to 70% (47, 61, 62). They are mainly major depressive disorders, anxiety disorders, cognitive disorders and dementia. Brief psychotic disorders and delirium are rare. Etiopathogenic hypotheses are similar as those in SLE, with some differences: antiphospholipide and antiribosome P autoantibodies are not usually found in SS and anti-Ro (SSA) autoantibodies in serum are associated with psychiatric disorders (3-11, 61). According to Drosos et al. (29, 30), psychiatric disorders are explained by psychological distress. This slowly progressive fluctuating disease creates constant discomfort from dysphagia, dyspareunia and functional disability. Some of these manifestations can be treated by corticosteroids and psychotropic drugs. Drugs with anticholinergic side-effects, like phenothiazines, tricyclic antidepressants and hydroxyzine which can enhance the oral dryness have to be avoided. Social and psychological support is important too. The diversity of psychiatric morbidity in SLE and SS may be due to differences in patient selection and a lack of uniform clinical criteria. Studies which use standardized diagnostic criteria and control groups don't allow one to come to a conclusion about the relative prevalence of the psychiatric disorders in these autoimmune diseases. This will probably be resolved thanks to the recently published \"American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes\" (1). Finally, we can ask ourselves if there is a significant number of undiagnosed SLE and SS in psychiatric departments. Two studies report systematic search for SLE in psychiatric patients. In 1992, Hopkinson et al. (39) searched for several autoantibodies in serum samples of nearly 300 hospitalized psychiatric patients. In 1993, Van Dam et al. (65) did the same with more than 2,000 patients admitted to a psychiatric hospital. Hopkinson et al. found 1% undiagnosed SLE, which is much higher than in general population, and recommended to search SLE in every patient with a high erythrocyte sedimentation rate in psychiatric services. Results of the Van Dam et al. study suggest on the contrary, that SLE is not a common cause of admission to psychiatric hospitals. There is no study which report systematic search of Sjögren's syndrome in a psychiatric department. This is probably because most of patients receive or have recently received psychotropics with anticholinergic side-effects which is an exclusion criteria of SS. Psychiatrists should keep in mind that SLE and primary SS are potential causes of psychiatric manifestations when examining patients with multiple unexplained somatic complaints and psychiatric symptoms. They should then search for autoantibodies in the serum after careful physical examination. Diagnosis of SLE or SS could lead to a better adapted prescription of corticosteroids and/or immunosuppressive drugs and specific psychotropic drugs, making sure to avoid lupus-inducing drugs in SLE and drugs with anticholinergic effects in SS. The existence of psychiatric manifestations in SLE and SS constitutes an indisputable clinical reality that each practitioner must be able to recognize and treat." }, { "id": "pubmed23n0816_3802", "title": "[What you can do when dealing with emergencies in the dementia setting].", "score": 0.009433962264150943, "content": "Frequent emergencies in patients with dementia include aggressiveness, screaming, day/night reversal, other behavioral disorders, and falls. They are often caused by delirium, especially if there has been a rapid change in the patient's state of health. Hypoactive delirium in particular is difficult to recognize in the dementia setting. Acute somatic diseases bear a different meaning in dementia than in non-dementia patients, and priorities must be given to the impaired cerebral performance. In addition to medical decisions, ethical ones need to be made. Special attention should be paid to the resources of the caregiver network. This article describes both non-pharmacological and pharmacological treatment modalities when dealing with emergencies in dementia patients. " }, { "id": "pubmed23n0659_1459", "title": "Discovering gifted children in pediatric practice.", "score": 0.009345794392523364, "content": "Casey is a first grader who is brought to the pediatrician for consideration of ADHD. His mother is concerned that he is very difficult to focus at home when asked to do anything and gets so distracted at meals that he eats very little. The teachers last year and this year say that Casey is very distracted, always \"in a fog\" and just can't seem to get his work done. \"He's in his own world.\" His report card has several unsatisfactory marks because of poor completion of work, doing things other than the assignment and talking too much to the kids around him. The parents are very upset as they see their son as very bright. His advanced vocabulary, early reading skills and his extensive knowledge of engines, machines and aircraft were all noted in his medical chart in the past as part of his health supervision visits. He has lots of friends, mostly third graders and plays soccer with moderate success. The paternal grandmother says Casey is just like his dad who is now a biochemical geneticist. He too had a hard time getting his work in as a child and \"always talked back\" to the teacher. Casey's mother would like him on medication before the Iowa Basics come around. The Vanderbilt rating scales by both teacher and parent are positive for inattention and borderline for hyperactivity. Casey took it upon himself to speak to the principal about how bored he was with the classroom work. She agreed that he could have some special assignments. In the pediatrician's office, Casey is a delightful, verbal, thin boy who has about 100 things to talk about, from train engines to the sports scores, acquired from the television sports channel, to what should be done to \"fix\" his school. He said he was bored and knew more about volcanoes than the science teacher. He just wanted to get home each day and work on his elaborate train setup. He doesn't seem overly active, distractible, anxious, inattentive or oppositional. Testing by the school psychologist showed him to have an IQ of 138 with an even verbal/performance profile. Sam is a 4-year old whose parents brought him to the local private school for application to kindergarten. The admission requirements consisted of a group \"developmental\" test, given to groups of 20 youngsters at a time. Sam failed the test. The report said that he was too immature, talked out of turn and generally wasn't ready for the vigorous academic program planned at that school. He asked too many questions and argued with the admissions person. They suggested he might need medication before he attempted school. His parents asked their pediatrician for an opinion on the school report. They asked for a referral for testing as they could not believe their son was a preschool failure. The psychologist reported that his IQ was 142 (verbal 146 and performance 136)." }, { "id": "Neurology_Adams_2761", "title": "Neurology_Adams", "score": 0.009345794392523364, "content": "As mentioned this is usually accompanied by disorientation and distractibility, leaving the patient at the mercy of every stimulus. In parallel, sequences of movement reveal impersistence and poor planning. Severely confused and inattentive persons are unable to do more than carry out the simplest commands, and these only inconsistently and in brief sequence. Speech may be limited to a few words or phrases; or the opposite pertains—namely, some confused individuals are voluble. They give the appearance of being unaware of much that goes on around them, are disoriented in time and place, do not grasp their immediate situation or the predicament of their own confusion, and may misidentify people or objects. These illusions may lead to fear or agitation. Occasionally, hallucinatory, illusionary, or delusional experiences impart a psychotic cast to the clinical picture, obscuring the deficit in attention." }, { "id": "pubmed23n0748_25563", "title": "\"When the prescription pad is not enough\": attention-deficit hyperactivity disorder management 2.0.", "score": 0.009259259259259259, "content": "Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, \"he seemed like a robot.\"He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor's Vanderbilt's, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities. His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has \"learning problems.\"Jose's family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.His school has been deemed a \"recovery school\" because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.The family is very concerned about the possibility of retention but have decided that \"medicine does not help,\" and they look to you for other recommendations. Where do you go next?" }, { "id": "pubmed23n0090_12476", "title": "Conceptual analysis of agitation in the confused elderly.", "score": 0.009259259259259259, "content": "Agitation is a significant behavior problem for many elderly nursing-home residents with dementia. Lack of conceptual clarity constrains effective management of agitated behaviors. This conceptual analysis examines the meaning of agitation and attempts to disentangle its antecedents, critical attributes, and consequences. Measurement and management implications are examined." }, { "id": "pubmed23n0895_1209", "title": "\"When the Prescription Pad Is Not Enough\": Attention-Deficit Hyperactivity Disorder Management 2.0.", "score": 0.009174311926605505, "content": "Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, \"he seemed like a robot.\"He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor's Vanderbilt's, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities.His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has \"learning problems.\"Jose's family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.His school has been deemed a \"recovery school\" because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.The family is very concerned about the possibility of retention but have decided that \"medicine does not help,\" and they look to you for other recommendations. Where do you go next?" }, { "id": "pubmed23n0774_9053", "title": "[The confused elderly patient].", "score": 0.009174311926605505, "content": "Mental confusion has long-time been likened to dementia, while it is in fact an acute disturbance of a person's alertness and attention capacities. Generally reversible and temporary, it is brought on by high levels of stress. Nursing care is an essential element of its treatment." }, { "id": "pubmed23n0674_3848", "title": "\"He is just a little shy like me\": screening for autism in a young child.", "score": 0.00909090909090909, "content": "Jacob is a 22-month-old wonderful boy, who is being seen a few months late for his 18-month-old visit because of scheduling snafus, as both parents work outside the home. At this visit, it is routine in our practice to administer the Modified Checklist for Autism in Toddlers (MCHAT) and the Parents' Evaluation of Developmental Status (PEDS). On the PEDS, in response to the question, \"Do you have any concerns about how your child talks or makes speech sounds?\" the parents respond \"He only says 2 words in Hebrew and none in English.\" On the MCHAT, they reply \"no\" to 3 items: (1) \"Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?\" (2) \"Does your child respond to his/her name when you call?\" and (3) \"Does your child sometimes stare at nothing or wander with no purpose?\" This results in failing 1 critical and 3 total items. Our practice protocol recommends a referral for a diagnostic evaluation. Jacob has been a healthy child, and this is the first time that his parents have fallen behind in routine health care maintenance visits. His medical history is unremarkable. He was born at term, weighing 3.2 kg, without any perinatal complications. His parents had emigrated from the Poland in their teenage years and have been married for 8 years. They also have a 5-year-old daughter. They both report that, in Poland, there are some relatives who were \"very late talkers,\" but they do not know about any definitive family history of autism. At the 15-month visit, the parents reported that Jacob had expressive jargoning but no recognizable words. They stated then that he was not interested in toys but liked to play with the television remote control. He is in full-time child care--initially with a nanny in their home, but at 15 months started 3 days a week in a center-based childcare with many families from their community, where children speak Polish, English, and Hebrew at home. His mother works full time as an accountant and father as a physicist in a commercial laboratory. Both have graduate degrees and are trilingual. The parents are conflicted in their interpretation of Jacob's behavior. His father is concerned that he is autistic and his mother feels that \"he is just a little shy like me.\" His physical examination is normal. He is somewhat inhibited and anxious but will sit still on the examination table and alone during the examination. You update his immunizations and then struggle with where to head next." }, { "id": "pubmed23n0106_11522", "title": "Neurologic fragments. I. Clinical observations in demented patients.", "score": 0.00909090909090909, "content": "Some 28 clinical observations of behavior, mainly in demented patients, have been singled out for brief description and comment. Most are familiar, and the aim of the presentation is to identify and codify them, complementing formal psychological tests. Several have been given names--eg, insistence, balking, dread of being alone, the obligatory alibi, lability of temper, amphigory, reaching out, etc. Others draw attention to and characterize fragments of behavior--eg, ambient echolalia, periodic repetition of questions and comments, failure to recognize the spouse, turning the back, etc. Finally, a few clinical phenomena are commented upon." }, { "id": "pubmed23n0984_8677", "title": "Features of Catatonia in a 12-Year-Old Boy with Autism Spectrum Disorder.", "score": 0.009009009009009009, "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": "pubmed23n0015_13227", "title": "The agitated patient.", "score": 0.009009009009009009, "content": "The emergency management of the agitated patient is a common medical problem. Agitated behavior is not a diagnosis but a descriptive term; the initial task of the physician involves determining the etiology of the behavioral disturbance and evaluating the possible contribution of organic factors. Such factors as age of onset, acuteness of onset, concurrent illness, evidence of delirium or dementia, or use of exogenous pharmacologic agents require careful evaluation. Agitated patients will generally fall into one of four diagnostic categories: agitation precipitated by drug intoxication, agitation precipitated by drug withdrawal, agitation precipitated by an organic brain syndrome, or agitation precipitated by a functional disorder. Appropriate pharmacological and psychological management techniques for these situations are discussed." }, { "id": "pubmed23n0722_15245", "title": "Teasing out specific language impairment from an autism spectrum disorder.", "score": 0.008928571428571428, "content": "Marcus is a handsome, sweet, 7½-year-old boy with a significant history of delayed development, specifically in speech and language skills, as well as difficulties with social interactions that have led other specialists to be concerned about a diagnosis of an autism spectrum disorder.He has been seen in our primary care practice since birth. He was born full-term after vaginal delivery weighing 6 pounds, 6 ounces. There were no pregnancy or delivery complications noted. Genetic testing revealed normal chromosomes, fragile X, and microarray testing. Marcus was a picky eater and good sleeper and had delays in toilet training.There is no family history of attention-deficit hyperactivity disorder (ADHD), autism, or substance abuse. Maternal grandmother and mother have a history of learning difficulties, and his father and a paternal uncle have a history of depression and anxiety. Marcus lives in a supportive environment with his mother, father, and sister.Marcus was noted to have significantly delayed language, stuttering, and immediate echolalia as a toddler. Gross and fine motor milestones were met on time, but he did not talk or follow directions until 4 to 5 years old. As a younger child, he would pretend to talk on the phone or mow the grass with a pretend lawn mower, but other household activities were not of interest to Marcus.Currently, he enjoys puzzles, reading, and board games. He likes to play with other children and can interact with familiar adults. Marcus is reported to initiate social interactions, although he has difficulty in understanding personal space. Imaginative play is preferred over other types. He seeks out adult attention and will bring objects over to an adult especially to share his perceived accomplishment. Marcus has difficulty in playing cooperatively with his sister.He is independent with activities of daily living. Marcus is noted to have auditory defensiveness including covering his ears to loud noises and becoming distressed. Parents feel he is immature and inattentive for his age. Marcus responds well when a routine is followed.Previous testing about 2 years ago revealed significant language deficits on the Clinical Evaluation of Language Functioning with average scores on the Woodcock Johnson Achievement Testing and Test of Nonverbal Intelligence Version 3. Marcus was not referred for early intervention and he did not attend preschool. In a regular education Kindergarten, he received speech and occupational therapy along with reading and math support.Comments from teachers or evaluator include the following: Marcus looked to his peers for clues about what he should be doing. Marcus has great difficulty in understanding requests but seems to be interested in pleasing his teacher and others. Marcus' language difficulty makes socialization with his peers problematic; however, he is interested in interacting with them and they seem to accept him willingly. Marcus has intent to communicate with others but relies on visual support to decipher social situations. Marcus has difficulty in attending to details and moves from activity to activity quickly. His short attention span is likely impacting not only learning but also his ability to socially interact with peers.On the day you see him for his 7-year-old checkup, he brought many toys over to show his father and interrupted your conversation to get your attention intermittently throughout the examination. He immediately pointed out a lit ceiling tile with Nemo illuminated to show his father. Marcus does not have any notable or significant repetitive motor mannerisms or stereotypies reported or observed. Marcus' gesture use was appropriate for age and included both symbolic (directing eye gaze and pointing) and concrete (hands up to be picked up and touching an item rather than pointing to it) gestures. Play observed today, although immature for age, was novel, imaginative, and functional. Answers to questions did not always match the question posed. He had a difficult time waiting for his turn before interrupting a conversation. Visual cues were helpful in understanding what was expected of him and what was going on socially.Marcus' speech is notable for persistent stuttering and difficulty in turn-taking in conversation. He gets frustrated easily and has a hard time being understood. He continues to confuse pronouns and makes some grammatical errors. He is able to follow simple directions but has a hard time following complex or multistep directions with accuracy. Nonverbal communication includes pointing to objects of interest in order to share the experience (\"Look mom!\"). He will point to identify an object and can follow a point across the room. He is able to use his eye contact to direct yours to moderate social interactions.Marcus has a special interest in Thomas the Tank Engine Train and Disney movies but is able to move away from those topics to engage in other play interests. Repetitive behaviors are not noted. Toe walking, hand flapping, or spinning, or unusual hand motions or observation of objects were not observed.Difficulties noted today include delays in his receptive and expressive language, poor intelligibility, dysfluency, and impaired motor planning. He recently underwent an audiogram which was normal. You decide to refer to a specialist for further evaluation." } ] } } }

{ "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, 210 ] ], "word_ranges": [ [ 0, 33 ] ], "text": "Warfarin-induced skin necrosis is a rare and serious adverse effect of oral anticoagulant therapy, occurring in only 0.01 to 0.1% of patients and is especially related to coagulation protein C and S deficiency." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Antithrombin deficiency.", "2": "Factor V Leiden.", "3": "Hyperhomocysteinemia.", "4": "Protein C deficiency.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0214_12167", "title": "[Role of thrombolytic treatment in thrombosis of valvular prostheses. Apropos of 2 cases and review of the world literature].", "score": 0.017324133793310333, "content": "The authors report 2 cases of thrombolytic therapy by Urokinase at the dose of 4 500 U/kg/hour, for 24 hours, in patients with thrombosis of a Bjork aortic and Lillehei mitral valve prostheses, and assess the efficacy with a review of the world literature. The first case was a 65 year old woman who received a Bjork No 25 aortic valve prosthesis for aortic regurgitation. Two years later oral anti-vitamin K anticoagulants were replaced by an association of Aspirin-Persantine. She developed acute pulmonary oedema secondary to thrombosis of her valve during the fifth postoperative year. Treatment with Urokinase was successful (4 500 U/kg/hour for 24 hours). The second cases was a 33 year old woman who received a Lillehei No 27 mitral valve prosthesis for mitral regurgitation due to infective endocarditis. Six years later, during a period of apparently ineffective oral anticoagulation, she developed subacute pulmonary oedema due to thrombosis of her prosthesis. Urokinase therapy was successful after 4 hours, but the valve surface area on cardiac catheterisation was decreased and elective reoperation to change the prosthesis was decided upon. Prosthetic valve thrombosis is a serious complication with an operative mortality of 68.6% (35 deaths out of 51 reoperations in the worl literature) whilst the efficacy of thrombolytic therapy would appear to be about 80%. When thrombosis is progressive, the valve has to be changed surgically, but when it is secondary, thrombolytic therapy at least helps the patient survive the acute phase." }, { "id": "pubmed23n0746_11191", "title": "Multiple-shower thromboembolism in an artificial mitral valve patient.", "score": 0.013997113997113998, "content": "Late acute left atrial thrombosis is a rare life-threatening complication that mostly appears with predisposing primary coagulopathy, such as Protein C, Protein S, antithrombin 3 deficiency, antiphospholipid syndrome or hyperhomocysteinemia. We present grave outcome due to lack of anticoagulation in a patient with artificial mitral valve. A 47-year-old male known to have an artificial valve was hospitalized in another hospital due to an acute illness. Anti-coagulation therapy was not provided during that hospitalization. He was transferred to our hospital due to lower limb weakness and diagnosed by us as having extensive emboli disease with complete occlusion of the distal aorta. Multiple infarcts were found in the abdominal organs and leg muscles. He suffered from multiple organ failure and eventually died. Neglecting the common practice of anticoagulation to a patient with a mechanical heart valve may, in rare cases, lead to immediate catastrophic event caused by shower thrombemboli with disseminated vascular occlusion from the left atrium to the abdominal aorta causing complete occlusion, spleen, kidney and muscle infarcts." }, { "id": "pubmed23n0720_8543", "title": "[Skin necrosis during long-term fluindione treatment revealing protein C deficiency].", "score": 0.013176972281449893, "content": "Cutaneous necrosis is a rare complication of vitamin K antagonist therapy. It presents as cutaneous hemorrhagic necrosis and usually occurs at the start of treatment. We describe an atypical case of recurrent skin necrosis after two years of treatment with fluindione. A 70-year old woman with a history of venous thromboembolism and obesity presented with a large haemorrhagic necrosis of the abdominal wall. She had been treated with fluindione for two years. Genetic protein C deficiency was discovered. Resumption of vitamin K antagonist therapy was followed by recurrence of skin necrosis despite concomitant administration of heparin. Treatment with vitamin K antagonists could not be continued. This observation is unusual due to the late onset of skin necrosis. The condition usually begins shortly after initiation of vitamin K antagonist therapy, generally between the third and the sixth day of treatment. It is due to a transient hypercoagulable state in patients with protein C deficiency or, in rare cases, protein S deficiency. This late-onset skin necrosis, occurring many years after initiation of anticoagulant therapy, may be explained by a sudden worsening of pre-existing protein C deficiency due to infectious and iatrogenic factors." }, { "id": "pubmed23n0373_5790", "title": "[The best in 2000 on valve diseases].", "score": 0.012084917162733988, "content": "During the year 2000, publications on valvular heart disease have concerned all aspects of this field of cardiology at a time when old and dated therapeutic procedures are being reassessed. The ageing population of the developed world has led to aortic stenosis playing a large part, and the study of its natural history has provided two keynote publications. Aortic valve replacement, increasingly involving older patients, led to the evaluation of this surgery in this age group in which bioprostheses are often associated with coronary bypass surgery. Conversely, in younger patients, there is a regain in interest in autograft (Ross' procedure) or homograft valve replacement which requires a rigorous infrastructure of supply. In mitral valve disease, the indications of conservative surgery of mitral incompetence, ideal in degenerative forms of the posterior leaflet, have been progressively extended to include bacterial endocarditis in many cases and ischaemic mitral regurgitation according to some authors. Rheumatic lesions are not commonly treated by this technique although some encouraging results have been reported. Percutaneous mitral commissurotomy has attained maturity in the treatment of mitral stenosis, even in the less favourable forms such as restenosis after an initial percutaneous procedure or even after surgical commissurotomy. Valve replacement surgery by prosthetic valves is forty year old and many long-term retrospective and prospective evaluations of the results on large patient population either with one type of prosthesis or comparing different bioprostheses or bioprostheses with mechanical valves have been performed. The ideal age for implanting bioprostheses remains uncertain, between 60 and 70, depending on the authors. Finally, problems of anticoagulation in patients with prosthetic valves were the object of three interesting publications about the use of low molecular weight heparin, aspirin and the risks during pregnancy. 2000 was a year of steady and regular progress in the study of valvular heart disease without any major revolutionary contributions." }, { "id": "pubmed23n0278_19328", "title": "[New approaches for treating skin necrosis in protein C deficiency].", "score": 0.010935917835961232, "content": "A 62-year-old woman with a 8-month-history of recurrent deep and superficial vein thrombosis developed multiple areas of skin necrosis during warfarin treatment initiation. Routine coagulation tests did not revealed any abnormalities. Protein C plasma activity and concentration were significantly decreased (59.9% and 63.3% of the normal value, respectively). Antithrombin III and protein S (total and free) content were in the normal range. Initially, the adjusted dosage of standard heparin and fresh frozen plasma was administered. Thereafter, the treatment with low doses of oral anticoagulant (acenocoumarol) was reinstalled simultaneously with Protein C Concentrate (Immuno, Vienna) intravenous administration. After six days of the oral anticoagulation the therapeutic value of prothrombin time was obtained and administration of Protein C Concentrate could have been discontinued. No adverse reactions and post-transfusions complications were observed." }, { "id": "pubmed23n0395_19985", "title": "Cutaneous necrosis revealing the coexistence of an antiphospholipid syndrome with acquired protein S deficiency, factor V Leiden and hyperhomocysteinemia.", "score": 0.009900990099009901, "content": "We report an exceptional case of cutaneous necrosis due to the coexistence of 4 thrombophilic factors, inherited and acquired. We would like to draw attention to these unrecognized associations. A 72-year-old woman was admitted with a 5 month history of necrotic nonhealing, painful ulcer of both legs and recently a purple toe. She had a history of 3 deep venous thromboses of the leg complicated by pulmonary embolism. A skin biopsy of the ulcer and purple toe showed only thrombosis in the dermal vessel. Laboratory findings showed a circulating lupus anticoagulant, positive anticardiolipin antibodies, antinuclear antibodies (1/320 dilution) and an anti Sm. Moreover, activated protein C resistance associated with factor V Leiden mutation and hyperhomocysteinemia was found; protein S was transiently low. With iloprost, oral anticoagulant, vitamin B12 and folic acid, the evolution was good, with healing of ulcer. cutaneous necrosis can reveal hypercoagulable states, sometimes complex. We find 4 thrombophilic factors in our case, i.e. antiphospholipid antibodies, factor V Leiden, protein S deficiency and hyperhomocysteinemia. This is exceptional but highlights the role of several constitutional and acquired thrombophilic factors in the genesis of thrombosis. Extended protein C pathway disturbances could explain the mechanism that leads to cutaneous necrosis, in this patient, with an antiphospholipid syndrome. This case shows that it is necessary in some circumstances to make a complete hemostatic laboratory search to detect several thrombophilic factors. If they are present they can justify an oral anticoagulant treatment and a familial screening." }, { "id": "pubmed23n0293_15737", "title": "[Study of hemostasis in patients with a recent thromboembolic complication].", "score": 0.009900990099009901, "content": "The clinical history of well-documented personal or familial episodes of thromboembolism with systematic construction of a genealogical tree orients the diagnosis of hereditary or acquired thrombophilia. The presence of favorable medical or surgical conditions for pulmonary embolism (surgical operation, prolonged bed rest, oral contraception, pregnancy, etc) are commonly observed in thrombophilia. Young age, under 40, at the time of the first episode, the recurrent nature of thromboses and a positive family history are three criteria in favour of the diagnosis of hereditary thrombophilia. Laboratory tests should be performed, if possible anticoagulant therapy, or taking into account its effect on the results, heparin reducing the antithrombin level and the oral anticoagulants those of proteins C and S and affecting the \"classical\" test of resistance to activated protein C. This abnormality is observed in nearly 20% of patients with previous thromboembolism in familial thrombophilia whereas it is twice less common in deficits of antithrombin, protein C and protein S. The other more or less acknowledged causes, alteration of plasminogen, dysfibrinogenaemia, homocysteinaemia, particular blood diseases, indicating systematic association of a full blood count with blood clotting tests, are much more rare. Of the acquired thrombophilias, the commonest is the presence of circulating anticoagulant and/or anticardiolipine antibodies, these two conditions also requiring systematic investigation. Biological examinations for determining the cause of unexpected pulmonary embolism is essential but should not delay instauring treatment. It should be associated with a familial enquiry if the patient has a hereditary thrombophilia. Interpretation of the results should obey the rule of the 3 cs: is the biological abnormality the cause, a coincidence or the consequence of the affection?" }, { "id": "wiki20220301en010_162499", "title": "Pulmonary embolism", "score": 0.00980392156862745, "content": "The development of thrombosis is classically due to a group of causes named Virchow's triad (alterations in blood flow, factors in the vessel wall, and factors affecting the properties of the blood). Often, more than one risk factor is present. Alterations in blood flow: immobilization (after surgery, long-haul flight), injury, pregnancy (also procoagulant), obesity (also procoagulant), cancer (also procoagulant) Factors in the vessel wall: surgery, catheterizations causing direct injury (\"endothelial injury\") Factors affecting the properties of the blood (procoagulant state): Estrogen-containing medication (transgender hormone therapy, menopausal hormone therapy and hormonal contraceptives) Genetic thrombophilia (factor V Leiden, prothrombin mutation G20210A, protein C deficiency, protein S deficiency, antithrombin deficiency, hyperhomocysteinemia and plasminogen/fibrinolysis disorders)" }, { "id": "pubmed23n0048_7095", "title": "[Disclosure of protein C deficiency with pulmonary embolism followed by cardiac arrest during the recovery period].", "score": 0.00980392156862745, "content": "A case of unexpected cardiac arrest occurring in a 17-year-old male patient is reported. The patient had been admitted after sustaining hand trauma. A first emergency surgical procedure was carried out, followed about three weeks later by another one. No incidents occurred during or after either of these two operations. A third procedure was required about two months after the accident (free toe graft to the thumb of the left hand). The twelve-hour operation was carried out under general anaesthesia and axillary block. The patient was given intravenous heparin (800 IU.h-1) during the procedure on the arm. The patient recovered quickly, and was extubated before his transfer to the recovery room. Fifteen minutes later, the patient's heart rate decreased to 40 b.min-1, followed by a transient cardiorespiratory arrest. The suspicion of pulmonary embolism was confirmed by pulmonary scintigraphy. Thrombolysis was carried out with 2,000 IU.kg-1.h-1 of urokinase for a 72 h period, combined with continuous heparin administration (16 to 36 x 10(3) IU.day-1). The patient recovered after one week. No thrombophlebitis was found for origin of the emboli. Biological investigations carried out both before and after 10 minutes of anoxia revealed a normal fibrinolytic system, but a deficit in protein C (62% antigen, 64% activity). Two years after the episode of pulmonary embolism, the patient, still taking acenocoumarol, remained free from any sequela. Current perioperative management of patients with a known protein C deficit is discussed." }, { "id": "pubmed23n0408_865", "title": "Protein C, S and antithrombin III levels in patients with acute mechanical valve thrombosis.", "score": 0.009708737864077669, "content": "Mechanical prosthetic heart valve thrombosis is a serious complication with an incidence of 1-6%. The reduction in active vitamin-K dependent protein C and S levels caused by warfarin treatment also results in a prothrombotic state. This study was conducted to investigate the connection between protein C (PC), protein S (PS), antithrombin III (ATIII) deficiency and prosthetic mechanical valve thrombosis. Twenty-nine of the 283 patients who underwent valve replacement with St. Jude medical prosthesis had mechanical valve thrombosis (group 2). The rest were considered as group 1. Twelve of the 29 patients (41.4%) had isolated aortic valve replacement, 12 had isolated mitral valve replacement (41.4%) and 5 patients had double valve replacement (17.2%). Most of the patients had rheumatic valve disease at their 1st operation. The mean time of occurrence for mechanical valve occlusion was 4.1+/-1.0 years following surgery. The values of PC, PS and ATIII were obtained when the mechanical valves stuck or at routine follow-up. PC, PS and ATIII levels were significantly lower in the mechanical valve thrombosis group. PC levels were 75.4+/-37.6% and 49.9+/-32.2% in group 1 and 2, respectively (p=0.001). PC, PS and ATIII values were mostly lower in the 2nd group but this difference only became significant after at least 2 years of warfarin usage. Natural anticoagulant levels can be low during the use of warfarin. In which case the dose can be increased in order to hold the international normalized ratio (INR) at 3-3.5. However, more frequent follow-up is required and patients should be investigated for hypercoagulation states or deficiency in anticoagulant proteins. Patients referred to hospital with any mechanical valve thrombosis or recurrent thromboembolism should be evaluated for hypercoagulant proteins." }, { "id": "pubmed23n0389_20264", "title": "[Changes in the clinical profile of patients treated with oral anticoagulants in the 1990's].", "score": 0.009708737864077669, "content": "During the last few years the efficacy of oral anticoagulant treatment in the prevention of thromboembolic complications among patients with cardiac diseases has been well established. This has determined an increase in the number of patients undergoing this therapy and a change in the clinical profile of these patients. To determine the number and the changes in the clinical characteristics of patients treated with oral anticoagulants during the last decade. The charts of 5,771 hospitalized patients between January 1, 1991 and December 31, 1999, were retrospectively reviewed. We analyzed the number of patients discharged with anticoagulant treatment, the clinical profile and the evolution during the decade. 761 (13.1%) patients were discharged with anticoagulants. The therapy was prescribed to 7.4% of the patients from 1991-1993 and to 15.1% of the patients from 1998-1999. The mean age of the patients was 60.4 from 1991-1993 and 67.1 from 1998-1999 (p &lt; 0.001). At the beginning of the decade, 90% of the patients had prosthetic valves, suffered from rheumatic heart disease or had had thromboembolic phenomena previously. At the end of the decade, only 49% could be included in these groups. a) The use of oral anticoagulants among our hospitalized patients has been duplicated during the past ten years; b) the clinical profile has changed, patients are now older and with different morbidity; c) the rheumatic heart disease and the prosthetic valves are no longer the predominant indications, and d) the use of therapy as secondary prevention has decreased significantly." }, { "id": "wiki20220301en081_55982", "title": "Warfarin necrosis", "score": 0.009615384615384616, "content": "Notably, the prothrombin time (or international normalized ratio, INR) used to test the effect of warfarin is highly dependent on factor VII, which explains why patients can have a therapeutic INR (indicating good anticoagulant effect) but still be in a hypercoagulable state. In one third of cases, warfarin necrosis occurs in patients with an underlying, innate and previously unknown deficiency of protein C. The condition is related to purpura fulminans, a complication in infants with sepsis which also involves skin necrosis. These infants often have protein C deficiency as well. There have also been cases in patients with other deficiency, including protein S deficiency, activated protein C resistance (Factor V Leiden) and antithrombin III deficiency. Although the above hypothesis is the most commonly accepted, others believe that it is a hypersensitivity reaction or a direct toxic effect. Diagnosis" }, { "id": "pubmed23n0215_12844", "title": "Evolution of antithrombin III during the postoperative period.", "score": 0.009615384615384616, "content": "In a prospective study, antithrombin III (AT III) was performed preoperatively, peroperatively immediately after the surgical procedure and daily during the 8 postoperative days in 57 consecutive patients who underwent major abdominal surgery without prophylactic anticoagulant therapy. On d 8, according to the results of a bilateral radiological phlebography, the patients were divided into 2 groups: Group I: presence of deep venous thrombosis (DVT): n = 28 (49%) and Group 2: absence of deep venous thrombosis: n = 29 (52%). The results of the study showed that the preoperative AT III value did not constitute a marker of the postoperative DVT risk. During the postoperative period, AT III level decreased immediately following the intervention and resumed its preoperative value within 8 d. Nevertheless, this evolution was not different in the 2 groups and was not related to the presence of postoperative DVT." }, { "id": "wiki20220301en011_12893", "title": "Venous thrombosis", "score": 0.009523809523809525, "content": "Inherited Antithrombin deficiency Protein C deficiency Protein S deficiency (type I) Factor V Leiden Prothrombin G20210A Dysfibrinogenemia Non O-blood type Mixed Low free protein S Activated protein C resistance High factor VIII levels Hyperhomocysteinemia High fibrinogen levels High factor IX levels High factor XI levels" }, { "id": "pubmed23n0111_12230", "title": "[Recurrent thrombosis of an aortic valve prosthesis in a pregnant woman. Treatment with urokinase].", "score": 0.009523809523809525, "content": "A 36 year old woman developed two thromboses on aortic valve prosthesis. The first thrombus at the 14th week of pregnancy was treated with urokinase (2,000 U/kg/h) plus heparin (700-1,000 U/h) over 24 hours and normal wing kinetics were obtained. The second thrombus developed at the 36 th week of pregnancy when the patient was receiving calciparin, and only transient improvement was obtained with similar doses of urokinase hourly over 72 hours. Progressive worsening resulted in higher doses (4,000 U/kg/h) being given without heparin and the thrombus then resolved. The use of urokinase for the first time in this indication allowed therefore, on two occasions and without hemorrhagic complications the cure of this recurrent thrombosis on aortic prosthesis, and the birth, by caesarean, of a healthy baby." }, { "id": "pubmed23n0963_22296", "title": "Fourth mitral valve replacement in a 15-year span in a woman of childbearing age.", "score": 0.009433962264150943, "content": "There is no report of four valve replacement surgeries in a woman during 15-year follow-up. A 23-year-old female was diagnosed at 7 years with rheumatic fever. She developed severe mitral regurgitation and at the same age a prosthetic valve was placed. In the next 15 years her mitral valve was changed 3 times because of clinical, echocardiographic, and histopathologic evidence of thrombosis. Her coagulation tests all showed infratherapeutic international normalized ratio and by the age of 15 years she had had an ischemic stroke with total recovery. She developed a normal pregnancy by the age of 19 years with no complications. This case exposes the complexity of the decision making that cardiologists face in terms of choosing the type of prosthetic valve that should be indicated in a woman of childbearing age. With each surgical valve replacement prognosis is less favorable and choosing the best therapy remains a challenge for the heart team. &lt;<bLearning objective:</b Valvular heart disease remains a challenging problem due to anticoagulation issues. Prosthetic valvular replacements need a thorough follow-up for anticoagulation goals. Women of childbearing age can both have mechanic and biologic prosthesis.&gt;." }, { "id": "pubmed23n0321_10298", "title": "[Venous thrombosis. Experience in treatment, problems and perspectives].", "score": 0.009433962264150943, "content": "Venous thromboembolic disease is a recurring reason for death, it is often well-known but sometimes misunderstood. The right treatment for this pathology should not follow one approach only, but several strategies with respect to the seriousness and extension of the several clinical pictures. In particular the pharmacological therapy tries to find the balance between risks and benefits. It is well-known that a weak treatment may cause an increase in the risk of the pathology extension or of recurrence; on the other hand, a therapy exceeding the well known ranges exposes to important hemorrhagic risk. This work presents the personal seven years' experience in patients affected by limb venous thrombosis, in some cases combined with pulmonary embolism. For all patients the pathology seriousness has been assessed by echoduplex scanner and angio-CT, and routine serum electrolite and enzymes analysis and blood counts have been carried out. Different therapies have been investigated, their evolution over the years (on the basis of international and personal experience) and the follow-ups. The foudamental implications of this experience are: the more remarkable use of vena cava filters do not improve clinical findings' follow-up. On the contrary, it can cause the extension of pathology; heparin therapy must start early and the therapeutic range must be reached as soon as possible. Any delay, together with immobilization, can cause the extension of the pathology; diagnosis research cannot stop at the acuity moment but it should study also the etiopathogenetic picture. This affects the future therapeutic strategy in the follow-up; fibrinolitic therapy, once recommended for extended femoral-iliac thrombosis, should be used for serious levels of the same pathology and only for patients with low haemorrhage risk, or for patients affected by periodic pulmonary thromboembolism which may compromise haemodynamic system." }, { "id": "pubmed23n1065_4377", "title": "Anticoagulation Resumption in a Patient With Mechanical Heart Valves, Antithrombin Deficiency, and Hemorrhagic Transformation Following Thrombectomy After Ischemic Stroke.", "score": 0.009345794392523364, "content": "Anticoagulation is essential for patients undergoing mechanical heart valve replacement; however, the timing to reinitiate the anticoagulant could be a dilemma that imposes increased risk for bleeding events in patients suffering from the life-threatening hemorrhagic transformation (HT) after ischemic stroke. Such a situation was presented in this case report. A 71-year-old woman was transferred directly to the Neurocritical Care Unit because of a HT that occurred following the mechanical thrombectomy for ischemic stroke. Since she had a history of prosthetic metallic valve replacement, how the anticoagulating therapy could balance the hemorrhagic and thrombotic risks was carefully evaluated. On day 6 after the onset of hemorrhage transformation, the laboratory results of coagulation and fibrinolysis strongly suggested thrombosis as well as antithrombin deficiency. The short-acting and titratable anticoagulant argatroban was immediately initiated at low dose, and thrombosis was temporarily terminated. On day 3 of anticoagulation resumption, argatroban was discontinued for one dose when the prothrombin time and activated partial thromboplastin time significantly prolonged after argatroban infusion. Aortic valve thrombosis was detected the next day. The anticoagulation was then strengthened by dose adjustment to keep mitral valve intact, to stabilize the aortic valve thrombosis, and to decrease the aortic flow rate. The intravenous argatroban was transited to oral warfarin before the patient was discharged. This study is the first report of administering argatroban and titrating to its appropriate dose in the patient with valve thrombosis, antithrombin deficiency, and HT after mechanical thrombectomy for acute ischemic stroke. Notably, the fluctuations argatroban brings to the coagulation test results might not be interpreted as increased bleeding risk. This case also suggested that the reported timing (day 6 to day 14 after hemorrhage) of anticoagulant resumption in primary intracerebral hemorrhage with mechanical valves might be late for some patients with HT." }, { "id": "pubmed23n0014_5082", "title": "[The risk of hemorrhage versus the thromboembolic risk in patients with prosthetic valve].", "score": 0.009345794392523364, "content": "376 adults were followed up for between 2 and 153 months after surgery (mean: 3.8 years); all of them, with the exception of 8, received anticoagulant treatment. The results were subjected to statistical analysis using several tests. Thromboembolic complications occurred in 16 per 100 after 5 years, and 8.5. per 100 of them were fatal. Among the factors favoring this complication are the type of valvular disorder (the rate of throembolism being 4 times greater with mitral valve defects), the type of prosthesis, and the efficiency of the anticoagulant therapy (the risk of thromboembolism being four times greater in those patients whose treatment has been inneffective). Against the vitamin antagonists must be set the haemorrhages: the incidence of lethal haemorrhage in this series was 6.4 per 100 patients per treatment year. There was a proven hypoprothrombinaemia to below the desirable level in two thirds of these cases, and in one case out of four an additional predisposing factor could be demonstrated. Haemorrhage and thromboembolism are together responsible for one in four of the late deaths. In order to reduce the mortality, several solutions are considered, one of which is to utilise anti-aggregation treatment. However, the vitamin K antagonists remain an essential part of treatment in the majority of cases; it can only be justifiable to withhold them in those patients in whom the risks of haemorrhage are for various reasons considered to be too high. The introduction of biological valves or of valves with a lessened risk of embolism is highly desirable in such cases." }, { "id": "pubmed23n0871_11886", "title": "Factor V and VIII deficiency treated with therapeutic plasma exchange prior to redo mitral valve replacement.", "score": 0.009259259259259259, "content": "A 33-year-old male was admitted to the hospital for a repeat mitral valve replacement. The original surgery, performed in India in 2008 due to rheumatic heart disease, required massive amounts of plasma replacement during and after the surgery. The patient was admitted to our hospital with extremely low Factor V and Factor VIII activities due to a rare combined Factor V and Factor VIII deficiency. His clinical condition on admission was grave due to severe pulmonary hypertension. It was decided to replace the patient's Factor V using therapeutic plasma exchange (TPE) with fresh frozen plasma (FFP) just prior to surgery, and his Factor VIII with Factor VIII concentrate. The patient tolerated the valve replacement surgery very well, without excessive bleeding, and received several more TPE procedures postoperatively. He was successfully made replete with both coagulation factors with little to no bleeding during the procedure and postoperatively. TPE is a promising modality for the treatment of patients with similar factor deficiencies for which a specific factor concentrate is not available, especially those at risk of fluid overload from plasma transfusion. J. Clin. Apheresis 32:196-199, 2017. © 2016 Wiley Periodicals, Inc." }, { "id": "pubmed23n0498_9600", "title": "[Impact of biochemisty on the duration of treatment for pulmonary embolus].", "score": 0.009259259259259259, "content": "Can the biochemical evidence for \"new thrombophilic factors\" influence the duration of AVK treatment following the occurrence of a first pulmonary embolus? Certainly for the classic but very rare antithrombin defects as well as for the existence of circulating anticoagulant. Possibly for protein C and S defects. On the other hand, the existence of a heterozygotic \"Leiden\" mutation of factor V, or factor II, and an increase of factors VIII, IX, or XI, do not at present warrant a change in AVK prescription. In effect, in the case where the existence of a thrombogenic state implies a prolongation of AVK treatment with its significant potential complications, it is indispensable that the risk/benefit ratio is well founded, which is not the case for these \"new\" thrombophilic states. The coexistence of several of these new biochemical anomalies (for example the association of a factor V and factor II mutation) probably represents an excess risk of thrombosis, but in this situation the reasoning remains the same. On the other hand, faced with a confirmed recurrence, the studies in the literature tell us that very long term treatment should be debated independently from the biochemical results. It is conceivable that there are biochemical anomalies (sometimes quite frequent which should be viewed as \"normal variants\") which, although they have great significance for improving the understanding of venous thrombo-embolic disease, do not at present warrant a change in our therapeutic protocols. Another facet of the problem concerns the use of D-dimers following the first months of AVK treatment in order to possibly distinguish patients at low risk of recurrence. The first results of this approach are interesting, but require confirmation before they can be used in practice." }, { "id": "pubmed23n0480_21365", "title": "Warfarin-associated multiple digital necrosis complicating heparin-induced thrombocytopenia and Raynaud's phenomenon after aortic valve replacement for adenocarcinoma-associated thrombotic endocarditis.", "score": 0.009174311926605505, "content": "Necrosis of the digits is a rare complication of warfarin therapy of obscure pathogenesis. We report a 61-year-old woman with a 12-month history of Raynaud's phenomenon who developed multiple digital necrosis following aortic valve replacement with mechanical prosthesis for aortic insufficiency caused by nonbacterial thrombotic endocarditis. Exacerbation of Raynaud's phenomenon occurred during the postoperative period, with daily episodes of ischemia of the fingers and toes that improved with local warming. However, coincident with the occurrence of immune heparin-induced thrombocytopenia, and while undergoing routine warfarin anticoagulation because of the mechanical valve prosthesis, the patient abruptly developed progression of digital ischemia to multiple digital necrosis on postoperative day 8, at the time the international normalized ratio reached its peak value of 4.3. All limb pulses were readily palpable, and vascular imaging studies showed thrombosis only in the superficial femoral and popliteal veins of the right leg. Coagulation studies showed greatly elevated levels of thrombin-antithrombin complexes and prothrombin fragment F1.2 levels, consistent with uncontrolled thrombin generation. After vitamin K administration, no abnormalities of the protein C anticoagulant pathway were identified, consistent with previous studies of other patients with warfarin-induced necrosis complicating heparin-induced thrombocytopenia. Subsequently, the patient was shown to have metastatic breast adenocarcinoma, which explained the patient's initial presentation with nonbacterial thrombotic endocarditis. This patient case suggests that multiple digital gangrene can result from the interaction of various localizing and systemic factors, including compromised microvascular blood flow (Raynaud's phenomenon), increased thrombin generation (heparin-induced thrombocytopenia, adenocarcinoma), and warfarin-induced failure of the protein C natural anticoagulant pathway." }, { "id": "pubmed23n0089_2044", "title": "[Postoperative pulmonary embolism].", "score": 0.009174311926605505, "content": "Post-operative thrombo-embolic disease remains a frequent occurrence in spite of advances in their prophylaxis. Evaluation of 60 case-reports of this disease which often includes peripheral manifestations and always pulmonary manifestations, enables to specify the role of the procedure itself (mostly orthopaedic surgery 60%), pelvic surgery 20%, the chronology of events (possibility of early embolism between D1 and D3 and usual occurrence of manifestations between D8 and D18, and the importance of the background, whether investigated or not: deficiencies in anti-thrombin III, protein C and S: 4 cases. The diagnosis is based on clinical signs (non-specific) and the laboratory tests, especially scintigraphy (screening) and angiography, absolutely necessary for the diagnosis and evaluation of the amputation coefficient (Miller index). With a diagnosis of pulmonary embolism, it is always necessary to look for a proximal venous thrombosis. The treatment, calls for heparin (quite seldom), thrombolytics (Urokinase, Plasminogen in our experience), the indication of which must take into consideration the delays and the nature of the previous procedure, and finally surgery (massive forms where thrombolytics are contraindicated). The thrombo-embolic manifestations with thrombogenic thrombopenia secondary to heparin are quite frequent, in a surgical environment (10 cases) and difficult to treat." }, { "id": "wiki20220301en081_55979", "title": "Warfarin necrosis", "score": 0.00909090909090909, "content": "Warfarin-induced skin necrosis is a condition in which skin and subcutaneous tissue necrosis (tissue death) occurs due to acquired protein C deficiency following treatment with anti-vitamin K anticoagulants (4-hydroxycoumarins, such as warfarin). Warfarin necrosis is a rare but severe complication of treatment with warfarin or related anticoagulants. The typical patient appears to be an obese, middle aged woman (median age 54 years, male to female ratio 1:3). This drug eruption usually occurs between the third and tenth days of therapy with warfarin derivatives. The first symptoms are pain and redness in the affected area. As they progress, lesions develop a sharp border and become petechial, then hard and purpuric. They may then resolve or progress to form large, irregular, bloody bullae with eventual necrosis and slow-healing eschar formation. Favored sites are breasts, thighs, buttocks and penis, all areas with subcutaneous fat. In rare cases, the fascia and muscle are involved." }, { "id": "pubmed23n0513_2829", "title": "[Upper limb deep venous thrombosis. Risk factors, outcome, and posthrombotic syndrome].", "score": 0.00909090909090909, "content": "Our objective was that of describing a series of episodes of upper limb deep venous thrombosis, with special emphasis on the incidence of posthrombotic syndrome and its impact in the quality of life of the patients. 33 episodes (29 patients) of upper limb deep venous thrombosis were studied, between January 1995 and January 2002; episodes until September 1999 (18 episodes) were considered retrospectively while those which took place starting in this date (15 episodes) were considered prospectively. In all, 24 patients were cared in hospital clinic. It was possible to obtain complete data in 16 cases, in which evolution toward posthrombotic syndrome, venous revascularization, and impact of the pathological process in the global quality of life of patients were studied. Average age of patients was 58.9 years. In 25 episodes (75.8%) some risk factor for venous thrombosis existed, the presence of a venous catheter being the most frequent. Subclavian axillary affectation was predominant (18 episodes, 55%) and in the left side (25 episodes, 76%). Twenty-eight episodes were diagnosed with echography (84.8%). Mean D-dimers concentration (N = 16) was 1,046 ng/ml (standard deviation [SD]: 826.9). One of the episodes (3%) was associated to lung thromboembolism. Treatment consisted on the administration of low molecular weight heparin during the acute phase in 70% of the cases. In 13 episodes (39%) additional treatment of thrombosis (endovascular in most) was carried out. In 29 episodes (88%) chronic treatment was administered with acenocoumarol, while in 4 episodes (12%) the administration of low molecular weight heparin was kept. No patient died during hospitalization. In 15 patients (52%) control of revascularizacion was performed. We detected complete revascularization in 6 patients (40%), revascularization with collateral circulation in 4 patients (27%), partial revascularization in other 4 patients (27%) and presence of permeability but with expansion and tortuosity of deep venous system in 1 case (6%). Posthrombotic syndrome was considered mild or nonexistent in 10 patients (62.5%) and moderate in 6 patients (37.5%). Quality of life of patients with moderate posthrombotic syndrome was significantly worse than that of patients with mild posthrombotic syndrome (73 vs 90, p &lt; 0.035). Most of upper limb deep venous thrombosis are associated to the use of intravenous catheters. Echography is the primary diagnostic technique. At the time of the diagnosis, patients tend to show elevation in D-dimers levels. Evolution toward posthrombotic syndrome is frequent; this syndrome does not use to be serious but indeed influences the quality of life of patients." }, { "id": "pubmed23n0860_7318", "title": "[Mechanic valve prosthesis and pregnancy: Is Phenprocoumon replaceable?].", "score": 0.009009009009009009, "content": "We report the case of a 30-year-old pregnant patient with mechanical valve replacement in mitral and aortic position. She had discontinued Phenprocoumon-treatment in the 5+4 week of pregnancy by herself. Because of rheumatic fever she had undergone a mechanical aortic and mitral valve replacement 12 years ago. Due to a thrombosis of the mitral valve, an acute reoperation had to be done 5 years later. 2 years ago, a partially re-thrombosis of the mechanical mitral valve was treated by intravenous thrombolysis. These complications had been probably due to incomplicance. The patient had experienced 3 abortions before. The vaginal sonography determined an intact gestation. The laboratory test revealed an INR of 1.2. The transesophageal echocardiography showed a partially thrombosed mechanical mitral valve. The abdominal ultrasonography detected an embolic splenic infarction. These findings were consistent with partially thrombosed mechanical mitral valve with thromboembolic splenic infarction among incompetent oral anticoagulation. After initial heparinization with under twice daily control of the partial thromboplastin time the joint decision was made to restart Phenprocoumon (target INR 2.5 to 3.5, and additional ASS 100 mg /day). 9 days later the patient had a missed abortion. An uncomplicated curettage was performed under therapeutic i.v. heparinization. The use of coumarins in pregnancy carries a fetal risk. But it is the most secure anticoagulation after a mechanical valve replacement, especially in high-risk patients. Alternatives are heparins. They don't cross the placenta but are associated with a slightly elevated risk of thromboembolism." }, { "id": "pubmed23n0220_9430", "title": "[Mitral valve prosthesis without anticoagulant treatment. Apropos of 46 cases].", "score": 0.009009009009009009, "content": "Out of a total of 90 patients with valvular prosthesis not treated with anti-coagulants, 46 only had a prosthesis in the mitral position. These patients were treated in Professor Ben Ismail's department for an average of 58 months (extreme limits 26 and 116 months). The average age of these patients at the time of the operation was 13.6 years. It is important to note that these patients greatly improved as attested to by the evolution of the functional symptoms, cardiac volume, capillary and pulmonary arterial pressure. 7 patients had a thromboembolism (15.5 per cent or 3 embolisms per 100 patient-years). Three cases were minor or rapidly regressed and out of four major cases, one died. This complication is much more frequent in patients treated with anti-coagulants as is the risk of haemorrhage which is sometimes serious or even mortal. In view of these results, it seems legitimate, in these young patients, especially when they are in sino-astrial rhythm, have a good clinical history and are haemodynamic to forego anti-coagulant treatment which may be dangerous in these undisciplined patients under irregular and unusual treatment." }, { "id": "pubmed23n0066_11199", "title": "Progressive hemolytic anemia due to delayed recognition of a Beall mitral valve prosthesis.", "score": 0.008928571428571428, "content": "In addition to a working knowledge of general complications such as thromboembolism and infective endocarditis, optimal care of the patient with a prosthetic valve requires specific knowledge concerning the characteristics of a given patient's prosthesis. This may need to include the ability to identify the valve roentgenographically when history and records are unavailable. A 53-year-old woman with mitral stenosis secondary to rheumatic heart disease and status post a reported Bjork-Shiley mitral valve (MV) replacement 17 years prior to hospital admission was referred for evaluation of severe hemolytic anemia. Previous cinefluoroscopy in 1986 at the time of a cerebrovascular accident revealed a normally functioning caged disc prosthesis and not the tilting disc of a Bjork-Shiley prosthetic valve. The valve was not further characterized and she continued receiving warfarin therapy until May 1989 when she presented with laboratory findings showing a marked hemolytic anemia with a hemoglobin of 6.5 mg/dl and lactate dehydrogenase (LDH) value of 2100 IU. Echocardiography revealed normal valvular function without evidence of perivalvular leak. The patient was referred for further evaluation with chest roentgenogram at the time of hospital admission revealing a valve configuration characteristic of the Beall model 103/104 series that has been found to manifest progressive disc variance with a high degree of hemolytic anemia (despite normal noninvasive evaluation of MV function), disc tilting with intermittent regurgitation, and catastrophic disc embolization in extreme cases. The precise identification of valvular prosthesis in patients after valve replacement is crucial for optimal management. As in our case, the mere identification of a particular valve may necessitate certain management and therapy based on the natural history of that valve. In the absence of reliable history and/or records, the roentgenographic examination should lead to the precise identification." }, { "id": "pubmed23n0315_17011", "title": "[Thrombosis of mechanical heart valve prosthesis. Predisposing factors and results of surgical treatment].", "score": 0.008928571428571428, "content": "Heart valve thrombosis is a serious complication. From February, 1995 to January, 1996, 19 patients were studied to identify predisposing factors and results of surgical management. Mean age was 47.3 years. Thirteen patients (73.6%) had an irregular surveillance of anticoagulation therapy. Fifteen patients showed low anticoagulation effect during their evolution. Sixteen patients were in functional class III and 80% (15 patients) showed imaging of thrombus in the echocardiographic study. All patients presented thrombus on both sides of the prothesis. There were no deaths, and 15 patients returned to functional class I. It was concluded that the main predisposing factor in this series of patients was deficient anticoagulation therapy, and surgical results are comparable to those other authors." }, { "id": "pubmed23n0766_419", "title": "[Multiple mitral valve aneurysms, mycotic arterial embolism and aneurysms with infective endocarditis].", "score": 0.008849557522123894, "content": "A 30-year-old woman with a more than 6-month history of fever, weight loss, general fatigue and dysesthesia of lower extremities was admitted to our hospital with a diagnosis of infective endocarditis. Blood cultures revealed Staphylococcus oralis. Echocardiography revealed severe mitral and moderate tricuspid regurgitation, as well as massive vegetations and aneurysms on the mitral valve. Computed tomography revealed an abdominal aortic aneurysm, left common and external iliac arterial aneurysms, and occlusion of the left common iliac, the deep femoral arteries and the bilateral tibioperoneal trunk. The ankle brachial pressure indices (ABI) were 0.94 (right) and 0.61 (left). She initially underwent mitral valve replacement and tricuspid annuloplasty. On postoperative day 24, the affected segments of the arteries were replaced with a woven Dacron bifurcated graft after resection of the mycotic abdominal and the iliac arterial aneurysms. We could not obtain a sufficient amount of omental pedicle to wrap the prosthesis. Her postoperative course was uneventful and mycotic arterial embolism and aneurysm did not recur. " }, { "id": "pubmed23n0687_18672", "title": "Outcomes and associated risk factors for mitral valve replacement in children.", "score": 0.008771929824561403, "content": "We aim to report time-related outcomes following mitral valve replacement (MVR) in children and to identify factors affecting outcomes. Clinical records from 307 children who underwent MVR between 1985 and 2004 were reviewed. Competing-risks methodology determined time-related prevalence of three mutually exclusive end-states: death, mitral reoperation and survival without subsequent MVR, and their associated risk factors. Mean age was 11.4 ± 5.6 years including 36 (12%) patients &lt; 2 years old. There were 154 (50%) males. Underlying pathology was rheumatic fever (n = 195, 64%), congenital (n = 83, 27%) and other (n = 29, 9%) with congenital pathology predominant in younger children while rheumatic fever predominant in older children. Hemodynamic manifestation was regurgitation (83%), stenosis (5%), or mixed disease (12%). One hundred and twenty-six patients (41%) had undergone a prior cardiac surgery including mitral surgery (n = 96, 31%). Initial mitral prosthesis was mechanical (n = 229, 75%), tissue (n = 71, 23%), or homograft (n = 7, 2%). Concomitant cardiac surgery was required in 141 patients (46%). Competing-risks analysis predicted that 20 years following MVR, approximately 17% of patients have died, 51% have undergone mitral reoperation and only 33% were alive and free from mitral reoperation. Risk factors for death without mitral reoperation included younger age &lt; 3 years [PE (parameter estimates): +1.66 ± 0.31, p &lt; 0.001], longer cross-clamp time (PE: +0.11 ± 0.04/10 min, p = 0.005), postoperative complications (PE: +1.5 8 ± 0.31, p &lt; 0.001), and higher prosthesis size/body surface area (BSA)-predicted mitral annulus ratio (PE: + 0.48 ± 0.10, p &lt; 0.001). Risk factors for mitral reoperation included implantation of homograft or tissue prosthesis (PE: +1.12 ± 0.23, p &lt; 0.001) and smaller prosthesis size (PE: +0.06 ± 0.03/1 mm, p = 0.05). Fifteen-year freedom from pacemaker implantation, endocarditis, bleeding, and thromboembolism was 92%, 96%, 82%, and 92%, respectively. Mortality and mitral reoperation are common after MVR in children and outcomes can be predicted based on patient's age, prosthesis size, and other associated factors. Some modifiable factors such as avoiding oversized prostheses may improve outcomes especially in the smallest children." }, { "id": "pubmed23n0379_11164", "title": "[An uncommon cause of severe soft tissue bleeding during phenprocoumon treatment].", "score": 0.008771929824561403, "content": "A 66-year-old patient presented to our clinic with extensive left arm and left flank haematomas, anaemia, a prolonged activated partial thromboplastin time (aPTT), and reduced factor IX activity 6 weeks after prosthetic mechanical aortic valve implantation. Treatment with both vitamin K and a single injection of factor IX concentrate led to normalization of the activated partial thromboplastin time and factor IX activity, which remained constant for several days. No acquired factor IX inhibitor was detectable. Analysis of exon 2 of the factor IX gene revealed a C--&gt;T mutation in codon 10 of the propeptide region, resulting in the substitution of alanine by valine. Echocardiography revealed a significant paravalvular leak. The substitution of valine for alanine in the factor IX propeptide leads to an impaired affinity of factor IX to the vitamin K-carboxylase complex. In this situation, treatment with coumarin derivatives can profoundly reduce factor IX activity and result in severe bleeding episodes. This patient was re-exposed to warfarin under close hematological monitoring. After 4 days factor IX activity had decreased to 15%, which was associated with an increase of the aPTT and a mild decrease of the prothrombin time. Due to rapid progression of the paravalvular leak and almost impossible long-term orale anticoagulation with coumarin derivatives, we recommended replacement of the prosthetic mechanical valve with a biological device. The development of severe bleeding in the context of initiating warfarin therapy raises the suspicion of a factor IX propeptide mutation. The initial screening test is the activated partial thromboplastin time, which is elevated in the presence of the mutation. If concomitantly diminished factor IX activity is found the factor IX propeptide mutation should be excluded. Use of lifelong coumarin derivatives is contraindicated in patients with this mutation. However, a general screening of the activated partial thromboplastin time after coumarin initiation is not justified by cost/benefit analysis." } ] } } }

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{ "1": "Immediate intravenous broad-spectrum antibiotherapy.", "2": "Exhaustive debridement-wound lavage in the operating room with at least 10 liters of saline.", "3": "Urgent stabilization of the fracture by external fixation and early wound closure.", "4": "Early wound closure with antiseptics and oxygen therapy at two liters per minute.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en305_15769", "title": "Gustilo open fracture classification", "score": 0.018362533692722373, "content": "In 1976, Gustilo and Anderson refined the early classification system proposed by Veliskasis in 1959. An early study conducted by Gustilo in 1976 showed that primary closures with prophylactic antibiotics of Type I and type II fractures reduced the risk of infection by 84.4%. Meanwhile, early internal fixation and primary closure of the wound in Type III fractures have a greater risk of getting osteomyelitis. However, Type III fractures occur in 60% of all the open fracture cases. Infection of the Type III fractures is observed in 10% to 50% of the time. Therefore, in 1984, Gustilo subclassified Type III fractures into A, B, and C with the aim of guiding the treatment of open fractures, communication and research, and to predict outcomes. Based on the results of the previous studies, Gustilo initially recommended therapeutic irrigation and surgical debridement for all fractures with primary closure for Type I and II fractures; secondary closure without internal fixation for Type III" }, { "id": "pubmed23n1009_12107", "title": "Prevention of infection in open fractures: Where are the pendulums now?", "score": 0.01803107139982291, "content": "Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures." }, { "id": "pubmed23n0595_738", "title": "Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures.", "score": 0.018000642880102863, "content": "Prevention of infection is a paramount concern after open fracture of the tibia. Previous studies have shown that delay in soft-tissue coverage may raise infection rates. Use of vacuum-assisted closure devices in open fracture wounds has become common. The authors analyzed whether use of the vacuum-assisted closure sponge can allow delay of flap coverage for open tibia fractures without an increase in infection rate. The authors identified 38 patients with Gustilo grade IIIB open fractures from their trauma registry with a minimum 1-year follow-up. From the medical record, the authors collected information on the time from injury to definitive wound coverage, type of fixation, type of coverage, and demographics. Infected patients were defined as patients that required surgical debridement after coverage with positive cultures. Patients who underwent definitive coverage within 7 days had a significantly decreased rate of infection (12.5 percent) compared with patients who had coverage at 7 days or more after injury (57 percent) (p &lt; 0.008). The overall infection rate was 36 percent with routine use of the vacuum-assisted closure sponge. Patients who developed infection had a greater mean time to coverage than patients who did not develop infection (8.9 days versus 4.8 days; p &lt; 0.029). Routine use of vacuum-assisted closure with open tibia fractures is safe and provides a good primary dressing over open wounds. For Gustilo grade IIIB tibia fractures, vacuum-assisted closure therapy does not allow delay of soft-tissue coverage past 7 days without a concomitant elevation in infection rates." }, { "id": "pubmed23n0848_13685", "title": "Acute Management of Open Fractures: An Evidence-Based Review.", "score": 0.0179549114331723, "content": "Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma." }, { "id": "wiki20220301en142_30273", "title": "Open fracture", "score": 0.016986496090973704, "content": "An open fracture, also called a compound fracture, is a type of bone fracture in orthopedics that is frequently caused by high energy trauma. It is a bone fracture associated with a break in the skin continuity which can cause complications such as infection, malunion, and nonunion. Gustilo open fracture classification is the most commonly used method to classify open fractures, to guide treatment and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. Cephalosporins are generally the first line of antibiotics. The antibiotics are continued for 24 hours to minimize the risk of infections. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections. Causes" }, { "id": "pubmed23n0856_8504", "title": "Operative Treatment and Soft Tissue Management of Open Distal Tibial Fractures - Pitfalls and Results.", "score": 0.01620224435758416, "content": "Open tibial fractures usually result from high-energy trauma. Severe soft-tissue injuries are often combined with open fractures of the distal tibia. A consecutive series of 42 patients with open extraarticular distal tibial fractures (Gustilo I-IIIc) operated on between July 2006 and February 2009 were included in the study reported here. We performed open reduction and internal fixation for the Gustilo I cases. Soft tissue was closed directly after antibiotic beads had been temporarily applied. For the Gustilo II and III cases, our treatment protocol included soft-tissue debridement of all devitalized soft tissue and bone fragments, pulsatile jet irrigation, and external stabilization. Soft tissue was temporarily closed with Epigard_ after the application of antibiotic beads. A second-look operation was scheduled after 3-5 days. Gustilo II patients needed an average of 1.1 (0-3) revisions until wound closure, compared to the average of 2.1 revisions necessary for the Gustilo III patients. It took 5.6 (0-16) days to obtain definitive wound closure in the Gustilo II patients and 9.9 (3-28) days in the Gustilo III patients. Skin grafting was sufficient for definitive softtissue closure in ten cases, local flaps in eight cases, and free musculocutaneous flaps were needed in six cases. Gustilo II patients with primary wound closure remained hospitalized for 11 days, while patients with secondary wound closure stayed in hospital for an average of 20 days. Our early results concerning infection rate, number of reoperations, and time to bony consolidation can be compared with other studies. Functional results will have to be evaluated at clinical follow-up. " }, { "id": "pubmed23n0867_7628", "title": "[Acute therapeutic measures for limb salvage Part 2 : Debridement, lavage techniques and anti-infectious strategies].", "score": 0.014931129476584024, "content": "The quality of the primary care of Gustilo-Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60 %. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36-48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3-9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain \"decontamination\" and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure. " }, { "id": "wiki20220301en142_30289", "title": "Open fracture", "score": 0.014724310776942355, "content": "Wound management Early wound closure is recommended to reduce the rates hospital-acquired infection. For Grade I and II fractures, wound can be healed by secondary intention or through primary closure. There is conflicting evident to suggest the effectiveness of Negative-pressure wound therapy (vacuum dressing), with several sources citing a decreased risk in infection, and others suggesting no proven benefit." }, { "id": "pubmed23n0981_19560", "title": "Does delay in surgical debridement increase the risk of infection in open tibia fractures in Saudi patients? A retrospective cohort study.", "score": 0.01467673683646687, "content": "Infection is the most common and devastating complication of open fractures, with a reported incidence of 3-40%. Tibia bone along its anteromedial surface has relatively thin soft tissue coverage; hence the open tibia fracture incidence rate ranges from 49.4% to 63.2%. Open fractures are usually classified based on the Gustilo &amp; Anderson classification system, which is used by surgeons as an index for the severity of an injury and as a prognostic tool. Our current practice follows the 6-h rule of irrigation and debridement (I&amp;D). Nevertheless, there is little support for this opinion in the literature. Our study concentrates on identifying the risk factors of infection in open tibia fractures and comparing the rate of infection if surgical irrigation and debridement was delayed. The medical records of 389 patients with open fractures were reviewed. Of these cases, 113 patients with open tibia fracture who presented to our Hospital from the period 1997 to 2008 fit the inclusion criteria and were included in a retrospective cohort study. A total of 113 tibia fractures were reviewed, with an average patient age of 31.70 years; 87.1% of the fractures were high-energy fractures, and the most common mechanism of injury was a motor vehicle accident (62.4%). The data analysis revealed no difference in overall infectious outcome when comparing initial I&amp;D performed within 6 h to when I&amp;D was performed after 6 h (<iP</i = 0.201). The data analysis showed a significant relationship between infection and wound closure in first surgery in both univariate and multivariate analysis (<iP</i = 0.0003 and <iP</i = 0.014), respectively. This study showed no significant evidence to support the 6-h rule, but it did demonstrate a significant relationship between the Gustilo stage and infection, as well as an increased infection rate if external fixation was used or if the wound was left open during the initial irrigation and debridement. We believe that more studies are required to identify the relationship between infection and the delay in irrigation and debridement; a meta-analysis of the currently available data may provide an answer to this question." }, { "id": "pubmed23n0867_13035", "title": "[Effect of Negative Pressure Wound Therapy on Infectious Complications in Grade III Open Fractures].", "score": 0.014644569522618304, "content": "PURPOSE OF THE STUDY Grade III open fractures are associated with infectious complications in 25-66% of injuries. Negative pressure wound therapy (NPWT) applied to an injured soft tissue coverage provides an impermeable barrier between the injured structures and the external environment, in addition to early secretion draining and a positive effect on the site of application. All this also prevents secondary bacterial contamination. The objective of the study was to compare the results of treatment methods in view of infectious complications in patients with soft tissue injury in grade-III open fractures managed either by NPWT and primary closure or by covering with combined dressing fabric (COM) in combination with continual wound lavage. MATERIAL AND METHODS This retrospective study comprised 77 patients with 80 grade III open fractures treated in the years 2008-2012; of these, 39 patients with 41 fractures met the inclusion criteria and were finally evaluated. The patients were divided into two groups. The control group included 19 patients with 20 fractures treated by the standard surgical procedure using stabilisation with an external fixator or intramedullary nail, thorough soft tissue debridement, continual wound lavage and suture of skin lesions or using a primary coverage of the defect with COM. The trial group consisted of 20 patients with 21 fractures treated according to the same principle, but NPWT was applied to injured soft tissue coverage first and skin suture or any other type of skin defect coverage was carried out when the healing process was good and bacteriological findings were negative. The results of both methods were evaluated based on the following criteria: development of superficial or deep infection in the wound, interval to negative bacteriological findings and osteomyelitis rate. The results were analysed by Fisher's exact test and the Man Whitney U test. RESULTS Infectious complications were recorded in a total of 15 (37%) fractures: 11 (55%) in the control group and four (19.1%) in the trial group (p = 0.025). Recurrent infection was observed in five control group fractures (25%) and in none of the trial group fractures (p = 0.021). Osteomyelitis was found only in two control group fractures. The average interval before negative bacteriological results were obtained was 22 days in the control group and 12 days in the trial group (p = 0.001). DISCUSSION The NPWT use as a temporary coverage of soft tissue defects in open fractures results in a significant reduction of infectious complications, as shown by many relevant studies including this study. In comparison with Gopal's \"fix and flap\" concept, the NPWT in our patient group had slightly higher incidence of infectious complications (15.4% versus 19.1%). However, these results can be achieved only if a specialist in reconstructive surgery and appropriate technical facilities are readily available. If this is not possible, then the NPWT, in comparison with conventional methods, provides the best possible way of temporary protection for an injured soft tissue coverage. CONCLUSIONS Application of NPWT within the primary treatment of injured soft tissue coverage in grade III open fractures results in a statistically significant reduction of bacterial contamination at the site of injury, as well as a reduction of the subsequent incidence of infectious complications. Primary application of NPWT also significantly reduced the risk of recurrent infection. open fracture, negative pressure wound therapy, continual wound lavage, infection." }, { "id": "pubmed23n0716_20288", "title": "[Open fractures of the tibia in the adult: surgical treatment and complications].", "score": 0.014509605662285137, "content": "Open tibial shaft fractures represent high-energy trauma and are associated with a substantial risk of complications. Management is an emergency, and the first steps in treatment include antibiotic prophylaxis, tetanus booster, surgical debridement, irrigation of the wound and stabilization of the fracture. The Gustilo and Anderson classification helps to guide definitive treatment. Intramedullary nailing is the surgical technique of choice. An indirect approach utilizing external fixation is recommended for Gustilo IIIB and IIIC fractures. The most prevalent complications are compartment syndrome (10%), infection (2%-40% without antibiotics according to Gustilo grading, most notably in the presence of vascular lesions), aseptic nonunion (23%), venous thromboembolism (60% without prevention) and anterior knee pain (&gt;50%)." }, { "id": "pubmed23n0960_14334", "title": "[Primary soft tissue management in open fracture].", "score": 0.014236410698878342, "content": "Debridement of soft tissue and bone in an open fracture situation to minimize infection risk and achieve primary skin closure, or to provide conditions for early soft tissue coverage. Indications are Gustilo-Anderson grade I-III A-C open fractures. Contraindications are injuries requiring amputation, burns, and life-threatening injuries which make appropriate treatment temporarily impossible. Removal of gross contamination and macroscopic contaminants; debridement of the wound; complete resection of contaminated and dirty tissue; sparse step-by-step resection of contaminated or non-vital wound and bone margins until vital, bleeding tissue begins; low-pressure irrigation with isotonic irrigation fluid; diagnostic biopsies for microbiological testing; reduction of dead space by interpositioning of muscle or cement spacers loaded with local antibiotics; primary wound closure if tension-free closure possible; otherwise, if resources and knowhow permit and satisfactory clean debridement was achieved, local flap; if flap impossible, debridement not satisfactory, secondary tissue necrosis likely, potential remaining contamination or contamination with fecal matter, then vacuum-assisted closure therapy. Wound inspection on the second postoperative day, generous indication for second-look surgery after 36-48 h, wound inspection on the second postoperative day, wound inspection every other day, primary antibiotic prophylaxis with a first- or second-generation cephalosporin (e. g., cefuroxime), and adaptation of antibiotic therapy according to susceptibility screening. Infection rates of 2-4.7% are reported for immediate primary wound closure in Gustilo-Anderson grade I, II, and III A open fractures. For Gustilo-Anderson grade III B, good wound healing, bony consolidation, and no need for secondary surgery was reported in 86.7% when primary wound closure was achieved." }, { "id": "pubmed23n0791_12913", "title": "Controversies in Initial Management of Open Fractures.", "score": 0.014219114219114218, "content": "Treatment of open fractures continues to be a challenge for orthopedic and trauma surgeons, and early treatment recommendations, which persist in the literature for decades, often do not have supporting data. This is a critical review of the literature surrounding controversies in the initial management of open fractures. It also focuses on the utility of negative pressure dressings in the care of associated complex wounds. Studies were selected based on their relevance to the treatment of open fractures. A total of 40 studies were included. The following topics were critically discussed: timing of initial debridement, antibiotic coverage, utility of obtaining cultures, and timing of wound closure. The majority of open fractures require urgent, not emergent, irrigation and debridement. Antibiotics are essential in preventing infection in open fractures. Timely wound closure after all necrotic tissue has been debrided decreases complications in open fractures. Finally, negative pressure wound therapy has dramatically changed the care of associated complex wounds." }, { "id": "pubmed23n0666_17234", "title": "Timing of wound closure in open fractures based on cultures obtained after debridement.", "score": 0.013369915512586011, "content": "The timing of wound closure in open fractures has remained an inexact science. Numerous recommendations have been made for the management of these injuries regarding the optimal time to perform competent wound closure, with all advice based on subjective parameters. The purpose of this study was to determine the utility of a prospective protocol with use of wound cultures obtained after irrigation and debridement as a guide to the timing of wound closure following an open fracture of an extremity. Four hundred and twenty-two open fractures had emergency irrigation and debridement, fracture stabilization, and open wound management. Wound cultures were obtained for aerobic and anaerobic analysis following debridement. At forty-eight hours after debridement, patients were again returned to surgery. If the initial culture results were positive, a repeat irrigation and debridement was carried out, and additional cultures were obtained after debridement. This procedure was repeated, and the wound was not closed until negative culture results were achieved. Of the 422 open fractures, 346 were available for long-term follow-up. The overall deep infection rate was 4.3%. Gustilo Type-II fractures had a deep infection rate of 4%, and Type-III fractures had an infection rate of 5.7%. Type-III fractures demonstrated differences among the fracture patterns within this type, as infection developed in 1.8% of Type-IIIA injuries, 10.6% of Type-IIIB fractures, and 20% of Type-IIIC fractures. Fractures requiring multiple debridement procedures and those in patients with diabetes or an increased body mass index demonstrated higher rates of infection. With the numbers studied, fractures in which the wound was closed in the presence of positive cultures (a protocol breach) did not have a significantly increased risk of deep infection (p = 0.0501). The use of this standardized protocol was shown to achieve a very low rate of deep infection compared with historical controls. An increased number of irrigation and debridement procedures are required to achieve this improved outcome. Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence." }, { "id": "wiki20220301en305_15765", "title": "Gustilo open fracture classification", "score": 0.01249657106281813, "content": "Although this classification system has a fairly good ability to predict fracture outcomes, it is not perfect. The Gustillo classification does not take into account the viability and death of soft tissues over time which can affect the outcome of the injury. Besides, the number of the underlying medical illnesses of the patient also affects the outcome. Whether the timing of wound debridement, soft tissue coverage, and bone have any benefits on the outcome is also questionable. Besides, different types of bones have different rates of infection because they are covered by different amounts of soft tissues. Gustilo initially does not recommend early wound closure and early fixation for Grade III fractures. However, newer studies have shown that early wound closure and early fixation reduces infection rates, promotes fracture healing and early restoration of function. Therefore, assessment of all open fractures should include the mechanism of injury, the appearance of soft tissues, the" }, { "id": "wiki20220301en142_30283", "title": "Open fracture", "score": 0.012396845772969008, "content": "There has been no agreement on the optimal duration of antibiotics. Studies has shown that there is no additional benefits of risk of infection when giving antibiotics for one day, when compared to giving antibiotics for three days or five days. However, at present, there is only low to moderate evidence for this and more research is needed. Some authors recommended that antibiotics to be given for three doses for Gustilo Grade I fractures, for one day after wound closure in Grade II fractures, three days in Grade IIIA fractures, and three days after wound closure for Grade IIIB and IIIC." }, { "id": "wiki20220301en453_3946", "title": "Early appropriate care", "score": 0.011832186168469355, "content": "History Early total care (ETC) became widespread in the 1980s, when studies showed early definitive fixation of long bone fractures lead to better outcomes, with a reduction in incidence of secondary ARDS, fat embolism and sepsis. Subsequent studies showed that in the unstable patient, long operations lead to a 'second hit' which actually worsened mortality outcomes. A philosophy of damage control orthopaedics (DCO) was proposed in 2000, aiming to prevent early death in a critically wounded patient via stabilization and not definitive fixation, often with the use of external fixation systems. The term early appropriate care was first proposed in 2013 as an evolution of DCO, with a focus on resuscitation rather than injury severity score. See also Damage control surgery References Traumatology Trauma surgery" }, { "id": "pubmed23n0550_23953", "title": "Comparison of delayed and primary wound closure in the treatment of open tibial fractures.", "score": 0.01132747868143057, "content": "Primary wound closure in the management of open tibial fractures has generally been discouraged. Several prior studies suggest that infections are not caused by the initial contamination, but are instead the result of organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation could therefore be considered a reasonable option. We analysed 95 patients with open tibial fractures (Gustilo-Anderson type 1 to 3A) treated with primary fracture stabilisation and either delayed wound closure (group I) or primary wound closure (group II), with a minimum follow-up of 12 months. Group I included 46 patients with a mean age of 30.2 years (16-56), and a mean follow-up of 13.5 months (12-18). Group II included 49 patients with a mean age of 33.4 (18-69), and a mean follow up of 13.7 months (12-16). One infection developed in group I (2%), and two infections developed in group II (4%). This difference was not found to have any statistical significance. Our results support other recent reports that the infection rate is not increased following primary wound closure after thorough debridement of less severe open fractures. The length of stay following primary closure (group II) was significantly shorter, and that should result in substantially more cost effective care of these serious injuries. We conclude that primary wound closure is a safe option in properly selected cases. Prospective multi-centre studies are needed to further evaluate the safety and efficacy of this treatment alternative." }, { "id": "wiki20220301en142_30284", "title": "Open fracture", "score": 0.01096588719954951, "content": "Wound irrigation There has been no agreement for the optimal solution for wound irrigation. Studies found out that there is no difference in infection rates by using normal saline or other various forms of water (distilled, boiled, or tap). There is also no difference in infection rates when using normal saline with castile soap compared with normal saline together with bacitracin in irrigating wounds. Studies also have shown that there is no difference in infection rates using low pressure pulse lavage (LPPL) when compared to high pressure pulse lavage (HPPL) in irrigating wounds. Optimal amount of fluid for irrigation also has not been established. It is recommended that the amount of irrigation solution to be determined by the severity of the fracture, with 3 litres for type I fractures, 6 litres for type II fractures, and 9 litres for type III fractures." }, { "id": "pubmed23n1050_13936", "title": "An Updated Evidence About the Role of Timing to Debridement on Infection Rate of Open Tibial Fractures: A Meta-Analysis.", "score": 0.009900990099009901, "content": "Background and objectives Recent experimental and clinical evidence supporting early debridement for open fractures has been questioned. Therefore, this systematic review and meta-analysis aimed to summarize and evaluate the current evidence regarding the timing of surgical debridement of open tibial fractures. Methods A systematic review and meta-analysis were conducted on studies compared the infection rate following early versus late debridement of open tibial fractures. We performed an online, bibliographic, search through the period from January 2000 to June 2020 in five bibliographic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Medline via PubMed, Web of Science, Scopus, and EBSCO host. Results Nine retrospective studies and six prospective studies were included in the present meta-analysis study. The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the overall infection rate (RD 0.02, 95% CI [0 - 0.04], p = 0.94); there was no significant heterogeneity in the pooled estimate (I2 = 5%). The subgroup analysis showed that the non-significant difference was consistent regardless of the definition of early and late timing to debridement. Likewise, the pooled effect estimate showed no statistically significant difference between early and late debridement regarding the deep infection rate (RD 0.01, 95% CI [-0.01 - 0.03], p = 0.92); there was no significant heterogeneity in the pooled estimate (I2 = 0%). The pooled effect estimate showed no statistically significant difference between early and late debridement regarding the nonunion rate as well. The funnel lots showed little evidence of asymmetry by visual inspection. Conclusion In conclusion, the current evidence demonstrates no impact of timing to surgical debridement on the infection rate following open tibial fractures in the adult population. Our results demonstrated that the risks of infection, deep infection, and nonunion were similar between patients who underwent delayed versus early debridement." }, { "id": "pubmed23n1091_14605", "title": "The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis.", "score": 0.00980392156862745, "content": "Open tibial fractures are complex injuries with variable outcomes that significantly impact patients' lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; <ip</i = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; <ip</i = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo-Anderson classification or varying study characteristics. The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to 'as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h'." }, { "id": "pubmed23n0695_10113", "title": "Timing of antibiotic prophylaxis in tourniquet surgery.", "score": 0.009708737864077669, "content": "It is customary to administer prophylactic antibiotics before exsanguination of the limb and inflation of a tourniquet in extremity surgery. To compare the clinical outcome in lower limb operations when prophylactic antibiotics were administered before versus after limb exsanguination and tourniquet inflation, we randomized patients to the administration of prophylactic antibiotics 5 minutes before exsanguination and inflation of the tourniquet (ABT) and administration of prophylactic antibiotics 1 minute after inflation of the tourniquet (AAT). A total of 106 patients completed the study, including 76 males (71.7%) and 30 females (28.3%). Of the 106 patients, 54 (50.9%) received antibiotics before tourniquet inflation (ABT) and 52 (49.1%) after tourniquet inflation (AAT). Most of the operations (71.7%) involved open reduction and internal fixation of fractures. In the ABT group, 8 wounds (14.8%) developed postoperative infection. In the AAT group, 2 (3.9%) developed wound infection (P = .031). The mean period to wound healing in the ABT group was 4.0 ± 2.3 weeks and was 3.0 ± 0.5 weeks in the AAT group (P = .002). Overall, 100% of the patients in the AAT group were satisfied compared with 85.2% in the ABT group. The difference was statistically significant (P = .005). The results of our study suggest that administration of prophylactic antibiotics before exsanguination and inflation of a lower extremity tourniquet does not give better results than administration of the antibiotic shortly after inflation of the tourniquet." }, { "id": "Surgery_Schwartz_12448", "title": "Surgery_Schwartz", "score": 0.009695419669844222, "content": "are low energy and wounds are usually less than 1 cm.• Type II injuries have a wound length of 2 to 10 cm with mod-erate soft tissue damage and wound contamination.1ABCDEFFigure 43-1. Types of fractures. A. Normal bone. B. Transverse. C. Oblique. D. Spiral. E. Segmental. F. Comminuted.Figure 43-2. Transverse tibia fracture and segmental fibula fracture.Brunicardi_Ch43_p1879-p1924.indd 188122/02/19 10:40 AM 1882SPECIFIC CONSIDERATIONSPART II• Type III injuries are high-energy wounds usually greater than 10 cm in length with extensive muscle devitalization. The wound is highly contaminated with extensive soft tissue damage.These injuries require immediate administration of antibi-otics and irrigation and debridement of the wound. The goal of the treatment is to achieve fracture healing and to prevent wound infections and osteomyelitis. They are frequently associated with injuries to surrounding vessels and nerves, which must be addressed as well. When the wound is contami-nated, an" }, { "id": "pubmed23n0902_12477", "title": "The management of open tibial fractures in children: a retrospective case series of eight years' experience of 61 cases at a paediatric specialist centre.", "score": 0.009615384615384616, "content": "Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks <iversus</i 10.8 weeks, p <i=</i 0.016). Children aged &gt; 12 years had a significantly longer time to union than those aged &lt; 12 years (16.3 weeks <iversus</i 11.4 weeks, p <i=</i 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: <iBone Joint J</i 2017;99-B:544-53." }, { "id": "pubmed23n0204_1534", "title": "[External fixator in the prevention and treatment of infections (author's transl)].", "score": 0.009615384615384616, "content": "Although postoperative infection constitutes a serious complication after osteosyntheses of closed fractures and in the course of open fractures, application of the known principles permits the adaption of an optimistic attitude towards treatment. Stability of osteosynthesis preferably with external fixation, open-wound treatment with regular control of the wound, in special cases suction-irrigation drainage, local application of PMMA beat chains and short-term, high-dosed systemic antibiotic therapy after antibiogram are amongst the most important points to be taken into consideration." }, { "id": "pubmed23n0826_18041", "title": "Treatment of infection with improved pulsed lavage.", "score": 0.009523809523809525, "content": "To develop a more effective surgical lavage technique to improve the efficacy of treatment for infections after a tibia/fibula fracture. A retrospective analysis was performed on 46 patients who received pulsed lavage with a side-hole double-valve lavage tube in the Second Hospital of Tangshan, Tangshan, China. Patients with the same injury treated with conventional lavage techniques in the same period were used as controls. The lavage success rate and the infection cure rate were analyzed to evaluate this therapy. All patients showed wound healing by first intention, and there was no recurrence during the follow-up period of &gt; 12 months. Compared to the control group, the group that received pulsed lavage showed higher lavage success rates and cure rates. Pulsed lavage therapy with a side-hole double-valve lavage tube can improve the efficacy of treatment infections after tibia/fibula fractures and constitutes an effective modification to conventional lavage techniques. ." }, { "id": "pubmed23n0887_17404", "title": "Impact of negative pressure wound therapy on open diaphyseal tibial fractures: A prospective randomized trial.", "score": 0.009433962264150943, "content": "Open tibial fractures are associated with a high incidence of mainly osteomyelitis. Negative pressure wound therapy (NPWT) is a novel form of treatment that uses subatmospheric pressure to effect early wound healing. To determine the effect of NPWT on incidence of deep infections/osteomyelitis after open tibial fractures using a prospective randomized study design. Ninety-three open tibial fractures were randomized into two groups receiving NPWT and the second group undergoing periodic irrigation, cleaning and debridement respectively. The wounds were closed or covered on shrinkage in size and sufficient granulation. Evidence of infection was sought during the course of treatment and follow up. Also serial cultures were sent every time the wound was cleaned. Patients in the control group developed a total of 11 infections (22%) as opposed to only 2 (4.6%) in the NPWT group (<ip</i &lt; 0.05). The relative risk was 5.5 (95% confidence interval) suggesting patients who received NPWT were 5.5 times less likely to develop infection. Twenty patients developed positive growth when samples were sent for culture with 3 (6.9%) in the NPWT group and 17 (34%) in the control group (<ip</i &lt; 0.05). Only 5 patients (25%) went on the develop osteomyelitis, all being a part of the control group. Thus negative pressure wound therapy is indeed beneficial for preventing the incidence of both acute infections and osteomyelitis in open fractures. However a significant difference was not seen in the time required for the wound to be ready for delayed primary closure or coverage." }, { "id": "pubmed23n1036_1130", "title": "Management of Gustilo-Anderson Type II and IIIA Open Long Bone Fractures in Children: Which Wounds Require a Second Washout?", "score": 0.009345794392523364, "content": "Timing of wound closure in pediatric Gustilo-Anderson grade II and IIIA open long bone fracture remain controversial. Our aims are (1) to determine the proportion of patients with these fractures whose wounds can be treated with early primary wound closure (EPWC); (2) to compare the complication rates between EPWC and delayed wound closure (DWC); and (3) to determine factors associated with higher likelihood of undergoing DWC. At a level-1 pediatric trauma center, 96 patients (younger than 18 y) who sustained Gustilo-Anderson grade II and IIIA open long bone fractures (humerus, radius, ulnar, femur, or tibia) within a 10-year period (2006-2016) were included for this study. Decision for EPWC versus DWC was at the discretion of the attending surgeon at time of initial surgery. Data collection was via retrospective review of charts and radiographs. Particular attention was paid to the incidence of return to operating room rate, nonunion, compartment syndrome, and infection. Median follow-up duration was 7.5 months (interquartile range: 3.6 to 25.3 mo). All patients were followed-up at least until bony union. Overall, 81% of patients (78/96) underwent EPWC. Of the grade II fractures, 86% underwent EPWC. Four patients (5%) in the EPWC group and 1 patient (6%) in the DWC group had at least 1 complication. When controlling for mechanism of injury, Gustilo-Anderson fracture type and age, there was no difference in rate of complications between the EPWC and the DWC groups. Grade IIIA fractures and being involved in a motor vehicle accident were factors associated with a higher likelihood of undergoing DWC. The majority of grade II and IIIA pediatric long bone fractures may be safely treatable with EPWC without additional washouts. Future prospective research is required to further define the subgroups that can benefit from DWC. Level IV-therapeutic, case cohort study." }, { "id": "pubmed23n0716_8972", "title": "[Prevention of infection in the current treatment of open fractures: an evidence-based systematic analysis].", "score": 0.009345794392523364, "content": "Treatment of open fractures remains an interdisciplinary challenge. Even success and evidence of infection prevention especially of new treatment options is not clear. A systematic search in available electronic databases over the years 1974 until 2011 was conducted. Only clinical analyses with more than 5 adult patients in the German, English or French languages were included. All studies were rated according to Centre for Evidence-Based Medicine (CEBM) criteria. Over 855 articles were found due to the search and after applying the exclusion and inclusion criteria 49 studies were finally assessed to contribute to the evidence-based recommendations. Grade A recommendation: early application of antibiotics against gram-positive organisms for all open fracture types, additional coverage of gram-negative organisms for type III open fractures. Early surgical debridement should be performed. Grade B recommendation: type III open fractures should be treated with antibiotics for a minimum of 72 h but not longer than 24 h after wound closure. Vacuum treatment is justified and beneficial if wound closure is not achieved. Grade C recommendation: additional local antibiotic treatment in combination with systematic antibiotics may be of benefit. Definitive wound closure should be achieved within 1 week. This evidence-based analysis shows that there is good evidence for the treatment of open fractures with antibiotics and surgical debridement. Vacuum treatment can be recommended if wound closure is not possible." }, { "id": "pubmed23n0394_512", "title": "The reliability of the pre-operative classification of open tibial fractures in children a proposal for a new classification.", "score": 0.009259259259259259, "content": "The purpose of this observational study was to evaluate the accuracy of Gustilo's classification of open tibial fractures in children. Pre- and post-debridement (using the parameters of Gustilo's classification) wound gradings in 27 children with a mean age of 10 years (3 to 15 years) who had sustained an open tibial fracture were compared. Pre-operative Polaroid photographs of the wound were taken of all these patients in the accident and emergency department. In every case, the fracture was treated with prophylactic intravenous antibiotic administration, wound debridement and lavage. Following wound exploration in the operating theater, the wound was classified using Gustilo's parameters again; this was different from the initial grading. We compared post-debridement classification according to Gustilo to the new classification which we propose. The latter classification is a peroperative assessment of the extent of soft tissue damage and it addresses bone stability. According to this classification, the majority of open tibial fractures were stable, requiring no skin graft or flap and had a good outcome. Only five patients were treated by initial external fixation of the tibia; the remainder were treated by cast immobilization. Wounds were treated as appropriate. The clinical outcome study included the assessment of wound and fracture healing and the incidence of complications. The mean period for follow-up was 8 months (6 to 24 months). There were no cases of nonunion or deep wound infection and the wounds healed in all these patients. We conclude that Gustilo's classification is not specific and does not reflect the extent of soft tissue and skeletal damage. Factors such as the degree of soft tissue damage and periosteal stripping that are noticed following wound debridement and velocity of injury are far more important than the wound size. Our proposed peroperative classification covers the extent of soft tissue injury and skeletal stability, thus predicting the outcome more than the Gustilo classification." }, { "id": "pubmed23n0988_23170", "title": "Negative pressure wound therapy vs. conventional management in open tibia fractures: Systematic review and meta-analysis.", "score": 0.009174311926605505, "content": "Severe open tibia fractures are disastrous injuries associated with a high incidence of complications. Negative pressure wound therapy (NPWT) is a novel treatment for open tibia fractures; however, its efficacy remains unclear. This is a systematic review and meta-analysis performed to evaluate the effect of NPWT on decreasing the infection rate, amputation rate, nonunion rate, and flap-related complications in open tibia fractures. The MEDLINE, EMBASE, and Cochrane Library databases were systematically searched. Complications were evaluated in terms of the rates of infection, amputation, nonunion, and flap-related complications. Twelve studies were included. In the meta-analysis, NPWT showed significantly lower soft-tissue infection rate (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.34-0.68, P &lt; 0.0001), nonunion rate (OR 0.61, 95% CI 0.39-0.95, P = 0.03), flap necrosis rate (OR 0.37, 95% CI 0.21-0.63, P = 0.0003), and flap revision rate (OR 0.44, 95% CI 0.22-0.89, P = 0.02) than conventional wound management. However, no significant difference was found in osteomyelitis rate (OR 0.54, 95% CI 0.09-3.28, P = 0.50) and amputation rate (OR 0.89, 95% CI 0.36-2.22, P = 0.80) between the 2 groups. Lower rates of soft-tissue infection, nonunion, flap necrosis, and flap revision were observed in the NPWT group than in the conventional dressing group. However, additional high-quality studies are warranted to verify the efficacy of NPWT in the treatment of severe open tibia fractures. We could not make a definitive conclusion about the comparative efficacy of the 2 methods in terms of complications because of insufficient data." }, { "id": "pubmed23n1120_2405", "title": "The injury characteristics of open pilon fractures predictive of complications.", "score": 0.00909090909090909, "content": "Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C). Retrospective Case Series. Level I Trauma Center. A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria. The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required. Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications. Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from &gt; 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication. Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment. Level III." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 238, 376 ] ], "word_ranges": [ [ 38, 67 ] ], "text": "1 would be if he was making a profit, if he was knowingly simulating and to make a profit he was faking his illness. This is not the case." }, "2": { "exist": true, "char_ranges": [ [ 144, 237 ] ], "word_ranges": [ [ 22, 38 ] ], "text": "can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness." }, "3": { "exist": true, "char_ranges": [ [ 144, 237 ] ], "word_ranges": [ [ 22, 38 ] ], "text": "can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness." }, "4": { "exist": true, "char_ranges": [ [ 144, 237 ] ], "word_ranges": [ [ 22, 38 ] ], "text": "can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness." }, "5": { "exist": true, "char_ranges": [ [ 377, 506 ] ], "word_ranges": [ [ 67, 91 ] ], "text": "Conversive would be if the symptom wanted to transmit something to us, that is to say, it was a metaphor of its internal world..." } }

{ "1": "Factitious disorder.", "2": "Delusional disorder.", "3": "Hypochondriasis.", "4": "Major depressive disorder.", "5": "Conversive disorder." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n1038_19259", "title": "Filicide In Depressive Psychosis: Case Report Of An Emotionally Unstable Woman Slaughtering Her Two Children.", "score": 0.0112096887762287, "content": "Filicide is the murder of a child by the parent. It is associated with various psychiatric and nonpsychiatric conditions. We herein present a case report of a filicide by an emotionally unstable mother suffering from depressive psychosis. A thirty years old woman previously treated for depression with psychotic features, having undergone electro-convulsive therapy and on oral medication three years ago was brought by the police for psychiatric assessment. She had slaughtered her two sons of 4 and 7 years of age three days ago without any guilt or remorse. She had low mood, irritability, crying spells, hopelessness and loss of sleep, appetite and sexual desires for the past six months along with the delusions of poverty and infidelity for the past two months. She was a chain smoker. Multiple deliberate self-harm and suicidal attempts were reported in the past two months. She had disturbed family life and multiple conflicts with the husband. Psychometrics revealed BDI score of 32, BPRS score of 39 and PCL-R score of 28. She was diagnosed as a case of depressive psychosis with emotionally unstable personality traits leading to impaired judgment and poor comprehension of the consequences of her actions. This case report highlights the importance of accurately and timely diagnosing and managing a mental health disorder in order to avoid the harm towards self and others." }, { "id": "wiki20220301en484_32988", "title": "Death of Natasha McKenna", "score": 0.011067101584342964, "content": "Natasha McKenna (January9,1978February8,2015) was a 37-year-old African-American woman who died in Fairfax County, Virginia while in police custody. The catalyst event, extraction from her cell and being tasered while shackled, was captured on the video of the Fairfax County jail. During a team's efforts to extract the mentally ill prisoner, who resisted, they tasered her four times while she was restrained. No charges were filed against the deputies who tasered McKenna, but the case became the subject of a federal civil rights investigation because of several related issues. Early life At the age of 12, McKenna was diagnosed with schizophrenia, bi-polar disorder and depression. (Other sources say the diagnosis was made when she was 14 years old.) According to a family photograph, she was an honors graduate student from high school in Fairfax County. She had a 7-year-old daughter." }, { "id": "pubmed23n0544_16139", "title": "Erotomania revisited: thirty-four years later.", "score": 0.010505050505050505, "content": "Erotomania (also known as De Clerambault's syndrome) is usually described as a rare delusional syndrome that characteristically involves a woman who believes that a man, typically of higher social, economic or political status, is in love with her. Two cases are reviewed here that have been followed for over 30 years, making these some of the longest, single-case longitudinal studies yet reported. De Clerambault's syndrome remains a ubiquitous nosological psychiatric entity with uncertain prognosis. In 1980, we reported in this journal one woman diagnosed as having erotomania. At that time, she had been followed for approximately eight years. She has now been studied for over 30 years. In De Clerambault's original work, as reported by Enoch and Trethowan, a woman whose chronic, erotic delusion remained unchanged was followed for 37 years. Despite some psychological advances, our original patient, like De Clerambault's, has remained essentially entrapped by her psychotic thought disorder and erotomania. A thorough review of the literature to date was contained in our 1980 article and so, to avoid repetition, we refer the interested reader to that reference. At this time, the original patient's history will be presented along with the course of her disorder and treatment implications. Secondly, another patient will be presented and her case reviewed. Finally, we will argue that this disorder is not as rare as has been claimed and call for the continued recognition of this syndrome as its own entity despite recent opinions that such use be discontinued." }, { "id": "pubmed23n0477_1710", "title": "[A case report of factitious disorder with hallucinations].", "score": 0.009900990099009901, "content": "Although factitious disorder has been known for a long time, its diagnosis and treatment continue to be a problem. It is an uncommon condition associated with considerable morbidity and health care expenditure. We present a case of factitious disorder with hallucinations. A 37 year-old single woman has had auditory and olfactory hallucinations for six years. She had been diagnosed with schizophrenia, hospitalized for a short term, taking classical antipsychotic drugs for years. She has been performing her job as a teacher and living with her family. A suitable dose of atypical antipsychotic drugs was administered at a convenient time for her illness (Psychotic Disorder NOS) in psychiatric outpatient clinic of Kocaeli University. She was admitted to inpatient clinic twice in order to allow a clear diagnosis to be made. Psychotic disorder and temporal lobe epilepsy were ruled out. Borderline and histrionic personality traits were determined. Her complaints were unchanged over the course of treatment taking three years. She later started to come into the emergency department with anxiety symptoms, conversion like fits and suicide attempts; hospitalized for these complaints in another hospital. She was diagnosed with factitious disorder because of her unchanged complaints, her adding new complaints to the old ones, her complaints unrelated to psychosocial stressors, her ambitions to come to hospital, her increasing hospital dependence and having no prominent secondary gain. This case emphasizes the need for the careful observation of patients to prevent unnecessary investigations at the diagnosis and treatment stage and to establish a specific management strategy for the patients." }, { "id": "pubmed23n0373_3762", "title": "What's so unusual?", "score": 0.009900990099009901, "content": "You're probably asking yourself, \"What's so different about this case?\" The patient was on the side of the road, explained what she was doing there, denied any injuries and refused treatment and transport. Sounds like a routine call--what's the big deal? But this case did not end after the patient signed a treatment refusal form and was asked by law enforcement to get back in her car and drive on. The EMS providers returned to their station, only to get called back 30 minutes later to the same spot they had just responded to, again for a \"woman down.\" Upon this arrival, they found the same car on the side of the road, and a parked semi tractor trailer in a traffic [figure: see text] lane approximately 25 yards ahead of the vehicle. There was no damage to either vehicle, and providers noticed a familiar dog inside the woman's car. A police officer informed the providers that the woman, the driver of the vehicle, had jumped in front of the semi, as described by the truck's driver, and was hit at a very high rate of speed. The victim was deceased on the scene. Upon assessing the scene, providers confirmed that the victim was the same woman they'd responded to earlier. Several days after the incident, more information about the patient's medical history was released. She had been released on the morning of the accident from a mental health institution, where she'd been diagnosed as a manic depressive. Manic depression is a condition characterized by mood swings. For example, a patient might rapidly go from a state of euphoria to experiencing debilitating depression. Although this patient appeared fine on the exterior, she had been diagnosed with a severe psychological disorder. She presented as being alert, oriented and non-threatening moments before taking actions that led to her death. This case posed a significant challenge for the EMS providers because there was no clinical evidence that there was anything wrong with the patient. Moreover, the patient denied any past medical history. It was a lesson to all involved with this case: There is no such thing as a routine call." }, { "id": "pubmed23n0648_15276", "title": "Who rules the roost?", "score": 0.00980392156862745, "content": "Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother \"blames her\" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is \"too loud\" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to \"stop\" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states \"nothing works.\" When you ask about supports, she states \"I have nobody except Adam and the new baby now.\"Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?" }, { "id": "wiki20220301en631_11769", "title": "Murder of T. Maniam", "score": 0.00980392156862745, "content": "Execution of convicts On 16 February 2001, the three convicts - Venkatesan, Chandran and Julaiha - were hanged in Changi Prison at dawn. By then, Julaiha had one final wish before she was hanged, which was to see her daughters for the final time. However, she never got to fulfill her last wish as her daughters declined to visit her one last time. When asked in a documentary about why she did not go see her mother, Fairos did not give an explicit answer, but told the interviewer that her mother gave her and Sairah a father who loved them, and ultimately, she took her away from them. She stated that while she did not hate her mother, she despised what she has done." }, { "id": "pubmed23n0973_23808", "title": "Paraneoplastic Encephalopathy in a Patient With Metastatic Lung Cancer: A Case Study.", "score": 0.009708737864077669, "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": "pubmed23n0083_1204", "title": "[A rare and little-known method of elaborating the loss of the object in melancholia].", "score": 0.009708737864077669, "content": "The author presents a fully detailed report of the observation of two economically secure young women who were caught shop-lifting in a large department store; one woman was apprehended while suffering from depression, the other was caught just prior to the onset of a depressive episode. It is hoped that the details referred here may contribute to the insufficient data published on this subject up to the present. It is important to note that the thefts committed by these patients show the typical characteristics of \"impulsive behavior\". Furthermore, the impulse to steal may appear in various psychiatric conditions. Therefore, the author first considered the hypothesis that these thefts may have been computed during an acute dysthymic psychosis. Epilepsy was ruled out in both cases based on anamnestic data, electroencephalographic findings and, even after the administration of a pharmacological trigger, no epileptic symptoms appeared. These negative results prompted the author to propose a psychosemeiogenetic rapport between the depressive conditions and the thefts. Considering basic information regarding the psychodynamic of impulsive behavior in general, and that manifested in the course of melancholia in particular, the author confronts the problem of the psychosemeiogenesis of the impulsive to steal in the depressed patient. In order to understand this problem, the author proposes several interpretative hypotheses (equivalence of suicide or \"parasuicide\" according to Deshaies; attempt to give a concrete reason for the \"feeling of guilt\"; conduct to symbolically compensate the loss of the \"object\"). Following an in-depth, critical discussion, the author concludes that the \"parasuicide\" hypothesis is most accurate in the case of the first patient, whereas \"compensation\" more adequately explains the second. In conclusion, the interest that these cases present in the forensic medical sphere is also brought to light." }, { "id": "pubmed23n0895_1203", "title": "A 9-Year-Old Girl With Persistent Obsessive and Compulsive Behaviors in a Primary Care Pediatric Practice.", "score": 0.009615384615384616, "content": "Chloe is a 9-year-old gal whose mother made an initial visit to a new pediatrician for concerns about her behavior. Chloe is apprehensive about the visit and frequently hides behind her mother.Her parents first noticed Chloe becoming angry and more emotional 3 years ago, which her parents did not initially understand. However, over the past year, she has started to have more worries and unusual behavior.Chloe and her mother report that when she walks through doorways, she will almost always go back and walks through again. At home, she will walk through doorways multiple times and at school, she will pretend she forgot something so her friends do not notice. She often will not walk downstairs and occasionally her mother has to carry her. Clothes are problematic for Chloe. If her father touches something of a specific color and then touches Chloe, she will have to change her clothes or take a shower. Sometimes, she will never be able to wear those clothes again. She had a recent episode where she could not stop tapping a red paper, because if she stopped, she said it would burst into flame. During the 2 weeks before the pediatric visit, symptoms increased to the point that she is now refusing to go to school. When she stays home, she lays in 1 place all day.Chloe is a fourth grade student. The family does not report academic concerns. She has friends. She denies any appetite or sleep problems. She endorses periods of sadness, lack of energy, and decreased interest in social activities, mostly because she worries and is embarrassed. She kept her behaviors hidden from her 5 siblings for the past year, and she talked only to her mother about them. She is worried her friends might discover her behaviors.The family history is notable for multiple paternal family members with anxiety and bipolar disorder and depression on mother's side. A few months ago, Chloe's family adopted a 7-year-old child with special needs from China.Her growth, vital signs, and physical examination are unremarkable. Her mother filled out the Short Mood and Feelings Questionnaire and the Screen for Child Anxiety-Related Emotional Disorders, which both had elevated scores." }, { "id": "pubmed23n0354_17327", "title": "Delusional disorder: retrospective analysis of 86 Chinese outpatients.", "score": 0.009615384615384616, "content": "Patients who visited the psychiatric outpatient service of Chang Gung Medical Centre, Tao-Yuan, Taiwan during an 8-year period were studied retrospectively. Among the 10,418 outpatients, 86 (0.83%) were diagnosed as having DSM-IV delusional disorder (DD), including 61 (70.9%) with persecutory type, 12 (14.0%) with the mixed type, seven (8.1%) with jealous type, two (2.3%) with somatic type, two (2.1%) with unspecified type, one (1.2%) with erotomanic type, and another one with grandiose type. The ratio of women to men was 0.86. The mean age at onset was 42.4 +/- 15.41 years, with women being older than men. Thirty-seven cases (43.0%) presented with depressive symptoms at their first visit. Subjects were divided into four groups: persecutory type, jealous type, mixed type and others. There were no significant differences between the four groups in terms of gender, age at onset, time-lapse before seeking psychiatric help, the presence of hallucination or the presence of depression." }, { "id": "pubmed23n0824_6126", "title": "A 9-year-old girl with persistent obsessive and compulsive behaviors in a primary care pediatric practice.", "score": 0.009523809523809525, "content": "Chloe is a 9-year-old gal whose mother made an initial visit to a new pediatrician for concerns about her behavior. Chloe is apprehensive about the visit and frequently hides behind her mother.Her parents first noticed Chloe becoming angry and more emotional 3 years ago, which her parents did not initially understand. However, over the past year, she has started to have more worries and unusual behavior.Chloe and her mother report that when she walks through doorways, she will almost always go back and walks through again. At home, she will walk through doorways multiple times and at school, she will pretend she forgot something so her friends do not notice. She often will not walk downstairs and occasionally her mother has to carry her. Clothes are problematic for Chloe. If her father touches something of a specific color and then touches Chloe, she will have to change her clothes or take a shower. Sometimes, she will never be able to wear those clothes again. She had a recent episode where she could not stop tapping a red paper, because if she stopped, she said it would burst into flame. During the 2 weeks before the pediatric visit, symptoms increased to the point that she is now refusing to go to school. When she stays home, she lays in 1 place all day.Chloe is a fourth grade student. The family does not report academic concerns. She has friends. She denies any appetite or sleep problems. She endorses periods of sadness, lack of energy, and decreased interest in social activities, mostly because she worries and is embarrassed. She kept her behaviors hidden from her 5 siblings for the past year, and she talked only to her mother about them. She is worried her friends might discover her behaviors.The family history is notable for multiple paternal family members with anxiety and bipolar disorder and depression on mother's side. A few months ago, Chloe's family adopted a 7-year-old child with special needs from China.Her growth, vital signs, and physical examination are unremarkable. Her mother filled out the Short Mood and Feelings Questionnaire and the Screen for Child Anxiety-Related Emotional Disorders, which both had elevated scores." }, { "id": "wiki20220301en548_5875", "title": "Arwa Saleh", "score": 0.009523809523809525, "content": "Later life and published writing Salih's depression at the failure of the revolutionary Left's promise and the reality of Egypt in the 1980s led her to break away from the party. She later left for Spain. She wrote in this period, reflecting on her bitterness with the organizations she was once involved with, the sexual exploitation that women suffered within communist organizations and the behaviour of male intellectuals within the party and movement. In work later published posthumously, she wrote that she had received psychiatric treatment while she was away. Her first manuscript (which was lost and never published) and a posthumously published autobiographical text 'Strolling: Daydream of a Lonely Rover' was dedicated to patients in psychiatric clinics. She later also published an Arabic translation of Tony Cliff's 1984 book Class Struggle and Women's Liberation." }, { "id": "pubmed23n0479_16637", "title": "Cases from the Osler Medical Service at Johns Hopkins University.", "score": 0.009433962264150943, "content": "A 50-year-old African American woman presented with bilateral lower extremity pain, a history of falls during the past several months, and personality and behavior changes. She had been in good health until approximately 5 months before admission, when she began to fall with increasing frequency, often while going down a flight of stairs. She described these falls as her \"legs giving out\" and feeling very heavy and unsteady. There was no head trauma or loss of consciousness. Her daughter noticed that her gait had become somewhat unsteady during the last several months. Her family also noted a change in her personality at this time. Previously, she had been a very tidy person who took great care with her appearance, who was working as a customer service representative. However, she had become less social and very withdrawn. She had been observed putting on dirty clothes after showering, as well as eating constantly. The patient denied any fevers, chills, night sweats, headaches, vision changes, or tinnitus. She also denied any rashes, muscle pain, or intolerance to heat or cold. There was no history of seizure disorder or depression. Her past medical history was notable only for hypertension and being a passenger in a motor vehicle crash 1 year before admission. She denied any alcohol, tobacco, or illicit drug use, and had no travel history other than coming to the United States, as she was originally from Trinidad. On physical examination, she was a moderately obese African American woman with a flat affect, psychomotor slowing, and alopecia of the scalp. She was alert and oriented to person, place, and time, but had a score of 26 out of 30 on the Mini-Mental State Examination. She lost points only for recall; she had no difficulty with serial 7s. Her cranial nerves were intact and her speech was fluent, although sparse, and she did not make any paraphasic errors. Her muscle strength was 5/5 in both the upper and lower extremities. Reflexes were 2+ in the upper extremities and 1+ in the lower extremities, and toes were downgoing bilaterally. She had intact sensation to light touch and pinprick, but markedly diminished proprioception of her lower extremities bilaterally. She had a wide-based gait with a positive Romberg sign and was markedly ataxic. Rectal examination yielded a positive guaiac test with brown stool, normal tone, and no masses. The remainder of the physical examination was normal. Laboratory studies revealed pancytopenia with a hematocrit of 22.7% and a mean corpuscular volume of 118.2 fL. A peripheral smear that was performed on admission, prior to transfusion, revealed macrocytic red cells and hypersegmented neutrophils." }, { "id": "wiki20220301en639_23367", "title": "Cheong Chun Yin", "score": 0.009433962264150943, "content": "of his or her gender, a mentally ill drug trafficker can serve a mandatory life sentence without caning, and secondly, her age being above fifty and it would not be legal for offenders (often the males) above fifty years old to be caned. Pang was likely the third drug trafficker on death row to have her sentence commuted due to a mental illness after Dinesh Pillai Reja Retnam and Wilkinson Primus in March and October 2014 respectively, and both were also, like Pang, diagnosed with depression at the time they committed their respective crimes." }, { "id": "pubmed23n0953_12135", "title": "Dynamic Gender Presentations: Understanding Transition and \"De-Transition\" Among Transgender Youth.", "score": 0.009345794392523364, "content": "The following clinical scenarios are composite cases that illustrate clinically important phenomena based on several patients. Jamie is a 19-year-old who was assigned a female gender at birth and had a history of major depressive disorder in remission. She presented to her primary care physician, psychiatrist, and psychotherapist reporting dysphoria related to gender and requesting gender-affirming hormone therapy. Jamie had symptoms for at least 6 months consistent with DSM-5 criteria for gender dysphoria. After full clinical assessment by her therapist, psychiatrist, and primary care physician, her integrated care team initiated gender-affirming hormone therapy and provided close follow-up from her mental health providers. For 13 months, Jamie was treated with testosterone, changed her pronouns to he/him/his, and began wearing traditionally masculine clothing. Throughout this period, she remained engaged in regular care with her psychotherapist, who was experienced in providing gender-affirming care. Eventually, Jamie informed her care team that after the trial of testosterone and much reflection, she had come to understand her identity as a queer woman and wished to discontinue hormone therapy. Jamie reported being pleased about the hormone therapy trial, because this allowed her to clarify her gender identity. She did not regret her social affirmation or any physical changes that occurred during this process, such as fat redistribution and minor facial hair growth, in the context of otherwise being healthy. Lupita is a 23-year-old who was assigned a male gender at birth and had a history of major depressive disorder and panic disorder. At 18 years of age, after a comprehensive evaluation, she initiated gender-affirming hormone therapy with her primary care provider, changed her name to \"Lupita,\" changed her pronouns to she/her/hers, and started wearing more traditionally feminine clothing. That following year, she started attending college and faced continual gender-based harassment from other students as a result of her gender-nonconforming physical appearance. Her college health services were not affirming of her gender and referred to her repeatedly by her birth name and with he-series pronouns. Lupita became demoralized and after 5 months decided to de-transition. She became progressively more depressed and attempted suicide in her sophomore year. Then she transferred colleges, found gender-affirming clinical providers, and resumed estradiol and spironolactone (an antiandrogen) therapy and her social affirmation through name, pronouns, and style of dress. Her mood improved dramatically and she was able to graduate from college. Lupita now presents seeking breast augmentation surgery." }, { "id": "wiki20220301en008_39449", "title": "Trent Reznor", "score": 0.009345794392523364, "content": "Personal life During the five years following the release of The Downward Spiral in 1994, Reznor suffered from depression; his condition was worsened by the death of his maternal grandmother, who had raised him. He began abusing alcohol, cocaine, and other drugs, and successfully completed rehab in 2001. He said in a 2005 Kerrang! interview, \"There was a persona that had run its course. I needed to get my priorities straight, my head screwed on. Instead of always working, I took a couple of years off, just to figure out who I was and working out if I wanted to keep doing this or not. I had become a terrible addict; I needed to get my shit together, figure out what had happened.\" In contrast to his former suicidal tendencies, he admitted in another 2005 interview that he is \"pretty happy\"." }, { "id": "pubmed23n0910_1147", "title": "Weeding Out the Justification for Marijuana Treatment in Patients with Developmental and Behavioral Conditions.", "score": 0.009259259259259259, "content": "Alex is a 13-year-old adolescent with high-functioning autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD)-combined type, anxiety, and depression. He has been resistant to engaging in therapy and treatment with various medications has been unsuccessful. Alex's parents are concerned about his anxiety, isolation, oppositional behaviors, academic underachievement, truancy, and substance use. A recent altercation with his stepfather led to a police intervention and a brief removal of Alex from the home. Alex previously used alcohol and other drugs; at present, he reports that his current drug use consists of frequently smoking pot. Alex states that he uses marijuana to relieve his anxiety and does not understand why this is problematic as marijuana is now legal in his state.Kevin is a 24-year-old adult man with diagnoses of autism spectrum disorder, mild intellectual disability, and schizoaffective disorder. He has a long history of challenging and problematic behaviors including aggression toward self and others, property destruction, inappropriate sexual behaviors, elopement, emotional outbursts, anxiety, and suicidal ideation. Past diagnoses include bipolar affective disorder, depression, and intermittent explosive disorder. Kevin is notably obese and somnolent. His current medications include 8 psychotropic medications, 3 antiallergy medications, levothyroxine, and a fish oil supplement. His father reports that medications have gradually been added and dosages increased over time. Two weeks ago, his new psychiatrist initiated a trial of medical marijuana. His father hopes that the marijuana will allow Kevin's other medications to be decreased or discontinued.Linda is an 11-year-old girl with high-functioning autism spectrum disorder, anxiety, and ADHD-inattentive subtype. Anxiety has been her most impairing condition, and Linda has been responding well to a treatment with cognitive behavioral therapy and a selective serotonin reuptake inhibitor. She is also working with her therapist on strategies to address her symptoms of ADHD. Linda has had no side effects from her medication and she and her family have been pleased with her progress. At a follow-up appointment, her mother brings an article from the lay press authored by a parent who claims that marijuana \"saved\" her autistic son. Linda's mother asks if marijuana should be considered for her daughter." }, { "id": "wiki20220301en521_16922", "title": "Not My Presidents Day", "score": 0.009259259259259259, "content": "curb\" in the street was pushed to the ground by police, had his arms pinned to his back, and was then pepper-sprayed in the face; and a woman was shoved to the sidewalk and then shot by police with \"pepper balls\". A 66-year-old woman was also tackled and hurt by the police when she attempted to shield her 72-year-old friend from being pushed. Several of the people arrested were minors, with six young people including a 14-year-old being cited. The adults were arrested on charges of disorderly conduct in the second degree, with one man also being charged with resisting arrest and giving false information to the police." }, { "id": "pubmed23n0377_21741", "title": "[Psychiatric manifestations of a new variant of Creutzfeldt-Jakob disease. Apropos of a case].", "score": 0.009174311926605505, "content": "The new variant of Creutzfeldt-Jakob disease (nvCJD) was first described in the UK in 1996 (16). The nvCJD differs from sporadic, genetic and iatrogenic CJD. Creutzfeldt-Jakob disease is closely associated with an abnormal isoform PrPSc of a cell-surface glycoprotein, prion protein (14). Molecular analysis suggests that nvCJD is caused by the same prion strain as bovine spongiform encephalopathy (BSE) (4, 10). To the end of September 2000, there have been 82 cases of nvCJD in the UK. We report the second French case of nvCJD to our knowledge (5, 13). This 36 year old woman was referred by a local general practitioner with a 6 month history of psychiatric symptoms of major depressive disorder. According to her family, the patient had suffered from personality change for several months before the onset of depression including apathy, emotional lability, infantile affect. There was no history of health problems. As she was admitted to the psychiatric department of our hospital in Paris suburbs, she presented a major depressive disorder. There were no specific psychiatric features allowing distinction from common depressive disorders, except a marked emotional lability. The patient's condition progressed rapidly within the following days. She presented memory impairment and disorientation. Drug treatments, clomipramine (125 mg/day) and venlafaxine (200 mg/day), were used with no benefit. She presented subsequently transient delusions and auditory hallucinations, fleeting for some hours. The predominant delusional themes were somatic type and pregnancy. The delusions were concomitant with delusions of the onset of cognitive impairment. The patient tested negative for the P 14.3.3 protein in the CSF. Computed tomography scan of the brain did not show any relevant abnormality. The electroencephalogram showed non specific slow wave activity. The neurological symptoms developed 7 months after the onset of depressive symptoms including ataxia, myoclonus, excessive daytime drowsiness, headache. After the onset of neurological symptoms, the illness progressed rapidly over the next 2 months with cognitive impairment, particularly memory impairment, myoclonus, ataxia, incontinence of urine and progressive immobility leading to dependency. CSF tests were negative. She was referred to a neurology department where the diagnosis was confirmed by brain biopsy (detailed elsewhere). The patient died in a state of akinetic mutism. The clinical features of our patient were consistent with previous descriptions of nvCJD, mainly those of the National CJD Surveillance Unit studies (17): early psychiatric symptoms, prolonged duration of illness (median: 14 months), earlier age at death, compared with sporadic CJD. Psychiatric symptoms occur in the clinical course in about a third of cases of sporadic CJD (3). In contrast, of the 35 cases that have died of nvCJD identified in the study by Will et al. (17), 34 suffered from early and prominent psychiatric symptoms, mainly depression and anxiety. In most of the patients, the first symptoms were psychiatric. Drug treatment was used in most cases, some patients had a transient improvement (18). The patient without psychiatric symptoms reported by the NCJDSU (17) was emotionally labile. Infantile affect and emotional lability, found in our patient, are frequently reported in other studies (1, 18). Schizophreniform disorders have been described during the clinical course, with auditory and visual hallucinations and paranoid delusions (17, 18). The insomnia and excessive daytime drowsiness our patient presented have been described in similar cases (18). Investigations are important to rule out alternative diagnoses. EEG records do not show periodic triphasic complexes as in sporadic CJD. The P 14.3.3 protein in the CSF is positive in half the cases of nvCJD (17). First neurological symptoms developed 6 months after the onset of psychiatric symptoms including ataxia, myoclonus and persistent painful sensory symptoms (17, 18). In most of the cases, MRI brain scans show bilateral pulvinar high signal (17), found subsequently in our patient and detailed elsewhere (13). The terminal stages are progressive cognitive impairment, helplessness and akinetic mutism. The first symptoms of this patient were purely psychiatric and difficult to distinguish from common psychiatric disorders. Clinical surveillance of human prion disease is crucial in France, as in UK. The link with BSE has dramatically highlighted the need for neurological and neuropsychological precise investigations." }, { "id": "wiki20220301en105_54144", "title": "Emily Horne", "score": 0.009174311926605505, "content": "Cautions and verdicts In August 2004, Horne was cautioned by the police for two cases of bigamy. Her first sentence for bigamy was handed down by Ipswich Crown Court around 2004, when she was sentenced to six months in prison. In June 2009, she was charged again, this time at Minshull Street Crown Court in Manchester. The court passed sentence on 27 July 2009; she was given a ten-month jail sentence, suspended for two years, since the court learned that she was diagnosed with bipolar disorder and was under medication. In 2011, Horne was arrested and tried for trying to obtain prescription drugs by posing as her seventh husband. Found guilty, she was due to be sentenced on 20 January 2012, but the verdict was postponed pending psychiatric evaluation. On 20 March 2012, she was handed a 12-month community order with supervision. The judge also imposed a 28-day electronically tagged curfew from 7pm to 7am. References" }, { "id": "pubmed23n1099_6059", "title": "Importance of Trauma-Informed Practice in Evaluation of Children Diagnosed with Autism Spectrum Disorder.", "score": 0.00909090909090909, "content": "As part of a multidisciplinary adoption support clinic, Erin, a 5-year-old girl, adopted approximately 6 months before the clinic visit, presents for postadoption evaluation. Erin was born at full term. Her birth history was significant for reported maternal treatment for liver failure during pregnancy. Her previous medical history included hospitalization for a viral illness at age 2 months, recurrent ear infections, and a fractured forearm. Family history was significant for a maternal history of bipolar disorder, depression, anxiety, borderline personality disorder, and concern for substance abuse; a paternal history of attention-deficit/hyperactivity disorder (ADHD) and depression; and full biological brother with a history of ADHD and oppositional defiant disorder. Erin and her brother lived with their parents until she was approximately 3 years old. At that time, there were concerns for poor hygiene, inconsistent medical care, poor school attendance for her brother, financial instability, and significant neglect. Erin was reportedly confined to her crib for hours at a time. She and her older brother were removed from the home because of concerns for significant neglect and placed into foster care. Approximately 3 months after foster placement, Erin underwent testing because of concerns for abnormal behaviors and possible developmental delays. Symptoms included poor sleep, repetitive behaviors such as head banging, delayed speech that primarily involved grunting, and lack of toilet training. She was hyperactive and aggressive and had poor caregiver attachment. On evaluation, she was small for age, poorly groomed, and easily distracted with poor eye contact and did not tolerate interactions with examiners. Neuropsychological testing consisted of symptom checklists and caregiver interview only because she did not tolerate diagnostic testing. She was diagnosed with autism spectrum disorder and global developmental delay with intellectual and language impairments. Over the following year, Erin was transitioned to a second foster family and was subsequently adopted. She received speech, occupational, and physical therapy, along with trauma-informed therapy. She made significant gains in multiple domains and was able to graduate from trauma-informed therapy after 1 year. On examination, Erin greets you with appropriate eye contact and reports that she is feeling \"good.\" She is verbal and interactive with her brother and parents. She looks to parents for support when asked to participate in the physical examination. She does not display any significant repetitive behaviors. Erin's parents are concerned that her initial diagnoses of autism spectrum disorder and global developmental delay do not accurately reflect her current level of functioning and are afraid she may have been misdiagnosed. How would you proceed with next steps to address these diagnoses?" }, { "id": "wiki20220301en144_34826", "title": "The Woman Who Came Back", "score": 0.00909090909090909, "content": "The local townspeople become suspicious and paranoid, believing that Lorna caused the illness of young Peggy, Matt's niece. Desperate to prove that there is nothing supernatural affecting the town or the woman he loves, Matt discovers the personal journal of Elijah Webster. Inside are the details of how Webster forged confessions of witchcraft to further his political standing. Matt hurries to show Lorna the journal, but finds her house being vandalized by some of the townspeople and Lorna fleeing in hysterical terror. Lorna hallucinates and falls into the river. Matt saves her and, in the process finds the body of the old woman. Now believing that she'd been a victim of superstition, Lorna stays in town and marries Matt. Cast Production The Woman Who Came Back was shot at Chaplin Studios in April 1945. The film was developed under the working title The Web." }, { "id": "pubmed23n0853_1036", "title": "\"Is It Her Hormones?\": Psychiatric Diagnoses and Polycystic Ovarian Syndrome.", "score": 0.009009009009009009, "content": "Beth, whom you have cared for in your primary care practice since she was born, is a 15-year-old adolescent girl with no prior psychiatric history who developed significant symptoms of clinical depression, associated with self-injurious behavior (cutting on wrists, arms, and thighs). She denied any known precipitant for her depression.She is a ninth grade honors student in the gifted program at a local high school and is described as a talented musician, playing multiple musical instruments as well as soccer and basketball. She has good family support, was sociable, and had several close friends. She denied any history of trauma and denied ever using recreational drugs or other mood-altering substances.At this visit, she reported feeling \"sad and anxious.\" Family history was significant for maternal depression, which persisted through her teens and twenties. Her older sister had been diagnosed with Social Anxiety Disorder. Beth reported anhedonia, fatigue and irritable mood, lack of motivation, impaired concentration, and anxiety related to failing grades.You decide to begin medication because of the severity of her symptoms, and 1 week after starting fluoxetine 10 mg, she reportedly overdosed on an unknown quantity of acetaminophen. Within a few days of switching to escitalopram (due to persistent gastrointestinal complaints while taking fluoxetine), she developed homicidal ideation. She reported feeling grandiose, empowered, invincible, elated, and \"crazy,\" although she never demonstrated or endorsed psychotic symptoms. She became fixated upon the idea that she could kill someone and \"get away with it.\" At the time she tried to suffocate a peer with her hands, she was described as having \"a glazed over look in her eyes.\" Moods were now described as alternating between depressed and elated, with mood shifts occurring every few days. These symptoms did not improve after the antidepressant medication was discontinued.Subsequently, patient was admitted for acute psychiatric care, at which time she was described as depressed, but with an \"expansive and irritable\" mood, and with obsessive suicidal ideation. She had developed a plan to hang herself in the home. She started to believe that her mother was trying to give her \"poison.\" She reported panic attacks and said that she wanted to be in the hospital where she could feel \"safe.\" She claimed to have an \"entity inside of her body who was a bully\" and who was \"taking over her body\" and stated that he put her hand over her peer's mouth, as she watched.Psychological testing included the Minnesota Multiphasic Personality Inventory-Adolescent, showed significant paranoia, bizarre mentation, and poor reality testing. Along with interview and observation, it was determined that patient met criteria for the DSM-IV-TR clinical diagnosis of Other Specified Bipolar Disorder, with psychotic features.Aripiprazole was initiated at a dosage of 2 mg; however, moods were still described as fluctuating between extremes every few hours. It was discontinued after reaching 5 mg due to affective blunting. Risperidone 0.5 mg twice daily helped patient to feel and act \"more like herself\"; however, she continued to report significant depression. The addition of lamotrigine 25 mg daily, in addition to individual Dialectical Behavior Therapy, finally led to improvement of mood and a gradual return of her normal baseline, with reportedly stable emotional, social, and academic functioning.The patient's mother remained convinced that this adolescent's mood instability was caused by underlying hormonal problems so you refer her to endocrinology. Beth developed puberty at age 8, with menses occurring on average of twice yearly. She was found to have elevated free testosterone level of 8.6 (reference range, 1.2-7.5). She was of normal weight (body mass index = 21.85 kg/m) and did not manifest acne, male pattern hair thinning, or hirsutism. Thyroid functions, 17-OH progesterone, follicle-stimulating hormone/luteinizing hormone, and estradiol were within normal limits. Prolactin elevation (46.3) was assumed to be due to Risperidone. Patient refused ovarian ultrasound.After starting oral contraceptives to establish monthly menses, patient's emotional and behavioral symptoms continue to remain stable. After Beth decided on her own to discontinue psychotropic medications, she continued for 17 months following her initial visit to remain free of neuropsychiatric symptoms.Now that her symptoms seem resolved; you wonder what the medical diagnosis for Beth was? You wonder if \"hormones\" may have caused or contributed to her psychiatric presentation." }, { "id": "wiki20220301en193_8488", "title": "Deanna Laney murders", "score": 0.009009009009009009, "content": "Five mental health experts were consulted in Laney's case: two each by the prosecution and defense, and one by the judge. All of them arrived at the conclusion that she suffered from psychotic delusions which made her unable to know right from wrong at the time of the killings. A Smith County court found her not guilty by reason of insanity. She was committed to Kerrville State Hospital for eight years until her release in May 2012. However, she is subject to a list of conditions, including that she have no unsupervised contact with minors and submit to regular drug tests to ensure that she takes required medication. See also Other cases of filicide in Texas: John Battaglia Darlie Routier Andrea Yates Yaser Abdel Said is accused of filicide References The Dallas Observer. \"Psycho Mom,\" January 20, 2005. Retrieved on May 29, 2007. USA Today. \"Texas woman who killed kids acquitted,\" April 4, 2004. Retrieved on May 30, 2007." }, { "id": "pubmed23n0876_17161", "title": "Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl.", "score": 0.008928571428571428, "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": "wiki20220301en057_180", "title": "Joshua Huddy", "score": 0.008928571428571428, "content": "Early life Huddy was born November 8, 1735, to a prosperous family in Salem County, Province of New Jersey, the oldest of seven brothers. His grandfather, Hugh Huddy, was a well-known judge in Burlington. Huddy spent most of his early life in Salem, where he was considered rebellious and a troublemaker. He was disowned by Quakers in Salem in 1757 for his \"disorderly\" conduct. His \"rough ways\" continued into adulthood; he was tried and convicted several times for crimes including assault and theft and repeatedly had financial difficulties. He was forced to sell a 300-acre (1.2 km²) plantation in Salem to pay his debts and was forced into debtor's prison for a time. In 1764, he married his first wife, the widowed Mary Borden, by whom he had two daughters, Elizabeth and Martha, before her death." }, { "id": "pubmed23n0855_5498", "title": "[Factitious disorders in dermatology: Value of the dissociative state concept].", "score": 0.008849557522123894, "content": "Factitious disorders in dermatology consist of intentionally self-inflicted skin lesions that vary in morphology and distribution and occur on surfaces readily accessible to the patient's hands. They tend to be a chronic condition that waxes and wanes according to the circumstances of the patient's life. Patient management poses a particular challenge to the clinician and the prognosis is considered poor. The aetiopathogenesis of factitious disorders in dermatology is not completely understood. We present a case in which we suggested the occurrence of factitious behaviour during a dissociative state, and we briefly describe our diagnostic and therapeutic approach. A 48-year-old unemployed woman was referred to our department of psychiatry by her dermatologist for suspected factitious disorder. The patient was diagnosed with diabetes mellitus type 1 and had been hospitalized repeatedly for confirmed diabetic ketoacidosis. The onset of the disease was related to marital discord with her spouse. Numerous skin lesions had appeared on her face, arms, legs, neck and back. These lesions resulted in multiple hospital admissions and in amputation of her left leg. The condition had worsened considerably after her separation from her husband. During the initial conversation, the patient was unable to provide a clear history of the disease. She denied any knowledge of the circumstances in which these skin lesions appeared, and she did not admit self-infliction. Her mood was depressed and her speech was slow. We suspected that our patient was herself causing her skin lesions while in a dissociative state. Several arguments militate in favour of our hypothesis, particularly her history of childhood maltreatment and the association of traumatic life events with simultaneous deterioration of the skin. The explanation of the dissociative mechanism helped us to strengthen the therapeutic relationship. Within a few days, we noted a slow regression of the lesions, but the patient was still unable to explain how the lesions had occurred. The pathophysiology of factitious disorders in dermatology is poorly understood. It has strong ties with other psychiatric disorders, and according to several authors, skin lesions occur in dissociative states, after which patients do not remember how the skin change started. Management of this disease is challenging. An improved understanding of its mechanisms may enhance the prognosis for this particular group of patients." }, { "id": "wiki20220301en639_23366", "title": "Cheong Chun Yin", "score": 0.008849557522123894, "content": "In the same trial and court, much to the relief of her relatives in court, 60-year-old Pang Siew Fum was also given an approval of her re-sentencing application despite failing to meet the criteria of a courier, as psychiatrists assessed and found Pang to be suffering from major depressive disorder which sufficiently impaired her mental responsibility. After Pang's lawyers presented the medical report to the court, Justice Choo accepted that Pang should not be hanged based on her diminished responsibility. Hence Pang, by gaining eligibility under the alternative re-sentencing criteria, was re-sentenced to life imprisonment from the date of her capture, and no caning was imposed due to her being a female. Even if Pang was a male, she would not face caning as well because firstly, regardless of his or her gender, a mentally ill drug trafficker can serve a mandatory life sentence without caning, and secondly, her age being above fifty and it would not be legal for offenders (often the" }, { "id": "pubmed23n1007_19220", "title": "Maintaining Safety and Planning for the Future.", "score": 0.008771929824561403, "content": "Kevin is a 12-year-old boy with autism spectrum disorder, intellectual disability (nonverbal IQ scores in mid-40s), and attention-deficit/hyperactivity disorder who has been followed up by a developmental-behavioral pediatrician (DBP) and a child psychologist for medication and behavioral management since he was 4 years old. Kevin was placed in the care of his great-great-aunt shortly after he turned 2 years of age because of concerns of neglect. She is now his legal guardian.Kevin is predominately nonverbal but does use a few single words to make requests or label items. He attends a public school and receives full-time special education support. He has a personal care assistant (PCA) who provides in-home support 5 to 6 days/wk for 3 to 4 hours at a time. The PCA is working on toilet training, using a \"clock-training\" approach, and also takes Kevin outdoors to play or on short outings during her visits. In his free time, Kevin prefers to watch cooking shows on television.Over the past year, Kevin's behaviors have become more concerning. There have been several episodes of Kevin waking up during the early morning hours and going to the kitchen to \"cook.\" After one of these episodes, his guardian was not aware that Kevin had woken up until the next morning when she found a concoction of corn starch, coffee grounds, cottage cheese, and powdered drink mix in the blender. Kevin had also woken up during the night and ventured out of the house into the back yard. His guardian had woken up immediately as the alarm system sounded when he opened the outer door from the house to the yard.A door alarm was added to Kevin's bedroom door so that his guardian would be alerted when he leaves his bedroom; however, the alarm is not used consistently because there are times when the alarm cannot be found at bedtime. Kevin's guardian was able to obtain a GPS device for him to wear on his shoe from the local police department. He wears this without resistance every day.Kevin's guardian is in her mid-70s, and she has had several health issues over the past 2 to 3 years. There are no other family members who are willing or able to care for Kevin if his guardian were no longer able to. The DBP and child psychologist have encouraged Kevin's guardian to explore long-term residential care options with the state agency that provides support for individuals with intellectual disabilities and with Kevin's insurance provider, but the guardian is very reluctant to do this. She fears that Kevin will be removed from her care or placed in a \"home\" where someone will \"do bad things to him.\"What else would you recommend or actions would you take to support Kevin's guardian in ensuring Kevin's safety and planning for his future care?" }, { "id": "wiki20220301en463_10770", "title": "Rose Spector", "score": 0.008771929824561403, "content": "Among her many judicial opinions, her dissent in Twyman v. Twyman is often studied in family law. In that case, the majority opinion was authored by then-justice John Cornyn, adopting the Restatement of Torts standard for intentional infliction of emotional distress, but Justice Spector dissenting, arguing that in this case, award of damages to the wife for the proven abuse of the wife by her husband should be upheld under the standards for negligent infliction of emotional distress that had been thought to apply at the time of the lower court's verdict. References Sources Twyman v. Twyman, 855 S.W.2d 619 (Texas 1993). An Unusual History of Women Serving on the Texas Supreme Court Interview with Rose Spector, UTSA Oral History Project Cossman's The Story of Twyman v. Twyman: Politics, Tort Reform, and Emotional Distress in a Texas Divorce, in Carol Sanger, Family Law Stories" }, { "id": "pubmed23n0295_9154", "title": "[A 63-year-old woman with muscle weakness, myotonia, and parkinsonism].", "score": 0.008695652173913044, "content": "We report a 63-year-old woman who presented myotonia and parkinsonism. The patient was well until 15 years of the age when she noted that the ring finger of her left hand at times flexed when she did not intend to do so. She noted weakness in her left upper extremity at the age of 40, and difficulty in relaxing her hand grip at 45. She had an onset of tremor in her right foot at age 50, which was followed by difficulty in gait and hand writing. She was admitted to Juntendo University Urayasu Hospital when she was 63-year-old. Her mother, two sisters, and a son were affected with similar muscle weakness and myotonia. Although some of them developed stooped posture in the late stage of the disease, none of them had overt parkinsonism. General physical examination was unremarkable. Neurologic examination revealed an alert and oriented woman with some recent memory loss. She had bilateral ptosis, facial weakness, and a masked face. Myerson's sign was present. Her speech was small and monotonous. The sternocleidomastoid muscles were markedly atrophic and weak. The remaining of the cranial nerves were intact. She walked in small steps with freezing with support. She showed bradykinesia, retropulsion, and resting tremor in her right leg. Slight distal dominant weakness was noted in both upper and lower extremities more on the left. No cerebellar signs were noted. Muscle stretch reflexes were within normal limits in the upper extremities and diminished in the lower limbs. Sensation was intact. Routine laboratory findings were unremarkable. Cranial CT scan and MRI revealed slight cortical atrophy and leukoaraiosis. She responded to levodopa and she became able to walk by herself. She was transferred to another hospital one month after her admission. She had several bouts of airway obstruction with one episode of respiratory arrest. She expired six month after the transfer. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that this patient suffered from myotonic dystrophy and Parkinson's disease which set in later years. Postmortem examination on the iliopsoas muscle revealed uneven muscle fiber diameters, central nuclei, and type 1 fiber predominance; the pathologic finding was consistent with myotonic dystrophy. The substantia nigra showed marked cell loss and Lewy bodies in the remaining neurons. The finding was consistent with Parkinson's disease. In myelin stain, diffuse myelin pallor was noted in the cerebral white matter which was the pathologic substrate of leukoaraiosis in this patient. Combination of these two disorders have never been reported in the literature to our knowledge. It appears to be that the coincidence is just a by-chance phenomenon, but it seems interesting to note that accelerated aging process appears to be present in both myotonic dystrophy and Parkinson's disease." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 937, 1075 ] ], "word_ranges": [ [ 150, 169 ] ], "text": "Alcohol exerts a direct immunosuppressive effect, moreover, alcoholism is related to the affectation of immunity in the respiratory tract." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Isoniazid, ethambutol, pyrazinamide for 12 months.", "2": "Isoniazid, ethambutol, pyrazinamide for 12 months and streptomycin for two months.", "3": "Isoniazid, ethambutol, pyrazinamide for 12 months and a quinolone for two months.", "4": "Isoniazid, ethambutol, pyrazinamide and a quinolone for 18 months.", "5": "Isoniazid, ethambutol, pyrazinamide for 18 months and streptomycin and a quinolone for 2 months." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0225_3332", "title": "Controlled trial of 4 three-times-weekly regimens and a daily regimen all given for 6 months for pulmonary tuberculosis. Second report: the results up to 24 months. Hong Kong Chest Service/British Medical Research Council.", "score": 0.018978233495232956, "content": "Five 6-month antituberculosis regimens, allocated at random to patients with acid-fast bacilli in their sputum on microscopy, were studied. Four, given 3 times a week throughout, contained isoniazid and rifampicin together with 1. streptomycin, pyrazinamide and ethambutol, 2. streptomycin and pyrazinamide, but no ethambutol, 3. streptomycin and ethambutol, but no pyrazinamide, 4. pyrazinamide and ethambutol, but no streptomycin. The fifth was a daily regimen of isoniazid, rifampicin, pyrazinamide and ethambutol. All 833 patients with drug-sensitive strains of tubercle bacilli pretreatment had a favourable bacteriological response during chemotherapy, and the bacteriological relapse rate during 18 months after stopping chemotherapy was 1% for the three-times-weekly regimens containing streptomycin and pyrazinamide in addition to isoniazid and rifampicin (regimens 1 and 2, above) and for the daily regimen, 2% for the regimen of isoniazid, rifampicin, pyrazinamide and ethambutol three times a week (regimen 4), but 8% for the only regimen which did not contain pyrazinamide (regimen 3). The results achieved by the 4 pyrazinamide regimens were practically as good for the 110 patients with bacilli resistant to isoniazid, streptomycin, or both drugs pretreatment as they were for the patients with drug-sensitive strains." }, { "id": "pubmed23n0203_11804", "title": "Controlled trial of four thrice-weekly regimens and a daily regimen all given for 6 months for pulmonary tuberculosis.", "score": 0.017940466613032984, "content": "Five 6-month antituberculosis regimens, allocated at random to patients with acid-fast bacilli in their sputum on microscopy, were studied. Four, given three times a week from the start, contained isoniazid and rifampicin together with (1) streptomycin, pyrazinamide, and ethambutol, (2) streptomycin and pyrazinamide, (3) streptomycin and ethambutol, or (4) pyrazinamide and ethambutol. The fifth was daily isoniazid, rifampicin, pyrazinamide, and ethambutol. All 833 patients with drug-sensitive strains of bacilli before treatment had a favourable bacteriological response during chemotherapy, and the bacteriological relapse rates during 12 months after stopping chemotherapy were 2% or less for all regimens except thrice-weekly isoniazid, rifampicin, streptomycin, and ethambutol (the only regimen without pyrazinamide), which had a relapse rate of 8%. The results were equally good for the 138 patients with bacilli resistant to isoniazid, streptomycin, or both drugs initially. The incidence of potentially serious toxicity was low. The daily regimen is relevant to programmes in which patients self-administer their drugs, and the 3 pyrazinamide-containing intermittent regimens are relevant to fully supervised outpatient programmes." }, { "id": "pubmed23n0409_7987", "title": "Treatment of isoniazid-resistant tuberculosis with isoniazid, rifampin, ethambutol, and pyrazinamide for 6 months.", "score": 0.01647457627118644, "content": "In 1992 the Seattle-King County Department of Public Health Tuberculosis Clinic began to treat patients with isoniazid-resistant tuberculosis with a regimen of isoniazid, rifampin, pyrazinamide, and ethambutol daily for 6 months. To conduct a review of clinical and bacteriological outcomes of treatment for patients who received the four-drug, 6-month regimen for isoniazid-resistant tuberculosis. A retrospective review of medical records of TB cases meeting the study criteria, a Mycobacterium tuberculosis isolate resistant to isoniazid, and intent to treat with a 6-month course of isoniazid, rifampin, pyrazinamide, and ethambutol. Through December 1999, 44 consecutive patients with isoniazid-resistant, rifampin-susceptible tuberculosis were started on the four-drug, 6-month daily regimen. Among 42 patients followed until completion of therapy, three required changes in the regimen due to side effects. There was one case of drug-induced hepatotoxicity. Among 39 patients with pulmonary involvement, 37 converted sputum cultures from positive to negative within 2 months of starting treatment. There were no treatment failures. On passive follow-up of at least 2 years on all patients, two patients relapsed. The single patient with bacteriological relapse did not develop further drug resistance. The regimen of isoniazid, rifampin, pyrazinamide, and ethambutol given daily for 6 months produced successful outcomes when used in a public health tuberculosis clinic as routine therapy for isoniazid-resistant tuberculosis." }, { "id": "pubmed23n0004_4028", "title": "Controlled trial of 6-month and 8-month regimens in the treatment of pulmonary tuberculosis. First report.", "score": 0.01588177581555065, "content": "Four short-course antituberculosis regimens allocated at random were studied; (1) streptomycin, isoniazid, and rifampin given daily for 6 months; (2) these 3 drugs plus pyrazinamide given daily for 2 months, followed by twice-weekly administration of streptomycin, isoniazid, and pyrazinamide; (3) a regimen that differed from regimen 2 only in that ethambutol replaced pyrazinamide, and (4) streptomycin plus isoniazid plus rifampin plus pyrazinamide given 3 times per week for 4 months, followed by streptomycin plus isoniazid plus pyrazinamide administered twice per week. The last 3 regimens were given for 6 or 8 months at random. All except 1 of 680 patients with tubercle bacilli drug-susceptible before treatment had a favorable bacteriologic response during chemotherapy. The relapse rates during the first 6 months after chemotherapy were low, except in the ethambutol series, in which 19 per cent of the patients relapsed after 6 months of treatment, and 8 per cent relapsed after 8 months. A substantial proportion of the patients with strains initially resistant to either isoniazid or streptomycin had a favorable response to their allocated regimen, but the results were not as good for those patients with strains resistant to both drugs. An important finding is that the incidences of immunologic febrile reactions to rifampin and of rifampin-dependent antibodies were very low during the 3-times-weekly regimen." }, { "id": "pubmed23n0552_13224", "title": "[Efficiency of a new standard chemotherapy regimen in the treatment of patients with recurrent pulmonary tuberculosis].", "score": 0.014775925525005413, "content": "The efficiency of conventional chemotherapy regimens was comparatively studied in 75 patients with recurrent pulmonary tuberculosis. In the patients with recurrent pulmonary tuberculosis, conventional chemotherapy regimen \"2b\" including isoniazid, rifampicin, pyrazinamide, ethambutol, fluoroquinolone (ofloxacin, ciprofloxacin, and levofloxacin), and canamycin (amikacin) versus conventional chemotherapy regimen \"2a\" including isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin could cease bacterial isolation after 3-month therapy, as evidenced by sputum microscopy (86.1 and 62.5%, respectively; p &lt; 0.05). Cavity closure was more frequently observed after 6-month chemotherapy using regimen \"2b\" (76.7 and 48.0%, respectively; p &lt; 0.05). In patients with recurrent pulmonary tuberculosis who isolated Mycobacterium tuberculosis (MBT) resistant to isoniazid and other antituberculous drugs (exclusive of rifampicin), 3-month use of conventional regimen \"2b\" led to cessation of bacterial isolation (as evidenced by the inoculation test) in 66.7% of cases; but this did not occur with conventional regimen \"2a\" in any case. Similarly, 3-month use of regimens \"2b\" and \"2a\" in patients isolating MBT resistant to rifampicin and other agents (exclusive of isoniazid) resulted in the cessation of bacterial isolation in 80 and 0% of cases, respectively. In multidrug resistance, these parameters were 11.1 and 0%, respectively." }, { "id": "pubmed23n0672_13818", "title": "[A case of multidrug-resistant tuberculosis who acquired additional resistance to ethambutol before the result of the initial drug sensitivity test was reported].", "score": 0.014499605988967691, "content": "On December 6, 2008, a 52-year-old man presented to a clinic with chronic cough, sputum, and chest discomfort, which had lasted since mid-November. Since the chest radiograph showed a small cavity with small nodules and granular shadows, he was referred to another hospital. On TB-PCR, the gastric juice was positive. Therefore, on December 16, 2008, treatment for pulmonary tuberculosis was initiated with isoniazid, rifampicin, ethambutol, and pyrazinamide. However, on February 4, 2009, a drug susceptibility test revealed that the bacilli were resistant to isoniazid and rifampicin. Therefore, he was referred to our hospital. At that time, he had no symptoms and his sputum smear was negative. We performed a right upper lobectomy. The smear result of the surgical specimen was heavily positive (equivalent to Gaffky 6), and the drug susceptibility test showed resistance to ethambutol in addition to isoniazid and rifampicin. After surgery, we treated him with pyrazinamide, streptomycin, para-aminosalicylate, ethionamide, and levofloxacin. We report this case of multidrug-resistant tuberculosis without past treatment who acquired additional resistance to ethambutol during the first 2 months of chemotherapy. When treating multidrug-resistant tuberculosis, very careful consideration of susceptibility to other drugs is warranted." }, { "id": "pubmed23n0124_7179", "title": "[Results of a therapeutic trial comparing a 6-month regimen to a 12-month regimen in the treatment of pulmonary tuberculosis in the Algerian Sahara. Final report: results 3 years after the onset of treatment].", "score": 0.014433962264150942, "content": "This study has compared a daily 6-month short-course chemotherapy regimen and a daily 12-month standard duration regimen in the treatment of smear positive pulmonary tuberculosis in a rural area of Algeria where the population contains a relatively high proportion of nomads. The 6-month regimen (6M) was isoniazid and rifampicin throughout with ethambutol and pyrazinamide in addition for the first 2 months, and the 12-month regimen (12M) was isoniazid and ethambutol supplemented by streptomycin during the first month. All the 601 patients admitted had one or more sputum smears positive on examination in the local laboratory and 70% had a positive culture in the reference laboratory in Algiers. Most patients were admitted to hospital initially for one or two months where chemotherapy was fully supervised and subsequently it was self-administered. In both nomads and settled residents known to have fully sensitive strains of tubercle bacilli pretreatment the 6-month regimen was highly effective with no failures during chemotherapy and only 3% relapses after stopping chemotherapy in 126 patients compared with a combined failure rate during chemotherapy and relapse rate of 21% in the 152 patients receiving the 12-month regimen (P less than 0.001). The results in patients with isoniazid-resistant strains pretreatment were also significantly better for the 6-month than for the 12-month regimen, one of 15 and 8 of 17 patients respectively being classified as failures or relapses (P = 0.03). To assess the results which might be achieved by these regimens under programme conditions the outcome at 3 years was also assessed in all patients admitted to the study irrespective of whether the disease was confirmed in the reference laboratory or at independent assessment and whether or not the allocated chemotherapy was modified or further courses of chemotherapy were given. At 3 years, 82% of the 6M and 80% of the 299 12M patients had achieved a favourable status and only one 6M patient and 4 12M patients were still known to have active disease with a positive culture. A further 23 6M and 22 12M patients were known to have died, 11 in each series probably or definitely from tuberculosis. The remaining 28 6M and 34 12M patients were lost from follow-up, but 24 and 22 respectively had completed their allocated chemotherapy before defaulting. It was estimated that, overall, 272 (94%) of the 6M and 263 (91%) of the 12M patients had a favourable status at 3 years.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0101_19614", "title": "Controlled clinical trial of a regimen of two durations for the treatment of isoniazid resistant pulmonary tuberculosis.", "score": 0.01442571899615314, "content": "Patients with pulmonary tuberculosis who were failures of primary chemotherapy with strains resistant to isoniazid or to isoniazid and streptomycin were allocated at random to receive a regimen of rifampicin and ethambutol for 6 (4RE) or 9 months (7RE), supplemented in both treatment series by streptomycin plus pyrazinamide for the first 2 months. The patients were treated in hospital for the first 2 months and thereafter treatment was supervised on a daily basis in the nearest health institution by an appointed member of staff or at home by responsible members of the community. A total of 306 patients was admitted and 226 patients remained for analysis at the end of chemotherapy, 179 with a strain resistant to isoniazid alone and 47 with a strain resistant to isoniazid and streptomycin. There were only two failures at the end of chemotherapy, one in the 6-month series who had resistance to both isoniazid and streptomycin pretreatment, and one in the 9-month series who had resistance to isoniazid alone. For the 144 patients with initial resistance to isoniazid alone assessed up to 30 months, the relapse rates were low in both series: 4% for the 72 patients in the 6-month series and 3% for the 72 patients in the 9-month series. However, for the 34 patients with resistance to both drugs, three of the 14 in the 6-month but none of 20 in the 9-month series relapsed." }, { "id": "pubmed23n0118_759", "title": "Clinical trial of two short-course (6-month) regimens and a standard regimen (12-month) chemotherapy in retreatment of pulmonary tuberculosis in Pakistan. Results 18 months after completion of treatment (Lahore Tuberculosis Study).", "score": 0.014288630332720964, "content": "This study compared the efficacy and tolerability of two 6-month daily regimens of isoniazid and rifampin in combination with either pyrazinamide or ethambutol (RHZ and RHE regimens) against a standard daily regimen of streptomycin, isoniazid, and ethambutol (SHE regimen) given for 6 months followed by isoniazid and ethambutol for an additional 6 months. Only previously treated sputum positive patients suffering from active pulmonary tuberculosis were entered into the study. Three hundred and fifty-eight patients were admitted to the study and 267 (75%) completed chemotherapy. Eighty-five percent of RHZ-regimen and 82% of RHE-regimen patients achieved sputum culture negativity compared to 55% of patients in SHE regimen. Successfully treated patients were followed up for 18 months, and among these, all 3 treatment regimens showed broadly similar levels of culture negativity at the end of the follow-up period. Final therapeutic outcome was based on sputum culture results obtained throughout the follow-up period, and no statistically significant difference in relapse rate was noticed in the 3 regimens. Severe drug intolerance necessitated discontinuation of therapy in only 2 patients." }, { "id": "wiki20220301en001_166553", "title": "Tuberculosis", "score": 0.014114024207690003, "content": "The recommended treatment of new-onset pulmonary tuberculosis, , is six months of a combination of antibiotics containing rifampicin, isoniazid, pyrazinamide, and ethambutol for the first two months, and only rifampicin and isoniazid for the last four months. Where resistance to isoniazid is high, ethambutol may be added for the last four months as an alternative. Treatment with anti-TB drugs for at least 6 months results in higher success rates when compared with treatment less than 6 months, even though the difference is small. Shorter treatment regimen may be recommended for those with compliance issues. There is also no evidence to support shorter anti-tuberculosis treatment regimens when compared to a 6-month treatment regimen. However recently, results from an international, randomized, controlled clinical trial indicate that a four-month daily treatment regimen containing high-dose, or “optimized,” rifapentine with moxifloxacin (2PHZM/2PHM) is as safe and effective as the" }, { "id": "pubmed23n0088_12575", "title": "[Short-term therapy of lung tuberculosis using a fixed combination of isoniazid, rifampicin and pyrazinamide. Results after 2 years].", "score": 0.013939057145503381, "content": "Treatment of tuberculosis should be as short and as simple as possible in order to improve patient compliance; and combinations of at least three drugs should be used in order to kill the different populations of mycobacteria and to avoid development of drug resistance.--In a controlled multicentre study two regimens were compared in 93 patients with newly-diagnosed pulmonary tuberculosis: 1) Six-month therapy (47 cases): Daily rifampicin and isoniazid, supplemented with pyrazinamide for the first 2 months. A tablet with a fixed combination of 120 mg rifampicin, 50 mg isoniazid and 300 mg pyrazinamide (Rifater) was used. 2) Present Swiss standard therapy (46 cases): Daily rifampicin, isoniazid and ethambutol for 2 months followed by rifampicin and isoniazid for 7 months.--The time-course of culture negativation and the frequency of adverse events were similar in the two groups. During a follow-up period of at least two years only one relapse was observed in the six-month regimen, 3 months after completion of treatment. This was one of three patients with pretreatment resistance to isoniazid. Nevertheless, two of them were cured with the six-month regimen containing Rifater.--Patient compliance, assessed during outpatient treatment by detecting isoniazid metabolites in the urine, was very good (93% of tests were positive in each group).--These results with a follow-up of more than 2 years, indicate that short-course therapy of 6 months duration with the fixed combination tablet may be recommended as treatment of choice in pulmonary tuberculosis except in cases of isoniazid resistance and other special situations (i.e. large cavitations, large number of viable bacilli)." }, { "id": "wiki20220301en039_79807", "title": "Tuberculosis management", "score": 0.013815655017371756, "content": "documented) – 2 months of Isoniazid, Rifampin, Ethambutol and Streptomycin followed by 6 months of Isoniazid and Rifampin • One hepatotoxic drug – 2 months of Isoniazid, Ethambutol & Streptomycin followed by 10 months of Isoniazid and Ethambutol • No hepatotoxic drugs – 18–24 months of Streptomycin, Ethambutol and Quinolones Patients with liver disease should have their liver function tests monitored regularly throughout TB treatment." }, { "id": "pubmed23n0335_3019", "title": "Replacement of streptomycin by ethambutol in the intensive phase of tuberculosis treatment: no effect on compliance.", "score": 0.013438735177865611, "content": "Seven tuberculosis clinics in the National Tuberculosis Programme of Madagascar. To compare the treatment efficacy and tolerance of regimens including either streptomycin or ethambutol for patient compliance during initial treatment of smear-positive tuberculosis. The 1023 patients included in the study were randomly divided into two treatment groups-one to receive streptomycin (S), isoniazid (H), rifampicin (R) and pyrazinamide (Z) (SHRZ), and the other to receive EHRZ, where streptomycin was replaced by ethambutol (E). During the 2-month intensive phase, drug delivery was completely supervised. The same 6-month continuation regimen was then given in both groups. Follow-up consisted of a clinical and bacteriological examination at the end of the second, fifth and eighth months. There was no significant difference between the two regimens as regards compliance with treatment, the number of patients lost or who died, or for bacteriological response during the intensive phase. EHRZ was better tolerated. During the continuation phase, the results of the two groups remained comparable, but treatment failures occurred earlier in the patients who had received streptomycin. Patient compliance was not better with streptomycin. The ethambutol-containing regimen was as efficient as the other, and better tolerated. There is no argument for preferring streptomycin in the intensive phase of treatment of smear-positive tuberculosis." }, { "id": "pubmed23n0564_6788", "title": "[Treatment results of rifampicin (RFP) resistant isoniazid (INH) susceptible tuberculosis, a hospital based study].", "score": 0.013368549370174725, "content": "To evaluate treatment results of Rifampicin (R) resistant Isoniazid (H) susceptible tuberculosis cases. Cohort analysis of twenty-three H susceptible R resistant tuberculosis cases started treatment in 1985-2004 at Fukujuji Hospital, by the retrospective review. Three cases became Multi-drug resistant tuberculosis (MDR TB), seventeen cases were cured, two cases died, and one case transferred out. One started treatment with HR became MDR, one of the two started treatment with HR+ Ethambutol (E) became MDR and one of them was cured, eight among ten cases started treatment with HR+Pyrazinamide + (E or Streptomycine (S)) were cured, one among the ten died and one among the ten transferred out, one started treatment with RZE was cured, three among the five cases started treatment with three effective drugs without Z were cured, one among the five died, one among the five became MDR. Three cases started treatment with four effective drugs were cured. Among the nineteen cases continued treatment for more than six months, ten cases treated with four or five effective drugs for at least two months were cured, two cases of nine cases treated with three drugs or less became MDR, seven of the nine cases were cured. Among the same nineteen cases, eleven cases not treated with two or less effective drugs were cured, one case treated with two or less effective drugs for six months became MDR and one of them treated with one or two effective drug for one to three months became MDR and some were cured. The used drugs were H, E, Pyrazinamide, Streptomycin, Kanamycin, Ethionamide and New Quinolones. The duration of treatment of cured cases were eleven to twelve months in 3 cases, twelve to eighteen months in 3 cases, eighteen to twenty-four months in 8 cases and more than two years in 3 cases. If the starting regimen is HRZE, we can cure R resistant H susceptible tuberculosis by the use of four effective drugs for more than two months and at least three effective drugs with the total duration of treatment for twelve to twenty-four months." }, { "id": "wiki20220301en039_79804", "title": "Tuberculosis management", "score": 0.013295383655645664, "content": "An alternative regimen is 2HRE/7HR, for which there is excellent clinical trial evidence. The 1994 US CDC guidelines for tuberculosis erroneously cite Slutkin as evidence that a nine-month regimen using only isoniazid and rifampicin is acceptable, but almost all of the patients in that study received ethambutol for the first two to three months (although this is not obvious from the abstract of that article). This mistake was rectified in the 2003 guidelines. This regimen (2HRE/7HR) is the first-line regimen used to treat M. bovis, since M. bovis is intrinsically resistant to pyrazinamide. Regimens omitting ethambutol EMB intolerance or resistance is rare. If a patient is truly intolerant or is infected with TB that is resistant to EMB, then 2HRZ/4HR is an acceptable regimen. The main motivator for including EMB in the initial two months is because of increasing rates of INH resistance. Tuberculosis and other conditions" }, { "id": "wiki20220301en039_79751", "title": "Tuberculosis management", "score": 0.01304546841623436, "content": "Drug regimens are similarly abbreviated in a semistandardised manner. The drugs are listed using their single letter abbreviations (in the order given above, which is roughly the order of introduction into clinical practice). A prefix denotes the number of months the treatment should be given for; a subscript denotes intermittent dosing (so 3 means three times a week) and no subscript means daily dosing. Most regimens have an initial high-intensity phase, followed by a continuation phase (also called a consolidation phase or eradication phase): the high-intensity phase is given first, then the continuation phase, the two phases divided by a slash. So, 2HREZ/4HR3 means isoniazid, rifampicin, ethambutol, pyrazinamide daily for two months, followed by four months of isoniazid and rifampicin given three times a week. In the US only, streptomycin is not considered a first line drug by ATS/IDSA/CDC because of high rates of resistance. The WHO have made no such recommendation." }, { "id": "wiki20220301en039_79748", "title": "Tuberculosis management", "score": 0.012968474761586588, "content": "Tuberculosis management refers to the medical treatment of the infectious disease tuberculosis (TB). The standard \"short\" course treatment for TB is isoniazid (along with pyridoxal phosphate to obviate peripheral neuropathy caused by isoniazid), rifampicin (also known as rifampin in the United States), pyrazinamide, and ethambutol for two months, then isoniazid and rifampicin alone for a further four months. The patient is considered to be free of living bacteria after six months. For latent tuberculosis, the standard treatment is six to nine months of daily isoniazid alone or three months of weekly (12 doses total) of isoniazid/rifapentine combination. If the organism is known to be fully sensitive, then treatment is with isoniazid, rifampicin, and pyrazinamide for two months, followed by isoniazid and rifampicin for four months. Ethambutol need not be used. Drugs" }, { "id": "pubmed23n1062_12528", "title": "Principles of chemotherapy for tuberculosis in national tuberculosis programmes of low- and middle-income countries.", "score": 0.012757104726016644, "content": "National tuberculosis programmes (NTPs) should aim for achieving a very high proportion of cure of all tuberculosis (TB) cases. Ineffective chemotherapy of TB that keeps a substantial proportion of patients alive without cure may amplify resistance during treatment and promote transmission of TB. In 2017, the World Health Organization (WHO) recommended that in patients who require TB retreatment, the retreatment regimen that comprised 8 months of isoniazid, rifampicin and ethambutol supplemented by streptomycin for the initial 2 months, and pyrazinamide for the initial 3 months (2SHRZE/HRZE/5HRE) should no longer be prescribed and drug susceptibility testing (DST) should be conducted to inform the choice of treatment regimen. While GeneXpert MTB/RIF assay may detect rifampicin resistance, it does not detect isoniazid resistance. A 6-month regimen consisting of rifampicin, isoniazid, pyrazinamide and ethambutol may be used for the treatment of previously treated cases in whom rifampicin resistance has been excluded but DST of isoniazid is not available. WHO recommended to treat isoniazid-resistant, rifampicin-susceptible TB (Hr-TB) with rifampicin, ethambutol, pyrazinamide and levofloxacin for a duration of 6 months. In several low- and middle-income countries, the majority of Hr-TB cases are detected after the initiation of treatment with first-line regimens. If patients have an unsatisfactory response to first-line treatment with persistent positive sputum, modification of regimens needs to be done very carefully. Adding a fluoroquinolone in cases with undetected rifampicin resistance runs the risk of acquired fluoroquinolone resistance. Recently, WHO advises NTPs to phase out the injectable-containing short regimen for multidrug-resistant and rifampicin-resistant TB (MDR-/RR-TB) and recommends that the preferred treatment option is a shorter, all-oral, bedaquiline-containing regimen. WHO emphasizes that access to rapid DST, especially for ruling out fluoroquinolone resistance, is required before starting the bedaquiline-containing shorter regimen. The problem is that access to rapid DST for ruling out fluoroquinolone resistance is limited in low- and middle-income countries. The use of WHO-recommended bedaquiline-containing regimens in the treatment of MDR-/RR-TB patients with undetected resistance to fluoroquinolones runs a high risk of acquired bedaquiline resistance, especially in settings with a high prevalence of fluoroquinolone resistance. It is crucial to mitigate the risks of both primary and acquired resistance of rifampicin, fluoroquinolone and bedaquiline by rational design of regimens and effective management of TB patients." }, { "id": "wiki20220301en051_40166", "title": "Denis Mitchison", "score": 0.01257396449704142, "content": "Research The framework of this work was a series of clinical trials in the UK and in larger numbers in East Africa, India, Hong Kong, Singapore and Czechoslovakia. This work passed through two stages; the first dealt with the problem of drug-resistant tubercle bacilli, which was solved by the use of regimens incorporating 2, 3 or 4 different anti-tuberculosis drugs. Starting with a publication in 1970, the second phase dealt with the shortening the treatment period from at least 12 months to 6 months by using rifampicin and pyrazinamide in so-called \"short-course\" regimens which have been the basis of current standard therapy with 2 months of 4 drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) followed by 4 months of rifampicin and isoniazid. He established specialist TB laboratories in Kenya, Uganda, Tanzania, Zambia and a central laboratory in Hong Kong." }, { "id": "wiki20220301en166_44925", "title": "WHO Model List of Essential Medicines", "score": 0.012366942428777141, "content": "Reserve group antibiotics Cefiderocolα Ceftazidime/avibactam (ceftazidime + avibactam)α Colistinα Fosfomycinα Linezolidα Meropenem/vaborbactam (meropenem + vaborbactam)α Plazomicinα Polymyxin Bα Antileprosy medicines Clofazimine Dapsone Rifampicin Antituberculosis medicines Ethambutol Ethambutol/isoniazid/pyrazinamide/rifampicin (ethambutol + isoniazid + pyrazinamide + rifampicin) Ethambutol/isoniazid/rifampicin (ethambutol + isoniazid + rifampicin) Isoniazid Isoniazid/pyrazinamide/rifampicin (isoniazid + pyrazinamide + rifampicin) Isoniazid/rifampicin (isoniazid + rifampicin) Isoniazid/rifapentine (isoniazid + rifapentine) Moxifloxacin Pyrazinamide Rifabutin Rifampicin Rifapentine Amikacinα Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid)α Bedaquilineα Clofazimineα Cycloserineα Delamanidα Ethionamideα Levofloxacinα Linezolidα Meropenemα Moxifloxacinα P-aminosalicylic acidα Streptomycinα" }, { "id": "pubmed23n0261_4982", "title": "[Six-month short course chemotherapy containing pyrazinamide for initial treatment of pulmonary tuberculosis].", "score": 0.012122993277249184, "content": "From January 1991 to December 1992, 419 patients with pulmonary tuberculosis were initially treated at Fukujuji Hospital. Among them, 190 patients, who were younger than 80 years old and had pulmonary tuberculosis with cavities or infiltration of extension 2 or 3, and/or were sputum-smear positive, had been treated by 6-month short course regimen containing pyrazinamide, 2HRS(E)Z/4HRE. And were eligible for the evaluation of the clinical usefulness of pyrazinamide-containing regimen for the initial treatment of pulmonary tuberculosis. The dose of pyrazinamide was 1.2 g per day irrespective of body weight. The patients of this treatment group consisted of 151 males and 39 females, and mean age of the males was 45.3 and that of the females was 43.8 years old. At the start of the treatment, 74% of the cases were smear positive, 70% were cavitary, and 6 cases each showed primary resistance to isoniazid and to streptomycin, respectively, and only one case showed resistance to both of isoniazid and streptomycin. There was no primary resistant case to either rifampicin or ethambutol. Bacteriologic negative conversion rates were 95% and 90% after 2 months of treatment by PZA-containing regimen and by the standard regimen, respectively, and treatment durations required to achieve the negative conversion of all cases were 3 and 6 months for respective regimens. Of 90 patients who completed 6-month PZA-containing regimen and could be followed-up, only one bacteriologic relapse (1.1%) was noticed. Elevation of serum GPT level higher than 150 IU/ml during the treatment was noticed in 6.3% of 175 cases under PZA-containing regimen in comparison with 4.0% of 174 cases under the standard regimen (not significant). The interval between the onset of the treatment and the detection of abnormal liver function was much shorter (mean 31.3 days) in the PZA-containing regimen than in the standard regimens (mean 63.4 days). Hyperuricaemia (&gt; 10 mg/ml) was noticed in 46.7% of 57 males and 59.4% of 19 females tested, but pyrazinamide was not discontinued in any case due to arthralgia. These results clearly show that pyrazinamide can be used rather safely for Japanese tuberculosis patients. If the pyrazinamide-containing regimen [2HRS(E)Z/4HRE] is adopted as the new standard regimen in place of on-going standard regimen in Japan, 6HRS(E)/3HR, the duration of chemotherapy could be shortened by three months with the same level of both efficacy and safety. We recommended pyrazinamide-containing 6-month regimen, 2HRS(E)Z/4HRE, as the new standard regimen for the initial treatment of pulmonary tuberculosis." }, { "id": "wiki20220301en030_65356", "title": "Rifampicin", "score": 0.011974789915966386, "content": "Medical uses Mycobacteria Rifampicin is used for the treatment of tuberculosis in combination with other antibiotics, such as pyrazinamide, isoniazid, and ethambutol. For the treatment of tuberculosis, it is administered daily for at least six months. Combination therapy is used to prevent the development of resistance and to shorten the length of treatment. Resistance of Mycobacterium tuberculosis to rifampicin develops quickly when it is used without another antibiotic, with laboratory estimates of resistance rates from 10−7 to 10−10 per tuberculosis bacterium per generation." }, { "id": "wiki20220301en095_36844", "title": "Rifampicin/isoniazid/pyrazinamide", "score": 0.011970306217135789, "content": "Rifampicin/isoniazid/pyrazinamide was approved for medical use in the United States in 1994. It is on the World Health Organization's List of Essential Medicines. Medical uses The hope of a fixed-dose combination pill is to increase the likelihood that people will take all of three medications. Also, if people forget to take one or two of their drugs, they might not then develop resistance to the remaining drugs. Society and culture It is manufactured by Aventis. See also Tuberculosis treatment Rifampicin + isoniazid + ethambutol References Anti-tuberculosis drugs Combination drugs Rifamycin antibiotics Wikipedia medicine articles ready to translate Sanofi World Health Organization essential medicines" }, { "id": "pubmed23n0300_7715", "title": "[Dynamics of isolation of mycobacterium tuberculosis during 2-stage standard chemotherapy].", "score": 0.011970110139179091, "content": "Two-stage standard chemotherapy was performed in 149 newly detected patients with pulmonary tuberculosis, by isolating Mycobacteria. Within the first 2 months, the patients received 4 drugs: isoniazid, rifampicin, pyrazinamide, streptomycin or ethambutol. Treatment with two agents (isoniazid and rifampicin) was continued for 4 months. Mycobacterial isolation was stopped in 104 patients after 2 months of treatment, in other 26 after 3 months, which amounts to 80.2%. Higher therapeutical results were observed in patients who had isolated Mycobacteria resistant to 1 and even 2 drugs." }, { "id": "pubmed23n0570_20667", "title": "Effect of initial isoniazid resistance on response to chemotherapy of tuberculosis: A review of clinical trials.", "score": 0.011876887576775595, "content": "This study evaluated seventeen clinical trials of short-course chemotherapy of tuberculosis and assessed the influence of initial resistance to isoniazed on the response to therapy. High failure rates were observed for the non-rifampicin-containing regimens. When rifampicin was included, there was a very good response among patients suffering from sensitive and resistant strains. Regimens that included both rifampicin and pyrazinamide yielded the best results, with low failure rates observed for sensitive and resistant patients. The addition of streptomycin and ethambutol to these regimens did not improve the response in patients with isoniazid-resistant bacilli. Prolonged therapy generally yielded a better response; however, in rifampicin-containing regimens, the use of pyrazinamide for more than two months did not influence the outcome of therapy. In patients with isoniazid-resistant strains, 4- and 6-month regimens containing rifampicin and pyrazinamide both yielded low failure rates. Initial isoniazid resistance had very little impact on the response to such regimens when therapy was carried out for 6 months." }, { "id": "pubmed23n0273_15005", "title": "[Disseminated tuberculosis with a multiresistant strain of Mycobacterium tuberculosis in an HIV-infected Swiss male].", "score": 0.011799105607155143, "content": "Multidrug-resistant M. tuberculosis in HIV-infected people has not yet been reported in Switzerland, and there have been no nosocomial epidemics as they have recently occurred in the USA. We present the case of a 38-ear-old HIV-infected man who developed disseminated tuberculosis as AIDS-defining disease. Initially he was treated with isoniazid, pyrazinamide and rifampin. Due to the emergence of resistance to isoniazid and streptomycin, ethambutol was added for one month. Later the therapy was changed back to the initial three drugs. The patient responded well to this therapy, but five months later developed a relapse. In addition to the originally diagnosed double-drug resistance, a reduced susceptibility to rifampin appeared. Ethambutol, ciprofloxacin and amikacin were added to the original three-drug regimen. This resulted in rapid clinical improvement, although sputum cultures remained positive for M. tuberculosis two months later. This isolate was resistant to pyrazinamide. For that reason pyrazinamide was replaced by clofazimine. 14 months after diagnosis the patient died of hepatic failure. Because there was a delay in isolation of one week, 37 potentially exposed health care workers were tested by the Mantoux skin test. No conversions were observed. This case report demonstrates that tuberculosis in HIV-infected patients in Switzerland may be caused by multidrug-resistant M. tuberculosis. We propose that until the results of a susceptibility assay are known, a four-drug combination should be used initially in this patient group." }, { "id": "pubmed23n0285_15669", "title": "[Therapy and prognosis of tuberculosis].", "score": 0.01105006105006105, "content": "Treatment and prognosis of tuberculosis. Worldwide the so-called short-course chemotherapy has become the standard treatment for tuberculosis. The 6-month regimen consists of isoniazid, rifampin, and pyrazinamid given for 2 month followed by isoniazid and rifampin for 4 month. Ethambutol or streptomycin is added in the first 2 month in patients with advanced disease. This recommendation applies to both HIV-infected and uninfected persons. The major determinant of the outcome of treatment is patient adherence to the drug regimen. In susceptible strains the success rate with the 6-month regimen in sputum conversion is far beyond 90% within the first two month of therapy. The relapse rate after 3 to 5 years is about 0-3%. Multiple-drug-resistant tuberculosis (i.e., resistance to at least two drugs) presents difficult treatment problems. Treatment must be individualized and based on susceptibility studies. For patients with tuberculosis that is resistant to rifampin and isoniazid, even the best available treatment is often unsuccessful. The role of new agents such as the quinolone derivatives and amikacin in the treatment of multidrug-resistant disease is not known, although these drugs are commonly being used in such cases." }, { "id": "wiki20220301en039_79869", "title": "Tuberculosis management", "score": 0.010392482034273079, "content": "There are several treatment regimens available: 9H—Isoniazid for 9 months is the gold standard and is 93% effective. 6H—Isoniazid for 6 months might be adopted by a local TB program based on cost-effectiveness and patient compliance. This is the regimen currently recommended in the UK for routine use. The US guidance exclude this regimen from use in children or persons with radiographic evidence of prior tuberculosis (old fibrotic lesions). (69% effective) 6 to 9H2—A twice-weekly regimen for the above two treatment regimens is an alternative if administered under Directly observed therapy (DOT). 4R—Rifampicin for 4 months is an alternative for those who are unable to take isoniazid or who have had known exposure to isoniazid-resistant TB. 3HR—Isoniazid and rifampicin may be given for 3 months. 2RZ—The 2-month regimen of rifampicin and pyrazinamide is no longer recommended for treatment of LTBI because of the greatly increased risk of drug-induced hepatitis and death." }, { "id": "pubmed23n0939_5706", "title": "Short-course Regimen for Subsequent Treatment of Pulmonary Tuberculosis: A Prospective, Randomized, Controlled Multicenter Clinical Trial in China.", "score": 0.010337642910567369, "content": "We designed a prospective, multicenter, randomized, controlled study to assess a 5-month regimen compared with the standard regimen on previously treated patients with pulmonary tuberculosis (TB). We enrolled 917 sputum smear-positive patients undergoing additional treatment in 27 major tuberculosis hospitals in China. Patients were randomly assigned to a test group (n = 626)treated with a 5-month regimen of moxifloxacin, pasiniazid, rifabutin, ethambutol, and pyrazinamide or a reference group (n = 291) treated with an 8-month regimen of isoniazid, rifampicin, and streptomycin. All patients with a favorable response were followed up for 5 years after the end of treatment. Of the study patients, 61 in the test group and 19 in the reference group had multidrug-resistant (MDR) TB. The treatment success rate in the study group was 74.12%, which was significantly higher than the 67.70% in the reference group (P = 0.04), whereas the treatment success rate of patients with MDR-TB was not significantly different between the test and reference groups (70.5% vs 63.1%, P =0.79). The adverse effects rates in the test and reference groups were 7.4% and 3.1%, respectively (P = .01). The difference in the TB recurrence rates between the group arm (9.6%) and the reference group (21.8%) was statistically significant (P &lt; 0.001). The moxifloxacin, pasiniazid, rifabutin, ethambutol, and pyrazinamide test regimen yielded higher success and lower recurrence rates than the currently recommended isoniazid, rifampicin, and streptomycin regimen, but the rate of adverse effects was higher. ClinicalTrials.gov identifier: NCT02331823." }, { "id": "wiki20220301en161_27940", "title": "National TB Elimination Program (India)", "score": 0.010286225402504472, "content": "Treatment Services Standardized treatment regimen composed of multiple anti-Tuberculosis drugs are provided through the program. Typically, drug regimen consist of a intensive phase of about two to six months and a longer continuation phase of four to one and half years. Based on the nature of anti-microbial resistance to the disease different treatment regimen are offered through the program. New Cases and those which exhibit no resistance are offered a six month, short course of the four first line drugs; Isoniazid-H: Rifampicin-R, Pyrazinamide-Z, and Ethambutol-E. The drugs are administered through daily weight band based doses of Fixed Dose Combinations, consisting of HRZE for the intensive phase of two months and HRE for the continuation phase of four months. For drug resistant cases, depending upon the pattern of drug resistance a number of regimen are available composed of a combination of 13 drugs.. Public private partnership under RNTCP" }, { "id": "pubmed23n0227_494", "title": "A controlled trial of individually-adapted short-course chemotherapy versus two-year scheme in original treatment of pulmonary tuberculosis. Report after a five-year follow-up.", "score": 0.009900990099009901, "content": "Patients with culture-positive pulmonary tuberculosis were allocated at random into two groups for a three-phase regimen in original course chemotherapy. The first group was given rifampicin (RMP) plus isoniazid (INH) plus ethambutol until sensitivity tests were completed, then RMP plus INH until culture conversion, thereafter INH alone for four months. The second group received the same drugs until obtaining culture conversion, thereafter IHN alone for a period lasting two years after onset of chemotherapy. One hundred sixty-eight patients were available for the final assessment after a five-year follow-up after culture conversion. Two bacteriologic relapses occurred among the two-year scheme patients, none in the short-course patients." }, { "id": "wiki20220301en028_67554", "title": "ATC code J04", "score": 0.00980392156862745, "content": "J04AM Combinations of drugs for treatment of tuberculosis J04AM01 Streptomycin and isoniazid J04AM02 Rifampicin and isoniazid J04AM03 Ethambutol and isoniazid J04AM04 Thioacetazone and isoniazid J04AM05 Rifampicin, pyrazinamide and isoniazid J04AM06 Rifampicin, pyrazinamide, ethambutol and isoniazid J04AM07 Rifampicin, ethambutol and isoniazid J04AM08 Isoniazid, sulfamethoxazole, trimethoprim and pyridoxine J04B Drugs for treatment of lepra J04BA Drugs for treatment of lepra J04BA01 Clofazimine J04BA02 Dapsone J04BA03 Aldesulfone sodium References Tuberculosis J04" } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 304 ] ], "word_ranges": [ [ 0, 41 ] ], "text": "This clinical picture is called Frey's syndrome and consists of an anomalous reinnervation of regional structures after parotidectomy due to lesion of the auriculotemporal nerve, so that during mastication, erythema and preauricular sweating occur. The treatment is intradermal botulinum toxin injection." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Extended total parotidectomy on suspicion of tumor recurrence.", "2": "Pregabalin.", "3": "Intradermal botulinum toxin injection.", "4": "Broad-spectrum antibiotherapy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0680_6897", "title": "[Thirteen years' experience with superficial partial parotidectomy as treatment for benign parotid tumours].", "score": 0.0177750058470414, "content": "Most authors agree that surgery is the treatment of choice for benign tumours of the parotid gland. However, the best surgical technique and the extent of surgery remain controversial. This study attempts to establish whether the implementation of a partial superficial parotidectomy (PSP) is appropriate for the treatment of benign parotid gland tumours. We selected 63 patients with benign parotid gland surgery, of whom 43 had a pleomorphic adenoma and 20, a Warthin tumour. Of this group of 63 patients, 6 could not be included. We consequently studied 57 patients, 41 of them diagnosed as pleomorphic adenoma and 16, as Warthin tumours. In all of them, a PSP was performed without intraoperative monitoring of the facial nerve. Transient facial nerve paralysis, 14 patients (24.5%). Ten cases were resolved within the first month after surgery and 4 before the third month, after indicating facial physiotherapy. One patient (1.7%) had a permanent difficulty in keeping one side of the lower lip aligned under pressure-mobility, without altering commissure mobility. None of the patients studied had a recurrence (control, 3-13 years). Although PSP is a technique with a few complications, it has a recurrence rate comparable to or lower than other techniques used for the treatment of pleomorphic adenomas or Warthin parotid tumours. Intraoperative facial nerve monitoring can be helpful during surgery. The lack of monitoring would not be considered a contraindication for surgery." }, { "id": "pubmed23n0347_17139", "title": "Botulinum toxoid in the management of gustatory sweating (Frey's syndrome) after superficial parotidectomy.", "score": 0.017182890855457225, "content": "Botulinum toxin has been successfully used to treat Frey's syndrome occurring in a 31-year-old patient following superficial parotidectomy for pleomorphic adenoma. An initial injection of 7.5 U (0.3 ml over 6 cm2 of cheek) resulted in 3 months' resolution of gustatory sweating and flushing and a second injection 12 months' symptomatic improvement. The symptoms recurred after further facial surgery." }, { "id": "pubmed23n0055_18124", "title": "[Treatment of recurrence of pleomorphic adenomas of the parotid gland].", "score": 0.017157397310069065, "content": "This is a retrospective study of 10 patients who underwent surgery for a first or multiple recurrence of pleomorphic adenoma (P.A.). Recurrence may come more than 10 years after an initial episode. During initial surgery, the risk of recurrence is related to pre-operative dissemination and to failure to identify tumoral prolongations in the parotid gland. Recurrence is generally multifocal. In 2 cases, carcinoma developed in association with P.A. Treatment of benign recurrence is surgical: it consists of totalizing the previous parotidectomy. If the previous parotidectomy has been total, tumorectomy is carried out. In all cases, surgery preserves the facial nerve trunk." }, { "id": "pubmed23n0376_14673", "title": "[Frey syndrome after lateral parotidectomy. Follow-up and therapeutic outlook].", "score": 0.016533442645350824, "content": "Gustatory sweating is a common complication of parotid surgery. In order to evaluate the incidence of Frey's syndrome following superficial parotidectomy, 69 patients who underwent surgery due to adenoma were studied. Forty-three patients (62%) suffered from gustatory sweating following superficial parotidectomy, and 33 of them requested treatment. Nineteen patients felt that their quality of life had been decreased by the symptoms. Minor's starch iodine test proved that 85% of the patients who did not notice Frey's syndrome after surgery actually had a subclinical manifestation. Eight patients were successfully treated with intracutaneous injections of botulinum toxin A. Within 1 week gustatory sweating disappeared. Frey's syndrome is present in almost all patients following superficial parotidectomy and there is a strong need for treatment. Intracutaneous injection of botulinum toxin A is an effective treatment in severe cases of the syndrome." }, { "id": "wiki20220301en421_8393", "title": "Parotidectomy", "score": 0.016515330964600606, "content": "Complications Complications that may occur due to parotidectomy involve nerve dysfunction, Frey’s syndrome (uncharacteristic sweating near glands), salivation from wound, numbness, facial asymmetry, necrosis (death of skin) near incision, and tumor reappearance. Prognosis There is a 25-50% risk of facial weakness directly after parotidectomy and a 1-2% risk of permanent weakness. Frey’s syndrome may occur in up to 90% of patients. Risk of mortality is very low in reference to the surgery. In a case of benign tumor, such as pleomorphic adenoma, a significant outcome is also the rate of tumor recurrence. Pleomorphic adenomas may recur after a very long time from primary surgery, on average over 7–10 years and up to 24 years. Survival rates due to malignancy depends on the patient and extent of disease. A 10-year survival ranges from 32-83%. Of all cancers, salivary gland tumors account for only 1%. Parotid tumors account for 7% of all head and neck cancers. Etymology" }, { "id": "pubmed23n0585_13388", "title": "[Frey syndrome secondary to submaxillectomy and botulinic treatment].", "score": 0.016453503863575806, "content": "A case of Frey syndrome (FS) secondary to submaxillar gland exeresis is presented and the results of the treatment with botulinum toxin (BTX) type A. FS is a condition of sweating cheek and preauricular area during realtime as a sequel detected in about 20-60% of patients after parotidectomy. The clinical symptoms include swelling, flushing and hyperhidrosis. The treatment choice for this condition is intracutaneous injection of BTX type A which blocks acetylcholine release at the sweat glands. A 30-year-old man, with thyroid medullar carcinoma diagnosed in 2002 received 6 cicles of cisplatin plus doxorubicin previous to the thyroidectomy with anterolateral neck dissection. During surgery the left ramus marginalis mandibulae was damaged. Two years later the patient referred sweating in submaxillar region during meals. CT scan demonstrated the absence of left submaxillar gland. Minor's test disclosed the affected area and BTX type A was injected (2.5 U/cm2/17 points). A twenty-one-day control showed a 95% reduction of the affected skin area. Persistent efficacy was observed up to one year follow-up time when he was reinjected. The FS, also known as \"gustatory hyperhidrosis\", was probably first reported by M. Duphenix in 1757. Lucja Frey considered its physiopathology as a disorder of both sympathetic and parasympathetic innervation. In our case the FS was caused by a misdirected regeneration of postganglionic parasympathetic nerve fibers that arrised from the nervus lingualis rami ganglionares of the nervus trigeminus. After nerve injury the colinergic parasympathetic fibers seek out colinergic receptors--sympathetic receptors of the skin--innervating sweat glands and small skin vessels. All previous cases were located at masseter region post-parotidectomy. We have not found any description of FS in the submaxillary region. The self-assessed efficacy of the treatment with a hyperhidrosis disease severity scale revealed a very satisfied patient at 20 months follow-up after being injected twice with BTX type A." }, { "id": "pubmed23n0299_15861", "title": "[Reoperation and recurrence of pleomorphic adenoma of the parotid. A propos of 62 cases].", "score": 0.016403361344537813, "content": "Between 1967 and 1994, 344 patients were treated with total conservative parotidectomy for benign pleomorphic adenoma of the parotid gland. Our retrospective study focuses on a sixty-two patients group treated for recurrence after biopsy, enucleation or total parotidectomy. Twenty-two patients underwent a systematic total parotidectomy after biopsy (n = 7) or enucleation (n = 15). Twenty-nine patients were treated with total parotidectomy for local recurrence after enucleation. The mean time before this treatment was 8 years-9 months. In the third group, 11 patients, (7 patients from our institution), were surgically treated for recurrence after total parotidectomy. After enucleation, the recurrence rate was high and insufficient margins were found in 27% of the cases. In this group, a multicentric recurrence was found in 45% of the cases. In our own experience, recurrence after total parotidectomy was noted in 2.4%. The surgical salvage was performed with enucleation after identification of the branches of the facial nerve. The operative microscope was usefull. In 1 case, a second recurrence occured, and in 1 case iterative recurrence was noted. The local control rate after total parotidectomy was 99.6% (292/293). Total conservative parotidectomy is, for us, the treatment of choice for pleomorphic adenoma of the parotid gland." }, { "id": "pubmed23n0297_7224", "title": "[Development and results of surgical treatment of pleomorphic adenoma of the parotid gland in 245 patients, 1974-1994].", "score": 0.01584627862000125, "content": "To describe the results of parotidectomy for pleomorphic adenoma of the parotid gland in 245 patients, 1974-1994. Descriptive. Academic Medical Hospital, Free University, Amsterdam, the Netherlands. Of all patients follow-up data were obtained by yearly physical diagnostic examination during 10 years, and by a questionnaire (1995) from the general practitioners involved. In the period 1974-1994, 246 primary surgical parotid procedures were performed on 245 patients for pleomorphic adenoma. The surgical procedures included: 131 'partial' and 61 'complete' superficial parotidectomies, 30 partial superficial/ deep lobe parotidectomies, 8 total parotidectomies, and 16 'selective' deep lobe parotidectomies. Eleven patients received postoperative radiotherapy for different reasons. The median follow-up was 95 months. Fourteen patients died without recurrent tumour. Two patients (0.8%) developed a local recurrence, both after total parotidectomy for a deep lobe tumour. None of the patients experienced permanent facial nerve paresis or paralysis. The incidence of auriculotemporal sweating for partial superficial parotidectomy proved to be 6.9% (9/I31) as compared with 13.1% (8/61) for complete superficial parotidectomy. In the later years, in the majority of patients, the posterior branch of the greater auricular nerve was preserved. In the hands of the experienced head and neck surgeon partial parotidectomy is an effective treatment for the great majority of pleomorphic adenomas: local recurrence is rare, while in general morbidity is minimal. Rarely there is a need for prolonged follow-up." }, { "id": "pubmed23n0416_22248", "title": "[Successful use of botulinum toxin injection in the treatment of salivary fistula following parotidectomy].", "score": 0.015844218674407353, "content": "A twenty-year-old woman underwent right superficial parotidectomy for pleomorphic adenoma. On the 10th postoperative day she presented with a salivary fistula, for which repeated aspirations with pressure dressings were applied for a month. Despite decreases in the salivary fluid volume, reaccumulation persisted. Following aspiration of the salivary fluid, 40 units of botulinum toxin was injected into the pouch. On the second day of injection, the discharge ceased and the pouch disappeared. No side effects were observed and the patient remained symptom-free during four-month follow-up." }, { "id": "pubmed23n0589_14957", "title": "Treatment of Frey's syndrome with botulinum toxin.", "score": 0.015297202797202798, "content": "Frey s syndrome or Gustatory sweating was first described by Baillarger in 1853. Lucie Frey had described a patient as \"auriculotemporal syndrome\" in 1923. The explanation for this symptom has been an aberrant regeneration of postganglionic parasympathetic fibers feeding the parotid gland that are severed during parotidectomy. After parotidectomy, these cholinergic parasympathetic fibers regenerate and anastomosis with postganglionic sympathetic fibers that supply vessel and sweat gland of the skin. According to a recent study, the treatment of Frey's syndrome has no treatment of choice. The authors investigated the effectiveness of botulinum toxin type A in the treatment of Frey's syndrome for the first time in Thai patients. The present study was a prospective non-randomized, exploratory study. Nine patients with a median involvement skin area of 4.2 cm2 (1-16.3) were injected intradermal with botulinum toxin type A 2 unit in every 1 cm2 of involved skin. The mean total dose was 10.6 units (range 2-32 unit). All of the patients showed improvement after 4-7 days. Five patients have no Gustatory sweating. In the same way, four patients present with a dramatic decrease in Gustatory sweating. When comparing the skin involvement area, indicated by Minor's iodine starch test and calculated by program ImageJ 1.34s, between before and after injection of botulinum toxin type A using sign test, the result is statistically significant with p = 0.0039. The result lasted for 9.2 months (7-10 months). Intradermal injection of botulinum toxin type A for patients with Frey's syndrome is not only effective with no side effect but also minimally invasive. The present report supports that intradermal injection of botulinum toxin type A should be the treatment of choice for Frey's syndrome." }, { "id": "pubmed23n0369_8023", "title": "[Post-parotidectomy Frey's syndrome. Treatment with botulinum toxin type A].", "score": 0.014564564564564564, "content": "The Frey's syndrome, manifest after parotid trauma, is characterized by head and neck hyperemia and abundant sweating of the hyperemic skin in response to gustatory stimuli. The use of the botulin toxin to treat the symptoms in patients with Frey's syndrome has been described in numerous studies. For some time up until now our Center has achieved excellent results using the group A botulin toxin to overcome the hypertonus of the cricopharyngeal muscle in patients who had undergone laryngectomy and were rehabilitated with voice button. We have sought to extend the use of this toxin to Frey's syndrome, a relatively frequent complication of parotidectomy. A total of 86 patients participated in the study: 41 males (47.6%) and 45 females (52.4%) ranging in age from 25 to 77 years (average age 51 years). Of these patients 7 (8.1%) had undergone post-operative radiotherapy. Of the 86 patients studied, 18 referred significant symptoms in terms of abundance and frequency. The syndrome was considered severe if the symptoms were present at each meal and if the patient indicated a significant worsening of his quality of life. Intermittent episodes were indicated by 22 patients. The remaining 46 (43.5%) did not complain of any symptoms. The exact extension of the cervicofacial gustatory sweating was evaluated using the Minor test and the involved region was divided into 1 square centimeters sections. The amount of skin surface involved ranged from 10 to 80 square centimeters. The type A neurotoxin was frozen and was reconstituted with a sterile saline solution at a final concentration of 2.5 UI/0.1 ml. The intracutaneous infiltration was performed without anesthesia, infiltrating 0.1 ml of solution, containing 2.5 UI of toxin into the center of each 1 square centimeters section. Statistical analysis was performed to evaluate the potential relationship between how long the treatment was effective, incidence of recurrence, seriousness of the crises and the following variables: age, sex, histology, cutaneous surface involved, injected dose of botulin toxin and post-operative radiotherapy. In the group of 18 patients with severe symptoms (20.9%) the benefit was immediate in all cases although the recurrence rate was 50%. The Frey's syndrome symptoms disappeared within 7 days of infiltration. In the group of 22 patients with less severe involvement (25.5%), the treatment gave positive, definitive results in 16 patients (72.7%). Those patients whose symptoms persisted were treated a second time with an infiltration of 2.5 UI per square centimeters. We feel that the use of the type A botulin toxin is the most appropriate treatment for the Frey's syndrome. In fact, such treatment offers the following advantages: it is effective within 7 days, has limited side effects, can be applied on an outpatient basis, is inexpensive and is positively considered by the patients." }, { "id": "wiki20220301en073_31938", "title": "Pleomorphic adenoma", "score": 0.014211334926596108, "content": "There have been several approaches for surgery of parotid pleomorphic adenoma in the course of time. Enucleation of the tumor (i.e. intracapsular dissection), a procedure that was common in the early 20th century, is nowadays obsolete due to very high incidence of recurrence. After the time of enucleations, pleomorphic adenomas of parotid gland were recommended to be routinely treated with superficial or total parotidectomy. These procedures combine complete tumor removal and identification of the main trunk of facial nerve during surgery to avoid any lesions to the nerve. However, extensive surgery may cause significant morbidity, such as Frey´s syndrome (excessive sweat while eating) and salivary fistula. Also, aesthetic outcome may be compromised. Therefore, less invasive procedures have been preferred in selected cases during the recent years, and introduction of perioperative neuromonitoring enabled the evolution of several different surgical techniques some twenty years ago." }, { "id": "pubmed23n0792_11512", "title": "Pleomorphic adenoma and benign parotid tumors: extracapsular dissection vs superficial parotidectomy--review of literature and meta-analysis.", "score": 0.013886907309649497, "content": "This study compared extracapsular dissection (ED) vs superficial parotidectomy (SP) in the treatment of pleomorphic adenoma and benign parotid tumors. The research covered the years 1950-2011 in PubMed, Ovid MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus. Of 1152 articles screened, 123 studies met the inclusion criteria. A review of the nomenclature of the different parotid surgery techniques was done. Recurrence rate, permanent facial nerve paralysis, and Frey syndrome of patients who underwent ED vs those who underwent SP were compared by meta-analysis. Our meta-analysis data comparing ED and SP found that: (1) the recurrence rate is higher in patients treated with SP; (2) SP has a higher incidence of cranial nerve VII paralysis; and (3) Frey syndrome is more common after SP. ED may be a viable option in the treatment of unilateral benign parotid tumors of the superficial lobe, sized less than 4 cm, without involvement of the facial nerve." }, { "id": "wiki20220301en073_31939", "title": "Pleomorphic adenoma", "score": 0.013858115457438664, "content": "Currently, the choice of surgical approach for parotid pleomorphic adenoma is mainly based on the size, location, and mobility of the tumor. The recommended main techniques include extracapsular dissection, partial superficial parotidectomy, and lateral or total parotidectomy. Nevertheless, the experience of surgeon plays a key role in the results of these distinct procedures. An important point of view is that recurrent pleomorphic adenomas may occur after a very long time from primary surgery, on average over 7–10 years but up to 24 years afterwards. Thus, it is of utmost importance to evaluate the ultimate results of these different surgical techniques in the future. The benign tumors of the submandibular gland is treated by simple excision with preservation of mandibular branch of the facial nerve, the hypoglossal nerve, and the lingual nerve. Other benign tumors of minor salivary glands are treated similarly." }, { "id": "pubmed23n0266_6450", "title": "[Pleomorphic adenoma of the parotid gland. Results of surgical treatment].", "score": 0.013599853961299745, "content": "Twenty years experience of lateral parotidectomy as suspical treatment for pleomorphic adenoma are reviewed. All cases were managed at the ORL Clinic of the University of Zürich. 167 patients were followed for the frequency of possible recurrent tumors. Three patients (3/123) operated primarily developed a recurrences. Recurrences appeared after an average of 10 years, ranging from 1-30 years. The follow-up time varied from 1 to 21 years (average, 8 years). 39% (13 of 33) of the patients, who were re-operated for a recurrent tumor, developed another recurrence. The second recurrence appeared after an average of 10 years, ranging from 1-22 years. A persistent partial paresis of the facial nerve was found in 1% of the patients operated primarily and in 9% of the patients operated more than once. No paralysis was seen. We now choose \"en-bloc\" resections of pleomorphic adenomas without intra-operative opening of the tumor capsule as the treatment of choice. This treatment was possible in 83% of all cases, using a lateral parotidectomy. If tumor extends into the medial parotid lobe, total parotidectomy is required." }, { "id": "pubmed23n0320_7935", "title": "[Surgery in benign parotid tumors: individually adapted or standardized radical interventions?].", "score": 0.013473116921392785, "content": "Several authors demand emphatically that the minimal operative procedure in benign parotid gland tumors has to be a superficial parotidectomy. Of a consecutive series of 372 patients with benign parotid tumors treated in our department between 1973-1996 81% of the patients could be followed up 1-24 years. in 10.9% a total parotidectomy was performed, in 16% a lateral parotidectomy and in 73.1% a simple extirpation of the tumor (often taking away a small margin of surrounding parotid parenchyma). The operating microscope and microsurgical techniques were used in all of these operations. Of all the followed-up patients 2.3% developed a recurrence. There were no recurrences of cystadenolymphomas or of rare types of adenomas. Recurrences of primary treated pleomorphic adenomas occurred in 3.0%. In recurrent pleomorphic adenomas a further recurrence could be seen in 7.4% of the cases. The over-all incidence of permanent facial nerve weakness was 2.1%: 0.7% after extirpation, 3.3% after lateral parotidectomy and 9.7% after total parotidectomy. we observed in 6.3% a gustatory sweating. Our data prove that with simple extirpation similar results compared to lateral parotidectomy can be achieved concerning recurrence, function of the facial nerve and the Frey's syndrome. We suggest a surgical management adapted to the extent, the size and the location of the parotid gland tumors. In our opinion lateral or total parotidectomy should be reserved for tumors of larger amount or deep located tumors." }, { "id": "article-73061_35", "title": "Parotidectomy -- Complications", "score": 0.01328016643550624, "content": "Frey’s syndrome: more accurately referred to as gustatory sweating. Patients report facial swelling and sweating at the site of the parotidectomy in occurrence with meals. Etiology is believed to be aberrant innervation of the sweat glands with branches emerging from the auriculotemporal nerve after their division during surgery. This provides parasympathetic innervation to the normally sympathetic-innervated sweat glands [38] . Diagnosis is usually based on patient history, however if there is any doubt an iodine-starch test (Minor test) will confirm the diagnosis, where iodine starch placed on the affected area turns blue signaling sweat secretion. The incidence historically has been reported as high as 50 to 100%, though, with modern techniques and the use of SMAS flaps and thicker skin flaps at the time of initial elevation, this is greatly reduced and is now quite rare. Should this develop, surgical treatment options can be disappointing, with the best results obtained using SMAS and superficial temporal artery flaps as a barrier between the surgical site and the skin. Gold standard treatment now is botulinum toxin injection. Relief of symptoms is obtained for 6 to 36 months. It works at the pre-synaptic level of the neuromuscular and neuroglandular junction by blocking the release of acetylcholine. [37] [39]" }, { "id": "pubmed23n1091_11060", "title": "Botulinum toxin for chronic parotid sialadenitis: A case series and systematic review.", "score": 0.01290028206404513, "content": "To evaluate salivary gland chemodenervation with botulinum toxin in chronic parotid sialadenitis. Patients who underwent parotid gland chemodenervation for chronic sialadenitis due to duct stenosis refractory to siaendoscopy were reviewed (case series). Additionally, a systematic review of the literature on botulinum toxin injection for chronic parotid sialadenitis was performed. Inclusion criteria included studies containing original data on botulinum toxin injections in patients with chronic sialadenitis symptoms. Sialadenitis symptoms from 10 patients with 13 affected parotid glands were examined. All had duct stenosis diagnosed on sialendoscopy, refractory sialadenitis symptoms, and received parotid onabotulinum toxin injection(s) (median dose 65U). Of patients with 3-month follow-up, 78% reported significant improvement in symptoms. Mean Chronic Obstructive Sialadenitis Symptoms (COSS) Score improved at 3 months post-injection (47-25.9, <iP</i = .039) with significant reduction in gland pain frequency and gland swelling severity. No patients had a facial nerve paralysis or increased xerostomia. With the systematic review, 518 abstracts were reviewed and 11 studies met inclusion criteria and included case series or case reports with a total of 40 patients treated with botulinum toxin for chronic parotitis. Thirty-four out of a total of 35 patients in the studies (97%) reported complete (9, 26%) or partial (25, 71%) improvement in sialadenitis symptoms with minimal complications. Parotid gland chemodenervation with botulinum toxin is a minimally invasive treatment option for symptomatic chronic sialadenitis refractory to medical treatment or sialendoscopy. Botulinum toxin injections alleviate gland pain and swelling associated with salivary obstruction and provide an alternative to parotidectomy for recurrent sialadenitis.Level of evidence: 4." }, { "id": "pubmed23n0303_6743", "title": "Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland.", "score": 0.01284219001610306, "content": "Recent modifications of surgical technique may have influenced outcome following parotidectomy. This retrospective study compares the results of the different surgical methods with regard to recurrence rate and the effects on morbidity between 1974 and 1994. A total of 246 primary surgical parotid procedures were performed on 245 patients for pleomorphic adenoma. These included 131 'partial' superficial parotidectomies, 61 'total' superficial parotidectomies, 30 partial superficial/deep lobe parotidectomies, eight total parotidectomies, and 16 'selective' deep lobe parotidectomies. In the recent past, the posterior branch of the greater auricular nerve was preserved in the majority of patients. Eleven patients received postoperative radiotherapy. Median follow-up was 95 months. Fourteen patients died without recurrent tumour. Two patients (0.8 per cent) developed local recurrence, both after total parotidectomy for a deep lobe tumour. No patient experienced permanent facial nerve palsy. The incidence of gustatory sweating for partial superficial parotidectomy was 6.9 per cent (nine of 131) compared with 13.1 per cent (eight of 61) for total superficial parotidectomy. Partial parotidectomy is an effective treatment for the majority of pleomorphic adenomas; local recurrence is rare and morbidity is low. Prolonged follow-up is unnecessary." }, { "id": "pubmed23n0546_18065", "title": "Treatment of gustatory sweating with low-dose botulinum toxin A: a case report.", "score": 0.012828947368421053, "content": "Frey's syndrome, gustatory sweating in the preauricular area, is an unpleasant phenomenon occurring during meals after surgery on the parotid gland. Recently, botulinum toxin A (BTX) has been shown to reduce the symptoms, but the variation in the reported doses is large. To quantify the effect of treatment with low-dose BTX in a case of Frey's syndrome over a period of 6 months. A 56-year-old woman was treated with 10 U Botox given as 20 single, intracutaneous injections of 0.5 U, one for each cm(2), 3 years after resection of the parotid gland. Before treatment and repeatedly during the 6-month period, the sweating was rated subjectively on a 100-mm visual analog scale (VAS) and by a severity index, and objectively by assessment of the extent of the involved skin area using Minor's iodine-starch test, staining the area of sweating dark. The treatment decreased the involved area from 20 to 5 cm(2) and the VAS ratings from 98 to 8 mm. The index showed that treatment affected the sweating intensity, not the frequency. After the 6-month period the patient was still satisfied, but the involved skin area had increased; however, not entirely to pretreatment values. The effect of BTX injections for gustatory sweating obtained in this case was comparable to results reported using higher doses. Low doses of BTX can therefore be used in the treatment of Frey's syndrome, but studies to clarify the dose-response relationship, in terms of both time-course and obtained effect, are needed." }, { "id": "pubmed23n0823_24953", "title": "Interventions for the treatment of Frey's syndrome.", "score": 0.012704933622427632, "content": "Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe. To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome. We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014. We included randomised or quasi-randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch-iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch-iodine test, the iodine-sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms). We used the standard methodological procedures expected by The Cochrane Collaboration. We identified no RCTs or quasi-RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full-text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment. We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome.RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures." }, { "id": "wiki20220301en110_5731", "title": "Frey's syndrome", "score": 0.01254551473022178, "content": "Treatments Injection of botulinum toxin A Surgical transection of the nerve fibers (a temporary treatment) Application of an ointment containing an anticholinergic drug such as scopolamine Cochrane reviews of interventions to either prevent or treat Frey’s syndrome have found little or no evidence to support their effectiveness or safety, and conclude that further clinical trials are needed. Epidemiology The condition is rare, although the exact incidence is unknown. The disorder most often occurs as a complication of the surgical removal of a parotid gland (parotidectomy). The percentage of individuals who develop Frey syndrome after a parotidectomy is controversial and reported estimates range from 30–50 percent. In follow-up examinations, approximately 15 percent of affected individuals rated their symptoms as severe. Frey syndrome affects males and females in equal numbers." }, { "id": "wiki20220301en421_8390", "title": "Parotidectomy", "score": 0.012411584145202189, "content": "Post-Operation After completion of a parotidectomy, patients can expect postoperative hospitalization ranging from one-to-three days, to help ensure the safest and most effective postoperative management. At this time, patients will be administered antibiotics to minimize risk of infection as well as an assessment of pain management throughout their stay. Duration of hospitalization is subject to change from patient to patient, with most patients being discharged within 24 hours after surgery. If a tumor was malignant, many patients are referred to radiation therapy. For benign tumors and slow growing cancers, surgery typically provides a complete cure or remission (no evidence for disease). Patient Care after Discharge" }, { "id": "wiki20220301en421_8385", "title": "Parotidectomy", "score": 0.012241689128481581, "content": "Throughout history, many different types and techniques have been developed in order to complete a parotidectomy and consequently, many different names have been associated with each type. However, there are really only two main distinctions to be made in parotidectomies: The specific nerve(s) to be dissected or not dissected The amount of gland excised It is important to note that the specific surgery chosen is based on preservation of the facial nerve in order to avoid significant morbidities (diseases). Furthermore, there are still many controversies regarding the choice of surgery and incidence of cancer recurrence. Below indicates the various and main techniques typically associated with a parotidectomy: Extracapsular dissection - excision of the parotid tumor surrounded by some millimetres of healthy tissue, without searching and exposing the main truck of the facial nerve." }, { "id": "pubmed23n0422_16114", "title": "Use of botulinum toxin type A in a case of persistent parotid sialocele.", "score": 0.012223600671385828, "content": "Sialocele is an uncommon complication of parotidectomy. Most cases resolve after conservative therapy consisting of repeated aspiration and pressure dressing. The condition is, however, occasionally resistant to such therapy. We report on a 52-year-old Chinese man who had a 10-year history of right parotid swelling. Following fine-needle aspiration cytology, Warthin's tumour was diagnosed, but after elective parotidectomy, a swelling developed and parotid sialocele was diagnosed. Botulinum toxin type A was given after the sialocele had persisted for almost 3 weeks after surgery, and after conservative management had been tried; the sialocele disappeared after two doses of treatment. Botulinum toxin therapy was thus an effective method of treating persistent sialocele." }, { "id": "pubmed23n0559_20248", "title": "Management of Frey syndrome.", "score": 0.012150314671323074, "content": "Almost all patients who undergo parotidectomy will to some extent develop Frey syndrome (auriculotemporal syndrome or gustatory sweating) after surgery, because of aberrant regeneration of cut parasympathetic fibers between otic ganglion and subcutaneous vessels. However, only the minority of these patients needs treatment. The syndrome consists of gustatory sweating, flushing, and warming over the preauricular and temporal areas. Thick skin flap and partial superficial parotidectomy are the most important techniques to minimize the risk of developing symptomatic Frey syndrome. Intracutaneous injection of botulinum toxin A is an effective, long-lasting, and well-tolerated treatment of Frey syndrome. If recurrence occurs, the treatment can be repeated." }, { "id": "wiki20220301en014_135359", "title": "Parotid gland", "score": 0.010909380474597866, "content": "Surgery Surgical treatment of parotid gland tumors is sometimes difficult because of the anatomical relations of the facial nerve parotid lodge, as well as the increased potential for postoperative relapse. Thus, detection of early stages of a parotid tumor is extremely important in terms of postoperative prognosis. Operative technique is laborious, because of relapses and incomplete previous treatment made in other border specialties. Surgical techniques in parotid surgery have evolved in the last years with the use of neuromonitoring of the facial nerve and have become safer and less invasive. After surgical removal of the parotid gland (Parotidectomy), the auriculotemporal nerve is liable to damage and upon recovery it fuses with sweat glands. This can cause sweating on the cheek on the side of the face of the affected gland. This condition is known as Frey's syndrome. Infections Bacterial infections" }, { "id": "pubmed23n1115_11257", "title": "Indications and Outcomes of Parotidectomy in Saudi Children: Experience From Two Tertiary Centers.", "score": 0.010658395601297053, "content": "Introduction Children can present with a wide variety of parotid diseases. However, most of them do not require surgical treatment. The indications of parotid surgery in children may differ from those in adults. In this study, we aim to review the indications and outcomes of parotidectomy in our pediatric population. Methods Retrospective review of the medical records of patients who underwent parotid surgery at age &lt;18 years in two tertiary centers over a 14-year period. Results A total of 18 parotidectomies were performed on 18 patients with a mean age of 13.5 years. All patients presented with a parotid mass. The most common procedure was superficial parotidectomy followed by total parotidectomy. Ten patients were diagnosed with a benign parotid disease (55.6%). The most common benign disease was pleomorphic adenoma. There were eight cases of parotid malignancy constituting 44.4% of all patients and 57% of patients presenting in the age range of 12-17 years. Mucoepidermoid carcinoma was the most common malignancy (six patients). Fine needle aspiration biopsy was performed in 12 children with a sensitivity, specificity, and overall accuracy of 62.5%, 50%, and 58.6%, respectively. The most common complication was temporary facial weakness (33.3%) which resolved in a mean time of 2.5 months. No disease recurrences were identified. Conclusions Parotidectomy is uncommon in the pediatric age group. Children with a solid parotid tumor have a higher risk of parotid malignancy when compared to adults. A parotid mass presenting in the second decade of life is more likely to be malignant than benign." }, { "id": "pubmed23n0060_16344", "title": "An audit of surgery for seventy-one primary parotid tumours.", "score": 0.010439605252426393, "content": "Seventy-one consecutive patients who presented with lumps in the parotid gland over an eight year period (1981-1989) were analysed. Two-thirds of the patients presented with a history of swelling for over one year, while a quarter (24%) had a parotid mass for over five years at initial referral. The pathology of these masses was diverse, with pleomorphic adenoma being the commonest (64%). Superficial parotidectomy was the commonest procedure employed (50/71) with local excision being performed only in the initial part of our series (15/71). There were five cases of permanent facial palsy, four following radical resection for malignancy. Tumour recurrence rate was 2/15 (13%) in cases treated by local excision while none of the 50 patients treated by superficial parotidectomy had tumour recurrence at a mean follow-up of five years. Only three patients developed Frey's Syndrome. It is recommended that increased community awareness of early referral of a parotid mass is necessary, as surgical treatment in the form of superficial parotidectomy, which is the ideal procedure for such lumps, carries minimal morbidity when performed by a surgeon with a special interest in parotid surgery." }, { "id": "pubmed23n0499_9257", "title": "Surgical management of epithelial parotid tumours.", "score": 0.01042224841924767, "content": "To describe the clinicopathological presentation and treatment options in epithelial parotid tumours with emphasis on surgery. Descriptive study. ENT Departments of Pakistan Institute of Medical Sciences, Islamabad and Holy Family Hospital, Rawalpindi and Surgical Units at Rawalpindi General Hospital and DHQ Teaching Hospital, Rawalpindi, during a ten year period 1993-2003. Epithelial parotid tumours diagnosed and operated by an ENT surgeon and a general surgeon in 10 years during their posting in different teaching hospitals were included in the study. Clinical presentation, preoperative investigations, operative procedure, histopathology report, postoperative complications and further management were recorded. The data was collected and reviewed from the records of all the patients maintained by the authors. Fifty-two patients presented with parotid tumour. Average age was 38 years. Commonest presentation was a painless lump over the parotid region (85%), pain (15%), facial palsy, and enlarged neck nodes. Majority of tumours were benign, only two were recurrent. Parotid pleomorphic Adenoma (PPA) was the commonest benign tumour, others being Warthin's tumour and monomorphic adenoma. Adenoid cystic carcinoma was the commonest malignant tumour 29% followed by mucoepidermoid carcinoma. Others were carcinoma in PPA, squamous cell carcinoma, malignant mixed tumour, malignant lymphoepithelioma and undifferentiated carcinoma. Superficial parotidectomy (SP) was the commonest operation performed in 69%. Other procedures were total conservative parotidectomy in 11%, total radical surgery in 9% and enucleation in only one patient earliest in the series. Neck node dissection was done in 2 patients. Except for one child, rest of the 13 patients received postoperative radiotherapy and one patient of lymphoepithelioma received chemotherapy in addition. Commonest postoperative complication was temporary facial weakness in 35% (18/52). Permanent facial palsy occurred in 08 patients. Of these 07 had a malignant process and only one patient had excision biopsy. Benign and malignant epithelial parotid tumours can be diagnosed by their clinical presentation supplemented with FNAC. Superficial parotidectomy (SP) was the operation of choice. Facial nerve can be saved in total conservative parotidectomy for benign tumour in deep lobe and early malignant tumour. Radical parotidectomy followed by radiotherapy and in selected cases neck node dissection are the recommended procedures for advanced malignant parotid tumours." }, { "id": "article-73061_30", "title": "Parotidectomy -- Technique or Treatment", "score": 0.010267573696145125, "content": "In the recovery room, facial nerve function should be assessed as soon as possible. Some facial weakness is to be expected, particularly in total parotidectomy. This typically resolves with time so long as all branches were definitively identified and preserved, though full recovery can take many months." }, { "id": "article-73061_8", "title": "Parotidectomy -- Indications", "score": 0.010198135198135198, "content": "By far, the most common indication for parotidectomy is the removal of a neoplasm. In 75% to 80% of cases, these neoplasms are benign and of primary parotid origin. Pleomorphic adenoma and Warthin tumors represent the majority of tumors, with pleomorphic adenoma representing the most common benign parotid tumor. Of malignant tumors, mucoepidermoid and adenoid cystic carcinoma are the two most common primary parotid tumors, in that order. Metastasis from a cutaneous primary represents the most common parotid malignancy in some series, notably in Australia [13] . Chronic parotitis and recurrent sialadenitis can be served with a parotidectomy when medical treatment and sialoendoscopy fail or are unavailable. Other indications include caseating granulomas, toxoplasmosis, branchial cleft cyst, symptomatic lymphoepithelial cyst, or tuberculosis. [14] [15] [16] [17] [18]" } ] } } }

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{ "1": "Secondary membranous glomerulonephritis.", "2": "Focal and segmental glomerulonephritis.", "3": "IgA nephropathy.", "4": "Rapidly progressive glomerulonephritis.", "5": "Minimal change nephropathy." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0820_14586", "title": "Renal biopsy findings and clinical indicators of patients with hematuria without overt proteinuria.", "score": 0.014789355829818256, "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": "pubmed23n0212_17134", "title": "Crescentic IgA nephropathy.", "score": 0.014118816803380563, "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": "pubmed23n0110_15364", "title": "IgA nephropathy. Evaluation of prognostic factors in patients with moderate disease.", "score": 0.01347183162478454, "content": "Previous studies of IgA nephropathy have demonstrated a number of prognostically significant clinical and pathological factors in groups of patients with the full histological spectrum of the disease. Whether these factors can be applied to a group of IgA nephropathy patients with disease of moderate degree is unknown. Forty patients (9 females, 31 males) with grade III IgA nephropathy (no more than 10% obsolete glomeruli and little or no interstitial fibrosis) were evaluated with respect to age, sex, degree of proteinuria, history of recurrent gross hematuria, hypertension, extent and type of segmental glomerulosclerosis, demonstration of IgG and/or IgM in deposits, presence of peripheral capillary deposits, whether or not there were crescents, and extent of vascular sclerosis. The mean age was 29.6 +/- (SD) 13.1 years. Sixteen patients presented with recurrent gross hematuria, and 24 had microscopic hematuria and proteinuria as the initial manifestation. Hypertension was seen in 5 patients. The mean serum creatinine concentration was 1.09 +/- 0.47 mg/dl (96.4 +/- 41.5 mumol/l), and the mean 24-hour urinary protein was 1.5 +/- 1.3 g. Nine patients had proteinuria greater than or equal to 2.0 g/24 h. Thirty-two patients demonstrated segmental glomerulosclerosis in their biopsies, 13 of which had more than 10% of the glomeruli involved. Seven patients developed established renal failure (Cr greater than or equal to 2.0 mg/dl; 176.8 mumol/l). The 60-and 100-month renal survival rates were 96 and 52%. Life table analysis disclosed that only the degree of proteinuria (greater than or equal to 2.0 g/24 h; p less than 0.05) and the extent of segmental glomerulosclerosis (p less than 0.025) were of prognostic significance.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0049_11777", "title": "[A case of anti-GBM nephritis (crescentic glomerulonephritis) associated with membranous nephropathy].", "score": 0.013186720593191776, "content": "We report a case of endstage renal disease due to simultaneous occurrence of membranous nephropathy and crescentic glomerulonephritis associated with anti-GBM antibodies. The patient was a 60-year-old male and was hospitalized for prolonged anorexia and general malaise. On admission, his body temperature was 38.5 degrees C. Urinalysis revealed 3+ proteinuria and the sediment contained abundant erythrocytes. The urea nitrogen was 142.4 mg/dl, the creatinine 19.5 mg/dl, the potassium 6.47 mEq/dl and CRP 10.1 mg/dl. Anti-GBM antibodies were 1000EU/ml. Immediately after initiating hemodialysis, pulse steroid therapy, plasma exchange and continuous heparinization were performed. However, renal function had been impaired and maintenance hemodialysis was required. Histological examination of the renal specimen revealed marked epithelial crescent formation, whereas thickening of basement membrane and mesangial proliferation were not observed. By immunofluorescent staining, both bright linear and fine granular fixation of IgG and fine granular fixations of C3 along the glomerular capillary walls were observed. Electron microscopy showed subepithelial electron lucent deposits and thickening of the glomerular basement membrane, diagnostic of the advanced membranous nephropathy (stage IV)." }, { "id": "wiki20220301en037_3240", "title": "Glomerulonephritis", "score": 0.012618387618387619, "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": "wiki20220301en046_56925", "title": "Membranous glomerulonephritis", "score": 0.012058116166441538, "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": "wiki20220301en026_25230", "title": "IgA nephropathy", "score": 0.011519101703665463, "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": "InternalMed_Harrison_3384", "title": "InternalMed_Harrison", "score": 0.011080652142547973, "content": "PROTEINURIA ON URINE DIPSTICK Quantify by 24-h urinary excretion of protein and albumin or first morning spot albumin-to-creatinine ratio RBCs or RBC casts on urinalysis In addition to disorders listed under microalbuminuria consider Myeloma-associated kidney disease (check UPEP) Intermittent proteinuria Postural proteinuria Congestive heart failure Fever Exercise Go to Fig. 61-2 Macroalbuminuria 300-3500 mg/d or 300-3500 mg/g Microalbuminuria 30-300 mg/d or 30-300 mg/g Nephrotic range > 3500 mg/d or > 3500 mg/g + Consider Early diabetes Essential hypertension Early stages of glomerulonephritis (especially with RBCs, RBC casts)Consider Early diabetes Essential hypertension Early stages of glomerulonephritis (especially with RBCs, RBC casts) Nephrotic syndrome Diabetes Amyloidosis Minimal change disease FSGS Membranous glomerulopathy IgA nephropathy" }, { "id": "wiki20220301en012_140472", "title": "Nephrotic syndrome", "score": 0.010163170163170164, "content": "The main signs of nephrotic syndrome are: A proteinuria of greater than 3.5 g /24 h /1.73 m2 (between 3 and 3.5 g/24 h /1.73 m2 is considered to be proteinuria in the nephrotic range) or greater than 40 mg/h/m2 in children. The ratio between urinary concentrations of albumin and creatinine can be used in the absence of a 24-hour urine test for total protein. This coefficient will be greater than 200–400 mg/mmol in nephrotic syndrome. This pronounced loss of proteins is due to an increase in glomerular permeability that allows proteins to pass into the urine instead of being retained in the blood. Under normal conditions a 24-hour urine sample should not exceed 80 milligrams or 10 milligrams per decilitre. A hypoalbuminemia of less than 2.5 g/dL, that exceeds the liver clearance level, that is, protein synthesis in the liver is insufficient to increase the low blood protein levels." }, { "id": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009900990099009901, "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": "pubmed23n0076_5103", "title": "[The survival of patients with mesangial immunoglobulin A glomerulonephritis].", "score": 0.009900990099009901, "content": "68 patients with immunoglobulin A glomerulonephritis (IgA-GN) were studied. 67.4% of them were men. The most frequent clinical manifestation is the microscopical hematuria--in 39.7% of the patients. A single episode of macroscopic hematuria was found in 32.3% of the patients and recurrent macroscopic hematuria--in 25% of the patients. Proteinuria was found in all patients but nephrotic syndrome--only in one patient. At the time of the biopsy 35.5% of the patients were with hypertension, 13.2%--with initial chronic renal failure. The survival of the patients with IgA--GN, assessed according to the registration life tables, was 93% at the 5-th year, 88% at the 10-th year and 70.6% at the 20-th year. It was statistically higher in the patients without hypertension. Among the patients with proteinuria below 1.0/24 h no one reached terminal chronic renal failure. The male sex was a factor for a statistically shorter survival only at the 20-th year. The survival of the patients with insignificant histological changes was 100% for the period of the study, whereas it was significantly lower for the other histological variants. According to the data of the study, the presence of arterial hypertension, proteinuria above 1.0 g/24 h, a more severe histological variant (focal-segment, diffuse proliferative and particularly sclerotic), and to a certain degree the male sex play an unfavorable role in the survival and determine a poorer prognosis for the patients with IgA-GN." }, { "id": "pubmed23n0285_14927", "title": "Nabumetone-associated interstitial nephritis.", "score": 0.00980392156862745, "content": "An 84-year-old woman was admitted to the hospital for progressive edema and decreased urine output. She had been taking nabumetone for 6 months, but had discontinued the agent 2 weeks before admission due to progressive edema. On admission she had 2-3+ pitting edema. Her serum electrolytes were sodium 122 mEq/L, potassium 5.9 mEq/L, chloride 93 mEq/L, and carbon dioxide 19 mEq/L. A urinalysis was significant for protein 3061 mg/dl, ketones 15 mg/dl, blood 2+, leukocytes 26-50/high-power field, and a protein:creatinine ratio 24.9. The serum creatinine and blood urea nitrogen concentrations were 2.7 mg/dl and 70 mg/dl, respectively. Throughout hospitalization the patient underwent aggressive diuresis. She developed congestive heart failure, and hemodialysis was initiated. A renal biopsy specimen on hospital day 9 showed tubular damage with minimal glomerular changes consistent with a diagnosis of nonsteroidal agent-induced nephropathy. On day 13, a 24-hour urine collection had a protein excretion of 3151 mg. Although the patient recovered from her renal failure (creatinine clearance 43 ml/min), the nephrotic syndrome persisted (13 g protein/day). The patient developed infectious complications and died on hospital day 32." }, { "id": "pubmed23n0123_910", "title": "[Clinico-morphological features and the course of glomerulonephritis in hemorrhagic vasculitis].", "score": 0.00980392156862745, "content": "Peculiarities of a clinical course and prognosis of glomerulonephritis in Schönlein-Henoch disease (SH-nephritis) were studied in 42 adult patients. The 5- and 10-year survival rates were 87% and 72%, respectively. Of unfavorable prognostic value were proteinuria over 1 g/l, nephrotic syndrome, particularly combined with hypertension, marked stable microhematuria, and the detection of diffuse fibroplastic, extracapillary, and mesangiocapillary nephritis on biopsy. SH-nephritis was characterized by a more severe course in male patients, in persons aged over 30, and in the involvement of the kidneys one year and more after the appearance of the first clinical signs of skin vasculitis. The level of blood serum IgA and the gravity of skin vasculitis had no prognostic importance." }, { "id": "pubmed23n0577_1624", "title": "Efonidipine reduces proteinuria and plasma aldosterone in patients with chronic glomerulonephritis.", "score": 0.009708737864077669, "content": "Efonidipine, a dihydropirydine calcium channel blocker, has been shown to dilate the efferent glomerular arterioles as effectively as the afferent arterioles. The present study compared the chronic effects of efonidipine and amlodipine on proteinuria in patients with chronic glomerulonephritis. The study subjects were 21 chronic glomerulonephritis patients presenting with spot proteinuria greater than 30 mg/dL and serum creatinine concentrations of &lt;or=1.3 mg/dL in men or &lt;or=1.1 mg/dL in women. All patients were receiving antihypertensive medication or had a blood pressure &gt;or=130/85 mmHg. Efonidipine 20-60 mg twice daily and amlodipine 2.5-7.5 mg once daily were given for 4 months each in a random crossover manner. In both periods, calcium channel blockers were titrated when the BP exceeded 130/85 mmHg. Blood sampling and urinalysis were performed at the end of each treatment period. The average blood pressure was comparable between the efonidipine and the amlodipine periods (133+/-10/86+/-5 vs. 132+/-8/86+/-5 mmHg). Urinary protein excretion was significantly less in the efonidipine period than in the amlodipine period (1.7+/-1.5 vs. 2.0+/-1.6 g/g creatinine, p=0.04). Serum albumin was significantly higher in the efonidipine period than the amlodipine period (4.0+/-0.5 vs. 3.8+/-0.5 mEq/L, p=0.03). Glomerular filtration rate was not significantly different between the two periods. Plasma aldosterone was lower in the efonidipine period than in the amlodipine period (52+/-46 vs. 72+/-48 pg/mL, p=0.009). It may be concluded that efonidipine results in a greater reduction of plasma aldosterone and proteinuria than amlodipine, and that these effects occur by a mechanism independent of blood pressure reduction. A further large-scale clinical trial will be needed in order to apply the findings of this study to the treatment of patients with renal disease." }, { "id": "pubmed23n0569_21470", "title": "The Pisa experience of renal biopsies, 1977-2005.", "score": 0.009708737864077669, "content": "Although several registries collecting data of patients with kidney diseases exist, only a few specifically collect data relating to renal biopsy. Kidney biopsy has been performed routinely in Pisa since 1977; the aim of this study was to report the relative frequency of nephropathies according to gender, age at time of biopsy, clinical presentation and renal function, based on histological diagnoses during the years 1977 through 2005. During this time, 3,810 kidney biopsies were performed, of which 89.3% were from native (n=3,446) and 10.7% from transplant kidneys. Throughout this period, 5% of renal biopsies were not diagnostic, so in this paper we report data regarding 3,269 native kidney nephropathies. During the years 1977 through 2005, data for renal biopsies were collected on specific registers filled out by clinicians. Information collected in the database included a variety of indicators, such as clinical anamnesis, creatinine clearance, daily proteinuria, hemoglobin levels, blood pressure, height and weight, clinical presentation, and current medications. Clinical presentation was defined as urinary abnormalities (UA), nephrotic syndrome (NS) and acute nephritic syndrome (ANS). Renal diseases were divided into 4 major categories: primary glomerulonephritis (GN), secondary GN, tubulointerstitial nephropathies (TIN) and vascular nephropathies (VN). From 1977 up to 1987, a mean of 95 +/- 18 renal biopsies/year were performed; this number significantly increased to 185 +/- 22 renal biopsies/year (range 138-200) (p&lt;0.001) in the following period (1988-2005). Renal biopsy was more frequently performed in males (59%) compared with females (41%). Of all diseases of the native kidney, primary GN was the most frequent (66%), followed by secondary GN (25.6%), TIN (4.2%) and VN (4.2%). The type of primary GN with the highest frequency was mesangial GN (both IgA and non-IgA) (45.7%), followed by membranous GN (23%), focal segmental glomerulosclerosis (19.8%), minimal change disease (5.3%), crescentic GN (4.2%) and postinfectious GN (2%). In terms of age, renal biopsy was more frequently performed in patients aged 20 to 60 years, and nearly 60% of patients presented a glomerular filtration rate (GFR) &gt;60 ml/min at the time of biopsy. The main clinical reason for performing renal biopsy was UA, in all the types of nephropathies. We confirm data that renal diseases are more frequent in men, with the exception of secondary GN. The mean age at diagnosis was 42 years resulting from the tendency not to perform renal biopsies in children and in elderly patients. Renal biopsy was mainly performed in patients with GFR &gt;60 ml/min and asymptomatic urinary abnormalities suggesting concern on the part of clinicians regarding glomerular diseases. The tendency to perform renal biopsies has been significantly increasing throughout our follow-up period." }, { "id": "pubmed23n0050_3646", "title": "Idiopathic membranous glomerulonephritis: a clinicopathologic and quantitative morphometric study.", "score": 0.009615384615384616, "content": "We evaluated clinical and morphological findings in 254 patients (138 men and 116 women), with idiopathic membranous glomerulonephritis (IMGN). The mean age was 44 years. At time of biopsy proteinuria was found in 98%, nephrotic syndrome (NS) in 45.2%, hypertension in 10%, elevated serum creatinine concentration of greater than or equal to 1.4 g/dl in 24%, and markedly decreased Ccr (less than or equal to 40 ml/min) in 12.5% of the patients. Of 254 patients, 51 (20%) were classified as Stage I, 131 (52%) as Stage II, 52 (20.5%) as Stage III, 9 (3.5%) as Stage IV and 11 (4.3%) as Stage V, which was a relapsing form. Both intraglomerular, peripheral electron dense deposit-size and mean thickness of the glomerular basement membrane (GBMt) were analyzed by ultrastructural morphometric methods. In patients with NS, both the mean deposit-size and the mean GBMt were largest when compared to all others (p less than 0.01). The largest subepithelial deposits (SED), in mean, were observed in Stages II and V, while the largest incorporated deposits (ICD) were measured in Stages II and IV. The mean GBMt was largest in Stage III. Furthermore, there were strong correlations between the degree of proteinuria and the deposit-size (r = 0.603, p less than 0.001), and GBMt (r = 0.456, p less than 0.001). The GBMt showed a correlation with serum creatinine concentration (r = 0.476, p less than 0.001) and Ccr (r = 0.471, p less than 0.001). We concluded that the size of the electron dense deposits and GBM thickness play an important role in the clinical manifestation of IMGN." }, { "id": "wiki20220301en464_20969", "title": "Hypertensive disease of pregnancy", "score": 0.009523809523809525, "content": "Preeclampsia superimposed on chronic hypertension occurs when a pregnant woman with chronic hypertension develops signs of pre-eclampsia, typically defined as new onset of proteinuria ≥30 mg/dL (1+ in the dipstick) in at least 2 random urine specimens that were collected ≥4 h apart (but within a 7-day interval) or 0.3 g in a 24-h period. Like ordinary pre-eclampsia, superimposed pre-eclampsia can also occur with severe features, which are defined as: systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg despite escalation of antihypertensive therapy; thrombocytopenia (platelet count <100,000/microL); impaired liver function; new-onset or worsening renal insufficiency; pulmonary edema; or persistent cerebral or visual disturbances. As a result, superimposed pre-eclampsia can be diagnosed without proteinuria when a sudden increase in previously well-controlled blood pressure is accompanied by severe features of pre-eclampsia." }, { "id": "pubmed23n0690_56", "title": "Maximal glomerular diameter as a 10-year prognostic indicator for IgA nephropathy.", "score": 0.009523809523809525, "content": "Although there have been many reports on clinicopathological studies of immunoglobulin A nephropathy (IgAN), reliable outcome predictors are still lacking. We therefore assessed maximal glomerular diameter (Max GD), an indicator of glomerular size, as a predictor of the long-term evolution of renal histopathology. Forty-three adult patients, diagnosed with IgAN, who had estimated glomerular filtration rate (eGFR) ≥50 mL/min/1.73 m(2), were enrolled in this study. Prognostic variables for renal survival were examined by using the multivariate Cox proportional hazards method. The optimal cut-off value of Max GD was 242.3 μm (AUC = 0.78, sensitivity = 62.5%, specificity = 81.5%) by using receiver operating characteristics analysis. In order to assess the characteristics of glomerular hypertrophy, we divided the cases into two groups according to the Max GD value (Group A, ≥242 μm; Group B, &lt;242 μm). Renal survival was also assessed by Kaplan-Meier curves with the log-rank test. The Max GD was significantly correlated with age, body mass index and serum triglyceride levels at the time of renal biopsy. During the 10-year follow-up period, the Max GD was significantly correlated with eGFR decline per year, and proteinuria, but not with hematuria. A multiple regression analysis by the Cox method adjusted for age, sex and eGFR showed that the Max GD values were significantly associated with a 1.5-fold increase in serum creatinine (Cr) values (hazard ratio = 1.04, P = 0.03). Renal function in 66.7% of the patients whose Max GD was ≥242 μm had at least a 1.5-fold increase in their serum Cr value at the 10-year follow-up examination (log-rank, P = 0.003). The results of this study suggest that Max GD is a simple quantitative prognostic indicator of the disease progression in IgAN patients." }, { "id": "pubmed23n0699_16116", "title": "Acquired glomerular lesions in patients with Down syndrome.", "score": 0.009433962264150943, "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": "pubmed23n0399_7723", "title": "[Renal histological lesions in patients with type II diabetes mellitus].", "score": 0.009433962264150943, "content": "Diabetic glomerulosclerosis is the most frequent cause of renal disease in patients with type II diabetes mellitus (DM), sometimes accompanied by vascular lesions. However, other glomerular pathologies are important in these patients. The aim of this study was to evaluate the prevalence of non-diabetic nephropathy (NDN) in selected patients with type II DM, and to identify clinical markers that may predict its presence in this population. We reviewed 20 renal biopsies performed on twenty patients with type II DM. Nine of them showed diabetic nephropathy (DN) (45%), whereas eleven showed NDN (55%): 1 IgA nephropathy, 3 vasculitis and 7 membranous nephropathy. We found no differences between the two groups with regard to sex, duration of DM, insulin therapy, glycosylated haemoglobin, proteinuria, presence of nephrotic syndrome, hypertension, serum IgA level or renal size. The NDN group had haematuria in 63.6%, whereas the patients with NDN had it in 44.4% (NS). Body mass index was higher in NDN patients (30 +/- 6.7 vs 22 +/- 2.9; p &lt; 0.01), The same was true for creatinine clearance (82.2 +/- 51.4 ml/m vs 40.4 +/- 19.6 ml/m; p &lt; 0.05). The age at the moment of diagnosis was higher in ND patients (67 +/- 11.2 vs 54.3 +/- 4.6; p &lt; 0.05). The 3 patients who had diabetic retinopathy were found to have DN on renal biopsy (diagnostic specificity = 100%), although 66.7% of the patients with diabetic glomerulopathy had no retinopathy. We conclude that patients with type II DM with renal findings suggesting non-diabetic renal disease frequently it have NDN, and a renal biopsy must be performed. The presence of retinopathy has a predictive value of 100% in predicting DN, therefore its existence may make this diagnostic procedure unneccesary." }, { "id": "wiki20220301en003_10293", "title": "Glucose tolerance test", "score": 0.009345794392523364, "content": "For gestational diabetes, the American College of Obstetricians and Gynecologists (ACOG) recommends a two-step procedure, wherein the first step is a 50 g glucose dose. If after 1 hour the blood glucose level is more than 7.8 mmol/L (140 mg/dL), it is followed by a 100 g glucose dose. The diagnosis of gestational diabetes is then defined by a blood glucose level meeting or exceeding the cutoff values on at least two intervals, with cutoffs as follows: Before glucose intake (fasting): 5.3 mmol/L (95 mg/dL) 1 hour after drinking the glucose solution: 10.0 mmol/L (180 mg/dL) 2 hours: 8.6 mmol/L (155 mg/dL) 3 hours: 7.8 mmol/L (140 mg/dL)" }, { "id": "pubmed23n0289_15595", "title": "[Microalbuminuria in patients with glomerulonephritis in remission].", "score": 0.009345794392523364, "content": "The authors focused their attention on residual changes in patients with glomerulonephritis who have a zero or only \"physiological\" proteinuria (under 0.15 g/24 hours), normal or slightly elevated s-creatinine and who do not suffer from hypertension. In these patients microalbuminuria in urine per 24 hours was assessed. Patients with albuminuria under 20 micrograms/min were included in the group with normal albuminuria (13 patients) and patients with albuminuria of more than 20 micrograms/min in the microalbuminuric group (11 patients). The two groups did not differ significantly as to age, sex, duration of the disease, maximum levels of proteinuria and s-creatinine values at the onset of the disease. S-creatinine and blood pressure values at the time of investigation were also comparable. The groups differed, however, significantly as to the period of \"absolute\" remission which the authors defined as the period during which proteinuria did not exceed the \"physiological\" limit. This period was in the normoalbuminuric group significantly longer--on average 5.1 years--while in the microalbuminuric group it was 2.1 years (difference at the 1% level of significance)." }, { "id": "wiki20220301en008_72953", "title": "Proteinuria", "score": 0.009259259259259259, "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": "article-25173_15", "title": "Minimal Change Disease -- Evaluation -- Basic labs:", "score": 0.009259259259259259, "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": "wiki20220301en025_59769", "title": "Gestational diabetes", "score": 0.009174311926605505, "content": "The test involves drinking a solution containing a certain amount of glucose, usually 75 g or 100 g, and drawing blood to measure glucose levels at the start and on set time intervals thereafter. The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes. The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT: Fasting blood glucose level ≥95 mg/dL (5.33 mmol/L) 1 hour blood glucose level ≥180 mg/dL (10 mmol/L) 2 hour blood glucose level ≥155 mg/dL (8.6 mmol/L) 3 hour blood glucose level ≥140 mg/dL (7.8 mmol/L)" }, { "id": "pubmed23n0920_23799", "title": "The Neglected Significance of Glomerular Density as a 5-year Progression Indicator for IgA Nephropathy^△.", "score": 0.009174311926605505, "content": "Objective To investigate whether glomerular density (GD) could be an independent prognostic factor for patients of IgA nephropathy with estimated glomerular filtration rate (eGFR) of 30 to 60 ml/min per 1.73 m<sup2</sup, or for patients with time-average proteinuria &lt; 0.5 g/d. Methods A total of 173 patients with biopsy-confirmed IgA nephropathy diagnosed from January 2000 to December 2010 were included. All of these patients were followed up for more than 5 years. The endpoint was a &gt; 30% of decline in eGFR from baseline after 5-year follow-up. The optimal cut-off value of GD was calculated by ROC curve. Kaplan-Meier method and Cox regression analysis was used for survival analysis. Results A 30% of decline in eGFR occurred in 14.5% of all patients. The optimal diagnostic cut-off value of GD was 1.99/mm<sup2</sup (AUC = 0.90, sensitivity = 84.0%, specificity = 81.8%) determined by ROC curve. The low GD group (GD &lt; 1.99 per mm<sup2</sup) experienced a significant increase in renal endpoint for patients with eGFR of 30 to 60 ml/min per 1.73 m<sup2</sup (six patients in lower GD group, while one patient in the other group). For patients with time-average proteinuria &lt; 0.5 g/d, the lower GD group showed a higher eGFR decline from baseline (4.5±16.7 ml/min per 1.73 m<sup2</sup vs. -8.1±21.4 ml/min per 1.73 m<sup2</sup, P = 0.038); two patients in this group reached the endpoint, while no patients in the higher GD group did. Conclusion GD could be an independent prognostic factor for patients of IgA nephropathy with eGFR at 30 to 60 ml/min per 1.73 m<sup2</sup of body surface, particularly for those with time-averaged amount of urine protein less than 0.5 g per day." }, { "id": "wiki20220301en033_21958", "title": "Acute pancreatitis", "score": 0.00909090909090909, "content": "At admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11.1 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall >10% Oxygen (hypoxemia PO2 < 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 The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis. Alternatively, pancreatitis can be diagnosed by meeting any of the following:[2] Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)" }, { "id": "pubmed23n0519_3770", "title": "[Frequency of diagnosis and clinic presentation of glomerulopathies in Uruguay].", "score": 0.00909090909090909, "content": "The Uruguayan Registry of Glomerulopathies began its activity in 1974 and since 1985 is a national registry. The aim of this report is to analyze the incidence and the variations in frequencies of the histological diagnosis and clinical presentation during the 1980-2003 period. From the 2,058 patients with renal biopsy in the whole period, we analyzed the histological diagnosis and the following data has been collected when the patients were registered: age, gender, clinical syndrome, proteinuria, hematuria, serum creatinine, blood pressure and time from the first symptom. Four periods of registry entry were considered: 1980-1989, 1990-1994, 1995-1999 and 2000-2003. Chi-square and Student test for independent samples were used to evaluate the differences among the variables frequencies in the four periods. The incidence of registered glomerulopathies per million population (pmp) increased from 13 (1980-1989) to 43 (2000-2003). In the 2000-2003 period, the incidences pmp were: primary glomerulopathy (PG), 25.3 and secondary glomerulopathy, 14.2. The highest incidences pmp were: focal and segmental glomeruloesclerosis (FSGS) 6.4; vasculitis 5.4; lupus nephritis 4.6; minimal change disease (MCD) 4.6; IgA nephropathy (IgAN) 4.5; and membranous nephropathy (MN) 4.0. The most frequent PG were the FSGS (29.3%) and the MCID (19.6%). The FSGS frequency decreased from 36.3% in 1995-1999 to 19.1% in 2000-2003. The IgAN frequency increased from 5.2% in 1980-1989 to 17.5% in 2000-2003. Nephrotic syndrome was the most frequent clinical presentation; its frequency was over 30% in the four periods. Asymptomatic urinary abnormality frequency increased from 14.0% in 1980-1989 to 22.7% in 2000-2003. The frequency of serum creatinine under 1.5 mg/dl, increased from 42.2% in 1980-1989 to 67.2% in 2000-2003 (p = 0.001). The frequency of serum creatinine over 6.0 mg/dl, decreased from 19.3% in 1990-1994 to 7.2% in 2000-2003. The percentage of patients referred since the first month of the apparent onset of the disease increased from 24.0% in 1980-1989 to 40.1% in 2000-2003 (p &lt; 0.001). In Uruguay, the incidence of glomerulopathies with histological diagnosis has increased and the frequency of the different types has changed. Several indicators seem to show that the reference of patients to the nephrologist tended to be earlier in the last years." }, { "id": "pubmed23n0050_18870", "title": "Long-term beneficial effects of angiotensin-converting enzyme inhibition in patients with nephrotic proteinuria.", "score": 0.009009009009009009, "content": "Angiotensin-converting enzyme inhibitors (ACEI) can reduce proteinuria in diabetic and nondiabetic nephropathy. However, no studies have determined whether this antiproteinuric effect modifies the progression of renal insufficiency. We studied the evolution of 46 nondiabetic patients with nephrotic proteinuria treated with captopril for a minimum of 12 months. The follow-up period before captopril treatment was 12 to 18 months. At the end of follow-up, after captopril introduction (24.4 +/- 7.6 months), proteinuria had decreased from 6.3 +/- 2.5 to 3.9 +/- 3.1 g/24 h (P less than 0.001), with a mean decrease of 45% +/- 28%. The proteinuria decrease was higher in patients with reflux nephropathy, proteinuria associated with reduction of renal mass, inactive crescentic glomerulonephritis, nephroangiosclerosis, and IgA nephropathy, whereas patients with membranous glomerulonephritis and idiopathic focal glomerulosclerosis showed a poorer response. Patients were separated according to a proteinuria reduction greater (group A, 23 patients) or lower (group B, 23 patients) than 45% of the initial value. At the end of follow-up, renal function had not significantly changed in group A with respect to values at the start of treatment: serum creatinine (SCr) was 229 +/- 167 mumol/L (2.6 +/- 1.9 mg/dL) versus 203 +/- 97 mumol/L (2.3 +/- 1.1 mg/dL), and creatinine clearance (CrCl) was 0.80 +/- 0.52 mL/s (48 +/- 31 mL/min) versus 0.87 +/- 0.47 mL/s (52 +/- 28 mL/min). The slope of the reciprocal of Scr (1/SCr) showed a significantly beneficial change after captopril introduction.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0335_7704", "title": "One-center experience with cyclosporine in refractory nephrotic syndrome in children.", "score": 0.008928571428571428, "content": "Uncontrolled or refractory nephrotic syndrome (NS), seen in a variety of glomerular disorders, leads to end-stage renal disease (ESRD). This study describes the use and efficacy of cyclosporine (CSA) for the treatment of refractory NS in 83 children seen over a 10-year period. The histological diagnosis leading to the NS was focal segmental glomerulosclerosis (FSGS) in 51% (n = 42), IgM nephropathy in 20% (n = 17), membranoproliferative glomerulonephritis in 10% (n = 8), lupus nephritis in 6% (n = 5), human immunodeficiency virus (HIV) nephropathy in 5% (n = 4), minimal change disease in 7% (n = 6), and membranous nephropathy in 1% (n = 1) of patients. During CSA therapy the mean proteinuria of the study population decreased from 5.14 g/24 h (4.80 g/m2 per 24 h) to 1.23 g/24 h (0.92 g/m2 per 24 h) (P &lt; 0.001), the mean serum albumin increased from 2.13 g/dl to 3.53 g/dl (P &lt; 0.001), the mean serum cholesterol decreased from 364 mg/dl to 223 mg/dl (P &lt; 0.001), and the mean serum creatinine increased from 0.77 mg/dl to 1.2 mg/dl (P &lt; 0.01). When analyzed by histological diagnosis, similar significant trends of reduction in proteinuria were seen in all but the lupus group. There was a rise in serum creatinine following the use of CSA in patients with FSGS, lupus nephritis, and HIV nephropathy; however the elevated serum creatinine was only significant in patients with FSGS. At the end of the study period, 20 patients had reached ESRD, of which 11 had FSGS, 5 had lupus nephritis, and 4 were patients with HIV nephropathy. Fifty-four patients were in remission at the end of the study period (48 with proteinuria &lt; 100 mg/24 h and 6 with proteinuria &lt; 500 mg/24 h). In conclusion, among children with refractory NS, CSA induced a remission in a large proportion. However toxicity, as noted by the rise in serum creatinine, was observed in several patients. Since this toxicity may be drug induced or a natural progression of the disease, careful monitoring and close follow-up are essential." }, { "id": "pubmed23n0305_13504", "title": "Histologic subclassification of IgA nephropathy: a clinicopathologic study of 244 cases.", "score": 0.008928571428571428, "content": "IgA nephropathy (IgAN) may present with a wide variety of histologic patterns on renal biopsy, ranging from a minimal lesion to a diffuse proliferative glomerulonephritis (GN). The histologic features of 244 cases of IgAN (not including Schönlein-Hanoch nephritis) diagnosed between 1980 and 1994 were reviewed, and each case was subclassified using the following, relatively simple histologic classification scheme: subclass I (39 cases): minimal or no mesangial hypercellularity, without glomerular sclerosis; subclass II (18 cases): focal and segmental glomerular sclerosis without active cellular proliferation; subclass III (110 cases): focal proliferative GN; and subclass IV (42 cases): diffuse proliferative GN; and subclass V (35 cases): any biopsy showing &gt; or = 40% globally sclerotic glomeruli and/or &gt; or = 40% estimated cortical tubular atrophy or loss. Subsequent analysis of renal survival in 109 patients who underwent biopsy before or during 1992 for whom such data were available showed a strong, statistically significant correlation between histologic subclass and renal survival, with an order I, II (greatest survival) &gt; III &gt; IV, V. Crescents were a significant negative prognostic indicator for renal survival in subclass III (but not in subclass IV), and interstitial expansion was a negative prognostic indicator in subclasses III and IV, although the statistical significance of these were not maintained after controlling for serum creatinine at the time of biopsy. The presence of peripheral glomerular capillary deposits ultrastructurally had no prognostic significance. With respect to clinical presentation, hypertension (systolic blood pressure &gt; or = 130 mm Hg and diastolic blood pressure &gt; or = 90 mm Hg) and proteinuria of &gt; or = 2.0 g/24 hr were significant negative prognostic indicators for renal survival, even when controlling for serum creatinine at the time of renal biopsy. The presence of gross hematuria correlated significantly with increased renal survival by univariate analysis, but not when controlling for serum creatinine at the time of renal biopsy. The findings of this study confirm the wide variety of clinical and histopathologic presentations of IgAN, and indicate the utility of the proposed histologic classification schema in assessing a patient's likelihood of ultimately developing end-stage renal disease." }, { "id": "pubmed23n0299_9493", "title": "[A 91-year-old man with a stroke, hypertension, and renal failure].", "score": 0.008849557522123894, "content": "We report a 91-year-old man who had a stroke and died of renal failure. He had been treated for hypertension since 20 years before the onset of the present illness. In addition, he was operated on a gastric cancer 17 years previously. Otherwise he was doing well until May 29, 1991 (when he was 87-year-old) when he had sudden onset of dysarthria and right facial weakness. He was admitted to our hospital. On admission, general physical examination was unremarkable, and neurologic examination revealed a mentally sound man with slight dysarthria, right facial weakness, orolingual dyskinesia, and dysequilibrium in which he showed difficulty in tandem gait; however, no cerebellar ataxia was noted. A cranial CT scan revealed leukoaraiosis with multiple low density areas in the cerebral white matter. His BUN was 37 mg/dl and Cr 2.2 mg/dl. His neurologic symptoms cleared within the next few weeks and he was discharged with ticlopidine 100 mg q.d.. He had been doing well after the discharge except for gradual worsening of his renal function; his BUN was 65 mg/dl and Cr 3.27 mg/dl in April of 1994. On March 10, 1995, he fell down and hit his back; he became unable to walk because of pain, and he was admitted again on March 16, 1995. On admission, his blood pressure was 170/80 mmHg. There was an 1 + pitting pretibial edema; otherwise general physical examination was unremarkable. Neurologic examination revealed an alert and oriented man, however, Hasegawa's dementia scale was 23/30. Higher cerebral functions as well as cranial nerves were intact. He showed some unsteadiness of gait, however, no motor weakness or ataxia was noted. Deep tendon reflexes were diminished, but Chaddock sign was positive bilaterally. Vibration was diminished in the feet, however, pain and touch sensations were intact. Laboratory examination revealed a compression fracture of the twelfth thoracic vertebra. Blood count and chemistries were as follows; Hb 7.6 g/dl, Hct 23.3%, TP 6.0 g/dl, Alb 3.6 g/dl, BUN 87 mg/dl, Cr 4.53 mg/dl, T-Chol 174 mg/dl, HDL-Chol 49 mg/dl, Glu 156 mg/dl, Na 142 mEq/L, K 5.4 mEq/L, Cl 115 mEq/L. A urine specimen contained 1 + protein and 1 + glucose, and the sediments contained hyaline casts. A cranial CT scan was essentially same as that taken four years ago. His hospital course was complicated with pneumonia, congestive heart failure, and progressive renal failure. He was treated with intravenous fluid, chemotherapy, and other supportive measures, however, he expired from respiratory failure on April 30, 1995. He was discussed in a neurologic CPC, and the chief discussant arrived at the conclusion that the patient had Binswanger's disease in the brain, benign nephrosclerosis from arteriolosclerosis due to hypertension, congestive heart failure, and pneumonia. Opinions were divided regarding the question as to whether or not this patient had Binswanger's disease. Although his cranial CT scan revealed leukoaraiosis, his dementia and gait disturbance was only mild until his fall on March, 1995. Clinical features did not conform to those of Binswanger's disease. Postmortem examination of the right hemisphere revealed wide spread atherosclerosis and arteriolosclerosis. The kidney showed benign nephrosclerosis due to arteriolosclerosis. Sclerotic changes were also seen in the coronary arteries and the left middle cerebral artery with 70% stenosis. Myelin stain showed diffuse myelin pallor of the cerebral white matters with scattered small infarcts. Arterioles in the white matter showed arteriolosclerosis. Small infarcts were also seen in the putamen and in the thalamus. This patient appeared to have had circulatory disturbance of the white matter which is the basic abnormality causing Binswanger's disease. However, white matter changes in this patient were not quite severe enough to make a pathologic diagnosis of Binswanger's disease." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 274 ] ], "word_ranges": [ [ 0, 46 ] ], "text": "We are dealing with a patient who has exhausted the pharmacological route given that he takes everything and has two important problems: genu varum and an important gonarthrosis. This means that we can do nothing with an arthroscopy, let alone a synovectomy (1 and 5 false)." }, "2": { "exist": true, "char_ranges": [ [ 717, 1007 ] ], "word_ranges": [ [ 125, 171 ] ], "text": "we may think that it is best to first try rehabilitation before considering surgery, but I discard this option because the question emphasizes that we have exhausted pharmacological measures (although it could be considered because they have not specified whether it has been tried or not)." }, "3": { "exist": true, "char_ranges": [ [ 1020, 1130 ] ], "word_ranges": [ [ 174, 193 ] ], "text": "with the knee prosthesis we correct the problem of osteoarthritis pain and we can also correct the knee varus." }, "4": { "exist": true, "char_ranges": [ [ 275, 560 ] ], "word_ranges": [ [ 46, 96 ] ], "text": "The genu varum could falsely make us think about an osteotomy, however even if we did it and corrected the varus now the damage is already done and the osteoarthrosis is severe. Perhaps years ago before the osteoarthritis took place it would have been resolutive but not now (4 false)." }, "5": { "exist": true, "char_ranges": [ [ 0, 274 ] ], "word_ranges": [ [ 0, 46 ] ], "text": "We are dealing with a patient who has exhausted the pharmacological route given that he takes everything and has two important problems: genu varum and an important gonarthrosis. This means that we can do nothing with an arthroscopy, let alone a synovectomy (1 and 5 false)." } }

{ "1": "Arthroscopic lavage of the knee.", "2": "Rehabilitation of the affected knee.", "3": "Arthroplasty of the affected knee.", "4": "Abduction supratuberosity tibial supratuberosity tibial osteotomy.", "5": "Knee synovectomy." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0739_20976", "title": "Arthroscopic lavage and debridement for osteoarthritis of the knee: an evidence-based analysis.", "score": 0.0172002601720026, "content": "The purpose of this review was to determine the effectiveness and adverse effects of arthroscopic lavage and debridement, with or without lavage, in the treatment of symptoms of osteoarthritis (OA) of the knee, and to conduct an economic analysis if evidence for effectiveness can be established. QUESTIONS ASKED: Does arthroscopic lavage improve motor function and pain associated with OA of the knee?Does arthroscopic debridement improve motor function and pain associated with OA of the knee?If evidence for effectiveness can be established, what is the duration of effect?What are the adverse effects of these procedures?What are the economic considerations if evidence for effectiveness can be established? Osteoarthritis, the most common rheumatologic musculoskeletal disorder, affects about 10% of the Canadian adult population. Although the natural history of OA is not known, it is a degenerative condition that affects the bone cartilage in the joint. It can be diagnosed at earlier ages, particularly within the sports injuries population, though the prevalence of non-injury-related OA increases with increasing age and varies with gender, with women being twice as likely as men to be diagnosed with this condition. Thus, with an aging population, the impact of OA on the health care system is expected to be considerable. Treatments for OA of the knee include conservative or nonpharmacological therapy, like physiotherapy, weight management and exercise; and more generally, intra-articular injections, arthroscopic surgery and knee replacement surgery. Whereas knee replacement surgery is considered an end-of-line intervention, the less invasive surgical procedures of lavage or debridement may be recommended for earlier and more severe disease. Both arthroscopic lavage and debridement are generally indicated in patients with knee joint pain, with or without mechanical problems, that are refractory to medical therapy. The clinical utility of these procedures is unclear, hence, the assessment of their effectiveness in this review. LAVAGE AND DEBRIDEMENT: Arthroscopic lavage involves the visually guided introduction of saline solution into the knee joint and removal of fluid, with the intent of extracting any excess fluids and loose bodies that may be in the knee joint. Debridement, in comparison, may include the introduction of saline into the joint, in addition to the smoothening of bone surface without any further intervention (less invasive forms of debridement), or the addition of more invasive procedures such as abrasion, partial or full meniscectomy, synovectomy, or osteotomy (referred to as debridement in combination with meniscectomy or other procedures). The focus of this health technology assessment is on the effectiveness of lavage, and debridement (with or without meniscal tear resection). THE MEDICAL ADVISORY SECRETARIAT FOLLOWED ITS STANDARD PROCEDURES AND SEARCHED THESE ELECTRONIC DATABASES: Ovid MEDLINE, EMBASE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and The International Network of Agencies for Health Technology Assessment. THE KEYWORDS SEARCHED WERE: arthroscopy, debridement, lavage, wound irrigation, or curettage; arthritis, rheumatoid, osteoarthritis; osteoarthritis, knee; knee or knee joint. TIME FRAME: Only 2 previous health technology assessments were identified, one of which was an update of the other, and included 3 of 4 randomized controlled trials (RCTs) from the first report. Therefore, the search period for inclusion of studies in this assessment was January 1, 1995 to April 24, 2005. EXCLUDED WERE: case reports, comments, editorials, and letters. Identified were 335 references, including previously published health technology assessments, and 5 articles located through a manual search of references from published articles and health technology assessments. These were examined against the criteria, as described below, which resulted in the inclusion of 1 health technology assessment and its corresponding update, and 4 articles (2 RCTs and 2 level 4 studies) for arthroscopic lavage and 8 papers (2 RCTs and 6 level 4 studies) for arthroscopic debridement. English-language articles from PubMed, EMBASE, Cochrane Systematic Reviews, and health technology assessments from January 1, 1995 onwardStudies on OA of the knee with a focus on the outcomes of motor function and painStudies of arthroscopic procedures onlyStudies in which meniscal tear resection/meniscectomy (partial or full) has been conducted in conjunction with lavage or debridement. Studies that focus on inflammatory OA, joint tuberculosis, septic joints, psoriatic joints (e.g., psoriatic knee joint synovitis), synovitis, chondropathy of the knee and gonarthrosis (which includes varotic gonarthrosis)Studies that focus on rheumatoid arthritisStudies that focus on meniscal tears from an acute injury (e.g., sports injury)Studies that are based on lavage or debridement for microfracture of the kneeStudies in which other surgical procedures (e.g., high tibial osteotomy, synovectomy, have been conducted in addition to lavage/debridement)Studies based on malalignment of the knee (e.g., varus/valgus arthritic conditions).Studies that compare lavage to lavage plus drug therapyStudies on procedures that are not arthroscopic (i.e., visually guided) (e.g., nonarthroscopic lavage)Studies of OA in children. Arthroscopic lavage or debridement, with or without meniscectomy, for the treatment of motor function symptoms and pain associated with OA of the knee. Studies in which there was a comparison group of either diseased or healthy subjects or one in which subjects were their own control were included. Comparisons to other treatments included placebo (or sham) arthroscopy. Sham arthroscopy involved making small incisions and manipulating the knee, without the insertion of instruments. IN EARLY OA OF THE KNEE WITH PAIN REFRACTORY TO MEDICAL TREATMENT, THERE IS LEVEL 1B EVIDENCE THAT: Arthroscopic lavage gives rise to a statistically significant, but not clinically meaningful effect in improving pain (WOMAC pain and VAS pain) up to 12 months following surgery. The effect on joint function (WOMAC function) and the primary outcome (WOMAC aggregate) was neither statistically nor clinically significant. IN MODERATE OR SEVERE OA OF THE KNEE WITH PAIN REFRACTORY TO MEDICAL TREATMENT, THERE IS: Level 1b evidence that the effect on pain and function of arthroscopic lavage (10 L saline) and debridement (with 10 L saline lavage) is not statistically significant up to 24 months following surgery.Level 2 evidence that arthroscopic debridement (with 3 L saline lavage) is effective in the control of pain in severe OA of the medial femoral condyle for up to 5 years.For debridement in combination with meniscectomy, there is level 4 evidence that the procedure, as appropriate, might be effective in earlier stages, unicompartmental disease, shorter symptom duration, sudden onset of mechanical symptoms, and preoperative full range of motion. However, as these findings are derived from very poor quality evidence, the identification of subsets of patients that may benefit from this procedure requires further testing.In patients with pain due to a meniscal tear, of the medial compartment in particular, repair of the meniscus results in better pain control at 2 years following surgery than if the pain is attributable to other causes. There is insufficient evidence to comment on the effectiveness of lateral meniscus repair on pain control. Arthroscopic debridement of the knee has thus far only been found to be effective for medial compartmental OA. All other indications should be reviewed with a view to reducing arthroscopic debridement as an effective therapy. Arthroscopic lavage of the knee is not indicated for any stage of OA. There is very poor quality evidence on the effectiveness of debridement with partial meniscectomy in the case of meniscal tears in OA of the knee." }, { "id": "pubmed23n0517_23193", "title": "Debridement and continuous irrigation for the treatment of pyogenic arthritis caused by the use of intra-articular injection in the osteoarthritic knee: indications and outcomes.", "score": 0.016464699683877766, "content": "To discuss the indications and therapeutic outcomes of synovectomy, debridement, and continuous irrigation for the treatment of pyogenic arthritis caused by intra-articular injection used in the treatment of osteoarthritis of the knee. Records of 41 patients with infectious arthritis of the knee who presented to our hospital from 1981 were reviewed. 11 of them had a history of intra-articular injection. They underwent synovectomy, debridement, and continuous irrigation using a Salem double-lumen tube after confirmation that one side of the femorotibial joint cartilage was basically healthy. The infection was successfully treated in 9 of the 11 patients. Of these 9 patients, one died after 3 years and 2 underwent total knee arthroplasty after 3 and 8 years. The remaining 6 patients were followed up for 5 to 15 years. Five of them had deteriorating arthropathy, and the condition was unchanged in the others. Two of these 6 patients had pain while walking, and their Japanese Orthopaedic Association scores were 70. The remaining 4 had good knee function and reduction of pain, with a mean Japanese Orthopaedic Association score of 91 and a mean range of motion of 131 degrees. Arthrodesis is frequently considered the treatment for osteoarthritis if the joint destruction has affected the weight-bearing surface. However, in our experience, even when inflammatory granulation develops in the cartilage surface of one side of the femorotibial joint, good results can still be obtained by synovectomy, debridement, and continuous irrigation. After the pyogenic arthritis has subsided, if osteoarthritis has advanced and bowleg has exacerbated, further treatment options are available, such as tibial resection and even joint replacement. Continuous irrigation should be considered a feasible treatment option for pyogenic arthritis." }, { "id": "wiki20220301en068_12266", "title": "Knee replacement", "score": 0.01201923076923077, "content": "It is important to explore multiple rehabilitation protocols used for recovery of total knee arthroplasty. Continuous passive motion (CPM) is a postoperative therapy approach that uses a machine to move the knee continuously through a specific range of motion, with the goal of preventing joint stiffness and improving recovery. There is no evidence that CPM therapy leads to a clinically significant improvement in range of motion, pain, knee function, or quality of life. CPM is inexpensive, convenient, and assists patients in therapeutic compliance. However, CPM should be used in conjunction with traditional physical therapy. In unusual cases where the person has a problem which prevents standard mobilization treatment, then CPM may be useful." }, { "id": "pubmed23n0495_12264", "title": "Surgical management of the middle age arthritic knee.", "score": 0.011956018930363306, "content": "There are several options available for management of the middle-aged arthritic knee. Arthroscopic techniques continue to evolve, but the true natural history of the arthritic process is probably not altered. Good to excellent short-term results can be expected with proper patient selection. Patient counseling is important in order to discuss the nature of the underlying disease process, the limited goals of the arthroscopic procedure, and the possible need for further surgery. Proximal tibial osteotomy for the treatment of medial compartment osteoarthritis can be effective for as long as 15 years. There is a deterioration of results over time that can often be correlated to the degree of correction achieved. Strict selection criteria can maximize success. Revision surgery to total knee replacement, albeit technically difficult, is a viable option with results similar to primary TKR. Unicompartmental knee arthroplasty remains a controversial procedure as its indications continue to evolve. Good to excellent results can be expected in 80% to 90% of patients at 10 years follow-up. Unicompartmental knee arthroplasty occupies a special niche in the treatment of unicompartmental osteoarthritis and supplements total knee replacement and high tibial osteotomy surgery." }, { "id": "pubmed23n0249_12596", "title": "Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology.", "score": 0.011120226050496763, "content": "Treatment of patients with OA of the knee should be individualized and tailored to the severity of the symptoms. In individuals with mild symptomatic OA, treatment may be limited to patient education, physical and occupational therapy and other nonpharmacologic modalities, and pharmacologic therapy including non-opioid oral and topical analgesics. In patients who are unresponsive to this treatment regimen, the use of NSAIDs in addition to nonpharmacologic therapy is appropriate unless medically contraindicated. Judicious use of intraarticular steroid injections has a role either as monotherapy or an adjunct to systemic therapy in patients with knee OA who have symptomatic effusions. The role of joint lavage and arthroscopic debridement in patients with OA of the knee who are unresponsive to conservative medical therapy needs further study, and these procedures cannot be routinely recommended for all patients at this time. Patients with severe symptomatic OA of the knee require an aggressive approach to decreasing pain, increasing mobility, and decreasing functional impairment; such patients may benefit from orthopedic consultation and evaluation for osteotomy or total joint arthroplasty." }, { "id": "pubmed23n0631_13275", "title": "Arthroscopic joint lavage in osteoarthritis of the knee. Is it effective?", "score": 0.009900990099009901, "content": "To assess the benefits of arthroscopic washout in osteoarthritis of the knee (OAK). One hundred and fifty patients who underwent arthroscopic washout for early OAK between January 2001 and December 2006, at the King Fahd University Hospital, Al-Khobar, Kingdom of Saudi Arabia were analyzed. Preoperative assessment of patients included clinical assessment by modified Lequesne grading (MLG), antero-posterior and lateral radiographs of weight bearing of knee joints and the skyline view of the patella, and was graded by Kellegren and Lawrence grading (KLG). Arthroscopically, the knee joint was graded by Outerbridge classification (OC). The data were entered in the database and analyzed using the Statistical Package for Social Sciences version 14. One-hundred and seven patients were analyzed. Fifty-five patients were males and 52 were females, with a mean age of 51+/-9.3 years. The mean follow up was 39.45 months. Preoperative MLG was 14.2 +/- 4.1, at 6 months it was 7.39, and at 12 months was 7.75 +/-0.37, which improved from 6 months onwards (p=0.001). Kellgren and Lawrence grading and OC were significantly lower in younger patients age (&lt; or = 50) as compared to older patients (&gt; or = 51 years) (p=0.05). Seventy-one percent of our patients had excellent and satisfactory results, and 12 (11.2%) had no improvement. Arthroscopic joint debridement has benefits in the extent of pain relief and improvement of joint mobility. We believe that this procedure should be carried out in patients with OA for pain relief and delay of definite arthroplasty." }, { "id": "pubmed23n0332_2724", "title": "Articular cartilage regeneration of the knee joint after proximal tibial valgus osteotomy: a prospective study of different intra- and extra-articular operative techniques.", "score": 0.00980392156862745, "content": "In this prospective study high tibial osteotomy for medial gonarthrosis was performed in 95 patients (105 knee joints). The patients underwent simultaneously diagnostic and operative arthroscopic surgery of the knee joint. A follow-up arthroscopic examination could be performed in 75 patients (85 knee joints) at the time of implant removal. In group 1 (20 knee joints), the osteotomy was performed after diagnostic arthroscopy without arthroscopic operation of the knee joint. The fixation of the osteotomy was accomplished by staples, postoperative plaster fixation and physiotherapy. In group 2 (20 knee joints), osteotomy was performed without additional operative arthroscopy after diagnostic arthroscopy, internal fixation by AOT-plate, no external fixation postoperatively and physiotherapy. In group 3 (22 knee joints), osteotomy was performed with additional operative arthroscopy (Pridie drilling), internal fixation by AOT-plate no external fixation postoperatively no external fixation, physiotherapy and continuous passive motion. In group 4 (23 knee joints), osteotomy was performed with additional operative arthroscopy (abrasio-arthroplasty), internal fixation by AOT-plate, no external fixation postoperatively, physiotherapy and continuous passive motion. All patients underwent arthroscopic examination of the knee with cartilage biopsies taken from three different regions of the femoral condyle during the same operative session as the osteotomy. At follow-up arthroscopy cartilage biopsies were taken from the same regions. There was no great difference in clinical outcome after 1 year between all groups. Arthroscopy as well as routine and electron microscopy showed better cartilage regeneration in groups 3 and 4. Groups 1 and 2 showed only regeneration isles, sometimes not well fixed to the underlying bone, while in groups 3 and 4 cartilage regeneration was thicker and more stable, sometimes covering all of the pre-existing erosions. Therefore, we recommend osteotomy of the tibia for osteoarthritis together with operative arthroscopy in the same operative session." }, { "id": "pubmed23n0353_2139", "title": "[Role of arthroscopy in the treatment of pyogenic arthritis of the knee in adults. Report of 16 cases].", "score": 0.00980392156862745, "content": "The goal of this study was to determine the place and the limit of the arthroscopic management of septic knee arthritis. This procedure is an alternative treatment to needle aspiration and to open arthrotomy drainage. Sixteen adult patients were treated between 1993 and 1997 for pyogenic septic arthritis of the knee. The duration of symptoms prior to arthroscopic debridement was 4.5 days (range, one to 14 days). In 8 patients the infection was hematogenous. 5 patients had post-operative infection, 2 had post-traumatic infection and one infection followed an intraarticular injection. All the patients were treated by arthroscopic debridement and irrigation of the knee. A partial synovectomy of the anterior compartment was carried out in 4 cases in which the infection diagnosis was delayed. In 6 patients with resistant germ or early unfavorable course (clinically or biologically), an early iterative arthroscopy was performed between 2 and 7 days after the first procedure. The medical treatment consisted in a double systemic antibiotherapy for an average duration of 4 weeks, followed by oral treatment for 3 weeks. The patients were encouraged to mobilize their knee as soon as C Reactiv Protein was normal (average 3 weeks, 0 to 12). The average follow up was 20.5 months (2 to 60). Two elderly patients died, one directly related to knee infection. One patient with prior patella osteosynthesis had a recurrent infection 10 months after the arthroscopy. Thirteen out of 14 patients had an excellent or good functional result. Arthroscopic drainage is a valuable alternative procedure for the treatment of the septic arthritis. Arthroscopic treatment leads to a more effective infectious result than needle aspiration procedure and the functional result is better than with open drainage. Septic arthritis in the elderly or in patients with multiple organ failure have a poor prognosis. The treatment of pyoarthrosis of the knee must be aggressive and we frequently propose an iterative arthroscopic drainage, specially in case of delayed treatment, early unfavorable course or multiresistant germ." }, { "id": "wiki20220301en295_27682", "title": "Knee pain", "score": 0.009768009768009768, "content": "In some diagnosis, such as in knee osteoarthritis, magnetic resonance imaging does not prove to be clear for its determination. Management Although surgery has a role in repairing traumatic injuries and broken bones, surgeries such as arthroscopic lavage do not provide significant or lasting improvements to either pain or function to people with knee pain, and therefore should almost never be performed. Knee pain is pain caused by wear and tear, such as osteoarthritis or a meniscal tear. Effective treatments for knee pain include physical therapy exercises, pain-reducing drugs such as ibuprofen, joint stretching, knee replacement surgery, and weight loss in people who are overweight. Overall, a combination of interventions seems to be the best choice when treating knee pain. Interventions such as exercises that target both the knee and the hip, foot bracing, and patellar taping are all recommended for use with patients suffering from knee pain." }, { "id": "pubmed23n0540_10664", "title": "High tibial osteotomy with Puddu plate for the treatment of varus gonarthrosis.", "score": 0.009708737864077669, "content": "In this study, the results of open-wedge osteotomy with Puddu plate for the treatment of varus gonarthrosis have been evaluated prospectively. This study assessed 65 knees of 60 patients with varus gonarthrosis who underwent high tibial osteotomies. Our study population consisted of 13 male and 47 female patients with a mean age of 54 (range 39-76) years. For the clinical evaluation of the patients Hospital of Special Surgery (HSS) score, American Knee Society and Oxford knee scores, and for the radiological assessment mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), femorotibial angle and Insall-Salvati index were basically taken into consideration. Our patients were followed up for an average of 34 (range 18-60) months. In the last assessments of our cases, mean improvements detected in HSS scores, Oxford knee scores, knee and functional scores of Knee Society were 26.72, 19.18, 49.9, and 30 points, respectively. The radiological examinations revealed that their mechanical axes on the average passed 5.09 mm laterally achieving an average of 6.5 degrees genu valgum, and a mean Insall-Salvati index of 1.09. As complications, superficial wound infection in two patients (3%), implant infections in one patient (1.5%), deep vein thrombosis in two patients (3%), peroperative lateral tibial plateau fracture in one patient (1.5%), and postoperative lateral tibial plateau fracture due to a falling down were encountered. According to the results obtained, postoperative pain resolves promptly and a significant degree of improvement of knee functions of the patients are achieved. Therefore, we believe that high tibial osteotomy with a Puddu plate is a valuable alternative to total knee arthroplasty in cases with varus gonarthrosis. Although early results are satisfactory, long-term follow-up studies are required especially in the middle aged and elderly patient populations." }, { "id": "pubmed23n0853_19434", "title": "[Case-control study on midterm follow-up effects of the extended release of posterior clearance in total knee arthroplasty].", "score": 0.009708737864077669, "content": "To evaluate the midterm follow-up results of extended release of posterior clearance in total knee arthroplasty. A total of 120 patients with knee osteoarthritis were equally randomly assigned to the experimental group and control group, and underwent unilateral TKA from March 2010 to March 2012. In experimental group, there were 21 males and 39 females with an average age of (62.2±10.9) years old. In the control group, there were 25 males and 35 females with an average age of (64.9±11.4) years old. All the patients were performed using the anterior knee approach. During operation, after osteotomy of the tibia and the femoral condyle, extended release of the posterior knee clearance were taken in experimental group, while only the clearance of osteophyte in the posterior condyle were performed in the control group. The KSS scores including knee functional score and knee clinical score,as well as the range of motion (ROM) of patients, were compared between the two groups at midterm follow-up. Totally 49 patients in the experimental group and 54 patients in the control group were followed up, and the median follow-up time was 46 months. The knee functional score of patients in the experimental group was 91.3±3.4, which was better than 86.4±3.9 of patients in the control group; initiative ROM of flexion of patients in the experimental group was (133.2±5.9)°, which was better than (126.9±7.4)° of patients in the control group. There were no significant difference of knee clinical score between 86.9±4.6 of patients in the experimental group and 85.7±5.1 of patients in the control group, and the initiative ROM of extension between (0.5±1.1)° and (0.3±1.2)°. Extended release of the posterior knee clearance contributes to the knee function and initiative flexion ROM during a midterm follow-up and patients benefit." }, { "id": "pubmed23n0774_13662", "title": "[The \"Oxford\" unicondylar knee prostesis (UCP): 21 reviewed cases].", "score": 0.009615384615384616, "content": "The unicompartimental knee prosthesis known as \"Oxford\" is a non constraint prosthesis, entrusting the whole of its stability to an intact ligamentary apparatus. Where the support surfaces of most prostheses remain limited, even punctiform, the originality of the Goodfellow prosthesis lies in the fact that the prosthetic condyle, whatever the flexion angle is, leans against a mobile prosthetic meniscus with spheric superior concavity of the same radius as the condylian radius, which increases considerably the prosthetic leaning surfaces and therefore lessens the pressure constraints. The superior surface, concave, of this prosthetic meniscus takes charge of the rolling, where the inferior plane surface realizes the gliding on the metallic tibial plate. The total conformity of the components minimizes the forces of friction.Between July 1988 and March 1993, 24 patients underwent the placing of UCP. Three patients died and 2 were lost of sight. 19 patients could be seen again or checked, corresponding of 21 operated knees. Two knees benefited from the start from UCP (medial and lateral) and 2 knees had a UCP in the first instance and then a second UCP in the compartment left safe primarily. For the 21 UCP, there are 16 medial and 3 lateral. Our mean drawback is of 3 years and 3 months, all the drawbacks being superior to 1 year and 4 months. The mean age is of 64 years. There were 17 female and 2 male patients. The mean weight is of nearly 80 kg (79,8) and nearly 52% of the operated patients have an important overweight (Body Mass Index superior to 30). Preoperative clinical analysis. It is based on a retrospective study of files using the quotation described by AUBRIOT for the «GUEPAR» group. This one establishes a gradation of four levels for each of the three criteria retained (Pain, Mobility, Instability), thus determining a global result imposed by the lowest level retained.For walking, other factors than just the state of the operated knee may intervene, this being the reason why it doesn't show in this chart. The GUEPAR group quantifies it with letters A, B, C, D.Concerning pain, all 21 knees were quoted as \"Bad\" in preoperative. Pain constitutes the decisive argument for the operative indication. In our series, only one knee had an average amplitude, all the others had a mobility superior to 89°. In 5 cases there was a flessum between 11 and 20° (penalizing of a level). Concerning walking and stability, they were taken into account, thanks to a precise questionnaire about the daily life acts. Concerning the walking perimeter, it was found as unlimited (A) in 1 case, superior to 500 m (B) in 2 cases, inferior to 500 m (C) in 17 cases and limited to home (D) in 1 case. The early after effects. At the end of the intervention, the knee is placed into a splint with limited flexion. As soon as the second day the patient is sat on the border of his bed. The first partial support at the third of the body weight is authorized between the fourth and the fifth day, when at the same time flexion exercises on electrical splint are started, as soon as the Redon draining is removed. The average hospitalization length was of a fortnight. Among secondary late complications and retakes, let us stop on meniscal luxations which constitute a specific complication of the Oxford arthroplasty. They concern 3 times the medial compartment and 4 lateral compartment. They happened in 1 case early, at D 22, in 3 cases within the 6 first months and in 3 cases after 2 years. They were treated : 3 times by reduction under general anæsthetic, no more ; 3 times changing the meniscusus for a meniscusus of superior size and once by placing a total prosthesis at the place of the UCP. The deteriorations of the opposed compartment not prosthesized occured in three cases. They were treated by unicompartmental additional arthroplasty in two cases and by total prosthesis in the third case. The clinical results on pain are very satisfactory as from the early check up onwards we have 17 successes (no pain 11 cases and occasional pains 6 cases) and as after 3 years and 5 months in average, we have 19 successes (no pain : 10 cases - occasional pain : 9 cases). At the maximal drawback, the mobility is quoted very good in 7 cases and good in 13 cases, mean in 1 case. At the latest check up, we note an excellent stability in 17 cases and good in 3 cases, that is to say 20 successes and 1 case of stability quoted as mean. At the latest check up we note 17 successes (A and B) and 4 relative failures (C) concerning the quality of walking.At the question «are you pleased with the intervention and would you advise it to a friend?» and with the nuance «very pleased» and «simply satisfied», we get 10 cases «very pleased», 8 cases «pleased» and 3 cases «moderately satisfied»; only those 3 cases advise against the intervention. The radiological results are less satisfying as they show frequent imperfections : • for the 16 medial UCP : only 9 cases hypocorrected or normo axed, but 1 case strongly hypocorrected (residual varus of 7°) and 6 hypercorrected cases. • for the 5 lateral UCP : 3 normo-axed cases, 1 case strongly hypocorrected (residual valgus of 6°) and 1 case strongly hypercorrected (10° varus). • the failures due to rapid deterioration of the non prosthetized compartment occurred on hypercorrected knees. • on 21 knees, 14 borders of tibial plate were noticed, out of which 9 had no plate displacement and 5 had a slight displacement, at the origin of a small angular loss. • accumulations of cement on the tibial side, towards the back or in medial were noticed in 8 cases, which explains a slope of the tibial plate to the back inferior to 5° in 11 cases (should be of 7°). • 4 femoral components seem to be too posterior and one shows curved.In total, only 7 cases out of 21 were estimated with no peculiarities on the radiological point of view. It seems difficult to place a UCP well. The meniscal luxations are favored by an alignment rotational defect of the tibial plate, specially for the lateral UCP, the meniscus coming to hit the lip of the tibial plate during the lifting from a sitting position. For 5 of these luxations, we must recognize the existence of a ligamentary collateral laxity which should have altered the surgical indication either to an osteotomy, or to a total arthroplasty. Conclusions. Under the condition of respecting the absolute counter indications, of thoroughly evaluating the relative counter indications and of reducing at the best the defects linked to the surgical technique, the unicompartmental arthroplasty, including that of Oxford, gives good functional results after more than three years. In our series, the result on pain is constant if we exclude the cases with risk with ligamentary laxity and that of centered gonarthrosis at obese subject, that is to say 15 successes on 15 knees thus selected retrospectively. The gain on mobility is weak, of 5° in average. The result on stability is, as for pain, excellent, if we exclude the cases with risk, as we get then also 15 successes on 15 knees. Concerning the global result according to the quotation of Aubriot-Guepar, we note 14 successes and 1 relative failure. 4 knees were bad indications and should have benefited from a total arthroplasty or from an osteotomy. " }, { "id": "wiki20220301en442_27487", "title": "High tibial osteotomy", "score": 0.009524652562627247, "content": "Patient selection The accepted protocol used for patient selection was developed in 2004 by the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine (ISAKOS). According to this protocol, an ideal patient is: Moderately active Between 40-60 years old Experiencing isolated medial joint line tenderness BMI <30 Malalignment <15° Tibia bone varus angle >5° Full range of motion in the knee Near-normal lateral and patellofemoral compartments without ligamentous instability A non-smoker Contraindications specified by ISAKOS are: Patients older than 65 Severe osteoarthritis of the medial compartment (Ahlback grade III or higher) Tricompartmental osteoarthritis Patellofemoral osteoarthritis Range of motion in the knee <120° Flexion contracture >5° Diagnosed inflammatory arthritis A large area of exposed bone on the tibial or femoral articular surface (> 15x15 mm) Heavy smokers" }, { "id": "pubmed23n1127_7377", "title": "Significant slope reduction in ACL deficiency can be achieved both by anterior closing-wedge and medial open-wedge high tibial osteotomies: early experiences in 76 cases.", "score": 0.009523809523809525, "content": "It has been proven that a steep tibial slope (TS) is a risk factor for anterior cruciate ligament (ACL) injury and graft insufficiency after ACL reconstruction (ACLR). Recently, there is an increasing number of case series on slope decreasing osteotomies after failed ACLR utilizing different techniques and strategies. Goal of the present study is to report on early experiences with slope decreasing osteotomies in ACL deficient knees with special emphasis on the amount of slope correction, technical details, and complications; and to further analyze differences of slope corrections between sole sagittal as well as combined coronal and sagittal realignment procedures. In addition, we wanted to study if sole sagittal corrections change the coronal alignment. Seventy-six patients with a minimum follow-up of 6 months were identified, who underwent a sole sagittal correction (anterior closed-wedge high tibial osteotomy (ACW-HTO)) or a combined procedure with an additional coronal realignment (medial open-wedge high tibial osteotomy (MOW-HTO)). In ACW-HTO, either infratuberosity or supratuberosity approaches were used. The medial TS was measured on lateral radiographs and the anatomical medial proximal tibial angle (aMPTA) was measured on anterior-posterior radiographs. Technical details and specific complications were recorded. Fifty-eight ACW-HTO and 18 MOW-HTO were performed. Regarding ACW-HTO, an infratuberosity (N = 48) or a supratuberosity (N = 10) approach was chosen. Sixty-seven patients had at least 1 previous ACLR. Mean TS changed from 14.5 ± 2.2° to 6.8 ± 1.9° (P &lt; 0.0001). Mean TS of ACW-HTO was significantly reduced (14.6 ± 2.3° vs. 6.5 ± 1.9°; P &lt; 0.0001), whereas in combined coronal and sagittal realignments, from 14.1 ± 1.9° to 7.6 ± 1.9° (P &lt; 0.0001). The TS reduction in sole sagittal corrections was significantly higher compared to combined procedures (8.1 ± 1.6 vs. 6.4 ± 1.6°; P = 0.0002). Mean aMPTA in ACW-HTO changed from 87.1 ± 2.1° to 87.4 ± 2.8 (n.s.). However, there was a significant inverse correlation between the amount of sagittal correction and coronal alteration (r = - 0.29; P = 0.028). There was one late implant infection, which occurred 5.5 months after the index surgery. ACW-HTO and MOW-HTO facilitate significant slope reduction with a low-risk profile in patients with ACL insufficiency and a high tibial slope. AOW-HTO does not significantly alter coronal alignment in the majority of patients. IV." }, { "id": "pubmed23n0800_13033", "title": "[Case-control study on earlier medial tibial pain after total knee arthroplasty].", "score": 0.009523809523809525, "content": "To compare the difference of anterior knee pain after total knee arthroplasty (TKA) between the ways using periosteal dissector and electric scalpel to release medial collateral ligament and pes anserinus. From September 2009 to September 2012, 220 patients with unilateral osteoarthritis were treated with primary TKA in hospital 301. All the patients were randomly divided into periosteal dissector group (110 cases) or electric scalpel group (110 cases). In the periosteal dissector group, there were 47 males and 63 females,with an average age of (58.8 +/- 17.2) years old; the degree of genuavarus was (14.0 +/- 3.5) degrees; the weight was (65.6 +/- 12.8) kg; the body mass index (BMI) was (26.6 +/- 3.6) kg/m2. In the electric scalpel group,there were 49 males and 61 females,with an average age of (59.6 +/- 16.7) years old;the degree of genuavarus was (15.0 +/- 4.7) degrees; the weight was (66.4 +/- 13.4) kg; the BMI was (27.4 +/- 4.1) kg/m2. The mean follow-up period was 24.6 months. The AKS, VAS and HSS were used to evaluate clinical results. All incisions healed at the first stage;no deep vein thrombosis of lower limbs or pulmonary embolism occurred. Knee infection occurred in 3 cases (1 in the periosteal dissector group and 2 in the electric scalpel group), and the 3 patients received stage 2 total knee revision using antibiotic bone cement and TC3 prosthesis. No recurrence of infection occurred during follow-up. Among the 20 patients who had anterior knee pain, 16 patients were in the periosteal dissector group and 4 patients were in the electric scalpel group. The occurrence rate of anterior knee pain in the electric scalpel group was lower than that in the periosteal dissector group. The AKS knee score and HSS score after total knee arthroplasty in the electric scalpel group were all higher than those in the periosteal dissector group, and the VAS in electric scalpel group was lower than that of periosteal dossector group. Compared with using electric scalpel,using periosteal dissector used to release medial collateral ligament and pes anserinus may cause more anterior knee pain after total knee arthroplasty." }, { "id": "wiki20220301en106_12159", "title": "Arthroscopic lavage", "score": 0.00948208066509381, "content": "Needle lavage should not be used in an attempt to treat persons seeking long-term relief for symptomatic osteoarthritis of the knee. The use of this treatment in this case has not been shown to decrease pain, stiffness, tenderness, or swelling, or to increase 50-foot walking time or body function. Technique Arthroscopic lavage is generally combined with arthroscopic debridement, where fronds of joint material or degenerative tissue are removed using a combination of injected fluid and a small vacuum, i.e. both washing (rinsing) and sucking. 'Arthroscopic' means that this is done using a tiny incision at the joint, where a thin arthroscope is pushed into the joint to inspect the structures. References External links progress-report-anthroscopic-lavage Endoscopy Orthopedic treatment" }, { "id": "pubmed23n0793_20467", "title": "Comparative analysis of the results obtained after unicondylar knee arthroplasty and high tibial osteotomy in isolated gonarthrosis.", "score": 0.009433962264150943, "content": "The AIM of this study was to analyse the results of the surgery and compare the outcomes of unicondylar knee arthroplasty and high tibial osteotomy performed in isolated gonarthrosis. Between 2007 and 2011, 65 patients were implanted a partial knee endo-prosthesis in the Clinic of Orthopedics and Traumatology. Men were 23 (35.4%) and women were 42 (64.6%). High tibial osteotomy was performed to manage the unicompartmental gonarthrosis in 92 patients (47 men and 45 women) for 13 years between 1975 and 1987. These two modalities were used only in cases in which one of the knee joint compartments was affected. Clinical, para-clinical, functional tests and radiographic examination were conducted of the affected knee joint. The results of the study were assessed by the rating system proposed by the Knee Society and modified by John Insall. At four-year follow-up study the outcomes of the partial prosthesis were assessed as excellent in 85.13%, good--in 13.11% and satisfactory in 1.77% of patients. After high tibial osteotomy the results were considered very good in 54.18% of patients, good--in 32.29%, satisfactory--in 6.25%, and poor--in 7.8%. Partial knee arthroplasty is a resurfacing procedure, while high tibial osteotomy is used only to slow the overall degenerative process with gradual progressive exacerbation of osteoarthritis with age. The results after prosthetic treatment had a better dynamics than that in high tibial osteotomy." }, { "id": "pubmed23n0948_3734", "title": "[Short-term effectiveness of joint distraction by Ilizarov combined with arthroscopic debridement in treatment of knee osteoarthritis].", "score": 0.009433962264150943, "content": "To investigate the short-term effectiveness of joint distraction by Ilizarov combined with arthroscopic debridement in the treatment of knee osteoarthritis (KOA). Between January 2014 and January 2015, 15 patients (15 knees) with KOA were treated using arthroscopic debridement assisting with the Ilizarov distraction technology. There were 7 males and 8 females, aged from 45 to 64 years (mean, 55 years). The left knee and the right knee were involved in 6 and 9 cases respectively. The disease duration was 2.0-9.5 years (median, 6 years). They all had received conservative treatment for 6 months and got poor clinical improvement. The preoperative visual analogue scale (VAS) score, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, the knee injury and osteoarthritis outcome score (KOOS), the range of motion (ROM) for knee, and the radiographic joint space width were 76.2±8.8, 59.3±5.7, 44.3±7.2, (75±21)°, and (2.5±0.4) mm respectively. According to Kellgren-Lawrence grade system, 11 cases were rated as grade III and 4 cases as grade IV. There was no poor incision healing, infection, and deep vein thrombosis. All the 15 patients were followed up 12-18 months (mean, 15.5 months). Patients achieved pain relief. The knee activity was obviously improved. The postoperative VAS score, WOMAC score, KOOS score, and ROM at 12 months were 20.9±7.8, 38.2±5.5, 92.1±6.9, and (118±14)° respectively, showing significant difference when compared with preoperative ones ( <it</i=18.213, <iP</i=0.000; <it</i=10.317, <iP</i=0.000; <it</i=18.564, <iP</i=0.000; <it</i=6.599, <iP</i=0.000). Postoperative X-ray film showed that joint space width at 12 months was (3.8±0.3) mm, showing significant difference when compared with preoperative one ( <it</i=10.070, <iP</i=0.000). Joint distraction by Ilizarov combined with arthroscopic debridement can effectively relieve pain, improve the function and quality of life. It was beneficial to cartilaginous tissue repair and delaying the degenerative process of KOA. The short-term effectiveness is satisfactory." }, { "id": "wiki20220301en495_23617", "title": "Simitri Stable in Stride", "score": 0.009345794392523364, "content": "In a Simitri Stable in Stride surgical procedure, unlike tibial-plateau-leveling osteotomy (TPLO) and tibial tuberosity advancement (TTA), no osteotomy (cutting of bone) is required making this a much less invasive procedure. A surgical incision is made on the inside of the affected leg and the Simitri implant is positioned over the center of the stifle (knee) joint. All components of the implant remain under the skin but outside the knee Joint. The architecture of the affected joint is unchanged and the biomechanics are not significantly altered. The implant is fixed in place with six cortical locking screws and once implanted provides immediate and continuous translational and rotational stability throughout the entire range of motion. Dogs are almost always able to weight bear on their surgical leg within 24 hours and are expected to begin a comprehensive rehabilitation program, including controlled leash walks the day they go home." }, { "id": "pubmed23n0881_13425", "title": "[Clinical effect of total knee arthroplasty on patients with knee osteoarthritis combined with mild to moderate valgus knee deformity].", "score": 0.009345794392523364, "content": "To investigate the clinical effect of total knee arthroplasty on patients with knee osteoarthritis combined with mild to moderate valgus knee deformity.
 A total of 15 patients received total knee arthroplasty for correcting mild (10°-15°) to moderate (15°-30°) valgus knee between January 2011 and February 2014 in Xiangya Hospital of Central South University. We adopted a stable prosthesis surgery through patellar medial approach, osteophytes cleaning, conventional osteotomy, a selective soft tissue release and balance technical correcting of knee valgus deformity. Then conventional anticoagulation and symptomatic rehabilitation was utilized. Preoperative and postoperative X-ray was conducted in patients with measuring femor-tibial angle (FTA) and inspecting the prosthesis position. FTA, visual analog scale (VAS) standard, and parallel knee scoring system (KSS) were used to evaluate the clinical effect.
 Fifteen patients were followed up for 14 to 36 (22.40±11.88) months. The hospitalization time was 7-13 (7.73±1.58) d; operative time was 58-110 (81.8±16.85) min, the dominant blood loss was 140-600 (337.30±143.65) mL. Two cases had knee extension hysteresis, and the knee activity recovered after exercise. Leg power lines were normal. Three postoperative cases suffered anterior knee pain. They were subjected to celecoxib analgesic treatment and the pain gradually eased after 3 months. One postoperative case showed incision discharge and swelling, which was healed after change of dressing. During follow-up, review of X-ray film does not show prosthesis loose, subsidence and other complications. The knee valgus angle (8.1±1.8)°, knee motion range (107.33±9.61)°, KSS knee score (74.7±14.5, 75.3±2.7) and pain score (2.5±0.9) were significantly better than the preoperative (P&lt;0.05). The clinical and function KSS scores showed that the improvement rate was 80%. 
 Total knee arthroplasty is an effective way to treat patients with knee osteoarthritis combined with mild to moderate valgus knee deformity. The correction of deformity and improvement of joint function can be achieved significantly. The clinical result is satisfactory and patients' quality of life is improved." }, { "id": "wiki20220301en213_36035", "title": "Unicompartmental knee arthroplasty", "score": 0.009259259259259259, "content": "Unicompartmental knee arthroplasty (UKA) is a surgical procedure used to relieve arthritis in one of the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may reduce post-operative pain and have a shorter recovery period than a total knee replacement procedure, particularly in people over 75 years of age. Moreover, UKAs may require a smaller incision, less tissue damage, and faster recovery times. In the United States, the procedure constitutes approximately 8% of knee arthroplasties. In comparisons with a more extensive surgical procedure called high tibial osteotomy, UKA has equal or better outcomes." }, { "id": "pubmed23n0105_11652", "title": "Arthroscopic irrigation and debridement of infected total knee arthroplasty: report of two cases.", "score": 0.009259259259259259, "content": "Various methods have been described for the treatment of the acutely infected total knee arthroplasty. These include antibiotic suppression, open debridement and irrigation, exchange arthroplasty, resection arthroplasty, arthrodesis, and amputation. A method not frequently reported is arthroscopic irrigation and debridement. Two cases of acutely infected total knee arthroplasty treated with arthroscopic irrigation and debridement are presented. In both cases there was a benign postoperative course averaging five months. Both infections were secondary to hematogenous seeding from a distant focus of infection. The patients presented within approximately 12 h after the onset of knee symptoms and were taken for arthroscopic irrigation and debridement within 12 h after presentation. Gram-positive organisms sensitive to the antibiotics being used were cultured in both. Postoperative knee function and range of motion returned rapidly and disability was minimal. At average 30-month follow-up both patients were pain free, had full activity of daily living, and had no clinical or radiographic evidence of infection. Arthroscopic irrigation and debridement appears to be an effective method of treatment in select cases of infected total knee arthroplasty." }, { "id": "pubmed23n1046_8564", "title": "Medial Open Wedge High tibial Osteotomy (MOWHTO) does not relevantly alter patellar kinematics: a cadaveric study.", "score": 0.009174311926605505, "content": "The purpose of this study was to quantify the influence of medial open wedge high tibial osteotomy on patellar kinematics using optical computer navigation, as anterior knee pain infrequently occurs postoperatively and the reason is still being unknown. Ten medial open wedge high tibial osteotomies at supratuberosity level in 5 full body specimens were performed. The effect of the surgical procedure on patellar kinematics, measured at 5 and 10 degrees of leg alignment correction angle, was analyzed and compared to native patellar kinematics during passive motion-regarding patella shift, tilt, epicondylar distance and rotation. Linear mixed models were used for statistical analysis, a two-sided p value of ≤ 0.05 was considered statistically significant. Tilt behavior, medial shift and epicondylar distance did not show a significant difference regarding natural patellar kinematics at both osteotomy levels. Both osteotomy correction angles showed a significant less external rotation of the patella (p &lt; 0.001, respectively) compared to natural kinematics. Except less external rotation of the patella, medial open wedge high tibial osteotomy does not seem to relevantly alter patellar alignment during passive motion. Future clinical studies have to prove the effect of MOWHTO on patellar kinematics measured in this experimental setup, especially regarding its influence on anterior knee pain." }, { "id": "article-23923_20", "title": "Total Knee Replacement Techniques -- Preparation -- Non-Operative Management", "score": 0.009174311926605505, "content": "The AAOS cannot recommend for or against manual therapy (i.e., chiropractic, joint manipulation), physical agents including electrotherapeutic modalities, biologic injections, corticosteroid injections, valgus directing force brace, acetaminophen, opioids, or pain patches." }, { "id": "wiki20220301en020_110045", "title": "Osteotomy", "score": 0.009141914191419142, "content": "Osteotomy is also used as an alternative treatment to total knee replacement in younger and active patients. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years. Surgery The location of the removed wedge of bone depends on where osteoarthritis has damaged the knee cartilage. The most common type of osteotomy performed on arthritic knees is a high tibial osteotomy, which addresses cartilage damage on the inside (medial) portion of the knee. The procedure usually takes 60 to 90 minutes to perform." }, { "id": "pubmed23n0120_9728", "title": "Tibial osteotomy in the treatment of genu recurvatum in the adult.", "score": 0.00909090909090909, "content": "The authors analyse the results of 23 cases of high tibial osteotomy for genu recurvatum in adults performed at the Rizzoli Orthopaedic Institute from 1968 to 1983. The osteotomy is at the supratuberosity level. After detaching the patella tendon an anterior bone wedge is inserted and the tendon reinserted at a higher level. This operation has produced better results than other surgical techniques. It is indicated in the osseous type of recurvatum or in the combined type in which the osseous component is predominant. In the combined type with a capsulo-ligamentous prevalence, the poor results obtained with osteotomy alone indicate the need for combining the operation with a plastic reconstruction of the posterior capsulo-ligamentous structures." }, { "id": "pubmed23n0929_1458", "title": "Curative effect of knee arthroplasty on patients with osteoarthritis and analysis of long-term joint function of these patients.", "score": 0.00909090909090909, "content": "The aim of this study was to explore the curative effect of knee arthroplasty on patients with osteoarthritis and analysis of their long-term joint function. Ninety-six cases of osteoarthritis patients, collected in our hospital from June 2010 to May 2011, were divided into control group and observation group (N.=48 in each group). Patients in observation group were treated by knee replacement, and patients in control group were treated by arthroscopic debridement. Bleeding during operation of patients and the operation time in both groups were comparable during their followed up for 6~60 months, with an average of 52 months. Neer score was used to compare the curative effect of patients after 6 months; knee society score (KSS) was used to compare knee joint function and knee joint of motion (ROM) of patients several days prior to surgery and after 6 months, 12 months, 24 months, and 48 months. Visual analogue scale (VAS) was used to compare pain degrees of patients at the last follow-up. By Neer score comparison, after 6 months excellent and good rate of patients in observation group (91.67%) was obviously higher than that of control group 70.83% (P&lt;0.05); ROM of patients in observation group was obviously higher than that in control group (P&lt;0.05); After six months, KSS score of patients in both groups greatly improved. As well, with the extension of time, their knee joint function showed a better trend, and KSS score of patients in observation group was obviously higher than that of control group (P&lt;0.05). Pain of patients in observation group was significantly lower than that in control group (P&lt;0.05). Both arthroscopy debridement and knee replacement have good curative effect. The curative effect of knee replacement was better, postoperative knee joint activity was obviously improved, the long-term recovery of knee joint function was good, and knee replacement can reduce the pain of the patients." }, { "id": "pubmed23n0313_12986", "title": "Revision total knee arthroplasty after failed high tibial osteotomy.", "score": 0.009009009009009009, "content": "Eleven patients (12 knees) who underwent revision total knee arthroplasty after failed high tibial osteotomy are reviewed. All patients were evaluated clinically and radiographically before osteotomy and arthroplasty, and in the follow-up period. The time from osteotomy until arthroplasty ranged from 9 months to 9 years, 6 months (average: 4 years, 5 months). The average follow-up period after arthroplasty was 6 years, 11 months (range: 1 year, 6 months to 13 years). On the basis of the Japan Orthopaedic Association osteoarthritic knee scoring system, the results of total knee arthroplasty after osteotomy were found to be comparable with the results after primary arthroplasty. Patients were divided into two groups according to the time from osteotomy to arthroplasty, alignment of the leg before arthroplasty, and the reason for requiring revision arthroplasty. Group 1 included 6 patients with 6 knees who underwent arthroplasty within 3 years after osteotomy. The main reason for revision arthroplasty in Group 1 was pain due to the recurrence of a varus deformity. Group 2 included 5 patients (6 knees) who underwent revision arthroplasty more than 5 years after osteotomy. The main reason for revision arthroplasty in Group 2 was pain or hydrarthrosis due to the progression to bi-compartmental or tri-compartmental osteoarthritis. There was no significant difference in the clinical results between the two groups. Concerning patellar height, LT/LP of Group 1 was significantly lower than that of Group 2. There were no significant differences in the radiographic findings among the two study groups and the control group of 71 patients (110 knees) who underwent primary total knee arthroplasty, except for alignment before arthroplasty. Using the Japan Orthopaedic Association osteoarthritic knee scoring system, previous osteotomy does not seem to affect the outcome of total knee arthroplasty. With refinement of the technique of high tibial osteotomy, revision total knee arthroplasty after 3 years or less would be avoidable, however, revision total knee arthroplasty due to osteoarthritic deterioration over time would be inevitable." }, { "id": "pubmed23n0255_7279", "title": "Short-term effects of knee washout for osteoarthritis.", "score": 0.009009009009009009, "content": "Twenty-nine knees in 23 patients with symptomatic osteoarthritis underwent washout with lactated Ringer's solution. Two arthroscopic cannulas were placed into the knee under local anesthetic. Three liters of fluid were run through the knee using varying inflow and outflow to alternately inflate and deflate the knee. We obtained Hospital for Special Surgery knee scores, Knee Society pain and function ratings, and visual analog pain scales before washout and up to 2 years after washout. At 1 year, the mean Hospital for Special Surgery score increased from 72 to 87, the Knee Society pain rating from 64 to 89, and the Knee Society function rating from 62 to 82. Twenty-five knees had a good or excellent result at 1 year. Twenty-one of these were observed at 2 years; 17 had good or excellent results. This study confirms the value of a fluid washout in an arthritic knee for some patients. This may explain some of the symptom relief seen with arthroscopic procedures in this condition." }, { "id": "wiki20220301en068_12232", "title": "Knee replacement", "score": 0.008990485405579746, "content": "Medical uses Knee replacement surgery is most commonly performed in people with advanced osteoarthritis and should be considered when conservative treatments have been exhausted. Total knee replacement is also an option to correct significant knee joint or bone trauma in young patients. Similarly, total knee replacement can be performed to correct mild valgus or varus deformity. Serious valgus or varus deformity should be corrected by osteotomy. Physical therapy has been shown to improve function and may delay or prevent the need for knee replacement. Pain is often noted when performing physical activities requiring a wide range of motion in the knee joint. Pre-operative preparation" }, { "id": "pubmed23n0995_10283", "title": "[Acupoint puncture combined with Ilizarov technique for the treatment of elderly paitents with knee osteoarthritis].", "score": 0.008928571428571428, "content": "To explore the clinical effect of acupoint puncture combined with Ilizarov technique in the treatment of knee osteoarthritis in the elderly. From March 2015 to February 2016, 76 patients with primary knee osteoarthritis were treated with tibial osteotomy acupoint puncture grouop and Ilizarov technique anatomical puncture group, including 24 males and 52 females, aged 56 to 75 years old with an average of 61.4 years old, and a course of 3 to 17 years with an average of 5.2 years. Among them, 38 cases were treated with external fixation of acupoint puncture needle and 38 cases were treated with external fixation of anatomical puncture needle. Preoperative full-length X-ray of both lower limbs showed tibial varus deformity, narrowing of medial knee joint space and enlargement of lateral knee joint space. The force line of the affected knee and lower limb was moved inward by body surface measurement, and the KSS knee function score was decreased. Symptoms included medial knee pain, flexion and extension, and conservative treatment for more than 2 years. The lower limb force lines of both groups were corrected and the osteotomy ends healed well. No nonunion of osteotomy, inadequate correction of lower limbs or recurrence of deformity were found. Seventy-five patients were followed up for 3, 6, 12 and 24 months after operation. There was no significant difference in knee joint mobility between the two groups before operation and on 6, 12, 24 months after operation(<iF</i=1.346, <iP</i&gt;0.05). There were significant difference in KSS pain and total score between the two groups at 3 months after operation, acupoint puncture group was better than anatomical puncture group(<iP</i&lt;0.05); there was no significant difference in KSS score at 12 months after operation(<iP</i&gt;0.05). The acupoint puncture group formed a potential acupuncture effect in the acupoint area by continuously tightening the steel needle on Ilizarov ring external fixator during the post-operative adjustment. Within three months after wearing external fixator, the knee pain symptoms of knee osteoarthritis were relieved rapidly, continuously and effectively, which was significantly better than that of the anatomical puncture group." }, { "id": "pubmed23n0661_1278", "title": "[The septic knee - arthroscopic treatment.].", "score": 0.008928571428571428, "content": "Arthroscopic irrigation has proved very effective in the treatment of the septic knee, provided that it is begun at the earliest possible time. We obtained very good results in 25 out of 27 cases treated by radical irrigation in the first three days after the start of infection. Cases where the infection had been present for more than six days were managed by synovectomy. Surgical therapy must be accompanied by intensive CPM treatment, combined with isometric exercises for the quadriceps muscle in order to achieve a good functional outcome. Key words: septic knee, arthroscopic irrigation." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 98, 458 ] ], "word_ranges": [ [ 15, 74 ] ], "text": "we will have to perform a cranial CT scan to rule out a hemorrhagic stroke. If the CT scan does not show bleeding, the patient has an acute ischemic stroke, probably cardioembolic due to his cardiac pathology, not anticoagulated. Given that his tumor process is under control, there are no contraindications for the administration of fibrinolysis in this case," }, "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": "Perform a cranial CT scan and if there are no hemorrhagic lesions or other contraindications in the analysis, start immediate intravenous thrombolysis.", "2": "Perform urgent cranial CT scan and if there is no bleeding, start anticoagulation.", "3": "Perform cranial CT scan and admission to rehabilitation center, since their attitude will not differ regardless of whether the etiology is ischemic or hemorrhagic.", "4": "Cranial CT scan is not necessary, although I would withdraw the antiaggregation.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0057_18090", "title": "[Two cases of cerebral embolism showing global aphasia without hemiparesis].", "score": 0.017304393227418516, "content": "We report two cases of typical global aphasia without hemiparesis due to cerebral embolism. Case 1 was a 65-year-old right-handed man with a history of old myocardial infarction. No spontaneous speech was noted by his family. Neurological examination upon admission revealed confusional state, global aphasia, conjugate deviation to the left and slight drift of the outstretched right limbs. The right hemiparesis rapidly recovered after admission. CT scan performed on the second hospital day showed discrete low density areas in the left posterior frontal lobe and left temporo-parietal regions. The extent and severity of his global aphasia were unchanged. The second case was an 82-year-old right-handed man with a history of atrial fibrillation. He was admitted to our hospital one hour after he was found unable to speak. Neurological examination upon admission revealed global aphasia, conjugate deviation to the left and suspected right homonymous hemianopia by confrontation. There was no sign of hemiparesis. CT scan showed extensive low density area in the left temporo-parietal regions. In both cases, cerebral angiography failed to demonstrate any occlusion of intra- and extra-cranial blood vessels. IMP-SPECT showed a depression of cerebral blood flow in the left anterior and posterior watershed areas in case 1 and 2. In the literature, there have been 20 cases of global aphasia without hemiparesis including our two cases. In many cases, the initial symptom was inability or difficulty in speaking.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n1114_23772", "title": "Thrombolytic Therapy in the Oldest Old: Successful Alteplase Administration in a 105-Year-Old Female With Ischemic Stroke.", "score": 0.01371326042378674, "content": "The elderly have a higher incidence of ischemic stroke along with higher mortality and morbidity compared to their younger counterparts. However, though studies have included people &gt;85 or 90 years of age, there haven't been reports of many individuals above 100 years of age. Among the oldest old, the oldest age studied for alteplase administration is possibly 101 years. We present a case of a 105-year-old woman with a medical history of a cerebrovascular accident in 2018 for which she received thrombolytic therapy with residual slurred speech and mild dysphagia. She was brought in from her nursing facility for worsening of slurred speech and right facial droop that began two hours before presentation to the emergency department. She was found to have aphasia, left-sided gaze preference, and upper motor neuron dysfunction of her right arm associated with drift. Her National Institutes of Health Stroke Scale (NIHSS) score at presentation was 17. An urgent CT scan of the head was performed that did not show any evidence of acute bleeding. CT angiogram of brain and neck was unremarkable with no evidence of high-grade stenosis, aneurysm, occlusion, or dissection. With the negative CT findings, the patient received thrombolytic therapy with alteplase<i. </iShe was monitored in the intensive care unit for 24 hours after alteplase administration with neurological checks every one hour. The repeated CT head after 24 hours was negative for any hemorrhage. She was discharged after two days of hospital admission and her NIHSS score on the day of discharge was 4. Our patient was 105 years old, which is arguably one of the oldest ages to receive alteplase. Her NIHSS score improved considerably and she did not suffer from hemorrhagic complications." }, { "id": "wiki20220301en003_97415", "title": "Headache", "score": 0.012246963562753036, "content": "One recommended diagnostic approach is as follows. If any urgent red flags are present such as visual loss, new seizures, new weakness, new confusion, further workup with imaging and possibly a lumbar puncture should be done (see red flags section for more details). If the headache is sudden onset (thunderclap headache), a computed tomography test to look for a brain bleed (subarachnoid hemorrhage) should be done. If the CT scan does not show a bleed, a lumbar puncture should be done to look for blood in the CSF, as the CT scan can be falsely negative and subarachnoid hemorrhages can be fatal. If there are signs of infection such as fever, rash, or stiff neck, a lumbar puncture to look for meningitis should be considered. If there is jaw claudication and scalp tenderness in an older person, a temporal artery biopsy to look for temporal arteritis should be performed and immediate treatment should be started. Neuroimaging" }, { "id": "wiki20220301en070_27960", "title": "Intraparenchymal hemorrhage", "score": 0.011728395061728394, "content": "Diagnosis Computed tomography (CT scan): A CT scan may be normal if it is done soon after the onset of symptoms. A CT scan is the best test to look for bleeding in or around your brain. In some hospitals, a perfusion CT scan may be done to see where the blood is flowing and not flowing in your brain. Magnetic resonance imaging (MRI scan): A special MRI technique (diffusion MRI) may show evidence of an ischemic stroke within minutes of symptom onset. In some hospitals, a perfusion MRI scan may be done to see where the blood is flowing and not flowing in your brain. Angiogram: a test that looks at the blood vessels that feed the brain. An angiogram will show whether the blood vessel is blocked by a clot, the blood vessel is narrowed, or if there is an abnormality of a blood vessel known as an aneurysm." }, { "id": "article-31124_25", "title": "Vertebrobasilar Stroke -- Treatment / Management -- Ischemic Strokes", "score": 0.01063321385902031, "content": "Treatment of ischemic strokes is time-dependent. If the onset of symptoms occurs before 4.5 hours without evidence of hemorrhage on a non-contrast CT scan, the patient is tissue plasminogen activator (TPA) eligible, the preferable agent being IV alteplase. The dose of alteplase is calculated as 0.9 mg/kg with a maximum dose of 90 mg. 10% of the total dose is given as a bolus over one minute, and the remainder is given over the next hour.  There is a set of inclusion criteria and contraindications that should be discussed with the patient to obtain informed consent before administering the medication. This is generally performed by a neurologist specializing in stroke; however, another physician can perform it with guidance. Most notable contraindications include recent intracranial surgery or trauma, active internal bleeding, intracranial hemorrhage, blood pressure greater than 180/90 mmHg. Inclusion criteria are stroke with a measurable neurological deficit occurring less than 4.5 hours. There are relative exclusion criteria for patients greater than 80 years old, NIHSS score greater than 25, and current anticoagulant use. [32]" }, { "id": "wiki20220301en019_110240", "title": "Thrombolysis", "score": 0.010360557717584599, "content": "Stroke Absolute contraindications: Uncertainty about time of stroke onset (e.g. patients awakening from sleep). Coma or severe obtundation with fixed eye deviation and complete hemiplegia. Hypertension: systolic blood pressure ≥ 185mmHg; or diastolic blood pressure >110mmHg on repeated measures prior to study. (if reversed, patient can be treated) Clinical presentation suggestive of subarachnoid haemorrhage even if the CT scan is normal. Presumed septic embolus. Patient having received a heparin medication within the last 48 hours and has an elevated Activated Prothrombin Time (APTT) or has a known hereditary or acquired haemorrhagic diathesis INR >1.7 Known advanced liver disease, advanced right heart failure, or anticoagulation, and INR > 1.5 (no need to wait for INR result in the absence of the former three conditions). Known platelet count <100,000 uL. Serum glucose is < 2.8 mmol/l or >22.0 mmol/l." }, { "id": "wiki20220301en023_84319", "title": "Stroke", "score": 0.009900990099009901, "content": "Imaging For diagnosing ischemic (blockage) stroke in the emergency setting: CT scans (without contrast enhancements) sensitivity= 16% (less than 10% within first 3 hours of symptom onset) specificity= 96% MRI scan sensitivity= 83% specificity= 98% For diagnosing hemorrhagic stroke in the emergency setting: CT scans (without contrast enhancements) sensitivity= 89% specificity= 100% MRI scan sensitivity= 81% specificity= 100% For detecting chronic hemorrhages, MRI scan is more sensitive. For the assessment of stable stroke, nuclear medicine scans SPECT and PET/CT may be helpful. SPECT documents cerebral blood flow and PET with FDG isotope the metabolic activity of the neurons. CT scans may not detect an ischemic stroke, especially if it is small, of recent onset, or in the brainstem or cerebellum areas. A CT scan is more to rule out certain stroke mimics and detect bleeding. Underlying cause" }, { "id": "pubmed23n0566_3998", "title": "[Follow-up brain imaging after strokes in internal medicine: frequently requested but rarely used for diagnosis or treatment].", "score": 0.009900990099009901, "content": "To assess the interest of a second computed tomography (CT) scan of the brain during hospitalization of stroke patients in an internal medicine department and study the characteristics of these patients. This retrospective study included 110 patients diagnosed with stroke between January 1, 2002, and August 31, 2004 in an internal medicine department. All patients had a brain CT scan soon after admission - within three hours, on average, of arrival at the hospital; however, the mean delay between the onset of symptoms and hospital arrival was 40 hours. Mean hospital stay was 19 days. Eighty patients (73%) had at least one more scan. Indications for these scans were: no acute cerebral ischemia on the initial image (34%), routine follow-up or reason not specified (34%), worsening of neurologic status (15%), before oral anticoagulation (5%), to search a tumor (5%), to look for a cause (4%), and clinic-radiologic discordance (3%). Only 29% of the indications had any diagnostic or therapeutic reason. Among these 80 patients, the repeat brain scan resulted in a change in the initial diagnosis for 4 patients (5%) and in a change of therapy for 11 (14%). In our study, repeat CT imaging was frequently ordered in ischemic stroke, despite the not uncommon absence of any diagnostic or therapeutic reasons. To optimize the use of medical resources and avoid unnecessary imaging, it would be useful to identify subgroups of patients for whom repeat imaging might be of interest." }, { "id": "pubmed23n0092_11644", "title": "Cerebral embolism and hyperthyroidism.", "score": 0.00980392156862745, "content": "Three different cases of cerebral embolism occurring in combination with hyperthyroidism are reported. Case 1; a healthy 37-year-old woman presented with sudden onset of left hemiparesis and left sided hypoesthesia of all modalities. Embolism in area of the right middle cerebral artery was confirmed by angiography and CT scan. Laboratory examination revealed hyperthyroidism and anemia. Antithyroid treatment brought about euthyroid function while slight hemiparesis remained present. Case 2; a 79-year-old woman who suffered from hypertension for one year had sudden onset of disorientation and left hemiparesis. Electrocardiogram showed atrial fibrillation. The CT scan indicated infarction in the right anterior and middle cerebral artery. The patient was diagnosed as having masked hyperthyroidism. Although antithyroid medication reduced it to euthyroid condition, the patient is now bedridden with hemiparesis. Case 3; a 45-year-old man who had partial thyroidectomy for Basedow's disease and had been treated with antithyroid and antiarrhythmic therapy for 10 years. Suddenly, he was in coma with dilated right pupil and left hemiplegia. Atrial fibrillation and hypothyroid function were observed. CT scan indicated hemorrhagic infarction in the territory of the middle cerebral artery with transtentorial herniation. He died on the 59th day of hospitalization following an episode of bronchopneumonia. On the basis of the cases presented here as well as on the basis of those described in the literature it appears that thyrotoxic patients with atrial fibrillation exhibit high incidence of cerebral embolism, and prophylactic anticoagulant therapy may be recommended." }, { "id": "pubmed23n0052_6415", "title": "[The early hemiparesis of stroke in evolution of basilar artery--case report].", "score": 0.00980392156862745, "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": "pubmed23n0277_17359", "title": "[A 81-year-old man with dementia, gait disturbance, hemiparesis, and sympathetic apraxia].", "score": 0.009708737864077669, "content": "We present a 81-year old male who developed dementia, gait disturbance and right hemiparesis. He was well until the age of 74 when he developed a hemorrhagic infarction in the right occipital region, which left him left homonymous hemianopsia. One year later he had one TIA attack consisting of dizziness, headache, and some clouding of consciousness. At that time, atrial fibrillation was found. At age 79, he was attacked by right hemiparesis. Cranial CT scans revealed a lesion consistent with a hemorrhagic infarct in the left middle cerebral artery territory. Two months prior to his final admission, he had a gradual onset of forgetfulness, labile affect, nocturnal agitation and hallucination which were followed by gait disturbance and urinary incontinence. On admission, he was alert but moderately demented. In addition he showed difficulty in repetition, limb kinetic and ideomotor apraxia of the left hand indicative of sympathetic apraxia, and constructional apraxia bilaterally. Granial nerves appeared intact except for left homonymous hemianopsia. His gait was wide-based and small stepped. No weakness or ataxia was noted. Deep reflexes were diminished on the left side. Plantar reflex was equivocally extensor of the left. Light touch and pain was slightly diminished on the right side. Cranial CT scans revealed a large low density area in the left fronto-temporo-parietal region. Also ventricular dilatation, diffuse low density change in the subcortical white matter, and diffuse cortical atrophy were seen. His clinical course was complicated by melena, anemia, pneumonia, cardiac failure and renal failure. He expired 2 months after his admission.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "Surgery_Schwartz_12129", "title": "Surgery_Schwartz", "score": 0.009708737864077669, "content": "followed rapidly by brain death. A patient exhibit-ing any of these symptoms needs an emergent neurosurgical evaluation for possible ventriculostomy or suboccipital crani-ectomy (removal of the bone covering the cerebellum). This situation is especially critical, as expeditious decompression can lead to significant functional recovery.StrokePatients presenting with acute focal neurologic deficits at a clearly defined time of onset (i.e., when the patient was last seen in a normal state of health) must be evaluated as rapidly as possible. An emergent head CT scan should be done. The study is often normal because CT changes from ischemic stroke may take up to 24 hours to appear (Fig. 42-6). A patient with a clinical diagnosis of acute stroke <4.5 hours old, without hemor-rhage on CT, may be a candidate for thrombolytic therapy with tissue plasminogen activator (tPA). When a proximal large-vessel obstruction is suspected, patients should be evaluated for endovascular mechanical" }, { "id": "pubmed23n0527_5853", "title": "[Is very old age a prognostic factor for outcome after a first stroke?].", "score": 0.009615384615384616, "content": "To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke. A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80. After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons. Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome. Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death." }, { "id": "wiki20220301en350_15354", "title": "Computed tomography of the head", "score": 0.009523809523809525, "content": "Comparison with MRI Magnetic resonance imaging (MRI) of the head provides superior information as compared to CT scans when seeking information about headache to confirm a diagnosis of neoplasm, vascular disease, posterior cranial fossa lesions, cervicomedullary lesions, or intracranial pressure disorders. It also does not carry the risks of exposing the person to ionizing radiation. CT scans may be used to diagnose headaches when neuroimaging is indicated and MRI is not available, or in emergency settings when hemorrhage, stroke, or traumatic brain injury is suspected. MRI (magnetic resonance imaging) provides more sensitivity in the evaluation of the cavernous sinus and the orbital apex. One advantage over a brain MRI is in the evaluation of intracerebral calcifications." }, { "id": "pubmed23n0863_16915", "title": "[Understanding the reasons behind the low utilization of thrombolysis in hyperacute ischemic stroke].", "score": 0.009523809523809525, "content": "The study aimed to analyze the influencing factors of thrombolysis therapy in acute ischemic stroke patients with onset time less than 4.5 hours. We consecutively prospectively screened acute ischemic stroke patients with onset time less than 4.5 hours from emergency department, outpatients and inpatients of neurology department, and image center in our hospital over a 31-month time period (April 2012-November 2014). The rate of thrombolysis and the reasons for not receiving thrombolysis were analyzed. A total of 538 patients who met the inclusion criteria were included (68.2% males, mean age 67±13 years old). Only 104 (19.3%) patients received thrombolysis. The main reasons for the patients not receiving thrombolysis included minor symptoms (172 cases, 39.6%), rapidly improving symptoms and high possibility of transient ischemic attack (TIA) (59 cases, 13.6%), patients or families refusing thrombolysis (44, 10.1%), in-hospital delay (38, 8.8%), elderly people with age over than 80 years old (38, 8.8%). The thrombolysis rate within time window of acute ischemic stroke is remarkably higher than that of several years ago in China. The main reasons for not receiving thrombolysis are minor and rapidly improving symptoms, patients or families' refusal, in-hospital delay, elderly people with age over than 80 years old." }, { "id": "Neurology_Adams_7021", "title": "Neurology_Adams", "score": 0.009507328990228013, "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": "pubmed23n0916_840", "title": "Successful intravenous thrombolysis for ischemic stroke after reversal of dabigatran anticoagulation with idarucizumab: a case report.", "score": 0.009433962264150943, "content": "Non-vitamin K antagonist oral anticoagulants, including dabigatran, are currently widely used for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. Recently, idarucizumab, a monoclonal antibody fragment for immediate reversal of dabigatran-induced anticoagulation, has been introduced into the market to be used in life-threatening bleeding or urgent surgery, allowing for rapid normalization of clotting parameters. The use of idarucizumab is not yet well established in patients presenting with acute ischemic stroke on dabigatran who are candidates for thrombolytic therapy. We report the case of a 71-year-old hypertensive Caucasian woman with non-valvular atrial fibrillation treated with dabigatran 150 mg twice daily, who presented with acute ischemic stroke causing right-sided hemiparesis and aphasia. Two hours after presentation to the emergency department, a decision was made to administer idarucizumab for achieving complete reversal of any potential anticoagulant effect of dabigatran and, in the absence of any contraindications, our patient underwent successful thrombolysis. At discharge, our patient was able to walk unassisted and had only residual aphasia. Twenty days later, she had completely recovered motor function of her right side, with further progressive improvement of aphasia. Repeat cranial computed tomography confirmed the absence of hemorrhage, and anticoagulant therapy with dabigatran 150 mg twice daily was resumed. Our case report adds to the evidence that idarucizumab administration is safe in the setting of patients with atrial fibrillation treated with dabigatran who develop acute ischemic stroke requiring thrombolysis." }, { "id": "pubmed23n0598_18179", "title": "Evolution of changes in the computed tomography scans of the brain of a patient with left middle cerebral artery infarction: a case report.", "score": 0.009433962264150943, "content": "Stroke is a common and important condition in medicine. Effective early management of acute stroke can reduce morbidity and mortality. A 63-year-old man presented to the Accident and Emergency department with a history of collapse and progressive right-sided weakness. Clinically this was a cerebrovascular accident affecting the left hemisphere of the brain causing right hemiplegia. Computed tomography scans, performed 3 days apart, showed the evolution of infarction in the brain caused by the thrombus in the left middle cerebral artery. This is one of the early signs for stroke seen on computed tomography imaging and it is called the hyperdense middle cerebral artery sign. Patients admitted with a stroke, undergo CT brain within 24 hours. The scan usually takes place at admission into the hospital and is done to rule out a bleed or a space occupying lesion within the brain. A normal CT brain does not confirm a stroke has not taken place. When scanned early, the changes seen on the CT due to an infarction from a thrombus may not have taken place yet. This paper highlights the early changes that can be seen on the CT brain following a stroke caused by infarction due to a thrombus in the middle cerebral artery." }, { "id": "pubmed23n1024_15828", "title": "Is intravenous thrombolysis safe for acute ischemic stroke patients taking warfarin with INR 1.9?: A case report.", "score": 0.009373902353354408, "content": "Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR &gt; 1.7 or PT &gt; 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9. A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92. Acute ischemic stroke. The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered. The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life. The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients." }, { "id": "wiki20220301en023_84279", "title": "Stroke", "score": 0.009345794392523364, "content": "The main risk factor for stroke is high blood pressure. Other risk factors include high blood cholesterol, tobacco smoking, obesity, diabetes mellitus, a previous TIA, end-stage kidney disease, and atrial fibrillation. An ischemic stroke is typically caused by blockage of a blood vessel, though there are also less common causes. A hemorrhagic stroke is caused by either bleeding directly into the brain or into the space between the brain's membranes. Bleeding may occur due to a ruptured brain aneurysm. Diagnosis is typically based on a physical exam and supported by medical imaging such as a CT scan or MRI scan. A CT scan can rule out bleeding, but may not necessarily rule out ischemia, which early on typically does not show up on a CT scan. Other tests such as an electrocardiogram (ECG) and blood tests are done to determine risk factors and rule out other possible causes. Low blood sugar may cause similar symptoms." }, { "id": "pubmed23n0585_12893", "title": "[Really drunk?].", "score": 0.009345794392523364, "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": "pubmed23n0301_16631", "title": "[Early surgery of subarachnoid hemorrhage from cerebral aneurysms. A material from health care region 5].", "score": 0.009259259259259259, "content": "During the period 1986 to 1993, 94 patients were admitted consecutively to the neurosurgical department of Tromsø university hospital following subarachnoid haemorrhage. Nine-three patients were operated on. Five patients were in extremely poor condition and three were operated on as emergency cases after computerized tomography without previous angiography. They are included in the total management outcome and also in the outcomes after early surgery. Of all the patients, 63.8% returned to their previous activities, 12.8% experienced moderate invalidity, and 9.6% had serious invalidities. The total management mortality was 13.8%. Fifty-four patients were operated on within three days, and 64.8% of these returned to their previous activities. Of these 14.8% ended up with moderate invalidity; mortality was 11.1%. Of eight patients above 70 years of age, five underwent early surgery. In six of these older patients the final outcome was good, one became disabled and one died. We consider early surgery to be by far the most important factor for achieving optimal results from surgery." }, { "id": "pubmed23n1019_24299", "title": "Acute Ischemic Stroke.", "score": 0.009174311926605505, "content": "A 77-year-old woman with a history of hypertension developed acute onset of aphasia and right hemiplegia and hemisensory loss. She was urgently referred to emergency department. Cerebral multidetector computed tomographic angiography (MD-CTA) revealed an acute ischemic stroke due to the occlusion of the left middle cerebral artery (Figure 1). Since the symptoms started three hours previously, the patient was candidate for mechanical thrombectomy. The patient then performed a selective digital subtraction angiography (DSA) of the left internal carotid artery that confirmed occlusion of the ipsilateral middle cerebral artery (Figure 2) and subsequently successfully performed the endovascular mechanical thrombectomy (Figure 2). Her clinical course has shown neurological symptoms improvement over time. Acute ischemic stroke can be caused by several factors, but the main ones are arterial and cardiac embolism, arterial wall disease or variants(1-4). The National Institutes of Health Stroke Scale (NIHSS) score, is widely used as clinical assessment for neurological deficits related to ischemic stroke(1). MDCTA and Magnetic Resonance Imaging are the two gold standard methods for diagnosis in acute ischemic stroke patients(1-5). Thrombolytic therapy of this pathological state began in the fifties, while the endovascular mechanical thrombectomy was defined as a new standard of care in 2015(1,5,6). This recent technique have added tissue window\" to the existing \"time window\" (5,6). So, nowadays patients with small ischemic core, large penumbra, and good collaterals vessel may benefit from endovascular mechanical thrombectomy(1,5,6); even if they arrive within 6-24 h of stroke onset(5." }, { "id": "pubmed23n0222_2569", "title": "[Four cases of cerebral venous angioma--with special reference to its surgical indication and CT diagnosis].", "score": 0.00909090909090909, "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": "pubmed23n0595_16112", "title": "[First experience with intravenous thrombolysis in ischemic stroke in Serbia].", "score": 0.00909090909090909, "content": "Systemic thrombolytic therapy in the first three hours of acute ischemic stroke (IS) significantly improves its outcome. This therapy was approved for treatment in USA in 1997, and in most European countries in 2002. First intravenous thrombolysis of 15 in Serbia was carried out in February 2006. We present our preliminary experience with intravenous thrombolysis in treating patients with acute IS and compare it with the results of other clinical studies. All patients with IS treated with intravenous thrombolysis in our department were included in the study. The time of stroke onset, first neurological exam, time of CT exam and beginning of therapy were recorded. The early CT signs of ischemia were graded by the ASPECTS score. Neurological deficit was assessed with NIHSS score and functional outcome with modified Rankin Scale (mRS). During the eight-month period intravenous thrombolysis was given to 12 patients with acute IS, aged 18 to 66 years, of whom 75% were younger than 55 years. Median time from symptom onset to hospital door was 57.5 minutes, median time door-to-CT was 32.5 minutes, and the time from symptom onset to treatment was 155 minutes. Early CT signs of ischemia were present in 10 patients with median ASPECTS score 9. Median initial NIHSS score was 16.5 with its decline during the first 24 hours for at least 5 points in 58% of patients. Symptomatic intracerebral haemorrhage was present in one patient. After 30 days of follow-up 42% of patients had favourable outcome (mRS&lt;1). In only 2 patients the outcome was poor (mRS 4-5). One patient died with signs of cardiac failure. Despite a small number of patients with short time of follow up, these results with thrombolysis in acute IS were found to be consistent with other authors' reports. Uniqueness of our series of patients who received thrombolysis as compared to other studies was their very young age." }, { "id": "wiki20220301en627_18716", "title": "Canadian CT head rule", "score": 0.009065439263558135, "content": "The Canadian CT head rule (abbreviated CCTHR or CCHR; also sometimes referred to as the Canadian Computed Tomography Head Rule) is a medical scale used to decide whether patients with minor head injuries should undergo cranial CT scans. It was originally described by Stiell et al. in a paper published in the Lancet in 2001, in which they initially used it only on patients with Glasgow Coma Scale scores of between 13 and 15. Since then, the CCTHR has become the most widely researched and extensively validated rule of its kind, though a 2011 systematic review noted that \"its exclusion criteria make it difficult to apply universally.\" Criteria The CCTHR excludes patients who: did not experience a traumatic brain injury have a Glasgow Coma Scale score of lower than 13, are under the age of 16, has a bleeding disorder or is using warfarin, and/or has a visible open skull fracture." }, { "id": "pubmed23n1155_24826", "title": "Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review.", "score": 0.009009009009009009, "content": "Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis. A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient's muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty. Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences." }, { "id": "pubmed23n0891_14250", "title": "Therapeutic route of patients at the acute phase of their stroke in Burkina Faso.", "score": 0.009009009009009009, "content": "The advent of the neurovascular units and thrombolysis has improved support for stroke in developed countries. Our objective was to study the therapeutic route of stroke patients in Burkina Faso, a country with limited resources. It was a prospective cohort study over a period of 4months, from February 02, 2014 to June 05, 2014, in medical emergencies and Neurology department of the teaching hospital Yalgado Ouedraogo. The study focused on patients diagnosed with stroke through brain imaging when they first entered hospital or during hospitalization. Variables of the study included socio-demographic data of the patients, route of the patients, nature of the stroke, treatment and clinical course. The time between the onset of clinical signs and the first contact with a peripheral public health unit extended from 30min to 24h with an average of 6h and 56min. The minimum time between the first contact with a peripheral public health unit and medical emergencies of the Teaching Hospital Yalgado Ouédraogo was 15min, and the maximum, two weeks. After their arrival in medical emergencies, patients spent on average 21h and 18min to achieve the cerebral CT scan. Concerning the treatment, the thrombolysis, which was not available yet, had never been prescribed, while 19% of patients were eligible according to the 4h30mn period criteria. Our study shows that the long delay in the access of neurological expertise is, in most cases, related to the therapeutic route of patients. Thus, the setting-up of a stroke sector would improve the management and the prognosis of cases in Burkina Faso." }, { "id": "wiki20220301en026_4627", "title": "Subarachnoid hemorrhage", "score": 0.008928571428571428, "content": "Angiography After a subarachnoid hemorrhage is confirmed, its origin needs to be determined. If the bleeding is likely to have originated from an aneurysm (as determined by the CT scan appearance), the choice is between cerebral angiography (injecting radiocontrast through a catheter to the brain arteries) and CT angiography (visualizing blood vessels with radiocontrast on a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm (see below). In emergency department patients complaining of acute-onset headache without significant risk factors for SAH, evidence suggests that CT scanning of the head followed by CT angiography can reliably exclude SAH without the need for a lumbar puncture. The risk of missing an aneurysmal bleed as the cause of SAH with this approach is less than 1%. Lumbar puncture" }, { "id": "pubmed23n1162_13547", "title": "Assessment of Cost-Effectiveness of Computerized Cranial Tomography in Children with Mild Head Trauma.", "score": 0.008849557522123894, "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": "pubmed23n1033_24185", "title": "[Migratory hyperdense posterior cerebral artery sign following intravenous thrombolysis].", "score": 0.008849557522123894, "content": "Computed tomography (CT) scanning of the brain continues to be the basic imaging mode in the acute phase of stroke. The hyperdense posterior cerebral artery sign is an early and infrequent radiological finding with topographic and prognostic value that must be taken into account in the initial CT scans. We report the case of a 79-year-old woman who suddenly presented with severe left homonymous hemianopsia, mild lower left facial paresis, 3/5 left hemiparesis and severe left hypaesthesia. In the initial brain CT scan, calcium hyper-density of the P1 segment is observed in the right posterior cerebral artery. Intravenous fibrinolytic therapy is administered. The patient shows clinical improvement, and in the follow-up brain CT scan at 24 hours after fibrinolysis, hyperdensity of the P3 segment is observed in the right posterior cerebral artery. Evidence of posterior cerebral artery hyperdensity is a rare radiological finding associated with an increased volume of ischaemic stroke. A computed tomography scan of the head in the acute phase is essential to try to clarify its causation. Calcium emboli are an under-diagnosed cause of stroke and occur spontaneously in a large proportion of cases. If calcium embolism is suspected, a study must be conducted in search of a carotid, valvular or aortic arch pathology. Migration of the arterial hyperdensity towards distal is associated with a better prognosis. This case presented good progress in contrast to the poor prognosis described in the literature in cases of arterial hyperdensity as an early marker of stroke in the acute phase." }, { "id": "pubmed23n0825_13218", "title": "Multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome: case study.", "score": 0.008771929824561403, "content": "Intracerebral hemorrhage is the most feared complication of intravenous thrombolysis for acute ischemic stroke. Such hemorrhage usually occurs within or at the margin of ischemic or manifestly infarcted brain tissue. A patient with Trousseau syndrome who developed multiple extra-ischemic hemorrhages following intravenous thrombolysis is described. An 80-year-old Japanese man with no other underlying disease was diagnosed with unresectable advanced lung cancer (stage IV) without brain metastasis and had not yet been treated. The patient suddenly presented with disturbance of consciousness, right hemiplegia, and total aphasia, and was admitted to our hospital. Magnetic resonance imaging revealed acute cerebral infarction extending from the basal ganglia to the corona radiata of the left cerebrum and multiple small areas of bilateral cerebral cortices. Cardiogenic cerebral embolism was considered among the differential diagnoses, but the brain natriuretic peptide level was within the normal range, and no arrhythmias such as atrial fibrillation were observed. With no other causes, the patient was diagnosed with Trousseau syndrome due to hypercoagulability associated with the advanced lung cancer. The patient received intravenous tissue plasminogen activator (t-PA) at 96 minutes after onset of symptoms. His symptoms partially improved, but they suddenly deteriorated at 84 minutes after the thrombolysis. A computed tomography (CT) scan immediately after the neurological deterioration revealed a subcortical hemorrhage in the left occipital lobe. A repeat CT scan the day after onset showed enlargement of the left occipital hemorrhage and two new subcortical hemorrhages in the right frontal and right temporal lobes. These hemorrhages were located in areas remote from the acute ischemic lesions. To the best of our knowledge, this is the first reported case of multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome. The course of this case suggests that intravenous t-PA administration for acute ischemic stroke with Trousseau syndrome may be associated with a higher risk of intracranial hemorrhage." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 125, 206 ] ], "word_ranges": [ [ 24, 34 ] ], "text": "Hepatocarcinoma can elevate (alone) alpha-fetus, seminoma LDH, lymphoma also LDH." }, "2": { "exist": true, "char_ranges": [ [ 125, 206 ] ], "word_ranges": [ [ 24, 34 ] ], "text": "Hepatocarcinoma can elevate (alone) alpha-fetus, seminoma LDH, lymphoma also LDH." }, "3": { "exist": true, "char_ranges": [ [ 125, 206 ] ], "word_ranges": [ [ 24, 34 ] ], "text": "Hepatocarcinoma can elevate (alone) alpha-fetus, seminoma LDH, lymphoma also LDH." }, "4": { "exist": true, "char_ranges": [ [ 18, 124 ] ], "word_ranges": [ [ 3, 24 ] ], "text": "In the ED it can be diagnosed with a pregnancy test (in males), because it detects that beta HCG in urine." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Metastatic hepatocarcinoma.", "2": "Extragonadal metastatic seminoma.", "3": "Mediastinal lymphoma.", "4": "Metastatic extragonadal nonseminomatous germ cell cancer.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0933_4769", "title": "Germ cell tumor causing pleural effusion: A diagnostic dilemma.", "score": 0.019142700128228614, "content": "Straw colored pleural fluid with raised adenosine deaminase (ADA) levels in young healthy adults usually raises suspicion of tuberculosis, sometimes leading to laxity in carrying thorough physical examination and missing out some important clues with potential disastrous consequences. A 35-year-old male was diagnosed to have left pleural effusion and anti-tubercular treatment was started on the basis of straw colored, lymphocyte-predominant pleural fluid with significantly raised ADA levels. When there was no improvement after 1 month of treatment he was investigated further and found to have a mediastinal mass along with hydro-pneumothorax. Fine needle aspiration cytology (FNAC) of the mass was done twice at different centers with different reports followed by biopsy from the mass to settle the diagnosis. Histopathological examination revealed yolk sac tumor. Testicular ultrasound showed a mass with ill-defined hypoechoic areas and lobulated margins in left testis, which was missed on clinical examination. Serum lactate dehydrogenase (LDH) and alpha fetoprotein (AFP) levels were found to be elevated. Beta-human chorionic gonadotropin (β-hCG) was normal. The final diagnosis of nonseminomatous germ cell tumor with mediastinal metastasis was made. The present case underlines the importance of good clinical examination, an art which is diminishing with availability of sophisticated investigations and a thin line of difference between potentially curable and fatal diagnosis, especially in young population, where malignancy is overlooked as a differential diagnosis. Furthermore, despite all its advantages, too much reliance on FNAC may be responsible for misdiagnosis in certain cases." }, { "id": "pubmed23n1070_2114", "title": "Late testicular relapse two decades after primary extragonadal germ cell tumor with uncommon metastases: a case report.", "score": 0.018089960886571055, "content": "Extragonadal germ cell tumor (EGCT) is a relatively rare condition, reportedly representing 3-7% of all germ cell tumors. We report a patient who had metachronous testicular tumor with uncommon metastases 20 years after primary retroperitoneal EGCT treatment, along with a corresponding literature review. A 49-year-old Japanese man visited our department in November 2017 with chief complaints of indolent right scrotum enlargement and a right inguinal mass. History showed that the patient visited our department of gastroenterology with chief complaints of blackish feces and ill complexion in February 1997. Computed tomography (CT) showed a right retroperitoneal tumor, which was removed in the same month. Histopathological examination showed a teratoma and yolk sac tumor. He was diagnosed with primary retroperitoneal EGCT and received three courses of chemotherapy (bleomycin/etoposide/cisplatin; BEP). Periodic imaging and the determination of tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [HCG], and lactate dehydrogenase [LDH]) showed no recurrence or metastasis during the 5 years postoperatively. Subsequently, he did not visit the outpatient ward. In August 1999, he underwent surgery of right hydrocele. Contrast-enhanced CT showed a 35-mm contrast effect with uneven content in the right testicle and enlarged nodes that raised suspicion for metastases in the right inguinal and right external iliac lymph nodes. All tumor markers were within normal ranges. He underwent right high orchiectomy and resection of the right inguinal lymph nodes in the same month. Histopathological findings revealed seminoma (pT1, pN2, M0, S0, and TNM stage IIB). He received postoperative chemotherapy, one course of BEP therapy, and three courses of etoposide and cisplatin therapy. Post-chemotherapy CT confirmed a complete clinical response at the right external iliac lymph nodes, and this response continued 12 months later. No recurrence or metastasis has been found so far. We report a patient in whom a testicular tumor with uncommon metastases occurred 20 years after primary retroperitoneal EGCT treatment. After EGCT treatment, testicular relapses tend to occur after relatively long-term follow-up. After EGCT treatment, such patients must be closely monitored for testicular recurrences and onset of testicular tumor." }, { "id": "pubmed23n0891_5837", "title": "Primary retroperitoneal seminoma - embryology, histopathology and treatment particularities.", "score": 0.017806267806267807, "content": "Retroperitoneal seminoma is a very rare form of cancer, with embryological origin represented by primordial germ cells from the urogenital ridges left behind during the fetal development. Extragenital germ cell tumors can also occur in the mediastinum or the pineal gland. The aim of this paper is to outline the particularities and draw embryological, histopatological and treatment conclusions regarding extragonadal germ cell tumors. A 43-year-old patient without any additional pathology was admitted for anemia of unknown etiology. The clinical examination revealed through deep abdominal palpation a mass in the left flank, and normal testes. Thoraco-abdomino-pelvic computed tomography (CT) scan showed a large retroperitoneal tumor adjacent to the great vessels in the left lumbo-iliac region. The blood work revealed just a low hemoglobin and hematocrit. With the established diagnosis of retroperitoneal tumor, radical surgical removal was decided. During the surgery, we were required to dissect a large solid encapsulated tumor mass from the aorta and the common iliac artery, starting at the renal pedicle all the way to the left iliac bifurcation. The surgical access was obtained through a transperitoneal left subcostal incision prolonged pararectally. Histopathological and immunohistochemical studies revealed a seminoma of the usual type. After the histological findings, the patient's tumor markers were investigated (LDH - lactate dehydrogenase, βHCG - beta-human chorionic gonadotropin, αFP - alpha-fetoprotein), all values being within normal ranges. In addition, the left testicle was thoroughly reexamined, clinically, through ultrasound and magnetic resonance imaging (MRI) scans, and no abnormalities were observed. After the surgery, the patient followed three courses of chemotherapy (BEP - Bleomycin, Etoposide and Cisplatin). The CT scan done 24 months after surgery found no signs of local or distant tumor recurrence. The patient entered a follow-up schedule consisting of periodical clinical, serological and imagistic evaluations. Primary retroperitoneal seminoma is a rare entity that must be taken into account when treating a retroperitoneal tumor. It develops out of the urogenital ridge, while the testes are normal. Thorough testicular evaluation (clinical, ultrasound and serum markers) is mandatory in all retroperitoneal tumors. The histopathological analysis is crucial for an accurate diagnosis and a proper management strategy. Through radical surgery and chemotherapy, the patients that are diagnosed prior to massive visceral metastatic dissemination can be cured." }, { "id": "pubmed23n1094_18909", "title": "A presumed extragonadal germ cell tumor that turned out to be a gastric cancer-a case report.", "score": 0.01700800793707037, "content": "A solely retroperitoneal mass in males in combination with elevated serum Alpha-Fetoprotein (AFP) and beta-human choriogonadotropin (β-HCG) levels is highly indicative of a metastatic testicular cancer. Although testicular cancers are rare, they represent the most common diagnosed cancer in males between 14 and 40 years. However, in cases without evidence of a primary testicular tumor, the rare diagnosis of a retroperitoneal extragonadal germ cell tumor (EGCT) must be assumed. Here, we describe the first published case of a 66-year-old man presenting with this typical clinical picture and the diagnosis of an AFP and β-HCG producing advanced gastric cancer with retroperitoneal lymph node metastases mimicking a primary retroperitoneal EGCT. The final diagnosis was only made by gastroscopy performed after a CT-guided retroperitoneal lymph node biopsy revealed an adenocarcinoma, suggesting an upper gastrointestinal tract primary origin. However, a specific initial anamnesis and also in the primary staging, including a full-body CT-scan there was no hint for another primary tumor. Only the slightly unusual extension of the retroperitoneal mass up to the ligamentum hepatoduodenale and the pylorus, as well as the atypical age made us question our initial diagnosis. This extraordinary case is of special clinical interest to all practising physicians and once again highlights the importance of keeping rare differential diagnosis such as AFP-producing gastrointestinal tumors in mind." }, { "id": "article-24855_11", "title": "Mediastinal Germ Cell Tumors -- Evaluation", "score": 0.01615833874107722, "content": "A thorough physical examination is necessary to evaluate a patient with suspicion of mediastinal germ cell tumors, paying particular attention to the gonads. Testicular ultrasound should be a part of the standard work-up to identify co-existing germ cell tumors. Further imaging, histological, and biochemical analysis are necessary to make a diagnosis. Patients usually present after an incidental anterior mediastinal mass is found on a chest X-ray or may present with symptoms related to a large anterior mediastinal mass. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) can assist in better defining the tumor size, location, and borders. Biochemical markers, alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (B-hCG), and lactate dehydrogenase (LDH) can be elevated and should be checked. Similar to germ cell tumor diagnostic pathways, a significant elevation in serum B-hCG of >1,000 U/L with or without elevation in AFP is supportive of diagnosing mediastinal germ cell tumors in the appropriate clinical setting. [1]" }, { "id": "pubmed23n0832_2126", "title": "[A case of metachronal testicular tumor eight years after medical treatment of extragonadal germ cell tumor].", "score": 0.015867066466766618, "content": "A 22-year-old man was admitted to our hospital complaining of a left cervical mass. Computed tomography (CT) showed multiple enlarged lymph nodes at the left cervical vein and para-aortic areas. Histological examination of a biopsy indicated an embryonal carcinoma. The levels of human β-chorionic gonadotropin (β-HCG) and lactic dehydrogenase (LDH) were both elevated. Ultrasonography revealed testicular calcification, but there were no findings on magnetic resonance imaging (MRI). The patient was diagnosed as having an extragonadal germ cell tumor. After four courses of chemotherapy with BEP protocol (bleomycin, etoposide and cisplatin), retroperineal lymph node dissection (RPLND) was performed and there was no involvement of the viable cells in the resected lymph nodes. Eight years after chemotherapy, he noticed an enlargement of his left scrotum without pain. β-HCG was again elevated. A unilateral high orchiectomy was performed, and histology revealed a seminoma. He was staged as pT1N0M0S0. Six months later he remains disease-free. " }, { "id": "pubmed23n0551_20904", "title": "[A non-seminomatous extra-gonadal germ cell tumor responding to intensive treatment: a case report].", "score": 0.014427457730079984, "content": "A 23-year-old man presented with lumbago as a chief complaint. Computed tomographic (CT) scan revealed multiple lung tumors, multiple liver tumors, bulky retroperitoneal tumors with marked elevation of serum lactic dehydrogenase (LDH), alpha-fetoprotein, and beta subunit of human chorionic gonadotropin (HCG-beta). The patient was referred to our hospital for treatment. Scrotal ultrasonography and physical examination revealed bilateral normal testes. Because of bulky retroperitoneal masses with elevated specific tumor markers as well as bilateral normal testes, our diagnosis led to extra-gonadal germ cell tumor. Because the pulmonary lesion had increased rapidly, chemotherapy was performed without the tumor biopsy. After multiple chemotherapy regimens including BEP (bleomycin, etoposide, cisplatin), high-dose chemotherapy, and TIN (paclitaxel, ifosfamide, nedaplatin), all tumor marker levels fell into within the normal range. The tumor size was decreased remarkably on CT. Then, retroperitoneal lymphadenectomy were performed to confirm whether they still contained viable tumor cells. They contained only necrotic tissues without viable cancer cells by pathological examination. Consequently, the patient has been free of recurrence for 18 months after intensive treatment." }, { "id": "wiki20220301en127_19325", "title": "Mediastinal germ cell tumor", "score": 0.014409086642260396, "content": "Cause Some investigators suggest that this distribution arises as a consequence of abnormal migration of germ cells during embryogenesis. Others hypothesize a widespread distribution of germ cells to multiple sites during normal embryogenesis, with these cells conveying genetic information or providing regulatory functions at somatic sites. Diagnosis The diagnosis of a mediastinal germ cell tumor should be considered in all young males with a mediastinal mass. In addition to physical examination and routine laboratory studies, initial evaluation should include CT of the chest and abdomen, and determination of serum levels of HCG and alpha-fetoprotein." }, { "id": "pubmed23n0349_20111", "title": "[A case of extragonadal germ cell tumor with inferior vena caval tumor thrombus].", "score": 0.013986697965571206, "content": "We report a case of retroperitoneal extragonadal germ cell tumor with tumor thrombus in the inferior vena cava. The patient referred to our hospital with lumbago. Computed tomography (CT) showed a bulky mass in the retroperitoneum. The levels of alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) in the serum were elevated. Histological examinations indicated embryonal cell carcinoma. Bilateral testicles did not contain any palpable mass upon careful palpation. No tumor mass was detected in the bilateral testicles on ultrasonography. Clinically, the diagnosis was a retroperitoneal extragonadal germ cell tumor associated with para-aortic lymph-node involvement. After the combination chemotherapy (BEP 1 course and EP 3 courses), the tumor mass was reduced in size and the tumor marker was normalized. Retroperitoneal lymph node dissection (RPLND) was performed and tumor thrombus in the inferior vena cava was resected. There was no involvement of the viable cells in the resected tumor. The patient has been in good condition with no evidence of disease." }, { "id": "wiki20220301en051_32662", "title": "Seminoma", "score": 0.013355521420037549, "content": "Diagnosis Blood tests may detect the presence of placental alkaline phosphatase (ALP, ALKP, ALPase, Alk Phos) in fifty percent of cases. However, Alk Phos cannot usefully stand alone as a marker for seminoma and contributes little to follow-up, due to its rise with smoking. Human chorionic gonadotropin (hCG) may be elevated in some cases, but this correlates more to the presence of trophoblast cells within the tumour than to the stage of the tumour. A classical or pure seminoma by definition do not cause an elevated serum alpha fetoprotein . Lactate dehydrogenase (LDH) may be the only marker that is elevated in some seminomas. The degree of elevation in the serum LDH has prognostic value in advanced seminoma." }, { "id": "article-24848_8", "title": "Mediastinal Nonseminoma -- Evaluation", "score": 0.012958881203921867, "content": "A complete physical exam including a genital exam is crucial. Alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (b-HCG), and lactate dehydrogenase (LDH) are the tumor markers that can be elevated in these patients [5] . Patients with benign teratomas do not have elevated b-HCG or AFP. Levels of AFP and HCG are elevated in the majority of patients with mediastinal non-seminomas. Cytogenticstudents are often done to rule out Klinefelter syndrome" }, { "id": "InternalMed_Harrison_7493", "title": "InternalMed_Harrison", "score": 0.012806924571630454, "content": "Careful monitoring of the serum tumor markers AFP and hCG is essential in the management of patients with GCT, because these markers are important for diagnosis, as prognostic indicators, in monitoring treatment response, and in the early detection of relapse. Approximately 70% of patients presenting with disseminated nonseminomatous GCT have increased serum concentrations of AFP and/or hCG. Although hCG concentrations may be increased in patients with either nonseminoma or seminoma histology, the AFP concentration is increased only in patients with nonseminoma. The presence of an increased AFP level in a patient whose tumor shows only seminoma indicates that an occult nonseminomatous component exists, and the patient should be treated for nonseminomatous GCT. LDH levels are less specific than AFP or hCG but are increased in 50–60% patients with metastatic nonseminoma and in up to 80% of patients with advanced seminoma." }, { "id": "pubmed23n1120_21433", "title": "Management of Residual Disease After First-line Chemotherapy in a Patient With a Nonseminomatous Germ Cell Tumor.", "score": 0.012610837438423644, "content": "The case An 18-year-old male presented with a one-month history of a nonpainful right testicular enlargement. He had no family history of neoplasia, nor any relevant past medical history. The physical examination was only remarkable for an enlarged right testicle. A testicular ultrasound revealed a 2.5-cm tumor, and serum tumor markers revealed an elevated β-human chorionic gonadotropin (β-HCG), 22 mUI/L (normal, &lt; 0.06 mUI/L); elevated alpha-fetoprotein (AFP), 329 ng/mL (normal, 0-9 ng/mL); and normal lactate dehydrogenase (LDH), 135 /L (normal, 179 U/L). A right radical inguinal orchiectomy was performed. Pathological examination revealed a 2.4 cm by 2 cm embryonal carcinoma with tumor invasion into the tunica albuginea. Postsurgical tumor markers obtained 3 weeks after orchiectomy were β-hCG, 100.5 mUI/L (normal, &lt; 0.06 mUI/L); AFP, 1075 ng/mL (normal, 0-9 ng/mL); and LDH, 180 U/L (normal, 179 U/L). A chest, abdomen, and pelvis CT scan showed a 2.7-cm retroperitoneal lymph node enlargement, without visceral metastasis. Given the presence of node-positive disease with S2 serum markers, the diagnosis of a stage IIIB intermediate risk nonseminomatous germ cell tumor (NSGCT) was determined, and the patient underwent sperm banking. The patient was started on chemotherapy with 4 cycles of BEP (bleomycin, etoposide, and cisplatin), with a favorable tumor marker decline according to the Gustave-Roussy nomogram. After completion of the fourth chemotherapy cycle, serum tumor markers were negative, and 8 weeks after chemotherapy, the follow-up CT showed a 1.6-cm residual retroperitoneal lymph node conglomerate." }, { "id": "article-24850_25", "title": "Mediastinal Cancer -- Evaluation -- Laboratory Studies", "score": 0.012409288824383163, "content": "Basic Laboratory tests such as complete blood count (CBC) and basic metabolic panel (BMP) can help in the differential diagnosis of lymphomas. In the instances of mediastinal masses, tumor markers can help support a presumptive diagnosis. These include: Beta-hCG (associated with germ cell tumors and seminoma) LDH (may be elevated in patients with lymphoma) AFP (associated with malignant germ cell tumors): Mediastinal non-seminomatous germ cell tumors are more likely to result in distinct elevations of serum AFP and less likely in elevations of beta-hCG compared to gonadal or retroperitoneal non-seminomatous germ cell tumors. Malignant germ cell tumors are closely related to serum tumor markers, especially AFP and beta-hCG. The measurement of these serum tumor markers is important in the diagnosis, management, and follow-up of these patients." }, { "id": "pubmed23n0836_22718", "title": "Extragonadal malignant germ cell tumors: a clinicopathological and immunohistochemical analysis of 48 cases at a single Chinese institution.", "score": 0.012165539547192003, "content": "Primary extragonadal malignant germ cell tumors (EMGCTs) are rare and characterized by the location in the midline of the body, including mediastinum, CNS, retroperitoneum and coccyx. EMGCTs present with different clinical and biologic characteristics in different tumor locations. Accurately diagnosing MEGCTs would be very difficult by performing on HE staining alone, and requires immunohistochemical verification. This study was to investigate the biological feature of EMGCTs and diagnostic value of immunohistochemical markers OCT3/4, CD117, PLAP, AFP, β-HCG and CD30 in EMGCTs. A retrospective study was performed on 48 patients with EMGCTs. EMGCTs were found to occur predominantly in males, especially for mediastinal MGCTs. The tumor locations included mediastinum, CNS and retroperitoneum. The mediastinum and CNS were the most common sites of EMGCTs. Seminoma/germinomas (64.6%) was the most common histological subtypes of EMGCTs. Chest pain, dyspnea, cough and fever were the most common clinical presentations in mediastinal MGCTs. Headache, visual disturbances, endocrine abnormalities, and signs of increased intracranial pressure were common clinical symptoms in CNS MGCTs. Abdominal mass with or without pain, backache and weight loss were common clinical presentations in retroperitoneal MGCTs. PLAP, CD117 and OCT3/4 were highly expressed in seminomas/gernimomas. CD30, EMA and CK AE1/3 staining were positive in embryonal carcinoma. AFP and β-HCG positive staining are characteristic in yolk sac tumors and choriocarcinoma, respectively. Patients with seminomas/germinomas had a better prognosis than those with NS/G-GCTs. Our finding suggests that the accurate diagnosis of EMGCTs is critical not only for predicting the tumor progression but also for patient management. Immunohistochemical markers have become an important tool in the diagnosis and differential diagnosis of EMGCTs. " }, { "id": "pubmed23n0082_14076", "title": "[Retroperitoneal germ cell tumors with high level of serum and urine hCG in an adult: a case report].", "score": 0.011369426751592356, "content": "A case of retroperitoneal germ cell tumors in a 32-year-old male is reported. He was admitted to our hospital with complaints of lumbago and abdominal mass. He was diagnosed with primary retroperitoneal malignant tumor and underwent resection of the tumor with retroperitoneal lymphadenectomy. The final pathological diagnosis revealed germ cell tumors of more than one histological type in the retroperitoneal space. Serum human chorionic gonadotropin (hCG) and hCG-beta levels were very high preoperatively (4,8000 mIU/ml, 57 ng/ml, respectively) and they decreased to normal after vinblastine-bleomycin cisplatin combination chemotherapy three times postoperatively. The patient later developed a solitary lung metastasis and died in another hospital 7 months after the operation. Retroperitoneal germ cell tumors in adults are rare. One question continually arises: are they extragonadal occurrences or germ cell tumors or do they represent metastatic lesions from occult testicular tumors?" }, { "id": "pubmed23n0979_5808", "title": "An Unusual Case of Primary Retroperitoneal Germ Cell Tumour in a Young Man.", "score": 0.011312434090691208, "content": "Some 2-5% of germ cell tumours are of extragonadal origin, with a retroperitoneal location being very rare. The majority of retroperitoneal germ cell tumours have metastasized from a testicular tumour. These tumours are diagnosed incidentally or symptomatically and nearly all present with high alpha-fetoprotein and lactate dehydrogenase levels. We describe the unusual case of a 31-year-old man with a yolk-sac, retroperitoneal germ cell tumour, with normal serum alpha-fetoprotein and lactate dehydrogenase levels, which has not previously been described. A testicular tumour was excluded by physical examination and additional tests. Our diagnosis was based on a high level of suspicion and histopathological results. As far as we know, this is the first case described with these characteristics. Extragonadal germ cell tumours are rare but can have fatal consequences if undiagnosed.The usual laboratory markers of the disease were absent in our patient.A high level of suspicion is required for diagnosis and close follow-up is required." }, { "id": "article-29984_28", "title": "Testicle Cancer -- Evaluation", "score": 0.011226502668832676, "content": "All patients with testicular germ cell tumors should undergo abdominopelvic imaging with computed tomography (CT). Patients with elevated serum tumor markers (AFP, α-fetoprotein; β-hCG, β-subunit of human chorionic gonadotropin; LDH, lactate dehydrogenase) should be evaluated further with computed tomography (CT) of the chest, abdomen, and pelvis for staging. [39] If testicular tumor markers are within the normal range, the rate of metastasis almost outside of the retroperitoneum is very low; therefore, the addition of a chest CT-scan to cross-sectional imaging of the abdomen and pelvis is highly unlikely to alter the treatment plan, and a chest radiograph suffices when combined with abdominopelvic CT imaging.  Choriocarcinoma has been shown to spread via hematogenous routes, and patients with high levels of β-hCG should undergo cross-sectional imaging of the brain to identify metastatic lesions due to choriocarcinoma hematogenously spreading to the brain." }, { "id": "Surgery_Schwartz_4891", "title": "Surgery_Schwartz", "score": 0.01115967365967366, "content": "PET is useful for distinguishing malignant from benign tumors and may help detect distant metastases in some patients. However, the role of routine PET imaging for staging surgically resectable lesions of the mediastinum has not been established.The use of serum markers to evaluate a mediastinal mass can be invaluable in some patients. For example, nonsemino-matous and seminomatous germ cell tumors can frequently be diagnosed and often distinguished from one another by the lev-els of α-fetoprotein (AFP) and human chorionic gonadotropin (hCG). In over 90% of nonseminomatous germ cell tumors, either the AFP or the hCG level will be elevated. Results are close to 100% specific if the level of either AFP or hCG is greater than 500 ng/mL. Some centers institute chemotherapy based on this result alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than" }, { "id": "wiki20220301en574_4534", "title": "Extracranial germ cell tumor", "score": 0.011061419200954084, "content": "Diagnosis Professionals use a combination of testaments to diagnose the type or stage of EGCT is present. Common testaments for EGCTs are a physical examination, tumor marker test, immunohistochemistry, cytogenetic analysis, MRI, chest x-ray, CT scan (CAT scan), ultrasound exam, and biopsy. Explanations for each testament are below. Physical examination: a body check to look for signs of disease, such as a lump in the testicle in males or abnormal virginal bleeding in females. Tumor marker test: two tumor markers are tested, alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-hCG), to detect and diagnose the EGCTs. Immunohistochemistry: the use of antibodies to detect the reaction of antigens in the human body. Cytogenetic analysis: a method to discover abnormal arrangement of chromosomes in the tumor cells. MRI: an instrument that uses magnetic field, radio waves, and a computer to investigate the condition inside the human body through a series of pictures." }, { "id": "article-29992_13", "title": "Testicular Seminoma -- Evaluation", "score": 0.01044735406437534, "content": "Several laboratory values may be useful in following tumor burdens. These include AFP, B-HCG, and LDH. Alpha-fetoprotein (AFP) elevation indicates at least some nonseminomatous disease, and those patients are then treated as nonseminomas, germ cell patients. LDH may be used to follow the overall seminomatous tumor burden. Beta-human chorionic gonadotropin (HCG) is present in 5% to 10% of seminoma patients; these usually demonstrate the syncytial cytotrophoblastic subtype. Such elevations tend to be associated with metastatic disease, but the beta-HCG elevation by itself has no connection with overall survival." }, { "id": "pubmed23n0991_26233", "title": "The role of ¹⁸F-FDG-PET/CT in evaluating retroperitoneal masses -Keeping your eye on the ball!", "score": 0.010326839135526455, "content": "Testicular germ cell tumour is the commonest malignancy affecting males aged between 15 and 35, with an increased relative risk amongst those with a history of cryptorchidism. In patients presenting with locoregional metastatic disease, retroperitoneal and pelvic soft tissue masses are common findings on ultrasound and computed tomography, which has several differential diagnoses within this demographic cohort. On staging <sup18</supF-FDG-PET/CT, understanding the typical testicular lymphatic drainage pathway facilitates prompt recognition of the pathognomonic constellation of unilateral absence of testicular scrotal activity, and FDG-avid nodal masses along the drainage pathway. We describe the cases of three young males presenting with abdominopelvic masses, in whom FDG-PET/CT was helpful in formulating a unifying diagnosis of metastatic seminoma, retrospectively corroborated by a history of testicular maldescent. In all three cases, the patients were males aged in their 30s and 40s who were brought to medical attention for back and lower abdominal pain of varying duration. Initial imaging evaluation with computed tomography and/or ultrasound revealed large abdominopelvic soft tissue masses, with lymphoproliferative disorders or soft tissue sarcomas being high on the list of differential diagnoses. As such, they were referred for staging FDG-PET/CT, all of whom demonstrated the pathognomonic constellation of, 1) unilateral absence of scrotal testicular activity, and 2) FDG-avid nodal masses along the typical testicular lymphatic drainage pathway. These characteristic patterns were corroborated by a targeted clinical history and examination which revealed a history of cryptorchidism, and elevated β-hCG in two of three patients. All were subsequently confirmed as metastatic seminoma on biopsy and open resection. These cases highlight the importance of clinical history and examination for the clinician, as well as a sound knowledge of the typical testicular lymphatic drainage pathway for the PET physician, which would assist with prompt recognition of the characteristic imaging patterns on FDG-PET/CT. It further anecdotally supports the utility of FDG-PET/CT in evaluating undiagnosed abdominopelvic masses, as well as a potential role in the initial staging of germ cell tumours in appropriately selected patients." }, { "id": "article-130655_33", "title": "Nonseminomatous Testicular Tumors -- Evaluation", "score": 0.0101280834914611, "content": "Alpha-fetoprotein is elevated in 50% to 70% of all patients with NSGCT.  Pure seminomas do not make alpha-fetoprotein, so if it's elevated in a patient diagnosed only with seminoma, it means that NSGCT elements were missed. The patient should be treated as having a mixed germ cell malignancy. Syncytiotrophoblasts manufacture human chorionic gonadotropins in seminomas and a few non-seminomatous germ cell tumors such as choriocarcinoma and embryonal carcinomas. LDH is generally a nonspecific tumor marker that is elevated in 20% to 60% of patients with NSGCT and is generally considered an indicator of bulky disease. Alpha-fetoprotein has a half-life of about 6 days, while the half-life of HCG is 24 to 48 hours.  In practical terms, HCG should begin to return to normal about 1 week after orchiectomy, while alpha-fetoprotein will take a minimum of 5 weeks. AFP and β-hCG are also elevated in various lung, liver, gut, bone, and live tumors. [47] [48] There are new markers to diagnose and evaluate germ cell tumors, like levels of circulating microRNAs, especially miR-371a-3p. However, their precise role in the management of testicular tumors is yet to be determined. [49]" }, { "id": "wiki20220301en127_19326", "title": "Mediastinal germ cell tumor", "score": 0.009900990099009901, "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": "pubmed23n0741_1461", "title": "Mixed germ cells tumour primarily located in the thyroid -- a case report.", "score": 0.009900990099009901, "content": "Germ cells tumours most frequently occur in the gonads. Extragonadal localisation is rare and concerns mainly the mediastinum, retroperitoneum and pineal. We present the first description of a patient with a mixed germ cells tumour located primarily in the thyroid. A 35-year-old man in a good clinical condition was admitted to diagnose metastasis revealed in an X-ray of his lungs. Abnormal laboratory tests showed high concentrations of beta-HCG and LDH. Ultrasound examination revealed: hypoechogenic area 8 × 4 × 5 mm in the left testicle, and enlarged left thyroid lobe with echogenically heterogenous mass. In cytological examination of the thyroid, carcinomatous cells were found, which suggested metastasis. A diagnosis of cancerous spread of testicular cancer to the lungs and thyroid was made. The left testicle, with spermatic cord, was removed, yet in the histopathological examination no carcinomatous cells were found. Rescue chemotherapy, according to the BEP scheme (bleomycin, etoposide, cisplatin) was started, but during its course the patient died. Histopathology disclosed primary mixed germ cells tumour in the thyroid, predominantly with carcinoma embryonale and focuses of choriocarcinoma. Extragonadal germ cells tumours rarely occur in the thyroid. In medical literature, some cases of teratomas and a single case of yolk sac tumour in the thyroid have been described. The presence of choriocarcinoma was responsible for the high serum concentration of beta-HCG. Surgery of germ cells tumours proves insufficient. The conventional chemotherapy is based on cisplatin. In conclusion, extragonadal germ cells tumours are rare, but should be considered while co-existing with elevated markers such as: AFP, beta-HCG and lack of abnormalities in the gonads." }, { "id": "InternalMed_Harrison_7705", "title": "InternalMed_Harrison", "score": 0.00980958988590811, "content": "Role of Serum Tumor Markers and Cytogenetics Most tumor markers, including CEA, CA-125, CA 19-9, and CA 15-3, when elevated, are nonspecific and not helpful in determining the primary tumor site. Men who present with adenocarcinoma and osteoblastic metastasis should undergo a prostate-specific antigen (PSA) test. In patients with undifferentiated or poorly differentiated carcinoma (especially with a midline tumor), elevated β-human chorionic gonadotropin (β-hCG) and α fetoprotein (AFP) levels suggest the possibility of an extragonadal germ cell (testicular) tumor. With the availability of IHC, cytogenetic studies are rarely needed." }, { "id": "pubmed23n0086_3828", "title": "Chemotherapy of extragonadal germ cell tumors.", "score": 0.00980392156862745, "content": "Forty-nine patients with histologically proven germ cell tumors arising in extragonadal sites were retrospectively reviewed. Included in the review were an additional seven patients with undifferentiated tumors with a pathologic appearance compatible with that of a germ cell tumor and elevated levels of serum biomarkers (beta subunit of human chorionic gonadotropin [beta-HCG] +/- alpha-fetoprotein [AFP]. Nineteen patients had a pure seminoma arising in an extragonadal site, whereas 30 patients had nonseminomatous germ cell tumors. Seven patients had primary undifferentiated tumors with elevated levels of serum biomarkers. Sixteen (84%) of the 19 patients with pure extragonadal seminomas with normal levels of serum AFP are alive and free of disease. Eighteen of these 19 patients received platinum-containing regimens and four had received prior chemotherapy that failed. Of the patients with nonseminomatous germ cell tumors, 12 (40%) of the 30 are alive and free of disease with vinblastine/bleomycin +/- cisplatin (13 patients) or CISCAII (cisplatin, cyclophosphamide, and doxorubicin) (nine patients) alternating CISCAII/VBIV (eight patients) chemotherapy. None of the seven patients with undifferentiated germ cell tumors are alive and free of disease. Three of the five patients with pure anterior mediastinal endodermal sinus tumors treated with chemotherapy remain alive and free of disease. Of the seven patients with choriocarcinomas arising in extragonadal sites, three are alive and free of disease. A classification for patients with extragonadal germ cell tumors incorporating site of origin, histology, and likelihood of being truly extragonadal is proposed. The implications of this classification are discussed." }, { "id": "wiki20220301en574_4541", "title": "Extracranial germ cell tumor", "score": 0.00961882605583393, "content": "Extragonadal GCT Under the classification of the biology GCT, there is a more detailed classification contains specific types of extracranial extragonadal germ cell tumor. There are two types, teratomas, and malignant GCTs. Lists of these two categories and its subtypes are shown below. Teratomas Mature teratomas Immature teratomas Malignant GCTs Seminomatous GCTs: seminoma, dysgerminoma, germinoma Non-seminomatous GCTs: yolk sac tumor (endodermal sinus tumor), choriocarcinoma, embryonal carcinoma, gonadoblastoma, teratoma & yolk sac tumor Mixed GCTs: a combination of EGCTs. Common combinations include teratoma & embryonal carcinoma & yolk sac tumor (11%), seminoma & embryonal carcinoma (16%), and teratoma & embryonal carcinoma (26%). The yolk sac tumor produce the AFP hormone, and the germinomas, choriocarcinomas, and seminoma are tumors that produce the β-hCG hormone. The hormones that are produced by the tumors can be detected while proceeding testaments." }, { "id": "pubmed23n0372_21589", "title": "Second-line chemotherapy in patients with relapsed extragonadal nonseminomatous germ cell tumors: results of an international multicenter analysis.", "score": 0.009615384615384616, "content": "Relapsed extragonadal germ cell tumors patients (EGGCT) are treated with identical salvage chemotherapy regimens, as are patients with metastatic testicular cancer. This investigation evaluates the results of second-line chemotherapy in nonseminomatous EGGCT and tries to identify prognostic factors for survival. We conducted a retrospective review of 142 patients treated at eleven European and American centers between 1975 and 1996. All had received cisplatin-containing regimens as induction treatment. Twenty-seven of 142 patients (19%) were long-term disease-free, 11% with primary mediastinal and 30% of patients with primary retroperitoneal disease. Median follow-up since start of salvage treatment was 11 months (range, 1 to 157) for all patients and 45 months (range, 6 to 157) for surviving patients. Forty-eight patients (34%) received high dose chemotherapy with autologous bone marrow transplant at relapse, and 10 of these patients (21%) are continuously disease-free. Primary mediastinal location (P =.003), sensitivity to cisplatin (P =.003), elevated beta-HCG at relapse (P: =.04), and normal LDH at diagnosis (P =.01) were shown to be significant negative prognostic factors for overall survival in univariate; mediastinal location [relative risk ratios (HR) = 1.9; 95% confidence intervals (CI), 1.2 to 3.0] and sensitivity to cisplatin [HR = 2.4; 95% CI, 1.1 to 5.2] were significant negative prognostic factors in multivariate analysis. Although current salvage strategies will cure between 20% and 50% of recurrent metastatic testicular cancer, relapsed nonseminomatous EGGCT patients appear to have an inferior survival rate, in particular in case of primary mediastinal location. Mediastinal primary tumor and inadequate response to cisplatin-based induction chemotherapy have been identified as independent negative prognostic factors, both associated with an approximately two-fold higher risk for failure of salvage treatment." }, { "id": "InternalMed_Harrison_7586", "title": "InternalMed_Harrison", "score": 0.009550743374272787, "content": "Neuroimaging is the only test necessary to diagnose a brain tumor. Laboratory tests are rarely useful, although patients with metastatic disease may have elevation of a tumor marker in their serum that reflects the presence of brain metastases (e.g., β human chorionic gonadotropin [β-hCG] from testicular cancer). Additional testing such as cerebral angiogram, electroencephalogram (EEG), or lumbar puncture is rarely indicated or helpful." }, { "id": "pubmed23n0043_18055", "title": "The Second Medical Research Council study of prognostic factors in nonseminomatous germ cell tumors. Medical Research Council Testicular Tumour Working Party.", "score": 0.009523809523809525, "content": "To assess prognostic factors in a large population of patients with metastatic nonseminomatous germ cell tumors (NSGCT) arising in gonadal or extragonadal sites. Data from 795 patients treated with chemotherapy between 1982 and 1986 in 13 centers were analyzed. Particular emphasis was placed on exact tumor measurements (eg, size of nodal masses, number of lung metastases), and the diagnostic pathology was also reviewed. Cox regression analysis was performed on these data. The patients were treated with a variety of cisplatin-containing chemotherapy regimens, 86% of which included etoposide. With median follow-up of 45 months, overall 3-year survival is 85%. The independently adverse features proved to be (1) the presence of liver, bone, or brain metastases; (2) raised marker levels (alpha-fetoprotein [AFP] level greater than 1,000 kU/L or beta subunit of human chorionic gonadotropin [HCG] greater than 10,000 IU/L [corrected]); (3) the presence of a mediastinal mass greater than 5 cm in diameter; (4) the presence of 20 or more lung metastases; (5) increasing age; and (6) absence of undifferentiated teratoma (embryonal carcinoma) or fibrous tissue from the primary tumor. The first four factors were used to define a simple prognostic classification. A good-prognosis group having none of these features comprised 67% of our patient population and had a 3-year survival of 93%. The remaining 33% of patients having at least one of these features had a 3-year survival rate of 68%. These patient groups are currently the subjects of international randomized clinical trials." }, { "id": "pubmed23n0300_18829", "title": "[Metastases of germ cell tumors to the ENT area--a rare differential diagnosis of lymph node metastases in unknown primary tumor].", "score": 0.009523809523809525, "content": "Germ cell tumors of the testis usually metastasize to retroperitoneal lymph nodes, lungs, and liver. Other lymphatic or organ metastases especially in the head and neck are rare. The cases of two men, ages 21 and 35, are presented. In both cases, the histologic examination of cervical lymph node specimen lead to the correct tumor diagnosis of testicular cancer. Multimodal urooncologic therapy led to long-lasting complete remissions in both cases. In young men between 20 and 35 years of age with cervical metastases of tumors of unknown primary site, germ cell tumors must be suspected. Histologic findings of non-squamous epithelial metastases (seminoma, embryonal carcinoma, chorionic carcinoma, teratoma, yolk sack tumor, and their combined forms) with or without retroperitoneal, mediastinal, or lung metastases; elevated tumor markers (human-chorionic gonadotropin, alpha-feto-protein, placental alkaline phosphatase, lactate dehydrogenase); and palpable intratesticular mass lead to the correct tumor diagnosis. Early detection of the disease is essential for successful therapy and long-term remission." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 33, 135 ] ], "word_ranges": [ [ 7, 24 ] ], "text": "FNA does not allow a histological study but a cytological one, therefore questions 1, 2 are eliminated." }, "2": { "exist": true, "char_ranges": [ [ 33, 135 ] ], "word_ranges": [ [ 7, 24 ] ], "text": "FNA does not allow a histological study but a cytological one, therefore questions 1, 2 are eliminated." }, "3": { "exist": true, "char_ranges": [ [ 137, 209 ] ], "word_ranges": [ [ 24, 39 ] ], "text": "Question 3 seems to have been put as a filler because it is not relevant." }, "4": { "exist": true, "char_ranges": [ [ 211, 269 ] ], "word_ranges": [ [ 39, 50 ] ], "text": "Question 4 could raise doubts if you are not a pathologist" }, "5": { "exist": true, "char_ranges": [ [ 274, 350 ] ], "word_ranges": [ [ 51, 64 ] ], "text": "the most logical answer is 5 since papillary carcinoma is the most frequent." } }

{ "1": "Distinguish between follicular adenoma or minimally invasive follicular carcinoma.", "2": "Identify the areas of capsular or vascular invasion of the follicular carcinoma.", "3": "Recognize G-cell hyperplasia associated with familial spinal cancer.", "4": "Distinguish between a Hurthle cell tumor and an oxyphilic follicular adenoma.", "5": "Identify the typical cytologic features of papillary carcinoma." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0540_8293", "title": "Does Hurthle cell lesion/neoplasm predict malignancy more than follicular lesion/neoplasm on thyroid fine-needle aspiration?", "score": 0.017966484047695776, "content": "Thyroid fine-needle aspiration (FNA) is a standard procedure for the clinical triage of thyroid nodules. The diagnosis of an adequately sampled thyroid FNA is generally grouped into three categories: benign, malignant, and indeterminate. The latter group usually includes follicular neoplasm, follicular lesion, and sometimes a more specific diagnosis such as Hurthle cell neoplasm or follicular lesion/neoplasm with Hurthle cell change. Whether a FNA diagnosis of Hurthle cell lesion/neoplasm (HLN) denotes a worse clinical outcome than follicular lesion/neoplasm (FLN) remains controversial. A cohort of 303 thyroid FNA cases with follow-up thyroidectomy in our institutes was identified, with the follow-up excision diagnosis compared to the FNA diagnosis in order to address this issue. Of this cohort, 87 cases had an FNA diagnosis of HLN while 216 cases had a diagnosis of FLN. Upon excision, the FNA diagnosis of HLN group had 14 cases of goiter/nodular hyperplasia (16%), 46 cases of adenoma (12 follicular adenoma (14%) and 34 cases of Hurthle cell adenoma (39%)), and 27 cases of carcinoma (31%, 12 papillary carcinoma and 15 Hurthle cell carcinoma). The FLN group had 74 cases of goiter/nodular hyperplasia (34.3%), 8 cases of Hashimoto thyroiditis (3.7%), 73 cases of follicular adenoma (33.8%), one case of granular cell tumor, and 60 cases of carcinoma (27.8%, 46 papillary carcinoma, 12 follicular carcinoma, and 1 Hurthle cell carcinoma and 1 parathyroid carcinoma) upon excision. There is no significant difference in predicting cancer between the two cytology diagnosis groups (HLN versus FLN, 31% versus 27.8%, P = 0.5771). When sorting all the cases by the surgical diagnosis, while comparable for age at diagnosis, the cancer group having the higher proportion of male patients than the non-cancer group (28.7% versus 16.7%, P = 0.0259). Hurthle cell carcinoma patients are typically older than patients with other cancer diagnoses (59 versus 44, P = 0.0077). Our results suggest that an FNA diagnosis of HLN does not predict more malignancy than FLN. Males and older patients with a HLN FNA diagnosis carry a higher risk of Hurthle cell carcinoma upon thyroidectomy." }, { "id": "wiki20220301en195_1146", "title": "Follicular thyroid cancer", "score": 0.017496229260935144, "content": "Hurthle cell variant Hurthle cell thyroid cancer is often considered a variant of follicular cell carcinoma. Hurthle cell forms are more likely than follicular carcinomas to be bilateral and multifocal and to metastasize to lymph nodes. Like follicular carcinoma, unilateral hemithyroidectomy is performed for non-invasive disease, and total thyroidectomy for invasive disease. Diagnosis It is difficult to correctly diagnose follicular neoplasms (FNs) on fine-needle aspiration cytology (FNAC) because it shares many cytological features with other mimicking lesions." }, { "id": "pubmed23n1057_5017", "title": "Preoperative diagnostic categories of fine needle aspiration cytology for histologically proven thyroid follicular adenoma and carcinoma, and Hurthle cell adenoma and carcinoma: Analysis of cause of under- or misdiagnoses.", "score": 0.015669515669515667, "content": "Cytologic diagnosis of thyroid follicular adenoma and carcinoma, and Hurthle cell adenoma and carcinoma (FACHAC) is challenging due to cytomorphologic features that overlap with other follicular-patterned lesions. This study was designed to analyze diagnostic categories (DCs) of preoperative fine needle aspiration cytology (FNAC) of histologically proven thyroid FACHACs to evaluate under- or misdiagnoses in FNAC and elucidate potential causes for such phenomena. A total of 104 thyroid nodules with preoperative FNAC which were diagnosed as FACHAC in resection specimens were included in this study. Of these, 66 cases had also undergone thyroid core needle biopsy (CNB); FNAC and CNB DCs were compared in these cases. Various cytologic and histologic parameters were compared between the nodules with different FNAC DCs. After a review of FNAC slides, DCs were re-assigned in 20 (19.2%) out of the 104 cases. Of the 66 cases with CNB diagnoses which were mostly classified as lower DCs in FNAC, 31 (47.0%) were diagnosed as suspicious for a follicular neoplasm in CNB. Cases which were underdiagnosed in FNACs were associated with lower cellularity, predominant macrofollicular pattern, absence of microfollicles arranged in trabecular pattern, and absence of transgressing vessels in cytology smears. High cellularity, microfollicles arranged in trabecular pattern, nucleolar prominence, and large cell dysplasia were more frequently found in malignancy than in benign neoplasm. In conclusion, thyroid FACHACs seem to be under- and misdiagnosed in preoperative FNAC. Innate characteristics of the nodules were associated with under-diagnosis as well as the quality of the FNAC specimens. Certain cytomorphologic features can be helpful in differentiating malignancy among FACHACs." }, { "id": "pubmed23n0367_4948", "title": "Thyroid nodules with FNA cytology suspicious for follicular variant of papillary thyroid carcinoma: follow-up and management.", "score": 0.015537488708220417, "content": "Thyroid nodules diagnosed as follicular neoplasm on fine-needle aspiration biopsy (FNAB) may represent hyperplastic/adenomatous nodules, follicular adenoma or carcinoma, and follicular variants of papillary thyroid carcinoma (FVPTC) on histologic follow-up. In our laboratory, we attempted to identify a subset of cases which showed cellular specimens with focal features (nuclear chromatin clearing, membrane thickening, and rare grooves) suspicious for the follicular variant of papillary thyroid carcinoma. These cases are reported as follicular-derived neoplasms with nuclear features suspicious for FVPTC to distinguish them from those diagnosed as follicular neoplasm. This study documents our experience with 52 cases so diagnosed and followed prospectively with histologic follow-up. A neoplastic nodule was confirmed in 45/52 cases (86%), of which 40 were malignant (77%). FVPTC was identified in 35/52 cases (67%). Four cases were usual papillary carcinoma, 3 were follicular adenoma, 2 were Hürthle-cell adenoma, and 1 was insular carcinoma. In 7 cases, the subsequent histologic findings were nonneoplastic (5 hyperplastic nodules and 2 colloid nodules). Our prospective study shows that in cellular smears from thyroid nodules, a careful search for the nuclear features of papillary carcinoma should be performed, and it is appropriate to diagnose cases as suspicious for FVPTC if the nuclear features of papillary carcinoma are focal. The surgical management of this group may include an intraoperative confirmation of cytologic diagnosis by scrape preparation and/or frozen section in order to avoid a second surgical intervention for completion thyroidectomy." }, { "id": "pubmed23n1011_3958", "title": "Computerized Cytological Features for Papillary Thyroid Cancer Diagnosis-Preliminary Report.", "score": 0.01498917748917749, "content": "Fine needle aspiration cytology (FNAC) is the final diagnosis of thyroid nodules before surgery. It is important to further improve the indeterminate FNAC diagnosis results using computerized cytological features. This retrospective cross-sectional study included 240 cases, of whom 110 had histologic diagnosis of papillary thyroid cancers (PTC), 100 had nodular/adenomatous goiters/hyperplasia (benign goiters), 10 had follicular/Hurthle cell carcinomas, and 20 had follicular adenomas. Morphological and chromatic features of FNAC were quantified and analyzed. The result showed that six quantified cytological features were found significantly different between patients with a histologic diagnosis of PTC and patients with histologic diagnosis of benign goiters in multivariate analysis. These cytological features were used to estimate the malignancy risk in nodules with indeterminate FNAC results. The Area Under the Receiver Operating Characteristics (AUROC) of the diagnostic accuracy with a benign or malignant nature was 81.3% (<ip</i &lt; 0.001), 78.7% (<ip</i = 0.014), and 56.8% (<ip</i = 0.52) for nodules with FNAC results of atypia, which is suspicious for malignancy and follicular neoplasm, respectively. In conclusion, quantification of cytological features could be used to develop a computer-aided tool for diagnosing PTC in thyroid nodules with indeterminate FNAC results." }, { "id": "article-131177_11", "title": "Hurthle Cell Thyroid Carcinoma -- Evaluation", "score": 0.014968082764692935, "content": "Non-thyrotoxic thyroid nodules should be evaluated with fine-needle aspiration (FNA) and biopsy. FNA is sufficient to diagnose papillary and anaplastic thyroid cancers. However, FNA cannot distinguish between a benign adenoma and malignant carcinoma for follicular and Hurthle cell tumor types, and this generally requires a thyroid lobectomy or thyroidectomy to perform a surgical pathological evaluation showing capsular invasion, vascular invasion, or infiltration of the thyroid gland to prove invasive cancer." }, { "id": "pubmed23n1044_12975", "title": "[Risk factors of malignancy in patients with fine needle aspiration biopsy results interpreted as \"suspicious for follicular neoplasm\"].", "score": 0.014675841307386302, "content": "Introduction: Approximately 10% of fine needle aspiration biopsy (FNAB) of thyroid nodules may be verified as \"suspicious for follicular neoplasm\"; this category involves follicular adenoma, follicular carcinoma, follicular variants of papillary carcinoma and subclass \"suspicious for Hurthle cell neoplasm\". At present, there is no diagnostic tool to discriminate between follicular adenoma and cancer. Most patients are required surgery to exclude malignant process. The aim: To define factors correlating with risk of malignancy in patients with FNAB of thyroid focal lesions and nodules verified as Bethesda tier IV. Materials and Methods: In this study 110 consecutive patients were included. All patients were operated because of FNAB result \"suspicious for follicular neoplasm\" of thyroid gland at a single institution from January 2016 until March 2020. From this set, six specific categories were defined and the clinical records for patients were collected: sex, age, presence of oxyphilic cells, diameter of the tumour, presence of Hashimoto disease, aggregate amount of clinical and ultrasonographic features of malignancy according to ATA. Results: In 18 patients (16,3%) thyroid cancer occurred. Most frequent subtype turned out to be papillary cancer (66,6%). In group of benign lesion (92 patients) predominance of follicular adenoma was disclosed - (49%). Age, gender, tumour diameter, aggregate amount of clinical and ultrasonografic factors, presence of Hashimoto disease and fine needle aspiration biopsy result suspicious for Hurthle cell neoplasm did not correspond to increased risk of malignancy. Conclusions: In patients with FNAB results classified as Bethesda tier IV there are no reliable clinical features associated with low risk of malignancy and surgery should be consider in every case as most appropriate manner to exclude thyroid cancer ." }, { "id": "pubmed23n0878_18161", "title": "Fine-Needle Aspiration Cytology of Noninvasive Follicular Variant of Papillary Thyroid Carcinoma Is Cytomorphologically Distinct From the Invasive Counterpart.", "score": 0.014474304573314476, "content": "To review a series of noninvasive encapsulated follicular variant of papillary thyroid carcinomas (FVPTCs) in an attempt to further define the role of cytopathology in the diagnosis of noninvasive follicular thyroid neoplasm with papillary-like nuclear features and invasive FVPTC. Surgical pathology cases diagnosed as FVPTC with correlating thyroid fine-needle aspiration (FNA) were identified and divided into two FVPTC groups: noninvasive and invasive. Cytologic diagnoses were compared between them. We identified 23 cases that met the criteria for noninvasive FVPTC and 27 cases that were typical infiltrative FVPTC (n = 16) or encapsulated FVPTC with either capsular and/or lymphovascular invasion (n = 11). Of the noninvasive FVPTC cases, there were four benign lesions, 14 follicular lesions of undetermined significance (FLUS), four follicular neoplasms (FNs), one suspicious case, and no papillary thyroid carcinomas (PTCs). In the invasive FVPTC group, there were no benign cases, four FLUS, three FNs, 12 suspicious cases, and eight PTCs. There is a distinction in the cytologic diagnosis between noninvasive and invasive FVPTC. The invasive subtype was diagnosed by FNA as suspicious for PTC or PTC in nearly 75% of cases, while only one (4%) case for the noninvasive subtype was diagnosed as suspicious for PTC (P &lt; .05)." }, { "id": "pubmed23n1010_4641", "title": "Macrofollicular Variant of Follicular Thyroid Carcinoma: A Rare Underappreciated Pitfall in the Diagnosis of Thyroid Carcinoma.", "score": 0.014332514332514333, "content": "<b<iBackground:</i</b Follicular-patterned thyroid nodules predominantly composed of macrofollicular structures without nuclear atypia are generally regarded as benign (i.e., hyperplastic nodules or follicular adenomas). In line with this concept, fine-needle aspiration cytology (FNAC) also assigns a benign connotation to the presence of macrofollicular structures, unless thyrocytes present papillary thyroid carcinoma (PTC)-related nuclear features that raise the possibility of a macrofollicular variant of PTC. However, cases showing macrofollicular architecture, capsular invasion, and no PTC features can also be observed. <b<iMethods:</i</b We describe the clinical, cytological, histological, and molecular genetic features of four cases of encapsulated follicular neoplasms that presented histologically with a predominant (&gt;70%) macrofollicular architecture, but which also showed clear signs of capsular invasion, and thus were classified as macrofollicular variant of follicular thyroid carcinoma (MV-FTC). <b<iResults:</i</b Cytologically, macrofollicular structures were identified in all cases, leading to a benign FNAC diagnosis in three of the four cases. Due to increasing nodule size, thyroidectomy was performed in all cases. Histology showed focal and limited capsular invasion, without vascular invasion. Next-generation sequencing (custom 394 gene panel) of each tumor compared with matched normal DNA revealed a total of 7 somatic variants, including dual (likely biallelic) mutations in the <iDICER1</i gene in 2 patients. The clinical outcome was excellent in all cases. <b<iConclusions:</i</b Similar to the classical minimally invasive follicular thyroid carcinoma, MV-FTC appears to behave indolently. MV-FTC has a high rate of false-negative FNAC results, but MV-FTC is very rare (&lt;0.05% of all thyroidectomies) and apparently has an indolent behavior. Further studies comprising larger series are necessary to better clarify the biology of this diagnostically challenging rare tumor." }, { "id": "wiki20220301en195_1147", "title": "Follicular thyroid cancer", "score": 0.014174494372514175, "content": "Diagnosis It is difficult to correctly diagnose follicular neoplasms (FNs) on fine-needle aspiration cytology (FNAC) because it shares many cytological features with other mimicking lesions. Classification It is impossible to distinguish between follicular adenoma and carcinoma on cytological grounds. If fine needle aspiration cytology (FNAC) suggests follicular neoplasm, thyroid lobectomy should be performed to establish the histopathological diagnosis. Features sine qua non for the diagnosis of follicular carcinoma are capsular invasion and vascular invasion by tumor cells. Still, focuses of the capsular invasion should be carefully evaluated and discriminated from the capsular rupture due to FNA penetration resulting in WHAFFT (worrisome histologic alterations following FNA of thyroid). Follicular carcinoma tends to metastasize to lung and bone via the bloodstream. Papillary thyroid carcinoma commonly metastasizes to cervical lymph nodes." }, { "id": "pubmed23n1154_944", "title": "Follicular Neoplasm of Thyroid Revisited: Current Differential Diagnosis and the Impact of Molecular Testing.", "score": 0.01387846961740435, "content": "The diagnosis of \"follicular neoplasm\" (FN) in thyroid cytopathology has a long history that originated not long after the practice of fine-needle aspiration (FNA) of thyroid nodules. From the outset, this interpretive category was intended to convey a set of differential diagnoses rather than a precise diagnosis, as key diagnostic features, such as capsular and vascular invasion, were not detectable on cytology preparations. Cytologic-histologic correlation studies over the past several decades have shown that FN interpretation can be applied to the spectrum of nonneoplastic tumors to carcinomas. Most tumors classified as FN include follicular adenoma, follicular carcinoma, noninvasive follicular thyroid tumor with papillary-like nuclear features, and follicular variant of papillary thyroid carcinoma. Less common entities that may be classified as FN on FNA include hyalinizing trabecular tumor (HTT), poorly differentiated thyroid carcinoma, medullary carcinoma, and nonthyroidal lesions such as parathyroid tissue, paraganglioma, and metastatic tumors. Advances in our ability to detect characteristic molecular alterations (eg, GLIS gene rearrangements for hyalinizing trabecular tumor) in FNA samples may assist in the identification of some of these entities. In this review, we summarize the pathophysiology, history, and evolution of the terminology and the current differential diagnosis according to the recently published 2022 World Health Organization classification, molecular testing, and management of nodules classified as FN." }, { "id": "pubmed23n1024_5900", "title": "Utility of frozen section analysis on follicular lesions of the thyroid.", "score": 0.013514130484408528, "content": "The experience of one surgeon (R.H.) with intraoperative frozen sections (FS) performed on thyroid nodules over a 10-year period was studied to assess the utility of FS in follicular thyroid lesions. One hundred and ten patients with dominant or solitary nodules demonstrating a follicular growth pattern were evaluated. The FS slides and subsequently the permanent sections of the nodules were reviewed by the pathologists in the study (M.P.B., VAL.) without knowledge of the original diagnoses. Our results indicate: (1) if the FS was definitively benign (58 patients), the final diagnosis was benign [these lesions consisted of adenomatous nodule, nodular goiter, follicular adenoma, and Hürthle cell adenoma); (2) if an FS diagnosis of malignancy was rendered (4 patients), it was confirmed on permanent sections (follicular variant of papillary carcinoma in all 4); and (3) if the FS diagnosis was deferred (48 patients), the final diagnosis was benign in all but 10 (21 %) (of these 10, 6 had minimally invasive follicular carcinoma [2 of the Hürthle cell type], and 4 had follicular variants of papillary carcinoma). Overall, sensitivity, specificity, and accuracy rates for FS diagnoses were 29, 100, and 91%. Because unilateral lobectomy may be acceptable therapy for well-differentiated thyroid cancers, and because the efficiency of FS evaluation in diagnosing malignancy is low (only 4 malignancies of 110 total patients were diagnosed at FS, or 3.6% overall), we conclude that in this era of cost-containment, FS is not useful in the evaluation of follicular thyroid nodules identified preoperatively as follicular lesions by fine-needle aspiration cytology. Several recommendations concerning the 3 categories of FS diagnosis (i.e., definitively benign, definitively malignant-especially the follicular variant of papillary carcinoma-and deferred) are also put forward." }, { "id": "wiki20220301en063_44806", "title": "International Classification of Diseases for Oncology", "score": 0.013454056216137595, "content": "M8331/3 Follicular adenocarcinoma, well differentiated (C73.9) Follicular carcinoma, well differentiated M8332/3 Follicular adenocarcinoma, trabecular (C73.9) Follicular carcinoma, trabecular Follicular adenocarcinoma, moderately differentiated FOlloicular carcinoma, moderately differentiated M8333/0 Microfollicular adenoma, NOS (C73.9) Fetal adenoma M8333/3 Fetal adenocarcinoma M8334/0 Macrofollicular adenoma (C73.9) Colloid adenoma M8335/3 Follicular carcinoma, minimally invasive (C73.9) Follicular carcinoma, encapsulated M8336/0 Hyalinizing trabecular adenoma (C73.9) (M8337/3)Insular carcinoma (C73.9) M8340/3 Papillary carcinoma, follicular variant (C73.9) Papillary adenocarcinoma, follicular variant Papillary and follicular adenocarcinoma Papillary and follicular carcinoma M8341/3 Papillary microcarcinoma (C73.9) M8342/3 Papillary carcinoma, oxyphilic cell (C73.9) M8343/3 Papillary carcinoma, encapsulated (C73.9)" }, { "id": "article-30139_13", "title": "Thyroid Cancer -- Histopathology", "score": 0.013358372900574018, "content": "FTC: The histological features of FTC can be highly variable, from a well-differentiated follicular pattern to a poorly differentiated pattern with marked nuclear atypia, absence of follicles, extensive capsular or vascular invasion, and solid growth. The latter changes are associated with a poor prognosis. [27] As described above, features that are characteristic of PTC should be absent. Differentiating a follicular carcinoma from a benign follicular adenoma can only be made based on extracapsular and/or vascular invasion. FTC is further classified as minimally invasive, encapsulated, angioinvasive, and widely invasive, depending on the extent of invasion. Hurthle cell carcinoma: This is characterized by the occurrence of eosinophilic oxyphilic cells with abundant cytoplasm (oncocytes) and prominent nucleoli. [28]" }, { "id": "pubmed23n0723_17780", "title": "Adenomatoid nodules are the main cause for discrepant histology in 234 thyroid fine-needle aspirates reported as follicular neoplasm.", "score": 0.013313843236409608, "content": "According to several large studies, the surgical pathologist renders a non-neoplastic diagnosis in ∼20-40% of thyroid fine-needle aspiration (FNA) cases reported as follicular neoplasm. This study analyzes the cause of this poor correlation between cytology and histology. Cases consisting of oncocytic (Hurthle) cells were excluded from study. During the study period from January 1996 to April 2010, histologic follow-up was available for 234 of 670 cases (34.9%) reported as follicular neoplasm on ultrasound-guided thyroid FNA. Sonographic and Doppler data were available in all cases and included nodule location, size, echogenicity, and vascularity. Of the 234 aspirates with follow-up, surgical pathology reported 130 cases (55.6%) of follicular adenoma, 15 cases (6.4%) of follicular carcinoma, 14 cases (6.1%) of follicular variant of papillary carcinoma, and 75 cases (32.3%) of nodular goiter. Recuts of those index nodules reported as nodular goiter were examined independently by two pathologists using the 2× objective lens. Adenomatoid nodule was defined as an insufficiently encapsulated \"blue\" nodule of increased nuclear density when compared with the surrounding thyroid. Of the 75 cases reported as nodular goiter, 60 index nodules (80%) fulfilled the described criteria for adenomatoid nodule, while 15 did not. In conclusion, adenomatoid nodules are the main cause of poor histologic correlation with follicular neoplasm reported by FNA. If \"increased nuclear density at scanning magnification\" were adopted by surgical pathologists as the major diagnostic criterion for follicular adenoma rather than encapsulation, noncorrelated cases would be reduced from 32 to 6.4%." }, { "id": "wiki20220301en498_25491", "title": "Noninvasive follicular thyroid neoplasm with papillary-like nuclear features", "score": 0.013211382113821137, "content": "History Patients in the distant past with this lesion would have been regarded as showing signs of having a benign lesion, a follicular adenoma. However, over time and with additional evaluation and molecular testing, these lesions came to be regarded as showing features of a papillary thyroid carcinoma because of their papillary carcinoma type nuclei. Thus, the \"follicular variant\" of a tumor that normally shows a papillary architecture and papillary nuclear features was named. Over the years, those cases that do not show invasion of either the capsule of the tumor or the vessels in the capsule, have been shown to behave in an indolent fashion, with only rare reported cases of metastatic disease." }, { "id": "wiki20220301en057_5940", "title": "Oncocytoma", "score": 0.013043797766019988, "content": "Symptoms Salivary gland oncocytomas are most common in ages 70–80, females, the parotid gland (85–90%), and are firm, slowly growing, painless masses of less than 4 cm. They may be bilateral. Thyroid oncocytoma Thyroid oncocytomas can be benign (adenomas) or malignant (carcinomas). Also known as Hürtle cell tumours. Grossly, oncocytic adenomas are encapsulated, solid nodules with a characteristic brown cut surface. The gross appearance of a minimally invasive oncocytic carcinoma is indistinguishable to that of an adenoma, while widely invasive oncocytic carcinomas are obviously invasive macroscopically and display pervasive vascular invasion with multifocal involvement of the thyroid gland. There are no reliable cytologic features which distinguish oncocytic adenomas from carcinomas and the only criterion for a diagnosis of malignancy is the identification of transcapsular or vascular invasion." }, { "id": "wiki20220301en163_38212", "title": "Thyroid adenoma", "score": 0.012895622895622894, "content": "Papillary adenomata are very rare. Differential diagnosis A thyroid adenoma is distinguished from a multinodular goiter of the thyroid in that an adenoma is typically solitary, and is a neoplasm resulting from a genetic mutation (or other genetic abnormality) in a single precursor cell. In contrast, a multinodular goiter is usually thought to result from a hyperplastic response of the entire thyroid gland to a stimulus, such as iodine deficiency. Careful pathological examination may be necessary to distinguish a thyroid adenoma from a minimally invasive follicular thyroid carcinoma." }, { "id": "wiki20220301en558_13574", "title": "Computed tomography of the thyroid", "score": 0.012860541183467142, "content": "Thyroid cancers Epidemiology Primary thyroid carcinomas include papillary, follicular, medullary, and anaplastic carcinomas. Lymphoma and metastasis of other primary malignancies to the thyroid gland represent a minority of thyroid carcinomas. Differentiated thyroid carcinomas (DTCs) originate from follicular epithelial cells and encompass PTCs and follicular thyroid carcinomas, including the Hurthle cell variant of follicular carcinoma. DTCs have an excellent prognosis and fortunately represent the majority of thyroid carcinomas. PTCs and follicular thyroid carcinomas represent 88 % and 8 %, respectively, of all thyroid malignancies. Medullary thyroid carcinoma arises from neuroendocrine C-cells and has a good prognosis. Anaplastic carcinoma is an aggressive undifferentiated tumour that usually affects the elderly and tends to have a worse prognosis. Role of imaging" }, { "id": "pubmed23n1101_21267", "title": "Suspicious thyroid nodules 4 cm require a diagnostic lobectomy regardless of their benign fine needle aspiration results.", "score": 0.01278937995790837, "content": "The diagnostic accuracy of fine needle aspiration biopsy (FNAB) seems limited in large thyroid nodules with Bethesda Cat. 2 result. We aimed to determine the incidence of carcinoma with benign cytology and the reason for the high false-positive rate in thyroid nodules ≥4 cm. The records of 103 patients with thyroid nodules ≥4 cm with preoperative cytological diagnosis of Bethesda Cat. 2 who underwent thyroidectomy were consecutively reviewed. Characteristics between patients with malignant vs. benign pathology were compared. Forty patients (38.8%) had malignancy. Malignancy was subclassified into follicular variant of papillary thyroid carcinoma (43%), minimally invasive follicular thyroid carcinoma (20.0%), and minimally invasive Hurthle cell thyroid carcinoma (10.9%). Patients with malignant cytology had significantly more suspicious ultrasound findings than those with benign cytology (p = 0.001). Preoperative FNAB showed high false-negative rates in patients with thyroid nodules ≥4 cm with benign cytology. These nodules have a high malignancy rate with suspicious ultrasound findings." }, { "id": "article-30136_13", "title": "Thyroid Adenoma -- Evaluation", "score": 0.012400118378218408, "content": "Fine needle aspiration (FNA) has ultimately been used in evaluating a thyroid nodule with suspicious radiology features, especially in patients with a high risk of malignancy. It should be mentioned that fine-needle aspiration may not provide a definite diagnosis in all cases. In patients with thyroid adenoma, the cytological sample has organized follicular epithelial cells. On the other hand, aspiration can show follicular cells with abnormal architecture and atypia. These patients are characterized as having atypia of undetermined significance. [26] A benign thyroid adenoma is confirmed only after ruling out capsular and vessel invasion in the final histological examination done by pathologists after a partial or total thyroidectomy operation. Genetic testing has also helped a lot in predicting the risk of thyroid cancer, and it has frequently been used in the final decision-making of proceeding to surgical intervention of removing a thyroid nodule versus not. [27]" }, { "id": "wiki20220301en163_38213", "title": "Thyroid adenoma", "score": 0.012184899107837854, "content": "Careful pathological examination may be necessary to distinguish a thyroid adenoma from a minimally invasive follicular thyroid carcinoma. Management Most patients with thyroid adenoma can be managed by watchful waiting (without surgical excision) with regular monitoring. However, some patients still choose surgery after being fully informed of the risks. Regular monitoring mainly consists of watching for changes in nodule size and symptoms, and repeat ultrasonography or needle aspiration biopsy if the nodule grows. For patients with benign thyroid adenomata, thyroid lobectomy and isthmusectomy is a sufficient surgical treatment. This procedure is also adequate for patients with minimally invasive thyroid cancer. When histological examination shows no signs of malignancy, then no further intervention is required. These patients should continue to have their thyroid hormone status regularly checked. References External links Thyroid cancer" }, { "id": "article-21869_34", "title": "Follicular Adenoma -- Differential Diagnosis", "score": 0.012183372183372183, "content": "Follicular adenomas typically present as a solitary nodule; thus, all other likely causes of a solitary thyroid nodule should be considered. [5] [4] [27] Follicular carcinoma Other benign neoplasms Hurtle cell adenoma Non-invasive follicular tumor with papillary like nuclear features (NIFTP) Other carcinomas Papillary thyroid carcinoma Medullary carcinoma Thyroiditis: rarely can present as a nodule" }, { "id": "wiki20220301en498_25492", "title": "Noninvasive follicular thyroid neoplasm with papillary-like nuclear features", "score": 0.012076493671585696, "content": "Over a multiyear time frame, an international consensus project was undertaken to re-define the pathological criteria for the encapsulated follicular variant of papillary thyroid carcinoma. Based on a rigorous review of the literature and a multicentre review of many cases with long-term follow-up (a minimum of 10 years) together with molecular analysis of some tumors, this working group has determined that tumors previously classified as the encapsulated follicular variant of papillary carcinoma—without any evidence of capsular or vascular invasion, provided that the entire periphery of the tumor (capsule if encapsulated or periphery if well circumscribed) has been sampled—can be reclassified as noninvasive follicular thyroid neoplasms with papillary-like nuclear features. There are several major inclusion and exclusion criteria." }, { "id": "wiki20220301en072_8874", "title": "Hürthle cell", "score": 0.01198512585812357, "content": "A Hürthle cell is a cell in the thyroid that is often associated with Hashimoto's thyroiditis as well as benign and malignant tumors (Hürthle cell adenoma and Hürthle cell carcinoma, formerly considered a subtype of follicular thyroid cancer). This version is a relatively rare form of differentiated thyroid cancer, accounting for only 3-10% of all differentiated thyroid cancers. Oncocytes in the thyroid are often called Hürthle cells. Although the terms oncocyte, oxyphilic cell, and Hürthle cell are used interchangeably, Hürthle cell is used only to indicate cells of thyroid follicular origin." }, { "id": "pubmed23n0752_15765", "title": "Fine needle aspiration cytology of thyroid follicular neoplasm: cytohistologic correlation and accuracy.", "score": 0.011894132653061225, "content": "This study evaluated the accuracy of fine needle aspiration cytology (FNAC) in cases of follicular neoplasm (FN) on the basis of histologic diagnosis, and reviewed the cytologic findings of FN according to the FNAC. Among the 66 cases diagnosed with thyroid FN by FNAC during the 7-year period from 2003 to 2009, 36 cases that had undergone thyroid surgery were available for review. Cytologic diagnosis was compared with the histologic diagnosis of each case. Among the 36 cases with a cytologic diagnosis of thyroid FN, histologic diagnosis was as follows: 20 follicular adenomas (55.6%), 3 Hurthle cell adenomas (8.3%), 2 follicular carcinomas (5.6%), 8 nodular goiters (22.2%), 2 papillary carcinomas (5.6%), and 1 Hashimoto's thyroiditis (2.8%), resulting in a diagnostic accuracy of FNAC for thyroid FN of 69.5%. This study shows that FNAC for thyroid FN is a useful primary screening method because when FN is diagnosed by FNAC, the rate of FN histologic diagnosis is relatively high, however, adequate sampling and experience is a prerequisite for this procedure." }, { "id": "wiki20220301en097_40042", "title": "Papillary thyroid cancer", "score": 0.011858076563958916, "content": "Several variants are recognized, although classic papillary thyroid carcinoma is the most frequent: microscopic-follicular variant, diffuse-sclerosing variant, tall-cell variant, columnar-cell variant, hobnail variant, and others. The encapsulated-follicular variant, specifically when noninvasive, has been newly reclassified as the noninvasive follicular thyroid neoplasm with papillary-like nuclear features. Although papillary carcinoma has a propensity to invade lymphatics, it is less likely to invade blood vessels. These kinds of tumors are most commonly unencapsulated, and they have a high tendency to metastasize locally to lymph nodes, which may produce cystic structures near the thyroid that are difficult to diagnose because of the paucity of malignant tissue. Furthermore, papillary tumors may metastasize to the lungs and produce a few nodules or the lung fields may exhibit a snowflake appearance throughout." }, { "id": "wiki20220301en195_1149", "title": "Follicular thyroid cancer", "score": 0.011842556107589516, "content": "Initial treatment If follicular cells are found on cytological testing, it is common to carry out hemithyroidectomy to distinguish between follicular adenoma and follicular carcinoma on histopathological examination, proceeding to completion thyroidectomy and postoperative radioiodine ablation where carcinoma is confirmed. This way total thyroidectomy is not carried out unnecessarily. Thyroidectomy is invariably followed by radioiodine treatment at levels from 50 to 200 millicuries following two weeks of a low iodine diet (LID). Occasionally treatment must be repeated if annual scans indicate remaining cancerous tissue. Some physicians favor administering the maximum safe dose (calculated based on a number of factors), while others favor administering smaller doses, which may still be effective in ablating all thyroid tissue. I-131 is used for ablation of the thyroid tissue. Minimally invasive thyroidectomy has been used in recent years in cases where the nodules are small." }, { "id": "wiki20220301en498_25487", "title": "Noninvasive follicular thyroid neoplasm with papillary-like nuclear features", "score": 0.011798031714510996, "content": "Exclusion criteria 1) Any invasion. 2) The presence of any other papillary thyroid carcinoma variant (examples would include tall cell, columnar cell, cribriform morular, diffuse sclerosing, etc.). 3) True papillary structures (a fibrovascular core surrounded by neoplastic cells). While originally limited to <1%, newer data suggests no papillary structures should be allowed. 4) Psammoma bodies. These are calcified remnants of papillary structures, and thus if a psammoma body is present anywhere within the tumor (in the correct location), then a NIFTP cannot be diagnosed. 5) Tumor necrosis: If there is true tumor necrosis not associated with a fine needle aspiration. 6) Increased mitoses: If there are ≥3 mitoses per 10 high-power fields, then this category cannot be used." }, { "id": "wiki20220301en072_8878", "title": "Hürthle cell", "score": 0.011605359031613586, "content": "and growth pattern of the tumor cannot be used to determine malignancy, although larger tumors have higher incidence of malignancy, Hürthle cell adenomas and carcinomas have to be separated by the presence, in the case of carcinomas, or absence, in the case of adenomas, of both capsular invasion and vascular invasion. Tumors displaying only capsular invasion tend to behave less aggressively than those with vascular invasion. Hürthle cell carcinomas are characterized as either minimally invasive or widely invasive tumors. While the minimally invasive or encapsulated carcinoma is fully surrounded by a fibrous capsule, the widely invasive carcinoma shows extensive area of both capsular and vascular invasion with the leftover capsule typically difficult to identify. Classification is important since widely invasive tumors can have outcomes with a 55% mortality rate." }, { "id": "wiki20220301en262_814", "title": "Thyroid cancer", "score": 0.011522212264754833, "content": "Thyroid cancers can be classified according to their histopathological characteristics. These variants can be distinguished (distribution over various subtypes may show regional variation): Papillary thyroid cancer (75 to 85% of cases) – is more often diagnosed in young females compared to other types of thyroid cancer and has an excellent prognosis. It may occur in women with familial adenomatous polyposis and in patients with Cowden syndrome. A follicular variant of papillary thyroid cancer also exists. Newly reclassified variant: noninvasive follicular thyroid neoplasm with papillary-like nuclear features is considered an indolent tumor of limited biologic potential. Follicular thyroid cancer (10 to 20% of cases) – occasionally seen in people with Cowden syndrome. Some include Hürthle cell carcinoma as a variant and others list it as a separate type." }, { "id": "wiki20220301en063_44807", "title": "International Classification of Diseases for Oncology", "score": 0.011519707436001624, "content": "Papillary and follicular carcinoma M8341/3 Papillary microcarcinoma (C73.9) M8342/3 Papillary carcinoma, oxyphilic cell (C73.9) M8343/3 Papillary carcinoma, encapsulated (C73.9) M8344/3 Papillary carcinoma, columnar cell (C73.9) Papillary carcinoma, tall cell M8345/3 Medullary carcinoma with amyloid stroma (C73.9) Parafollicular cell carcinoma C cell carcinoma M8346/3 Mixed medullary-follicular carcinoma (C73.9) M8347/3 Mixed medullary-papillary carcinoma (C73.9) M8350/3 Nonencapsulated sclerosing carcinoma (c73.9) Nonencapsulated sclerosing adenocarcinoma Nonencapsulated sclerosing tumor Papillary carcinoma, diffuse sclerosing M8360/1 Multiple endocrine adenomas Endocrine adenomatosis M8361/0 Juxtaglomerular tumor (C64.9) Reninoma M8370/0 Adrenal cortical adenoma, NOS (C74.0) Adrenal cortical tumor, benign Adrenal cortical tumor, NOS M8370/3 Adrenal cortical carcinoma (C74.0) Adrenal cortical adenocarcinoma Adrenal cortical tumor, malignant" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 225 ] ], "word_ranges": [ [ 0, 30 ] ], "text": "Kallman's syndrome or Morsier's syndrome is a congenital insufficiency associated with hypogonadotropic hypogonadism due to a deficit in GnRH hormone production. Repeated injections of GnRH are performed to restore fertility." }, "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": "Gn_RH infusion pump.", "2": "Monthly intramuscular administration of triptorelin.", "3": "Intramuscular administration of FSH and LH once a week.", "4": "Treatment with bromocriptine.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0011_8325", "title": "Hypogonadism, galactorrhoea and hyper-prolactinaemia: Evaluation of pituitary gonadotrophins reserve before and under bromocriptine.", "score": 0.015537488708220417, "content": "Twenty patients with hypogonadism (19 women with amenorrhoea and 1 man with impotence and infertility), galactorrhoea and hyper-prolactinaemia (range: 36 to 344 ng/ml) were studied. The radiological study of the sella turcica, including in all cases hypocycloidal tomograms, allowed classification of the patients into 3 groups: group I (n = 4) had a grossly enlarged sella turcica, group II (n = 12) had localized alterations indicating the probable existence of a prolactin-secreting microadenoma (\"microdeformation\") while group III patients presented no radiological abnormality. Before treatment, all the patients were submitted to a complete evaluation of the function of their anterior pituitary, including the LH and FSH responses to iv administration of Gn-RH. All the group I patients had low basal LH levels and a blunted response to Gn-RH. The basal LH and in response to Gn-RH were normal in most of the group II patients and in all of the group III patients. An exaggerated FSH response to Gn-RH was observed in 6/12 patients with microdeformation (group II) but not in groups I and III patients. A low LH and a blunted LH response to Gn-RH is highly suggestive of the existence of a pituitary prolactin-secreting adenoma in case of amenorrhoea and hyper-prolactinaemia patients; a normal response does not however rule out such a diagnosis. The reasons for a exaggerated FSH response to Gn-RH in patients with suspected prolactin-secreting microadenoma remain to be investigated though this pattern can also occur in other cases of amenorrhoea. Hence the Gn-RH test might contribute to the assessment of the hypothalamo-pituitary axis of patients with hyper-prolactinaemia. Six patients treated for 4 months with bromocriptine (CB-154) were submitted to re-evaluation of their pituitary gonadotrophins reserve. All the women experienced restoration of menses with 39 days of treatment and the male patient regained potency. It was observed that bromocriptine treatment and subsequent normalized prolactin levels in the 4 group II women tested were associated with normalization of their previously exaggerated FSH response to Gn-RH; LH responses were also diminished in these cases. These data are compatible with the hypothesis that hyper-prolactinaemia per se could interfere with the endogenous secretion of Gn-RH at the hypothalamic level. In one patient with grossly enlarged sella turcica and a previous lack of an LH and FSH response to Gn-RH, bromocriptine treatment restored a normal gonadotrophins response, confirming that, in this case, the alteration of this response was indeed due to a prolonged lack of endogenous Gn-RH secretion." }, { "id": "pubmed23n0130_16090", "title": "[The effects of bromocriptine on anovulatory patients with high LH and euprolactinemia].", "score": 0.014664664664664664, "content": "It is well known that an acute administration of Bromocriptine (dopamine agonist) suppresses the serum LH level either in normal women or in women with polycystic ovary syndrome, in whom the serum LH level is elevated. The present study was carried out to examine the effectiveness of Bromocriptine on anovulatory women with a high LH level (serum LH greater than 30 mIU/ml). Bromocriptine was administered for 3 months, 5 mg daily, to 9 anovulatory women with euprolactinemia (serum PRL less than 25 ng/ml). Ovulation was observed by their BBT charts. Before and after the treatment of Bromocriptine, FSH, LH and PRL secreting capacities were tested by LHRH and TRH injection. Also, estrone, estradiol and testosterone levels were measured before and after the Bromocriptine administration. Resting levels of LH, FSH and PRL were 45.4 +/- 11.0 mIU/ml, 11.4 +/- 3.0 mIU/ml, and 14.3 +/- 4.7 ng/ml (M +/- SD), respectively, before the treatment. As a result of the treatment, the LH level was markedly decreased to 27.3 +/- 14.5 (M +/- SD, P less than 0.05), and PRL decreased to 3.76 +/- 4.2 ng/ml (M +/- SD, P less than 0.005). On the other hand, FSH did not show a marked change. The responsiveness of LH to LHRH before the treatment showed a marked increase, which was suppressed by Bromocriptine. However, FSH showed no change. The responsiveness of PRL to TRH was suppressed by Bromocriptine. Serum estrone, estradiol and testosterone levels before the treatment were 115.5 +/- 76.7 pg/ml, 93.7 +/- 61.0 pg/ml and 0.809 +/- 0.209 ng/ml (M +/- SD), respectively, which showed no significant change after the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en061_51682", "title": "Desogestrel", "score": 0.013807240099009901, "content": "of FSH and testosterone levels. A previous study by the same authors found that increasing the dosage of desogestrel from 300 μg/day to 450 μg/day resulted in no further suppression of gonadotropin concentrations. The addition of a low dose of 50 or 100 mg/week intramuscular testosterone enanthate after 3 weeks increased testosterone levels and further suppressed LH and FSH levels, to the limits of assay detection (i.e., to undetectable or near-undetectable levels), in both the 150 μg/day and 300 μg/day desogestrel groups. Upon cessation of treatment, levels of LH, FSH, and testosterone all recovered to baseline values within 4 weeks." }, { "id": "pubmed23n0253_7357", "title": "Clinical and hormonal response to short-term intermittent versus continuous oral bromocriptine in hyperprolactinemic women.", "score": 0.012975560594608214, "content": "OBJECTIVE -- To determine if intermittent oral bromocriptine administration could be a useful therapeutic alternative in infertile hyperprolactinemic women. DESIGN -- Open, randomized and prospective study. SETTING -- Outpatient infertility clinic of a third-level medical institution. PATIENTS -- Fourteen low-income women, 23 to 36 years of age with anovulatory infertility (1-13 years in duration) secondary to hyperprolactinemia (&gt;35 ng/mL). Endocrine profile ruled out anovulation of other origin. INTERVENTIONS -- After a control period of 30 days, seven women (group 1) received daily oral bromocriptine (2.5-10.0 mg/day) continuously during two consecutive 30-day periods (T-1 and T-2), and seven women (group 2) received oral bromocriptine only from day 1 to 15 of each 30-day period of treatment. Morning blood samples were drawn similarly during the three periods on days 6 to 8, 13 to 15, and 21 to 23. MAIN OUTCOME MEASURES -- FSH, LH, and prolactin were determined in all samples, estradiol only in samples of days 6 to 8 and 13 to 15, and progesterone exclusively between days 21 and 23. Mean serum prolactin levels during the control period were similarly elevated in groups 1 and 2. A marked decrease occurred during period T-1 (P &lt; .004) and further during period T-2 (P &lt; .05) in both groups, but at no time were significant intergroup differences documented. During the control period all women had a serum progesterone &lt; 3.0 ng/mL (&lt;9.54 nmol/L); during period T-2 it was &gt; or = 3.0 ng/mL in three and five women of groups 1 and 2, respectively. Over the following 10 months of treatment, two and three normal pregnancies and deliveries ensued in groups 1 and 2, respectively. CONCLUSION -- The intermittent use of oral bromocriptine may indeed be a useful therapeutic approach in treating infertile hyperprolactinemic women." }, { "id": "wiki20220301en026_104912", "title": "Hypopituitarism", "score": 0.01252572564047974, "content": "Basal tests Levels of LH/FSH may be suppressed by a raised prolactin level, and are therefore not interpretable unless prolactin is low or normal. In men, the combination of low LH and FSH in combination with a low testosterone confirms LH/FSH deficiency; a high testosterone would indicate a source elsewhere in the body (such as a testosterone-secreting tumor). In women, the diagnosis of LH/FSH deficiency depends on whether the woman has been through the menopause. Before the menopause, abnormal menstrual periods together with low estradiol and LH/FSH levels confirm a pituitary problem; after the menopause (when LH/FSH levels are normally elevated and the ovaries produce less estradiol), inappropriately low LH/FSH alone is sufficient. Stimulation tests with GnRH are possible, but their use is not encouraged." }, { "id": "pubmed23n0871_1415", "title": "[Effect of pulsatile GnRH therapy on pituitary-testicular axis function in male patients with pituitary stalk interruption syndrome].", "score": 0.012142857142857143, "content": "To evaluate the efficacy of pulsatile gonadotropin-releasing hormone (GnRH) therapy in male patients with pituitary stalk interruption syndrome (PSIS). Fourteen male PSIS patients, who had received subcutaneous pulsatile GnRH therapy for at least four weeks at Peking Union Medical College Hospital from April 2014 to September 2015, were included in the study. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone level, testicular volume and sperm in ejaculation were measured. After treatment for four weeks, subjects with serum LH≥1.24 U/L were classified as\"good response group\", and others were classified as\"poor response group\". All patients were born by breech delivery and presented with absent pubertal development. Laboratory findings showed combined pituitary hormone deficiency in all patients. Pituitary stalk interruption syndrome was diagnosed based on MRI findings. Totally 11 out of 14 patients showed good response to pulsatile GnRH therapy. Their LH level increased from 0.32 (0.15, 0.61) U/L to 4.34(2.52, 7.39)U/L(P&lt;0.001), FSH from 0.84 (0.30, 1.50) U/L to 7.12 (4.53, 10.09) U/L(P&lt;0.001); serum testosterone level from 0 (0, 0.45) nmol/L to 2.46 (0.56, 11.45) nmol/L (P=0.004) and testicular volume from 2.0 (2.0, 4.0) ml to 4.0 (3.0, 6.0) ml (P=0.005). Sperm was detected in seminal samples after treatment for 8 weeks in two patients and for 12 weeks in one patients. Three out of 14 patients showed poor response to pulsatile GnRH therapy. Pulsatile GnRH therapy can effectively establish the pituitary-testicular axis function for most patients with pituitary stalk interruption syndrome, indicating enough reserve of gonadotrophs in the pituitary." }, { "id": "pubmed23n0083_6545", "title": "Testosterone administration inhibits gonadotropin secretion by an effect directly on the human pituitary.", "score": 0.011338815366825131, "content": "Testosterone (T) administration slows LH pulse frequency in man, presumably by an effect on the hypothalamic GnRH pulse generator, but it also may have a direct action on the pituitary. To determine if T does indeed affect gonadotropin secretion by acting directly on the pituitary, we studied the effect of T on GnRH-stimulated gonadotropin secretion. Six men with hypogonadotropic hypogonadism were treated with physiological doses of GnRH (5 micrograms every 2 h, sc by automatic infusion pump) for 6 weeks. Once their gonadotropin levels were normal, the men received a supraphysiological dosage of T enanthate (200 mg, im, weekly for 8 weeks) in addition to GnRH. They then received GnRH alone for a final 8-week period. Blood sampling was performed every 10 min for 8 h at the end of each of the three study periods. T administration suppressed the mean serum LH level to about 50% of the value during GnRH alone [18 +/- 2 (+/- SE) vs. 37 +/- 2 micrograms/L; P less than 0.05] and suppressed the mean serum FSH level to about 30% of the value during GnRH alone (39 +/- 6 vs. 128 +/- 28 micrograms/L; P less than 0.05). Eight weeks after stopping T, while continuing GnRH alone, serum LH and FSH levels were similar to those at the end of the first period of GnRH administration. The mean LH response to GnRH was reduced during T administration (17 +/- 3 micrograms/L) compared to that during the initial period of GnRH alone (31 +/- 4 micrograms/L; P less than 0.05). Serum T and estradiol levels were in the low normal range after GnRH alone before T administration (11 +/- 2 nmol/L and 105 +/- 17 pmol/L, respectively) and increased to just above the normal adult ranges after 8 weeks of T administration (36 +/- 5 nmol/L and 264 +/- 49 pmol/L, respectively). These results demonstrate that T and/or its metabolites inhibit LH and FSH secretion by a GnRH-independent mechanism, probably directly on the pituitary gland, in man." }, { "id": "Gynecology_Novak_5822", "title": "Gynecology_Novak", "score": 0.011245346098320797, "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": "wiki20220301en077_5952", "title": "Gonadotropin-releasing hormone agonist", "score": 0.011120768994784744, "content": "Agonists do not quickly dissociate from the GnRH receptor. As a result, initially there is an increase in FSH and LH secretion (so-called \"flare effect\"). Levels of LH may increase by up to 10-fold, while levels of testosterone generally increase to 140 to 200% of baseline values. However, after continuous administration, a profound hypogonadal effect (i.e. decrease in FSH and LH) is achieved through receptor downregulation by internalization of receptors. Generally this induced and reversible hypogonadism is the therapeutic goal. During the flare, peak levels of testosterone occur after 2 to 4 days, baseline testosterone levels are returned to by 7 to 8 days, and castrate levels of testosterone are achieved by 2 to 4 weeks. Following cessation of exogenous GnRH agonist it takes 5 to 8 days before normal gonadotropin secretion is completely restored." }, { "id": "pubmed23n0227_5127", "title": "Testicular function of actively immunized male rats with LH releasing hormone (LHRH): a possible role of prolactin on regulation of spermatogenesis.", "score": 0.009904873982543885, "content": "The effect of testosterone propionate (TP) on the recovery of spermatogenesis was compared in 3 types of experimentally induced gonadotropin-deficient rats; 1. hypophysectomized rats, 2. rats actively immunized to LHRH and 3. hypophysectomized and immunized rats bearing a pituitary isograft. In order to immunize animals to LHRH, deamidated LHRH conjugated with BSA (LHRH-BSA) was injected intradermally to male rats 4 times at 2 week intervals and additional booster injections continued once a month. Anti-LHRH titer was the highest on the 12th week and the titer remained at a relatively high levels thereafter. A remarkable decrease in testicular weight and testosterone production was achieved in 10 weeks associated with a drop in serum LH and FSH levels. In long term immunized rat (LIM rats) which had been immunized for more than 3 months, testicular atrophy advanced to a similar extent to that in long term hypophysectomized rats (HX rats). The administration of TP (1 mg/day) sc for 30 days restored spermatogenesis in LIM rats. The simultaneous administration of anti-LH and -FSH sera in addition to TP did not affect the restoration of spermatogenesis in LIM rats. The same TP treatment in HX rats, however, failed to restore spermatogenesis. Spermatogenesis was reinitiated after TP treatment if immunized-hypophysectomized rats received a pituitary isograft. Though the serum PRL level in LIM rats was one fifth of that in normal rats, a 2.5-fold rise in the PRL level was observed after TP treatment. These results suggest that PRL is involved in the process of spermatogenesis." }, { "id": "pubmed23n0226_13879", "title": "Treatment of hypogonadotropic hypogonadal male patients with the luteinizing hormone-relasing hormone (LH-RH) anolog D-Ser(TBU)6 EA10 LH-RH: transient disappearance of gonadotropin stimulation.", "score": 0.009900990099009901, "content": "We have studied the effect of prolonged treatment with a long-acting luteinizing hormone-releasing hormone (LH-RH) analog (D-Ser-(TBU)6 EA10 LH-RH in six patients with isolated gonadotropin deficiency. Before treatment, all subjects responded to LH-RH (100 microgram intravenously [IV]); one responded immediately, and five after 5 daily infusions of LH-RH (200 microgram). Treatment by LH-RH analog (348 microgram every 2 days with a nasal spray for 90 or 120 days) is only efficient for 1 month; a consistent increase in serum LH and a slight increase in testosterone (T) were observed in all patients, but no increase of serum follicle-stimulating hormone (FSH) was detectable. Then a paradoxical effect appeared: LH and T levels returned to the basal values. Moreover, this treatment induced refractoriness of the pituitary to LH-RH for several months after the end of treatment. The appearance of antibodies to LH-RH and LH-RH analog was eliminated. A pituitary response was obtained in three patients when a new LH-RH stimulation was repeated 7 and 11 months after the end of treatment. The mechanism of this pituitary desensitization is discussed." }, { "id": "InternalMed_Harrison_27423", "title": "InternalMed_Harrison", "score": 0.009827768841461023, "content": "Although a variety of treatment regimens are used, 1000–2000 IU of hCG or recombinant human LH (rhLH) administered intramuscularly three times weekly is a reasonable starting dose. Testosterone levels should be measured 6–8 weeks later and 48–72 h after the hCG or rhLH injection; the hCG/rhLH dose should be adjusted to achieve testosterone levels in the mid-normal range. Sperm counts should be monitored on a monthly basis. It may take several months for spermatogenesis to be restored; therefore, it is important to forewarn patients about the potential length and expense of the treatment and to provide conservative estimates of success rates. If testosterone levels are in the mid-normal range but the sperm concentrations are low after 6 months of therapy with hCG alone, FSH should be added. This can be done by using hMG, highly purified urinary hFSH, or recombinant hFSH. The selection of FSH dose is empirical. A common practice is to start with the addition of 75 IU FSH three times" }, { "id": "pubmed23n0553_4742", "title": "Testicular leydig cell tumor presenting as primary infertility.", "score": 0.00980392156862745, "content": "A 29-year old male and his wife presented with an 18 month history of primary infertility. History and initial investigations suggested no major female pathologic component but a semen analysis revealed azoospermia. There was no history of any sexual dysfunction and neither partner was receiving any medication. Clinical examination revealed normal secondary sexual characteristics. Both testicles were of normal consistency with a volume of approximately 15 ml but a 4 x 2 cm mass was palpable at the lower pole of the left testis. Laboratory investigations revealed: serum testosterone 37.1 nmol/l (NV:10.0-38.0 nmol/l), LH&lt;0.3 U/L (NV:3.0-12.0 U/L), and FSH &lt;0.1 IU/L (NV:3.0-11.0 U/L). Serum b-HCG, aFP, LDH, oestradiol and inhibin levels were within the normal range. A repeated semen analysis confirmed azoospermia. Testicular ultrasound demonstrated a well-defined hypoechoic mass, measuring 31 x 23 x 17 mm and containing several flecks of calcification, arising from the lower pole of the left testis. A left orchidectomy was performed. Macroscopical histopathological examination revealed a single firm dark brown nodule 2.8 cm in diameter arising from the lower pole of the testis. The tumor distended the capsule of the testis without extending through it. Microscopical examination was consistent with a Leydig cell tumor. Computerised tomography of the chest, abdomen and pelvis was normal. Six months later, laboratory investigations revealed a serum testosterone of 14.3 nmol/l, an LH of 5.4 U/L and an FSH of 4.3 U/L, respectively. A repeated semen analysis was normal: volume 1.8 ml(2-10 ml), count 124 x 10(6) (20-350 x 10(6)), motility 80%(&gt;60%), abnormal forms &lt;15%(&lt;15%). Three months later his wife was pregnant. In summary, our patient presented with azoospermia, secondary to a Leydig cell tumor, which was reversible after removal of the tumor." }, { "id": "pubmed23n0005_3512", "title": "[Effects of a new analogue of LH-RH, D-Ser(TBU)6- EA10-LH-RH, on gonadotropin liberation in males (author's transl)].", "score": 0.00980392156862745, "content": "Effects on the secretion of gonadotropins by D-Ser (TBU)6-EA10-LH-RH were investigated in 7 male volunteers without known endocrine disturbances. One week after subcutaneous injection of 100 mug of LH-RH the probands were given 5 mug of the LH-RH analogue subcutaneously into the abdominal wall. LH, FSH and testosterone concentrations were estimated in the serum and compared with each other at varying intervals after each injection. LH-RH caused a marked increase of the LH content in serum after 20 minutes with a maximum after 40 minutes. The effect of the analogue occurred with a delay. After 40 minutes an LH level was reached which still persisted 6 hours later. Contrary to LH there were considerable individual differences in serum FSH levels. In the initial phase after injection of LH-RH and LH-RH analogue that increase of the FSH level in serum was almost parallel. However, the analogue showed a marked depot effect. Serum concentrations of testosterone showed no significant changes after administration of the releasing hormones. D-Ser(TBU)6-EA10-LH-RH is approximately 20 times effective as LH-RH. A dose of 5 mug is effective for 6-8 hours." }, { "id": "pubmed23n0359_3396", "title": "Spontaneous and GnRH-provoked gonadotropin secretion and testosterone response to human chorionic gonadotropin in adolescent boys with thalassaemia major and delayed puberty.", "score": 0.009708737864077669, "content": "To elucidate whether the cause of sexual maturation arrest in thalassaemia is of gonadal or pituitary etiology, 10 males with thalassaemia and delayed puberty and 10 with constitutional delay of growth and pubertal maturation (CSS) were extensively studied. Their spontaneous nocturnal gonadotropin secretion and gonadotropin response to intravenous 100 micrograms gonadotropin-releasing hormone (GnRH) were evaluated. Circulating testosterone concentration and clinical response were evaluated after 3 days, 4 weeks and 6 months of intramuscular administration of human chorionic gonadotropin (HCG) (2500 U/m2/dose). Thalassaemic boys had significantly lower circulating concentrations of testosterone compared to those with constitutional delay of growth and sexual maturation (CSS) at the same pubertal stage. Short- and long-term testosterone response to administrations of HCG was markedly decreased in thalassaemic boys. After 6 months of HCG administration 50 per cent (5/10) of the boys did not show significant testicular enlargement or genital changes. Despite the low circulating concentrations of testosterone, none of the patients had high basal or exaggerated gonadotropin response to gonadotropin releasing hormone (GnRH) stimulation. Luteinizing hormone (LH) peak responses to GnRH were significantly lower as compared to controls. Follicle-stimulating hormone (FSH) peak responses to GnRH did not differ among the two study groups. The mean nocturnal LH and FSH secretion was significantly decreased in all thalassaemic boys as compared to boys with CSS at the same pubertal stage (testicular volume). These data proved that hypogonadotropic hypogonadism is the main cause of delayed/failed puberty in adolescents with thalassaemia major. MRI studies revealed complete empty sella (n = 5), marked diminution of the pituitary size (n = 5), thinning of the pituitary stalk (n = 3) with its posterior displacement (n = 2), and evidence of iron deposition in the pituitary gland and midbrain (n = 8) in thalassaemic patients, denoting a high incidence of structural abnormalities (atrophy) of the pituitary gland. Moreover, in many of the thalassaemic boys, the defective testosterone response to long-term (6 months) HCG therapy denoted significant testicular atrophy and/or failure secondary to siderosis. It appears that testosterone replacement might be superior to HCG therapy in these patients. This therapy should be introduced at the proper time in these hypogonadal patients to induce their sexual development and to support their linear growth spurt and bone mineral accretion." }, { "id": "pubmed23n0026_10025", "title": "Effect of a new LH-RH analogue (D-Ser(TBU)6-EA10-LH-RH) on gonadotrophin and gonadal steroid secretion in men.", "score": 0.009708737864077669, "content": "The effect of a new analogue of the gonadotrophin-releasing hormone LH-RH, D-Ser(TBU)6-EA10-LH-RH, on the secretion of LH, FSH, as well as testosterone, oestradiol, HGH, prolactin, TSH, and cortisol was studied in normal men. The same subjects were injected intravenously in 4-day intervals with 1.0, 2.5, 5.0, and 10.0 mug of this substance. A significant LH but no FSH release was seen after doses of 1.0 and 2.5 mug LH-RH analogue, while after 5.0 and 10.0 mug dose-dependent increases of LH and imposed elevations of FSH were observed. Peak levels of LH were reached after 30 min, those of FSH after intravenous injection after 120 min. LH and FSH remained elevated for 8-10 h. LH peak levels after 5 mug of LH-RH analogue were comparable to those seen after injection of 100 mug of the decapeptide LH-RH. Following the release of LH and FSH after doses of 5.0 and 10.0 mug LH-RH analogue, there was a late stimulating effect in testosterone and oestradiol secretion. HGH, TSH, prolactin, and cortisol were not influenced by the LH-RH analogue." }, { "id": "pubmed23n0738_23671", "title": "Comparison of detection of normal puberty in boys by a hormonal sleep test and a gonadotropin-releasing hormone agonist test.", "score": 0.009615384615384616, "content": "The magnitude of sleep-related gonadotropin rise required to activate pubertal gonadal function is not established. Our objective was to determine the normal relationship between sleep-related pubertal hormone levels and pituitary-testicular responsiveness to a GnRH agonist (GnRHag) test across the pubertal transition. DESIGN/SETTING AND PARTICIPANTS: We conducted a prospective study in a General Clinical Research Center with healthy 9- to 15-yr-old volunteer boys. INTERVENTIONS included overnight blood sampling followed by leuprolide acetate injection (10 μg/kg). LH, FSH, and testosterone levels were evaluated. LH levels during sleep and post-GnRHag rose steadily during the late prepubertal years. Sleep peak LH correlated highly with the LH response to GnRHag across groups (r = 0.913). A sleep peak LH level of at least 3.7 U/liter predicted pubertal testicular activation with 100% accuracy. LH of at least 14.8 and at least 19.0 U/liter 4 h after GnRHag, respectively, predicted puberty with 100% sensitivity/94% specificity and 100% specificity/94% sensitivity. Overweight pubertal boys had transiently prolonged responses to GnRHag. FSH rose during both waking and sleeping hours during the prepubertal years, and all pubertal boys had an FSH level of at least 0.9 U/liter awake and at least 1.2 U/liter asleep. Sleep LH was more closely related than FSH to testicular size. These data suggest that a critical LH level during sleep (≥3.7 U/liter) heralds the onset of pubertal virilization and that this level is predictable by LH of at least 14.8-19 U/liter 4 h after GnRHag. These data also suggest that LH stimulation of testicular androgen production plays a role in stimulating testicular tubule growth once a critical level of FSH is achieved." }, { "id": "pubmed23n0225_11278", "title": "[Increased and prolonged release of lh and fsh on intravenous administration of a synthetic analogue of lh-rh [d-ser(tbu)6-ea10-lh-rh] in healthy men of various age groups (author's transl)].", "score": 0.009615384615384616, "content": "Healthy male subjects of various age groups respond to the administration of D-Ser(TBU)6-EA10-LH-RH, an analogue of LH-RH substituted in positions 6 and 10, by a prolonged and increased release of LH and FSH. Increased serum concentrations of LH and FSH were observed 20 minutes after intravenous administration of the compound. Maximum concentrations of LH and FSH were seen after 60, and 60 to 240 minutes, respectively. Serum concentrations of both gonadotropins remained elevanted for up to 8 hours after the administration of 10 microgram of the LH-RH analogue. A dose response relationship was observed with regard to the serum concentrations of LH and FSH over the range of 1.25 to 5.0 microgram of the LH-RH analogue. The administration of 10 or 20 microgram of the compound, however, did not cause a further rise in plasma FSH, although the release of LH was further enhanced." }, { "id": "pubmed23n0387_5112", "title": "Daily testosterone and gonadotropin levels are similar in azoospermic and nonazoospermic normal men administered weekly testosterone: implications for male contraceptive development.", "score": 0.009523809523809525, "content": "Weekly intramuscular administration of testosterone esters such as testosterone enanthate (TE) suppresses gonadotropins and spermatogenesis and has been studied as a male contraceptive. For unknown reasons, however, some men fail to achieve azoospermia with such regimens. We hypothesized that either 1) daily circulating serum fluoroimmunoreactive gonadotropins were higher or testosterone levels were lower during the weekly injection interval, or 2) monthly circulating bioactive gonadotropin levels were higher in nonazoospermic men. We therefore analyzed daily testosterone and fluoroimmunoreactive gonadotropin levels as well as pooled monthly bioactive and fluoroimmunoreactive gonadotropin levels in normal men receiving chronic TE injections and correlated these levels with sperm production. After a 3-month control period, 51 normal men were randomly assigned to receive intramuscular TE at 25 mg (n = 10), 50 mg (n = 9), 100 mg (n = 10), 300 mg (n = 10), or placebo (n = 12) weekly for 6 months. After 5 months of testosterone administration, morning testosterone and fluoroimmunoreactive follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured daily for a 1-week period between TE injections. In addition, fluoroimmunoreactive and bioactive FSH and LH levels were measured in pooled monthly blood samples drawn just before the next TE injection. In the 100-mg and 300-mg TE groups, mean monthly fluoroimmunoreactive FSH and LH levels were suppressed by 86%-97%, bioactive FSH and LH levels by 62%-80%, and roughly half the subjects became azoospermic. In the 1-week period of month 6, daily testosterone levels between TE injections were within the normal range in men receiving placebo, or 25 or 50 mg of weekly TE, but were significantly elevated in men receiving 100 or 300 mg of weekly TE. At no point during treatment, however, were there significant differences in daily testosterone or fluoroimmunoreactive gonadotropin levels, or monthly bioactive gonadotropin levels between men achieving azoospermia and those with persistent spermatogenesis. This study, therefore, demonstrates that neither monthly nor daily differences in serum testosterone, or fluoroimmunoreactive or bioactive gonadotropins explain why some men fail to completely suppress their sperm counts to zero with weekly TE administration. Innate differences in the testicle's ability to maintain spermatogenesis in a low-gonadotropin environment may explain persistent spermatogenesis in some men treated with androgen-based contraceptive regimens." }, { "id": "pubmed23n0117_15714", "title": "Further acquisitions on gonadal function in bromocriptine treated hyperprolactinemic male patients.", "score": 0.009523809523809525, "content": "The diurnal variation of plasma total and free testosterone (tT and fT) and the gonadotropinemic response to LH-RH were evaluated in a group of hyperprolactinemic impotent males with pituitary microprolactinoma before and during therapy with bromocriptine, a well known dopamine agonist drug. Before treatment, basal levels not only of tT but also of fT were decreased and the diurnal variation of both tT and fT was absent. Moreover, the LH-RH test showed a delay in the LH response peak, together with normal basal levels of LH. Bromocriptine therapy caused normalization of both the secretion response of LH to LH-RH and of the secretion pattern of tT and of fT (basal levels and diurnal variation) besides a significant decrease in PRL levels and an improvement in sexual function. The possible effects of high plasma levels of PRL at various levels of the hypothalamus-pituitary-testicular axis are discussed." }, { "id": "wiki20220301en381_28806", "title": "Gonadotropin-releasing hormone insensitivity", "score": 0.00950197269215674, "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": "pubmed23n0104_6207", "title": "Gonadotropin-releasing hormone (GnRH) analog suppression renders polycystic ovarian disease patients more susceptible to ovulation induction with pulsatile GnRH.", "score": 0.009433962264150943, "content": "Pulsatile GnRH administration consistently restores normal reproductive hormone levels and ovulation in women with hypogonadotropic hypogonadism, but is less effective in those with polycystic ovarian disease (PCOD). We pharmacologically created a hypogonadotropic condition with a GnRH analog (GnRH-A) in six women with PCOD to investigate the role of deranged gonadotropin secretion in PCOD and to improve the response to pulsatile GnRH ovulation induction. Before GnRH and GnRH-A treatment the women with PCOD had increased LH pulse frequency [one pulse every 55 +/- 2 (+/- SE) min; P less than 0.05] and LH pulse amplitude (10.9 +/- 1.4 U/L; P less than 0.05) compared to normal women in the follicular phase of their menstrual cycle. Each PCOD woman completed one cycle of pulsatile GnRH administration for ovulation induction before (pre-A cycles; n = 6) and one or two cycles after (post-A cycles; n = 9) GnRH-A administration [D-Ser(tBu)6-Des,Gly10-GnRH; 300 micrograms, sc, twice daily for 8 weeks]. Pulsatile GnRH (5 micrograms/bolus) was given at 60-min intervals using a Zyklomat pump. Daily blood samples were drawn during the pulsatile GnRH ovulation induction cycles for the determination of serum LH, FSH, estradiol (E2), progesterone, and testosterone, and pelvic ultrasonography was done at 1- to 4-day intervals. Mean (+/- SE) serum LH levels were elevated during the pre-A cycle (49.2 +/- 3.1 IU/L) and decreased to normal levels during the post-A cycles (19.6 +/- 1.4 IU/L; P less than 0.0001). Mean testosterone concentrations were lower during the post-A cycles [88 +/- 2 ng/dL (3.1 +/- 0.1 nmol/L)] than during the pre-A cycles [122 +/- 3 ng/dL (4.2 +/- 0.1 nmol/L); P less than 0.0001]. In the follicular phase of the post-A cycles E2 levels were significantly lower [81 +/- 5 pg/mL (300 +/- 20 pmol/L) vs. 133 +/- 14 pg/mL (490 +/- 50 pmol/L); P less than 0.0001], preovulatory ovarian volume was smaller (24.6 +/- 2.0 vs. 31.4 +/- 2.4 cm3; P less than 0.01), and the FSH to LH ratio was higher (0.56 +/- 0.03 vs. 0.16 +/- 0.01) than in the pre-A cycle, suggesting more appropriate function of the pituitary-gonadal axis. Excessive LH and E2 responses to pulsatile GnRH administration in the early follicular phase of the pre-A cycle were abolished in the post-A cycles.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0012_2983", "title": "Pituitary and testicular response to LH-RH and to a long-acting analogue (D-leu-6-LH-RH-ethylamide).", "score": 0.009433962264150943, "content": "The LH, FSH and testosterone response to 50 microgram i.v. LH-RH and to 2.5, 5.0, 10.0, and 20.0 microgram i.m. D-Leu-6-LH-RH-ethylamide was studied in 6 subjects with normogonadotrophic, idiopathic oligozoospermia. All injections were given between 8:00 and 9:00 a.m. at weekly intervals. Blood samples were collected before and 30 and 45 minutes after injection of LH-RH, and before and 2, 4, 6, 12, and 24 hours after D-Leu-6-LH-RH-ethylamide injections. Serum levels of LH, FSH, and testosterone were measured by triplicate by R.I.A. LH and FSH responses to LH-RH showed peak values at 30 minutes, whereas following injections of D-Leu-6-LH-RH-ethylamide, maximal values were recorded between 4 and 6 hours and were higher than those obtained with LH-RH. A significant rise of serum testosterone levels was observed after all stimuli, with peak values 45 minutes after LH-RH and 4 to 6 hours after D-Leu-6-Lh-RH-ethylamide injections. The testosterone levels obtained following LH-RH and different doses of the analogue did not differ significantly from one another. The same sequence of maximal LH and FSH values was obtained after injections of LH-RH and of D-Leu-6-LH-RH-ethylamide, particularly at doses of 10.0 and 20.0 microgram. This suggests that the gonadotrophin response to these agents would be a true reflection of the individual mode of pituitary response." }, { "id": "pubmed23n0569_24477", "title": "Prolactinoma presenting as a failed vasectomy reversal.", "score": 0.009345794392523364, "content": "To present a case of prolactinoma presenting as a failed vasectomy reversal. Case report. University-affiliated teaching hospital. A 46-year-old male with severe oligospermia after bilateral vasovasostomy and his 31-year-old female partner who had normal cycles. Bromocriptine, carbegoline, and l IVF. Correction of hyperprolactinoma, improved semen analysis, and pregnancy achieved by assisted reproductive technologies. Semen analysis showing low volume (0.65 mL) and severe oligospermia (16 sperm) with zero motility on presentation. Endocrine evaluation showed prolactin of 650 ng/mL, T 0.37 ng/mL, and FSH 2.0 mIU/mL. A head CT scan showed a 1.2 cm pituitary adenoma. This was managed initially with bromocriptine, but due to side effects he was switched to carbegoline. In 1 month his PRL decreased to 16.9 ng/mL. Testosterone and FSH normalized. Repeat semen analysis after 5 months showed a volume of 4.5 mL and a concentration of 15 million/mL with 1% motility. Antisperm antibodies were positive. Because of antisperm antibodies and oligoasthenospermia, intracytoplasmic sperm injection with ejaculated sperm and, later, testicular extraction, were attempted without success. Donor sperm was eventually used. This is the first reported case of prolactinoma as a cause of infertility after vas reversal and demonstrates that not all cases of suspected failed vasectomy reversals are due to recurrent obstruction." }, { "id": "pubmed23n0214_10304", "title": "Reduction of follicle-stimulating hormone (FSH) secretion in FSH-producing pituitary adenoma by bromocriptine.", "score": 0.009345794392523364, "content": "An FSH-secreting pituitary adenoma was demonstrated in a 32-yr-old man who presented with unilateral optic atrophy without any clinical or laboratory evidence of hypogonadism. Semen analysis was normal, although basal FSH levels were markedly elevated (greater than 80 mIU/ml). He had normal plasma LH levels and no other detectable endocrine abnormalities. Administration of GnRH elicited delayed and sustained FSH and brisk LH responses. Administration of TRH resulted in TSH and PRL responses and unexpected FSH and LH elevations. Two surgical operations resulted in temporary reduction of plasma FSH levels, but it increased later concomitant with CT demonstration of tumor growth. After pituitary irradiation, no reduction in FSH levels occurred. A single dose of 5 mg bromocriptine elicited a significant reduction in FSH levels from 137 to 64 mIU/ml. Long term treatment with 15 mg/day bromocriptine resulted in further reduction of FSH level, to 36.4 mIU/ml, without any change in tumor size. This finding implies that bromocriptine could be an adjunctive therapy or an alternative to other modes of treatment in patients with these rare tumors." }, { "id": "pubmed23n0269_5123", "title": "Hypothalamic-pituitary-gonadal axis function in pubertal male and female siblings with glucocorticoid-treated nonsalt-wasting 3 beta-hydroxysteroid dehydrogenase deficiency congenital adrenal hyperplasia.", "score": 0.009259259259259259, "content": "We report pubertal maturation and dynamic studies of gonadotropin and gonadal hormone secretion in long term glucocorticoid-treated siblings with nonsalt-wasting classic adrenal and gonadal 3 beta-hydroxysteroid dehydrogenase (3 beta HSD) deficiency. The 18-yr-old female siblings spontaneously developed thelarche and menarche at 10 and 12 yr, respectively, and manifested irregular menses, hirsutism, and polycystic ovaries at 17 yr. The 16-yr-old male sibling spontaneously developed secondary sex characteristics at age 11 yr and exhibited Tanner IV-V pubic hair, a 6.5 x 3.0-cm surgically repaired penis, and enlarged nonnodular testes. Overnight (2200-0700 h) plasma gonadotropin (every 20 min) and gonadal steroid levels (every 2 h) under ACTH adrenal suppression revealed the following. In the male sibling, there were overall normal Tanner V male LH (3-21 mIU/mL) and FSH (1.2-13 mIU/mL) levels, normal peak frequency and amplitude of LH (70 +/- 62 min and 15 +/- 3 mIU/mL, respectively) and FSH (65 +/- 28 min and 13 +/- 3 mIU/mL), and low normal Tanner V testosterone (T) levels (11.4-17.9 nmol/L). In the female sibling, there were normal follicular phase range LH (10-28 mIU/mL) and FSH (5.1-17.2 mIU/mL) levels, normal peak frequency and amplitude of LH (96 +/- 17 min and 22 +/- 4.5 mIU/mL, respectively) and FSH (62 +/- 27 min, 13 +/- 4 mIU/mL), and early follicular phase estradiol (E2) levels (100-170 pmol/L). The LH-releasing hormone-stimulated LH response was in the normal adult range in the male and normal for the early follicular phase in the female. In contrast, ACTH and adrenal delta 5-steroid responses to CRH administration were elevated in each sibling. Gonadal suppression via Norlutin administration (30 mg/day for 3 days) after prolonged adrenal suppression by dexamethasone resulted in suppression of dehydroepiandrosterone (DHEA) and E2 in the female and DHEA and T in the male. Gonadal stimulation via hCG administration (5000 IU/day for 3 days, im) during continuous adrenal suppression resulted in a low E2 response in the female (200 pmol/L; control, 295-660 pmol/L) and a low T response in the male (15.3 nmol/L; control, 17-39 nmol/L), whereas delta 5-17-hydroxypregnenolone and DHEA levels rose 2- to 4.7-fold in each sibling. In conclusion, despite partial gonadal 3 beta HSD deficiency, the dynamics of gonadotropin and gonadal hormone secretion in these siblings indicate the absence of increased LH secretion, in contrast to the markedly increased ACTH secretion resulting from adrenal 3 beta HSD deficiency.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "wiki20220301en035_965", "title": "Kallmann syndrome", "score": 0.009229390681003584, "content": "Treatment for both males and females with KS/CHH normally consists of one of three options which can be used for both hormone replacement therapy and/or fertility treatment. Sex hormone replacement (testosterone or oestrogen & progesterone). Gonadotropin therapy (medications that replicate the activity of FSH and LH). GnRH pulsatile therapy. Hormone replacement therapy The method and dose of treatment will vary depending on the individual being treated. Initial treatment is normally made with lower doses in younger patients in order to develop the secondary sexual characteristics before adult doses are reached." }, { "id": "pubmed23n0285_11817", "title": "Serum hormone concentrations during treatment with multiple rising doses of recombinant follicle stimulating hormone (Puregon) in men with hypogonadotropic hypogonadism.", "score": 0.009174311926605505, "content": "To study increases of serum FSH and gonadal response in gonadotropin-deficient men treated with recombinant FSH (Puregon; NV Organon, Oss, The Netherlands). An open, prospective, multiple rising dose study in which volunteers received single daily IM doses of recombinant FSH for 3 weeks. The dose administered was increased at weekly intervals: the first 7 days, 75 IU/d; the subsequent 7 days, 150 IU/d; and the last 7 days, 225 IU/d. Nine men suffering from isolated gonadotropin deficiency or panhypopituitarism. Immunoreactive FSH, LH, inhibin, T, and androstenedione. Serum immunoreactive FSH (median) rose in accordance with the recombinant FSH doses administered from 0.5 mIU/mL (range &lt; 0.05 to 1.9 mIU/mL) at baseline to 4.3 mIU/mL (range 2.0 to 8.5 mIU/mL), 8.4 mIU/mL (range 4.9 to 17.8 mIU/mL), and 13.6 mIU/mL (5.6 to 28.4 mIU/mL) after 1, 2, and 3 weeks of medication, respectively. The elimination half-life of recombinant FSH was 48 +/- 5 hours (mean +/- SD), which was slightly longer than that reported after single dose administration of recombinant FSH (32 +/- 12 hours). The bioactivity of recombinant FSH was reflected by serum inhibin levels, which rose from 116 U/L (range 34 to 356 U/L) at baseline to 350 U/L (range 63 to 1,109 U/L) at day 22. However, serum FSH and inhibin levels did not correlate when compared after 1, 2, and 3 weeks of recombinant FSH administration. Serum immunoreactive LH, T, androstenedione, and E2 were 0.2 mIU/mL (range &lt; 0.05 to 0.7 mIU/mL [conversion factor to SI unit, 1.0]), 58 ng/dL (range &lt; 12 to 222 ng/dL [conversion factor to SI unit, 0.0347]), 14 ng/dL (range 6 to 115 ng/dL [conversion factor to SI unit, 0.0349]), and 14 pg/mL (range &lt; 14 to 16 pg/mL [conversion factor to SI unit, 3.67]), respectively, at baseline and remained unchanged during the entire treatment period. These data indicate that recombinant FSH treatment increases serum FSH in a dose-proportional fashion, increases inhibin secretion, and lacks intrinsic LH activity." }, { "id": "pubmed23n0226_2555", "title": "Pituitary function in normoprolactinaemic infertile men receiving bromocriptine.", "score": 0.009174311926605505, "content": "A double blind trial of bromocriptine 7.5 mg daily versus placebo was carried out in ten infertile men. Pretreatment basal plasma prolactin, thyroid stimulating hormone (TSH) testosterone and luteinizing hormone (LH) concentrations were normal, but plasma follicle-stimulating-hormone (FSH) was raised in four individuals. After 4 months treatment with bromocriptine a significant fall in plasma prolactin was observed (P less than 0.01), both under basal conditions and following thyroid stimulating hormone releasing hormone (TRH). Basal plasma gonadotrophin, testosterone and thyroid stimulating hormone (TSH) concentrations did not alter. No change in sperm density, volume or motility was noted. However an apparent fall in the peak plasma LH (but not FSH) response to gonadotrophin releasing hormone (LHRH) was observed in patients receiving bromocriptine. This reduction in plasma LH responsiveness was significant when compared with the baseline response (P less than 0.05) but failed to reach significance when compared with the placebo response. It is concluded that prolonged bromocriptine therapy in normoprolactinaemic men does not suppress FSH secretion, and any reduction in plasma LH responsiveness to LHRH is not accompanied by a significant fall in plasma testosterone." }, { "id": "pubmed23n0667_8518", "title": "Pituitary response to steroid replacement therapy in fertile, subfertile and infertile stallions after castration.", "score": 0.00909090909090909, "content": "Recent studies in our laboratory investigating plasma gonadotrophin concentrations before and after castration indicate that the hypothalamic-pituitary axis is not the original site of dysfunction in stallions with idiopathic infertility. In the present study, fertile, subfertile and infertile stallions were subjected to replacement therapy with oestradiol and testosterone 1 year after castration to investigate hypothalamic-pituitary axis function further. Fertile (n=5), subfertile (n=3) and infertile (n=2) castrated stallions of Light horse breeds, aged 11-23 years, were given either oestradiol cypionate or testosterone propionate for 28 days during the breeding season. Oestradiol cypionate in cottonseed oil (30 mg; 6 mg ml(-1)) was administered i.m. at 2 day intervals starting in May for 28 days. Eight weeks after the last oestradiol cypionate injection, testosterone propionate in vegetable oil (85 mg; 8.5 mg ml(-1)) was administered i.m. at 2 day intervals for 28 days. Heparinized blood samples were taken from the jugular vein three times a week from 3 weeks before the start of oestradiol cypionate treatment until 4 weeks after the last testosterone propionate injection. Saline or 25 microg GnRH in 1 ml saline were administered to the stallions on days 24 and 25, respectively, of the 28 day steroid treatments. Jugular blood samples were collected periodically through a catheter from 60 min before saline or GnRH injection until 420 min after injection. The plasma samples were stored at -20 degrees C until analysed for plasma LH, FSH, oestradiol and testosterone concentrations by validated radioimmunoassay. Exogenous steroid treatment increased plasma oestradiol and testosterone concentrations to concentrations close to normal circulating values (oestradiol: 49 pg ml(-1); testosterone: 1.3 ng ml(-1)) in all the groups. There were no significant differences in plasma LH or FSH concentrations among the groups during any of the treatment periods. Oestradiol treatment significantly increased (P &lt; 0.05) LH concentrations, whereas testosterone treatment decreased LH concentrations, although the difference was not significant. Oestradiol treatment significantly decreased FSH concentrations (P &lt; 0.05), whereas testosterone treatment significantly increased FSH concentrations (P &lt; 0.05). There were no differences in LH and FSH responses to GnRH challenge among the three groups of stallions. In conclusion, the results of the present study indicate that the hypothalamic-pituitary axes in these subfertile and infertile stallions were not the original sites of dysfunction. Further studies at the testicular level are required." }, { "id": "pubmed23n0226_2613", "title": "Results of three-times-per-week long-term administration of a luteinizing hormone-releasing hormone (LHRH) analog, D-Ser-(TBU)6-LHRH-(EA)10 in primary amenorrhea.", "score": 0.00909090909090909, "content": "The effectiveness of a luteinizing hormone (LH)-releasing hormone (LHRH) analog, D-Ser-(TBU)6-LHRH-(EA)10 (Hoe 766), applied intranasally in a 3 days-per-week regimen, was assessed in four patients with hypogonadotropic or normogonadotropic primary amenorrhea by measuring LH, follicle-stimulating hormone (FSH), and estradiol (E2) levels before and 4 hours after its application and by observing the clinical effects of these hormones on the genital tract. The LH response increased progressively over the first 21 days (nine applications) in three of the four patients; it was subsequently reduced but never abolished throughout the study, which was terminated with the 25th application on the 59th day. Basal values of E2 increased until the 12th to 14th day (fifth or sixth application) and then showed a definite decline despite the continuing increase in LH response. FSH release attained a maximum by the second to fourth application and its magnitude of response remained remarkably stable thereafter. The clinical response did not correspond to the serum levels of E2. It is postulated that the development of LH unresponsiveness is due to desensitization of the receptors by the analog. The poor response of the genital tissues to the normal levels of E2 and the subsequent decrease in E2 levels, which occurred despite increasing LH responsiveness, are attributed to an inhibitory action of the analog on E2 biosynthesis in the ovary and on E2 receptors in the genital organs." }, { "id": "wiki20220301en381_28878", "title": "Hypogonadotropic hypogonadism", "score": 0.00901797501777191, "content": "Administration of FSH is required to induce spermatogenesis by acting on Sertoli cells. FSH is required for maintaining the production of high numbers of good quality sperm. Gonadotropin therapy in HH men usually is able to generate enough sperm for fertility to occur, however sperm count is still lower than normal. In the female, the goal for gonadotropin therapy is to obtain ovulation. This is obtained with FSH treatment followed by hCG or LH to trigger ovulation. FSH will stimulate granulosa cells for follicular maturation while LH will act on luteal cells to produce steroids aiding follicular maturation and preparing the endometrium for pregnancy. For hyperprolactinaemia-caused AHH, dopamine agonists are used to improve GnRH secretion. Dopamine binds to D2 receptors on lactotrophs within the anterior pituitary This results in the inhibition of secretion of prolactin resulting in less direct and indirect inhibition of GnRH secretion." } ] } } }

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{ "1": "Fast IV saline.", "2": "Serum glucose 5% iv when blood glucose is less than 250 mg/dl.", "3": "Rapid human insulin iv.", "4": "Potassium chloride 100 mEq / day diluted in sera.", "5": "Sodium bicarbonate 1M 100 cc iv in 30 minutes." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0924_22169", "title": "[Opportunities to improve hospital emergency care of patients with diabetic ketoacidosis].", "score": 0.016662057522123894, "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": "pubmed23n0508_23158", "title": "A prospective study of the \"two-bag system'' in diabetic ketoacidosis management.", "score": 0.015458058649693112, "content": "The \"two-bag'' system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional \"one-bag'' system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p &lt; 0.001). The \"two-bag'' system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department." }, { "id": "wiki20220301en057_29614", "title": "Crush syndrome", "score": 0.01411104982533554, "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": "wiki20220301en086_257", "title": "Hyperosmolar hyperglycemic state", "score": 0.013858115457438664, "content": "Management Intravenous fluids Treatment of HHS begins with reestablishing tissue perfusion using intravenous fluids. People with HHS can be dehydrated by 8 to 12 liters. Attempts to correct this usually take place over 24 hours with initial rates of normal saline often in the range of 1 L/h for the first few hours or until the condition stabilizes. Electrolyte replacement Potassium replacement is often required as the metabolic problems are corrected. It is generally replaced at a rate 10 mEq per hour as long as there is adequate urinary output. Insulin Insulin is given to reduce blood glucose concentration; however, as it also causes the movement of potassium into cells, serum potassium levels must be sufficiently high or dangerously low blood potassium levels may result. Once potassium levels have been verified to be greater than 3.3 mEq/l, then an insulin infusion of 0.1 units/kg/hr is started. The goal for resolution is a blood glucose of less than 200 mg/dL. References" }, { "id": "InternalMed_Harrison_27954", "title": "InternalMed_Harrison", "score": 0.012049842530466932, "content": "3. Assess: Serum electrolytes (K+, Na+, Mg2+, Cl−, bicarbonate, phosphate) Acid-base status—pH, HCO3−, PCO2, β-hydroxybutyrate Renal function (creatinine, urine output) 4. Replace fluids: 2–3 L of 0.9% saline over first 1–3 h (10–20 mL/kg per hour); subsequently, 0.45% saline at 250–500 mL/h; change to 5% glucose and 0.45% saline at 150–250 mL/h when plasma glucose reaches 250 mg/dL (13.9 mmol/L). 5. Administer short-acting insulin: IV (0.1 units/kg), then 0.1 units/kg per hour by continuous IV infusion; increase twoto threefold if no response by 2–4 h. If the initial serum potassium is <3.3 mmol/L (3.3 meq/L), do not administer insulin until the potassium is corrected. 6. Assess patient: What precipitated the episode (noncompliance, infection, trauma, pregnancy, infarction, cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, ECG). 7." }, { "id": "wiki20220301en003_10293", "title": "Glucose tolerance test", "score": 0.011709860586376792, "content": "For gestational diabetes, the American College of Obstetricians and Gynecologists (ACOG) recommends a two-step procedure, wherein the first step is a 50 g glucose dose. If after 1 hour the blood glucose level is more than 7.8 mmol/L (140 mg/dL), it is followed by a 100 g glucose dose. The diagnosis of gestational diabetes is then defined by a blood glucose level meeting or exceeding the cutoff values on at least two intervals, with cutoffs as follows: Before glucose intake (fasting): 5.3 mmol/L (95 mg/dL) 1 hour after drinking the glucose solution: 10.0 mmol/L (180 mg/dL) 2 hours: 8.6 mmol/L (155 mg/dL) 3 hours: 7.8 mmol/L (140 mg/dL)" }, { "id": "wiki20220301en086_255", "title": "Hyperosmolar hyperglycemic state", "score": 0.011651257164372673, "content": "Diagnosis Criteria According to the American Diabetes Association, diagnostic features include: Plasma glucose level >30 mmol/L (>600 mg/dL) Serum osmolality >320 mOsm/kg Profound dehydration, up to an average of 9L (and therefore substantial thirst (polydipsia)) Serum pH >7.30 Bicarbonate >15 mEq/L Small ketonuria (~+ on dipstick) and absent-to-low ketonemia (<3 mmol/L) Some alteration in consciousness BUN > 30 mg/dL (increased) Creatinine > 1.5 mg/dL (increased) Imaging Cranial imaging is not used for diagnosis of this condition. However, if MRI is performed, it may show cortical restricted diffusion with unusual characteristics of reversible T2 hypointensity in the subcortical white matter." }, { "id": "pubmed23n0294_21491", "title": "Combined effect of bicarbonate and insulin with glucose in acute therapy of hyperkalemia in end-stage renal disease patients.", "score": 0.011648145668764227, "content": "This study was performed to evaluate the efficacy of various treatment modalities for hyperkalemia in 8 end-stage renal disease (ESRD) patients. Simultaneous administration of sodium bicarbonate and insulin with glucose was compared with infusion of either bicarbonate alone or insulin and glucose. Plasma potassium was measured at the baseline and after 60 min of infusion with each regimen. Infusion of 8.4% solution of sodium bicarbonate at 2 mEq/min for 60 min induced a significant rise in blood bicarbonate from 21.7 +/- 2.1 to 26.3 +/- 1.7 mEq/l (p &lt; 0.01), but failed to lower plasma potassium (6.4 +/- 0.1 vs. 6.3 +/- 0.2 mEq/l, before and after). Intravenous infusion of insulin and glucose (5 mU/kg/min for 60 min) significantly lowered plasma potassium from 6.3 +/- 0.1 to 5.7 +/- 0.1 mEq/l (p &lt; 0.01). The combined infusion of bicarbonate and insulin with glucose showed the greatest decline in plasma potassium, from 6.2 +/- 0.2 to 5.2 +/- 0.1 mEq/l (p &lt; 0.01). With the combined regimen, the increases in plasma bicarbonate (22.3 +/- 1.7 to 25.8 +/- 1.9 mEq/l, p &lt; 0.05) and blood pH (7.36 +/- 0.02 to 7.42 +/- 0.02, p &lt; 0.01) were significant, but somewhat less than those with bicarbonate administration alone. Plasma insulin levels before treatment were similar in all treatment regimens, and increased markedly following the infusion of insulin with glucose, either with or without sodium bicarbonate (9 +/- 1.5 vs. 10 +/- 10 microU/ml before insulin, and 196 +/- 18.0 vs. 201 +/- 26.4 microU/ml after insulin). Plasma epinephrine, norepinephrine, osmolality and plasma aldosterone before and after treatment did not show any significant differences among the 3 different regimens. In conclusion, the ineffectiveness of sodium bicarbonate alone and its synergistic effect with insulin and glucose in acute therapy of hyperkalemia in ESRD patients suggest that mild metabolic acidosis, which is common in patients on maintenance hemodialysis, may contribute to tissue insensitivity to the action of insulin on transcellular potassium shift." }, { "id": "wiki20220301en071_15812", "title": "Glucose test", "score": 0.011500547645125958, "content": "Reference ranges Fasting blood sugar A level below 5.6 mmol/l (100 mg/dl) 10–16 hours without eating is normal. 5.6–6 mmol/l (100–109 mg/dl) may indicate prediabetes and oral glucose tolerance test (OGTT) should be done for high-risk individuals (old people, those with high blood pressure etc.). 6.1–6.9 mmol/l (110–125 mg/dl) means OGTT should be done even if other indicators of diabetes are not present. 7 mmol/l (126 mg/dl) and above indicates diabetes and the fasting test should be repeated. Glucose tolerance test Postprandial glucose test Random glucose test See also Hyperglycemia Hypoglycemia References Blood tests" }, { "id": "Surgery_Schwartz_662", "title": "Surgery_Schwartz", "score": 0.011360911270983213, "content": "removal Kayexalate Oral administration is 15–30 g in 50–100 mL of 20% sorbitol Rectal administration is 50 g in 200 mL of 20% sorbitol DialysisShift potassium Glucose 1 ampule of D50 and regular insulin 5–10 units IV Bicarbonate 1 ampule IVCounteract cardiac effects Calcium gluconate 5–10 mL of 10% solutionD50 = 50% dextrose.Brunicardi_Ch03_p0083-p0102.indd 9508/12/18 10:07 AM 96BASIC CONSIDERATIONSPART ITable 3-15Electrolyte replacement therapy protocolPotassiumSerum potassium level <4.0 mEq/L: Asymptomatic, tolerating enteral nutrition: KCl 40 mEq per enteral access × 1 dose Asymptomatic, not tolerating enteral nutrition: KCl 20 mEq IV q2h × 2 doses Symptomatic: KCl 20 mEq IV q1h × 4 doses Recheck potassium level 2 h after end of infusion; if <3.5 mEq/L and asymptomatic, replace as per above protocolMagnesiumMagnesium level 1.0–1.8 mEq/L: Magnesium sulfate 0.5 mEq/kg in normal saline 250 mL infused IV over 24 h × 3 d Recheck magnesium level in 3 dMagnesium level <1.0" }, { "id": "article-61065_18", "title": "Euglycemic Diabetic Ketoacidosis -- Treatment / Management", "score": 0.01127651100268844, "content": "Initial management should be directed toward fluid resuscitation, as patients usually present as profoundly dehydrated. Begin with the administration of isotonic saline or lactated ringers solution. The American Diabetes Association (ADA) recommends 1 to 1.5 L/hr isotonic fluids during the first 1 to 2 hours. Continuous insulin infusion should follow fluid replacement, contingent on serum potassium levels greater than 3.3 mEq/L, starting at a rate of 0.05 to 0.1 U/kg/hr. In contrast to DKA management, since serum glucose in EDKA is less than 250 mg/dL, dextrose 5% should initially be added to the fluids to avoid hypoglycemia and hasten clearance of ketosis. [34] Consider increasing the amount of dextrose to 10% if ketoacidosis persists on D5%. [27] [35] [27]" }, { "id": "wiki20220301en027_57425", "title": "Insulinoma", "score": 0.011150935882118677, "content": "During the test, the patient may have calorie-free and caffeine-free liquids. Capillary blood glucose is measured every 4 hours using a reflectance meter, until values < 60 mg/dL (3.3 mmol/L) are obtained. Then, the frequency of blood glucose measurement is increased to every hour until values are < 49 mg/dL (2.7 mmol/L). At that point, or when the patient has symptoms of hypoglycemia, a blood test is drawn for serum glucose, insulin, proinsulin, and C-peptide levels. The fast is then stopped at that point, and the hypoglycemia is treated with intravenous dextrose or carbohydrate-containing food or drink." }, { "id": "wiki20220301en180_32350", "title": "Prediabetes", "score": 0.010972699772654679, "content": "Diagnosis Prediabetes can be diagnosed with three different types of blood tests: Fasting blood sugar (glucose) level of: 110 to 125 mg/dL (6.1 mmol/L to 6.9 mmol/L) – WHO criteria 100 to 125 mg/dL (5.6 mmol/L to 6.9 mmol/L) – ADA criteria Glucose tolerance test: blood sugar level of 140 to 199 mg/dL (7.8 to 11.0 mM) 2 hours after ingesting a standardized 75 gram glucose solution Glycated hemoglobin (HbA1c) between 5.7 and 6.4 percent, ie 38.9 and 46.4 mmol/mol Levels above these limits would justify a diagnosis for diabetes. Impaired fasting glucose" }, { "id": "pubmed23n0055_20336", "title": "Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized, placebo controlled trial.", "score": 0.010874542124542124, "content": "Intravenous sodium bicarbonate has been used for a long time in the treatment of diabetic ketoacidosis. However, there are no clinical studies showing its effectiveness in improving arterial pH in this condition. We therefore designed this study to investigate if bicarbonate therapy improves the rate of increase of arterial pH and to find out its effects on the recovery rate of the other metabolic abnormalities. Twenty patients with severe diabetic ketoacidosis (pH less than 7.15) entered a double-blind, randomized, placebo controlled trial: nine were included in the bicarbonate group and eleven in the placebo group. All patients were studied during the first 24 hours of treatment. Their management was similar, except for the use of sodium bicarbonate in one group and 0.9% saline solution in the placebo group. Heart rate, respiratory rate, arterial pressure, mental status, blood gases, blood glucose, sodium, potassium, and urea were assessed at the beginning of treatment, and then at 2, 6, 12 and 24 hours. No clinical or metabolic differences were found between groups. Two hours after therapy was begun, the arterial pH rose in the bicarbonate group from 7.05 +/- 0.08 to 7.24 +/- 0.04, while it only rose from 7.04 +/- 0.08 to 7.11 +/- 0.09 in the placebo group (p less than 0.02). Simultaneously, arterial bicarbonate increased from 2.87 +/- 1.2 to 6.1 +/- 1.5 mEq/L in the bicarbonate group and from 2.55 +/- 0.81 to 3.6 +/- 2 mEq/L in the placebo group (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en008_126419", "title": "Type 2 diabetes", "score": 0.010641709086536534, "content": "fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl) or with a glucose tolerance test, two hours after the oral dose a plasma glucose ≥ 11.1 mmol/l (200 mg/dl) A random blood sugar of greater than 11.1 mmol/l (200 mg/dl) in association with typical symptoms or a glycated hemoglobin (HbA1c) of ≥ 48 mmol/mol (≥ 6.5 DCCT %) is another method of diagnosing diabetes. In 2009 an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended that a threshold of ≥ 48 mmol/mol (≥ 6.5 DCCT %) should be used to diagnose diabetes. This recommendation was adopted by the American Diabetes Association in 2010. Positive tests should be repeated unless the person presents with typical symptoms and blood sugars >11.1 mmol/l (>200 mg/dl)." }, { "id": "wiki20220301en003_162159", "title": "Hyperglycemia", "score": 0.01023978594216322, "content": "Scientific journals are moving towards using mmol/l; some journals now use mmol/l as the primary unit but quote mg/dl in parentheses. Glucose levels vary before and after meals, and at various times of day; the definition of \"normal\" varies among medical professionals. In general, the normal range for most people (fasting adults) is about 4 to 6 mmol/l or 80 to 110 mg/dl. (where 4 mmol/l or 80 mg/dl is \"optimal\".) A subject with a consistent range above 7 mmol/l or 126 mg/dl is generally held to have hyperglycemia, whereas a consistent range below 4 mmol/l or 70 mg/dl is considered hypoglycemic. In fasting adults, blood plasma glucose should not exceed 7 mmol/l or 126 mg/dL. Sustained higher levels of blood sugar cause damage to the blood vessels and to the organs they supply, leading to the complications of diabetes." }, { "id": "wiki20220301en416_22141", "title": "Diabetes", "score": 0.010004008016032065, "content": "Diagnosis Diabetes mellitus is diagnosed with a test for the glucose content in the blood, and is diagnosed by demonstrating any one of the following: Fasting plasma glucose level ≥ 7.0 mmol/L (126 mg/dL). For this test, blood is taken after a period of fasting, i.e. in the morning before breakfast, after the patient had sufficient time to fast overnight. Plasma glucose ≥ 11.1 mmol/L (200 mg/dL) two hours after a 75 gram oral glucose load as in a glucose tolerance test (OGTT) Symptoms of high blood sugar and plasma glucose ≥ 11.1 mmol/L (200 mg/dL) either while fasting or not fasting Glycated hemoglobin (HbA1C) ≥ 48 mmol/mol (≥ 6.5 DCCT %)." }, { "id": "wiki20220301en002_195792", "title": "Diabetic ketoacidosis", "score": 0.009981005626635129, "content": "In general, insulin is given at 0.1 unit/kg per hour to reduce the blood sugars and suppress ketone production. Guidelines differ as to which dose to use when blood sugar levels start falling; American guidelines recommend reducing the dose of insulin once glucose falls below 16.6 mmol/l (300 mg/dl) and UK guidelines at 14 mmol/l (253 mg/dl). Others recommend infusing glucose in addition to saline to allow for ongoing infusion of higher doses of insulin." }, { "id": "wiki20220301en178_38961", "title": "Ranson criteria", "score": 0.009900990099009901, "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": "pubmed23n0063_15044", "title": "[Diabetic ketoacidosis (169 episodes in 131 patients in the course of 10 years)].", "score": 0.009900990099009901, "content": "Diabetic patient material--presenting hyperglycaemic ketoacidotic episode--observed in Gyula and Szekszárd County Hospitals in period 1980-89, was reviewed by authors. 131 patients were admitted with 169 ketoacidotic episodes (among them 23 patients had 62 recurrences). The mean age of patients were 49.4 years (14-84 years), duration of diabetes 9.5 years (from one month to 45 years). The common cause of diabetic ketoacidosis was respiratory (26 per cent) and enteral (35.5 per cent) infection. The consciousness of patients had shown close correlation with the increase of blood sugar and urea nitrogen level as well as with the decreasing of the pH value of capillary blood. The first step of the therapy was the parenteral fluid intake with isotonic solution (in the first hour the average 1351 ml). In 18 patients fast-acting insulin (Novo Actrapid MC) was given by constant infusion, in the remaining cases intravenous or intramuscular low doses of the same insulin were administered. The importance of early potassium replacement, and the dangers of forced and rapid correction of acidosis is emphasized. Lethality related to episodes was 10 per cent, related to the patients 12.9 per cent. The number of ketoacidotic cases did not decrease parallel with the improvement of therapeutic possibilities, as it was experienced by their earlier evaluations. The importance of the prevention of acute metabolic disorders is outlined might be resulted from increasing the efficacy of patients education and better knowledge of GP's, as well." }, { "id": "wiki20220301en033_21958", "title": "Acute pancreatitis", "score": 0.00980392156862745, "content": "At admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11.1 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall >10% Oxygen (hypoxemia PO2 < 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 The criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both gallstone and alcoholic pancreatitis. Alternatively, pancreatitis can be diagnosed by meeting any of the following:[2] Alternative Ranson score Ranson's score of ≥ 8 Organ failure Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)" }, { "id": "pubmed23n0339_7375", "title": "Severe diabetic ketoacidosis: the need for large doses of insulin.", "score": 0.00980392156862745, "content": "A 21-year-old female with Type 1 diabetes mellitus (DM) presented in ketoacidosis. She received intravenous normal saline and insulin at 6 U/h and 1.26% sodium bicarbonate solution. After the blood glucose had fallen to 9.5 mmol/l, the saline infusion was changed to 5% glucose solution and the insulin infusion rate to 2 to 3 U/h. The next day the patient became more drowsy (Glasgow coma scale 13/15, later falling to 4/15). Computed tomography (CT) scan suggested cerebral oedema and the patient was treated with dexamethasone and mannitol. She remained critically ill for 48 h, eventually making a full recovery. Insulin was given at rates of 8 to 14 U/h, with 10% or 20% glucose infusion to maintain the blood glucose above 5 mmol/l; despite this it was not until the fifth day that her serum bicarbonate became normal. Textbooks usually advise starting insulin at 6 U/h and reducing the infusion rate to 1-4 U/h when the blood glucose falls below a certain level. In this case, even with high rates of insulin infusion, it took 5 days before the patient's serum bicarbonate returned to normal. Thus, in severe diabetic ketoacidosis (DKA), protocols should advise that the insulin infusion be continued at high dose (4 to 6 U/h or more), with appropriate glucose infusion to prevent hypoglycaemia, until the serum bicarbonate is normal or nearly so." }, { "id": "pubmed23n0607_2341", "title": "[Hyperglycemia controlled with GIK solution in non-diabetic patients subjected to heart surgery].", "score": 0.009708737864077669, "content": "We prospectively compared, the glucose-insulin-potassium (GIK) solution 1,000 mL 10% glucose, 20 units of fast acting insulin and 60 mEq of potassium chloride, against a GIK solution with 1,000 mL of glucose, 40 units of fast acting insulin an 120 mEq of chloride, in the hyperglycemic control of non-diabetic patient subjected to cardiac surgery. We divided 40 patients in four groups ten patients each. Group A was the control they received 1,000 mL of 10% glucose in water, 20 units of fast acting insulin and 60 mEq of potassium chloride in a drops/ hour dose without an infusion pump. Group B received the same solution in a 50 mL/hour dose. Group C received 1,000 mL of 10% glucose in water, 40 units of fast acting insulin plus, 120 mEq of potassium chloride at the same infusion rate as Group A. Group D 2 1,000 mL of 10% of glucose in water, 40 units of fast acting insulin in the same rate as Group B. The GIK solution was started after anesthesia induction and maintained all along the extracorporeal circulation, the study continued until the patient was transferred to the intensive care unit. We measured blood glucose, circulating insulin and seric levels of potassium three times; basal before the anesthetic induction, during the extracorporeal circulation and at the intensive care unit arrival. The data were analyzed with measure of central tendency, dispersion and multivariate analysis. Among the four groups no statistically significant differences existed in demographic data. In Group A, glucose and potassium levels were higher as compared with the rest of the groups (p &lt;0.05) in all measurements; Group D was less hyperglycaemic as compared with Groups A, B, and C. The solution with low insulin dose does useful plasmatic insulin levels in the hyperglycemia in non diabetic patients subjected to cardiac surgery." }, { "id": "InternalMed_Harrison_27953", "title": "InternalMed_Harrison", "score": 0.009699823032488564, "content": "A bolus of IV (0.1 units/kg) short-acting insulin should be administered immediately (Table 418-8), and subsequent treatment should provide continuous and adequate levels of circulating insulin. IV administration is preferred (0.1 units/kg of regular insulin per hour) because it ensures rapid distribution and allows adjustment of the infusion rate as the patient responds to therapy. In mild episodes of DKA, short-acting insulin can be used SC. IV insulin mAnAgEmEnT of DiAbETiC kEToACiDoSiS 1. Confirm diagnosis (↑ plasma glucose, positive serum ketones, metabolic acidosis). 2. Admit to hospital; intensive care setting may be necessary for frequent monitoring or if pH <7.00 or unconscious. 3. Assess: Serum electrolytes (K+, Na+, Mg2+, Cl−, bicarbonate, phosphate) Acid-base status—pH, HCO3−, PCO2, β-hydroxybutyrate Renal function (creatinine, urine output) 4." }, { "id": "wiki20220301en053_51835", "title": "Ringer's lactate solution", "score": 0.009615384615384616, "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": "pubmed23n0321_10715", "title": "Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers.", "score": 0.009615384615384616, "content": "To evaluate the effect of administration of 1 ampule of 50% dextrose in water solution (D50W) on serum glucose levels in healthy adult volunteers, the authors set out to determine whether a pre-D50W serum glucose level can be predicted from the ED sample. This was a prospective, interventional study conducted from the ED of an urban, university-affiliated hospital. All subjects were healthy employee volunteers between 25 and 40 years of age. Baseline serum glucose levels were determined and all subjects were given an i.v. bolus of 25 grams of 50% dextrose solution. The main outcome measures were post-D50W serum glucose levels (observed) at 5 predetermined time intervals (5 min, 15 min, 30 min, 1 hr, and 2 hr). An expected change in serum glucose was calculated using the volume of distribution formula for glucose. Twenty-five volunteers (17 males and 8 females) participated in the study. The mean baseline serum glucose was 82.3 +/- 13.5 mg/dL. The mean post-infusion levels were: 244.4 +/- 44.6 mg/dL (5 min), 145.8 +/- 52.3 mg/dL (15 min), 88.1 +/- 28.8 mg/dL (30 min), 77.6 +/- 13.6 mg/dL (60 min), and 83.2 +/- 11.4 mg/dL (120 min). Using a mixed-effect regression model, statistically significant increases in serum glucose levels were found at 5 minutes (p &lt; 0.001) and 15 minutes (p &lt; 00001) following administration of D50W. There was a return to baseline serum glucose by 30 minutes. The expected change based on the volume of distribution formula (53.7 +/- 34.9) did not correlate with the observed changes at any measured time interval. Without pre-intervention blood drawing by emergency medical services, it is not possible to accurately predict pre-D50W serum glucose levels based on post-D50W glucose levels. The diagnosis of hypoglycemia as the etiology of altered mental status must therefore remain a diagnosis of exclusion. In addition, the return of serum glucose to baseline after 30 minutes suggests the duration of the effect of 1 ampule of D50W. Frequent re-evaluation of the serum glucose levels of suspected or proven hypoglycemic patients after administration of D50W should be considered." }, { "id": "wiki20220301en013_79143", "title": "Blood sugar level", "score": 0.009523809523809525, "content": "Normal blood glucose level (tested while fasting) for non-diabetics is between 3.9 and 7.1 mmol/L (70 and 130 mg/dL). The global mean fasting plasma blood glucose level in humans is about 5.5 mmol/L (100 mg/dL); however, this level fluctuates throughout the day. Blood sugar levels for those without diabetes and who are not fasting should be below 6.9 mmol/L (125 mg/dL). The blood glucose target range for diabetics, according to the American Diabetes Association, should be 5.0–7.2 mmol/l (90–130 mg/dL) before meals and less than 10 mmol/L (180 mg/dL) two hours after meals (as measured by a blood glucose monitor)." }, { "id": "pubmed23n0074_3669", "title": "[Treatment of hyperglycemic coma states in diabetics].", "score": 0.009523809523809525, "content": "In the treatment of acute decompensation of diabetes, diabetic ketoacidosis and hyperosmolar non-acidotic syndrome the basic demand is insulin administration--in small doses by the i.v. route, preferably by means of an injectomat in a permanent infusion. An alternative method for departments which do not possess a suitable infusion pump, is fractionated administration of small insulin amounts into the vein after 30 minute intervals. Equally important is rehydration treatment with saline; only in case of hypernatriaemia above 150 mmol/l the author recommends 0.45% NaCl. Acidosis in DKA is corrected by sodium bicarbonate only at pH 7.1 or less. As to K cations, the replacement of potassium ions is most important; the value of substitution of other cations (Ca, Mg) is doubtful and is not currently done, the same applies to phosphate anion replacement. It has not been proved that prevention of thromboembolic complications by heparin is expedient in these conditions." }, { "id": "pubmed23n0126_2509", "title": "Serum glucose changes after administration of 50% dextrose solution: pre- and in-hospital calculations.", "score": 0.009345794392523364, "content": "A prospective clinical trial was conducted to estimate the rise in serum glucose level after an intravenous bolus of 50 ml of 50% dextrose solution (D-50) in the emergency department setting. Fifty one subjects with altered levels of consciousness were studied. Of these, 23 patients were known diabetics, and 28 were not diabetic. The change in glucose level for the total study group ranged from a low of 37 mg/dl to a high of 370 mg/dl, with a mean of 166 +/- 77 mg/dl. The mean for the diabetic and non-diabetic groups were 177 +/- 80 mg/dl and 154 +/- 75 mg/dl. These results suggest that serum glucose levels cannot be quantitatively predicted after a single intravenous bolus of D-50." }, { "id": "article-74978_18", "title": "Adult Diabetic Ketoacidosis -- Evaluation", "score": 0.009332505557446979, "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": "wiki20220301en013_79144", "title": "Blood sugar level", "score": 0.009259259259259259, "content": "Despite widely variable intervals between meals or the occasional consumption of meals with a substantial carbohydrate load, human blood glucose levels tend to remain within the normal range. However, shortly after eating, the blood glucose level may rise, in non-diabetics, temporarily up to 7.8 mmol/L (140 mg/dL) or slightly more. For people with diabetes maintaining \"tight diabetes control\", the American Diabetes Association recommends a post-meal glucose level of less than 10 mmol/L (180 mg/dL) and a fasting plasma glucose of 3.9 to 7.2 mmol/L (70–130 mg/dL). The actual amount of glucose in the blood and body fluids is very small. In a healthy adult male of with a blood volume of 5 L, a blood glucose level of 5.5 mmol/L (100 mg/dL) amounts to 5 g, equivalent to about a teaspoonful of sugar. Part of the reason why this amount is so small is that, to maintain an influx of glucose into cells, enzymes modify glucose by adding phosphate or other groups to it. Other animals" }, { "id": "pubmed23n1010_24763", "title": "Just the Facts: Diagnosis and treatment of diabetic ketoacidosis in the emergency department.", "score": 0.009259259259259259, "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.\"" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 89 ] ], "word_ranges": [ [ 0, 14 ] ], "text": "The most influential cardiovascular factor for stroke in women over 70 is blood pressure." }, "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": "Achieve optimal blood pressure control.", "2": "Achieve optimal hemoglobin A1C levels.", "3": "Add an antioxidant to the treatment.", "4": "Smoking cessation.", "5": "Achieve LDL levels below 100 mg/dl." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0695_19851", "title": "Intensive glycaemic control in type 2 diabetes mellitus: does it improve cardiovascular outcomes?", "score": 0.019149715961150816, "content": "With growing urbanization and economic development, there is a rapid increase in the incidence of type 2 diabetes mellitus (T2DM) in India. T2DM is associated with 2-4 times higher risk for cardiovascular disease (CVD), including coronary artery disease, stroke and peripheral vascular disease. Several studies have shown the benefit of intensive glycaemic control in reducing the frequency of diabetic microvascular complications such as retinopathy and nephropathy. Results of long term follow up of patients with diabetes, who were enrolled in earlier trials, have shown that initial intensive glycaemic control led to a reduction in CVD outcomes when compared with standard therapy. However, it is unclear if intensive glycaemic control, aiming to reduce haemoglobin A1c to levels even lower than the current goal of &lt;7%, will similarly lead to reduction in the rates of CVD. Recently, the results of 3 large, randomized controlled trials have been published, which suggest that in established T2DM with previous CVD or high risk of CVD, the benefits of intensive glycaemic control when compared with conventional good control, are minimal with regards to reduction of cardiovascular outcomes. Intensive therapy increases the risk of side-effects such as severe hypoglycaemia and weight gain. The implementation of such a therapy, with rigorous attention to frequent monitoring of blood glucose and visits to the physician, is not likely to be possible on a large scale, especially in a developing country such as India. The aim of management of patients with established T2DM should be to achieve the goal of good glycaemic control (haemoglobin A1c&lt;7%), with avoidance of hypoglycaemia. It is equally, if not more important, to control other risk factors of CVD by paying greater attention to lifestyle measures (weight loss if overweight or obese, regular exercise, cessation of smoking), rigorous control of blood pressure (&lt;130/80 mmHg) and low density lipoprotein (LDL) cholesterol (&lt;100 mg/dl or &lt;70 mg/dl if already diagnosed with CVD) and the prophylactic use of low dose aspirin as per current recommendations. A multifactorial approach targeting multiple cardiovascular risk factors is likely to be most effective in reducing CVD outcomes in T2DM." }, { "id": "pubmed23n0326_15132", "title": "Care of adults with type 2 diabetes mellitus. A review of the evidence.", "score": 0.018543956043956044, "content": "The purpose of this study was to provide primary care physicians with a concise review of the evidence that guides selected aspects of type 2 diabetes care, including glycemic control, macrovascular risk reduction, and screening for microvascular complications of diabetes. We identified randomized clinical trials that addressed selected aspects of the care of adults with type 2 diabetes using systematic literature review, review of existing clinical guidelines, and other sources. The results of these trials were interpreted as absolute risk reduction, and the number of patients that need to be treated to obtain a specific clinical outcome was calculated. Good glycemic control with metformin may reduce overall mortality in obese patients with type 2 diabetes (number need to treat [NNT] = 14 for 10 years), and improved blood pressure control reduced diabetes-related mortality (NNT = 15 for 10 years); improved glycemic control with agents other than metformin, or with combinations including metformin, does not reduce diabetes-related or overall mortality. Major cardiovascular events (CVE) in type 2 diabetes can be prevented by control of blood pressure with low-dose diuretics, atenolol, or angiotensin-converting enzyme inhibitors (NNT = 10 to 20 for 5 to 10 years for primary prevention of one CVE); by use of aspirin (NNT = 45 for 5 years for primary prevention of one CVE); and by use of simvastatin to lower low-density lipoprotein (LDL) cholesterol (NNT = 6 for 5 years for secondary prevention of one CVE). Glycemic control (NNT = 19 for 10 years) and hypertension control (NNT = 6 for 10 years) slow the progression of complications in patients with type 2 diabetes. Retinopathy and nephropathy are more preventable than neuropathy. The benefits of glycemic control are less for patients with shorter life expectancy and are greater for those with the highest levels of Hb A1c because larger Hb A1c improvements can be achieved in such patients. Periodic screening of patients for eye, kidney, and foot complications is supported because effective early treatment of these complications is available. In patients with type 2 diabetes, control of hypertension reduces microvascular and macrovascular complications more than glycemic control does. Control of LDL cholesterol with statins, aspirin, and smoking cessation reduce major cardiovascular events. Metformin reduces overall mortality in obese patients with creatinine levels &lt; 1.5 mg/dL. Glycemic control reduces microvascular complications. The evidence supports angiotensin-converting enzyme inhibitors, atenolol, or low-dose diuretics for blood pressure control. Effective treatment of eye, kidney, and foot complications is available, and regular screening for these complications is justified." }, { "id": "pubmed23n0650_13044", "title": "[Therapeutic behavior to follow in the following clinical case: treatment of type 2 diabetes].", "score": 0.018137254901960782, "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": "pubmed23n0631_1922", "title": "Type 2 diabetes: Which interventions best reduce absolute risks of adverse events?", "score": 0.017905459175553078, "content": "Benefits of interventions are usually reported as relative risk reductions. Absolute risk reductions (ARRs)-most relevant to individual patients-are reported less often. Estimate ARRs for interventions in a patient with diabetes mellitus. We used the Archimedes Risk Assessment Tool to estimate 10-year risks of myocardial infarction (MI), cerebrovascular accident (CVA), end-stage renal disease (ESRD), blindness, foot ulceration, and amputation, and to estimate the ARRs associated with controlling blood pressure (BP), blood sugar, and low-density lipoprotein (LDL) cholesterol levels; moderate exercise; and taking aspirin and a beta-blocker. Our hypothetical base case was a 65-year-old white man. Three other hypothetical patients were a 50-year-old white man, a 65-year-old white woman, and a 65-year-old black man. Each patient had a 5-year history of diabetes mellitus, a sedentary lifestyle, body mass index (BMI) of 28 kg/m2, BP of 140/90 mm Hg, LDL of 120 mg/dL, high-density lipoprotein (HDL) of 45 mg/dL, and glycosylated hemoglobin (HbA1c) of 10%. For the base case, the risks of MI (22.3%) and CVA (14.4%) far exceeded the risks of ESRD, blindness, and amputation. ARRs for interventions to reduce MI risk were: aspirin, 6.8%; HbA1c to 7%, 5.1%; moderate exercise, 2.7%; BP to 130/80 mm Hg, 1.4%; and LDL to 100 mg/dL, 1.4%. The female patient had a lower ARR for aspirin and a greater ARR for exercise. The black male patient had greater ARRs for both aspirin and exercise. Estimates were similar for CVA. Patients resembling our base case and its variations would probably benefit more from aspirin and moderate exercise than from all other interventions combined." }, { "id": "pubmed23n1050_19904", "title": "Rationale, Design, and Implementation of Intensive Risk Factor Treatment in the CREST2 Trial.", "score": 0.01620097074642529, "content": "The CREST2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis) is comparing intensive medical management (IMM) alone to IMM plus revascularization with carotid endarterectomy or transfemoral carotid artery stenting for preventing stroke or death within 44 days after randomization or ipsilateral ischemic stroke thereafter. There are extensive clinical trial data on outcomes after revascularization of asymptomatic carotid stenosis, but not for IMM. As such, the experimental treatment in CREST2 is IMM, which is described in this article. IMM consists of aspirin 325 mg/day and intensive risk factor management, primarily targeting systolic blood pressure &lt;130 mm Hg (initially systolic blood pressure &lt;140 mm Hg) and LDL (low-density lipoprotein) cholesterol &lt;70 mg/dL. Secondary risk factor targets focus on tobacco smoking, non-HDL (high-density lipoprotein), HbA1c (hemoglobin A1c), physical activity, and weight. Risk factor management is performed by site personnel and a lifestyle coaching program delivered by telephone. We report interim risk factor data on 1618 patients at baseline and last follow-up through 24 months. The mean baseline LDL of 80.5 mg/dL improved to 66.7 mg/dL. The mean baseline systolic blood pressure of 139.7 mm Hg improved to 130.3 mm Hg. The proportion of patients in-target improved from 43% to 61% for systolic blood pressure &lt;130 mm Hg and from 45% to 67% for LDL&lt;70 mg/dL (both changes <iP</i&lt;0.001). The rigorous multimodal approach to intensive stroke risk factor management in CREST2 has resulted in significant improvements in risk factor control that will enable a comparison of cutting-edge medical care to revascularization in patients with asymptomatic carotid stenosis. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02089217." }, { "id": "pubmed23n0729_24141", "title": "Intensive statin therapy for Indians: Part-I. Benefits.", "score": 0.015189158667419538, "content": "The underlying disorder in the vast majority of cases of cardiovascular disease (CVD) is atherosclerosis, for which low-density lipoprotein cholesterol (LDL-C) is recognized as the first and foremost risk factor. HMG-CoA reductase inhibitors, popularly called statins, are highly effective and remarkably safe in reducing LDL-C and non-HDL-C levels. Evidence from clinical trials have demonstrated that statin therapy can reduce the risk of myocardial infarction (MI), stroke, death, and the need for coronary artery revascularization procedures (CARPs) by 25-50%, depending on the magnitude of LDL-C lowering achieved. Benefits are seen in men and women, young and old, and in people with and without diabetes or prior diagnosis of CVD. Clinical trials comparing standard statin therapy to intensive statin therapy have clearly demonstrated greater benefits in CVD risk reduction (including halting the progression and even reversing coronary atherosclerosis) without any corresponding increase in risk. Numerous outcome trials of intensive statin therapy using atorvastatin 80 mg/d have demonstrated the safety and the benefits of lowering LDL-C to very low levels. This led the USNCEP Guideline Committee to standardize 40 mg/dL as the optimum LDL-C level, above which the CVD risk begins to rise. Recent studies have shown intensive statin therapy can also lower CVD events even in low-risk individuals with LDL-C &lt;110 mg/dL. Because of the heightened risk of CVD in Asian Indians, the LDL-C target is set at 30 mg/dL lower than that recommended by NCEP. Accordingly, the LDL-C goal is &lt; 70 mg/dL for Indians who have CVD, diabetes, metabolic syndrome, or chronic kidney disease. Intensive statin therapy is often required in these populations as well as others who require a &gt; or = 50% reduction in LDL-C. Broader acceptance of this lower LDL-C targets and its implementation could reduce the CVD burden in the Indian population by 50% in the next 25 years. Clinical trial data support an extremely favorable benefit-to-risk ratio of intensive statin therapy with some but not all statins. Atorvastatin 80 mg/d is 100 times safer than aspirin 81 mg/d and 10 times safer than diabetic medications. Intensive statin therapy is more effective and safe compared to intensive control of blood sugar or blood pressure in patients with diabetes." }, { "id": "pubmed23n0386_14431", "title": "Treatment of cardiac risk factors in diabetic patients: How well do we follow the guidelines?", "score": 0.014917071197411001, "content": "Diabetic patients are at increased risk for both macrovascular and microvascular disease compared with nondiabetic patients. We conducted a prospective observational study to assess the control of multiple predetermined cardiovascular risk factors in 235 treated diabetic patients undergoing elective cardiac catheterization at our institution between December 20, 1997, and February 15, 2000. The following parameters were used to define optimal treatment in these patients: hemoglobin (Hgb) A1c &lt;7%, low-density lipoprotein cholesterol (LDL-c) &lt;100 mg/dL, high-density lipoprotein cholesterol (HDL-c) &gt;/=45 mg/dL for men and &gt;/=55 mg/dL for women, triglyceride (TG) level &lt;200 mg/dL, blood pressure (BP) &lt;130/85 mm Hg, body mass index (BMI) &lt;25, daily aspirin therapy, and current nonsmoking status. The use of b-blockers and angiotensin-converting enzyme inhibitors was also evaluated. The average patient age was 64 +/- 11 years; 155 (65%) were male. One hundred ninety-one (81%) patients had documented coronary artery disease at cardiac catheterization. The mean Hgb A1c level for all diabetic patients was 8.2% +/- 1.6%. Overall, 49 (21%) had an Hgb A1c level &lt;7%. The fasting cholesterol panel for all patients revealed a mean LDL-c level of 103 +/- 41 mg/dL, a mean HDL level of 39 +/- 11 mg/dL, and a mean TG level of 164 +/- 128 mg/dL. One hundred sixteen (52%) patients had an LDL-c &lt;100 mg/dL. Only 32 of 147 (22%) male patients and 14 of 80 (18%) female patients achieved an HDL-c &gt;/=45 mg/dL or &gt;/=55 mg/dL, respectively. One hundred seventy-seven of 232 (76%) patients had a TG level &lt;200 mg/dL. Only 23 of 233 (10%) diabetics were controlled to a BP of &lt;130/85 mm Hg, and 25 (11%) achieved a BMI &lt;25. Only one patient (0.4%) had optimal control of all modifiable risk factors. These data demonstrate the poor control of numerous cardiovascular risk factors in treated diabetics undergoing elective cardiac catheterization." }, { "id": "pubmed23n0785_4721", "title": "Achievement of optimal medical therapy goals for U.S. adults with coronary artery disease: results from the REGARDS Study (REasons for Geographic And Racial Differences in Stroke).", "score": 0.013594470046082949, "content": "In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial. In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures. The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure &lt;130 mm Hg and diastolic blood pressure &lt;85 mm Hg (&lt;80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol &lt;85 mg/dl, high-density lipoprotein cholesterol &gt;40 mg/dl, and triglycerides &lt;150 mg/dl; 4) fasting glucose &lt;126 mg/dl; 5) nonsmoking status; 6) body mass index &lt;25 kg/m(2); and 7) exercise ≥4 days per week. The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals. There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD." }, { "id": "pubmed23n0355_11939", "title": "Prevention of coronary heart disease. Part I. Primary prevention.", "score": 0.013425237644726765, "content": "The first concern in primary prevention is the physician's belief that primary prevention is important for all adults and that intervention can significantly affect risk. Given the coronary plaque burden over many years and the importance of the development of healthy lifestyles early in adulthood to decrease coronary plaque burden, there are excellent reasons to begin prevention even with young adults. At the very least, a patient seen for any reason should provide a smoking history, have knowledge of the presence of early CHD in first-degree relatives and measurements of blood pressure, height, and weight, provide evidence for a cholesterol level within 5 years (after age 20 according to NCEP guidelines or in middle age according to ACP guidelines), and be given an assessment of glucose tolerance or diabetes. Information about alcohol intake and physical activity status are also of some importance. Other than height, weight, and blood pressure, during the physical examination, the physician should initially assess the strength of pulses in the lower extremities, evidence for carotid or femoral bruits, and eyegrounds for retinal arterial changes, and the skin and subcutaneous tissue should be examined for xanthomas and the eyes should be examined for corneal arcus and xanthelesma. These elements should be part of any initial examination by a primary care physician and are not extraordinary. In addition to lipid and blood sugar analyses, other evaluations may include blood urea nitrogen and creatinine and electrolytes in patients with hypertension or diabetes or in patients who are on antihypertensive agents. It may be prudent to obtain an ECG for patients who are older than 40 years. The elements mentioned above are the elements of the history, physical examination, and laboratory examination in subjects without a past history of CHD and with no clinical evidence for CHD. Primary prevention management begins with a discussion of risk factors with the patient. The key interventions aim at the lowering of blood pressure to at least less than 140/90 mm Hg, the complete cessation of smoking, the lowering of lipid levels to less than 130 mg/dL, the lowering of triglycerides to less than 200 mg/dL (or, some would argue, &lt; 150 mg/dL), and the attempt to keep HDL cholesterol above 35 mg/dL (more than 40 to 45 mg/dL is a better goal) with the use of lifestyle modification. For patients with diabetes, strict control of glucose levels is essential to minimize disease of the microvasculature and possibly to minimize progressive renal disease. There are several lifestyle modifications for lipids. For patients with elevated LDL cholesterol, modifications include a less than 30% fat calorie diet and less than 300 mg of cholesterol intake daily, with fat calories approximately equally distributed among saturated fats, polyunsaturated fats, and monounsaturated fats (1/3, 1/3, 1/3; rule of 3s). The assistance of a dietician is extremely helpful in this regard. For patients with a low HDL cholesterol, weight reduction (for overweight patients) by calorie control and increased physical activity and smoking cessation will have some modest effect. For patients with elevated triglycerides, a diet similar to that for lowering of LDL cholesterol with the addition of stricter calorie limitation, avoidance of refined sugars, increase in complex carbohydrates, and avoidance of alcohol will be helpful. A decrease in the percent of fat calories to 20% to 25% will be of assistance to those patients with particularly high triglycerides. The treatment of underlying conditions such as diabetes mellitus, hypothyroidism, liver disease, and some renal conditions may also significantly modify high triglycerides. For patients with hypertension, limitation of sodium to 2 gm/d (6 gm sodium chloride), limitation of alcohol to 1 to 2 drinks a day, increased physical activity, and weight reduction are the key lifestyle modifications. (ABSTRACT TRUNCATED)" }, { "id": "pubmed23n0990_21870", "title": "Secondary prevention advices after cardiovascular index event: From drug prescription to risk factors control in real world practice.", "score": 0.013369915512586011, "content": "The present study aims at evaluating the achievement of blood pressure, lipid and blood glucose targets, healthy lifestyle changes and appropriate drug prescription/adherence in patients attending secondary prevention/CR ambulatory visit after index cardiovascular event in a time period ranging 1 to 5 year. At ambulatory visit, a predetermined set of data collection was used, including demographic data, cardiovascular risk factors and lifestyle habits, type and time of index event, current symptoms, physical sign, biochemistry and current medical treatment (including type and dosage). Cardiovascular risk profile (smoking habits, physical activity and body weight), secondary prevention goals (LDL-cholesterol, blood pressure, resting heart rate, glycated haemoglobin level) and the use of recommended drugs were also evaluated and categorized. Study population consisted of 800 patients [644 men (84.5%), aged 69±10.9 years)]. Cardiovascular index events were coronary artery bypass graft (CABG) (20%) ST segment elevation myocardial infarction (STEMI) (28%), non-ST segment elevation myocardial infarction (NSTEMI) (21%) and stable angina (13%) by unstable angina (13%) and stroke (5%). About 30% of patients was symptomatic (angina or dyspnoea) at the time of ambulatory visit. Major comorbidities were hypertension (73%), dyslipidaemia (64%) and diabetes (40%). More than 80% of patients achieved target levels for blood pressure. Patients that have participated to cardiac rehabilitation programmes after cardiovascular index event showed best achievement in blood pressure target (83.8% vs 76.8%, p=0.02). LDL-cholesterol target (&lt;70 mg/dl) was achieved in about 2/3 of patients; HbA1c target (&lt;7%) was achieved in 56.4% of diabetic population. About 75% of study cohort was treated with RAAS inhibitors, 85% with beta-blockers, 92% with statins and 87% with acetylsalicylic acid. All drugs were increasingly adopted from index event. Implementing secondary prevention guidelines into the 'real world' clinical practice in \"late\" interval from 1 to 5 years after a cardiovascular event improved risk factors control and appropriate drug prescription. Whether these improvements translated into prognostic advantages remains to be elucidated." }, { "id": "wiki20220301en262_11015", "title": "Polycap", "score": 0.012309324844143786, "content": "To be included in the study, patients had to be at intermediate risk for myocardial infarction, stroke, and cardiovascular death. The participants’ average age was 64 years. Men 50 years and older and women 55 years and older with an INTERHEART risk score ≥ 10 (or men and women 65 years and older with an INTERHEART risk score ≥ 5) were included in the international study. Roughly 53% of study participants were women. Mean LDL cholesterol level and systolic blood pressure at baseline were 121 mg/dL and 144.5 mm Hg, respectively. For the trial, participants were randomly assigned to one of four groups. They were asked to take one of the following daily: both the polypill and aspirin, the polypill alone, aspirin alone, or only a placebo. The top-enrolling countries were India, the Philippines, Columbia, and Bangladesh; Canada enrolled 131 patients. Medications included in the polypill were atenolol, 100 mg; ramipril, 10 mg; hydrochlorothiazide, 25 mg; and simvastatin, 40 mg." }, { "id": "Gynecology_Novak_888", "title": "Gynecology_Novak", "score": 0.012259980660312197, "content": "Figure 9.4 is a suggested algorithm for cholesterol control based on LDL levels. Cholesterol fat-lowering diet books abound in most bookstores and allow the patient to choose a diet she will best follow. The role of exercise and cigarette cessation should be stressed to all patients. Patients with a family history of cardiovascular disease (history of premature coronary artery problems and strokes) should be tested and started on conservative programs in their 20s. After 3 to 6 months, if the LDL remains above 160 mg/dL with zero to one risk factor or above 130 mg/dL with two or more risk factors, then medical therapy should be initiated. Any woman with coronary heart disease or equivalents such as diabetes or other forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) should initiate lifestyle changes if her LDL is 100 mg/dL or more and drug therapy if her LDL is 130 mg/dL or more. Anyone with an LDL 190" }, { "id": "pubmed23n0651_19726", "title": "Distribution of traditional and novel risk factors and their relation to subsequent cardiovascular events in patients with acute coronary syndromes (from the PROVE IT-TIMI 22 trial).", "score": 0.011454118261323587, "content": "Current guidelines recommend risk stratification largely based on traditional risk factors such as those in the Framingham Risk Score. We studied the distribution of 12 traditional and non-traditional risk markers (age &gt; or =65 years, male gender, family history of premature coronary heart disease, low-density lipoprotein cholesterol &gt; or =70 mg/dl, high-density lipoprotein cholesterol &lt;40 mg/dl in men and &lt;50 mg/dl in women, systolic blood pressure &gt;130 mm Hg, diabetes mellitus, smoking, C-reactive protein &gt; or =2 mg/L, triglycerides &gt;150 mg/dl, prediabetes defined as a fasting glucose level 100 to 125 mg/dl or hemoglobin A1c &gt;6, and obesity defined as body mass index &gt; or =30 kg/m(2)) in 3,675 patients from the PROVE IT-TIMI 22 trial at 4 months and evaluated the risk of cardiovascular events stratified by the number of risk factors. The median number of risk factors was 5. In individual risk factor subgroups, men, smokers, hypertensives, and patients with increased low-density lipoprotein cholesterol had just that added risk factor compared to their counterparts (median 5 vs 4). In contrast, patients with diabetes, prediabetes, and increased triglycerides, C-reactive protein, or body mass index had not only that, but also another added risk factor (median 6 vs 4). A higher risk factor count was strongly related with increased rate of death, myocardial infarction, unstable angina, stroke, or revascularization, from 0% to 38.6% at 2 years for 0 to &gt; or =9 risk factors (p &lt;0.0001). In conclusion, with the observed \"clustering\" of risk factors and the link between increasing risk factor count and adverse outcomes in a patient with 1 diagnosed risk factor, a comprehensive review of traditional and novel risk factors is important to fully assess cardiovascular risk." }, { "id": "Pharmacology_Katzung_7061", "title": "Pharmacology_Katzung", "score": 0.010424070125562662, "content": "A 53-year-old woman with a history of knee osteoarthritis, high cholesterol, type 2 diabetes, and hypertension presents with new onset of hot flashes and a question about a dietary supplement. She is obese (body mass index [BMI] 33), does not exercise, and spends a good portion of her work day in a seated position. She eats a low-sugar diet and regularly eats packaged frozen meals for dinner because she doesn’t have time to cook regularly. Her most recent laboratory values include a low-density lipoprotein (LDL) cholesterol that is above goal at 160 mg/dL (goal < 100 mg/dL) and a hemo-globin A1c that is well controlled at 6%. Her blood pressure is high at 160/100 mm Hg. Her prescription medications include simvastatin, metformin, and benazepril. She also takes over-the-counter ibuprofen for occasional knee pain and a multivitamin supplement once daily. She has heard good things about natural products and asks you if taking a garlic supplement daily could help to bring her blood" }, { "id": "pubmed23n0917_22125", "title": "Effect of Multifactorial Treatment Targets and Relative Importance of Hemoglobin A1c, Blood Pressure, and Low-Density Lipoprotein-Cholesterol on Cardiovascular Diseases in Chinese Primary Care Patients With Type 2 Diabetes Mellitus: A Population-Based Retrospective Cohort Study.", "score": 0.009900990099009901, "content": "The relative effect of hemoglobin A1c, blood pressure, and low-density lipoprotein-cholesterol (LDL-C) (\"ABC\" factors) on the prevention of cardiovascular diseases (CVD) among patients with type 2 diabetes mellitus is poorly understood. This study aimed to evaluate the association of key clinical parameters on CVD risk using a multifactorial optimal control approach in Chinese primary care patients with type 2 diabetes mellitus. A population-based retrospective cohort study was conducted on 144 271 Chinese type 2 diabetes mellitus primary care patients, aged 18 to 79 and without prior clinical diagnosis of CVD in 2008-2011. Cox regressions were conducted to examine the association between the combinations of ABC targets (hemoglobin A1c &lt;7%, blood pressure &lt;130/90 mm Hg, and LDL-C &lt;2.6 mmol/L) and risks of CVD (overall), coronary heart disease, stroke, and heart failure. Achieving more ABC targets incrementally reduced the incidence of total CVD and individual disease including coronary heart disease, stroke, and heart failure, irrespective of other patient characteristics. Compared with suboptimal control in all ABC levels, achieving any 1, 2, and all 3 ABC targets reduced the relative risk of CVD by 13% to 42%, 31% to 52%, and 55%, respectively. Among those achieving only 1 ABC target, LDL-C reduction was associated with the greatest CVD risk reduction (42%), followed by blood pressure reduction (18%), and hemoglobin A1c reduction (13%). To achieve the greatest risk reduction for the incidence of CVD, the ultimate goal of treatment should be to achieve target control of hemoglobin A1c, blood pressure, and LDL-C. If it is not possible to achieve all 3 targets, efforts should be prioritized on treating the LDL-C to minimize CVD risk." }, { "id": "pubmed23n0989_248", "title": "[Control of cardiovascular risk factors in patients after myocardial infarction].", "score": 0.009900990099009901, "content": "Despite significant improvements in the diagnosis and treatment of cardiovascular diseases that have occurred in recent years, they remain the main cause of morbidity and mortality in the population. In many European countries, the incidence of coronary heart disease is currently 50% lower than it was in the early 1980s, which is the result of cardiovascular prevention. A special group of patients are people after myocardial infarction with very high cardiovascular risk. They should definitely implement activities at the individual level e. g. work on improving the unhealthy lifestyle and pharmacologically control other risk factors. A diet low in saturated fats should be recommended, i.e. mainly containing whole grains, vegetables, fruits and fish, recommend regular physical exercise: 150 min / week of moderate, aerobic physical activity, reducing the supply of calories in order to get rid of overweight or obesity. Help in quitting tobacco addiction should take place through the minimal nicotine intervention and, if necessary, pharmacological therapy. Another thing is the control of other risk factors, i. e. the appropriate treatment of dyslipidemia (the primary target is LDL cholesterol &lt;1.8 mmol/l or reduction by ≥ 50%, if the initial concentration is between 1.8 and 3.5 mmol/l, treatment hypertension (target arterial pressure for most people aged 18-65 is in the range: 120-130/70-79 mmHg, if it is well tolerated, while for older people it is in the range: 130-139/70-79mmHg, if it is well tolerated), optimal diabetes therapy (target glycated hemoglobin &lt;7%) and appropriate antiplatelet therapy (in most patients double antiplatelet therapy is recommended for 12 months after acute coronary syndrome). These activities lead to a significant improvement in quality of life and a decrease in mortality due to cardiovascular diseases." }, { "id": "Surgery_Schwartz_5389", "title": "Surgery_Schwartz", "score": 0.00987520975176963, "content": "statement summarize the secondary prevention recommendations.37 Class I recommendations include smoking cessation and avoid-ance of environmental tobacco exposure, blood pressure con-trol to under 140/90 mmHg (under 130/80 mmHg in those with diabetes or chronic kidney disease), LDL cholesterol levels less than 100 mg/dL, aspirin therapy in all patients without contra-indications, a BMI target of less than 25 kg/m2, diabetes man-agement with target HbA1c <7%, and encouragement of daily moderate-intensity aerobic exercise. β-Blockers should be used in all patients with LV dysfunction and following MI, ACS, or revascularization, unless a specific contraindication is pres-ent. Renin-angiogensin-aldosterone system blockade in patients with hypertension, LV dysfunction, diabetes, or chronic kidney disease should also be considered.Clinical ManifestationsPatients with CAD may have a spectrum of presentations, including angina pectoris, myocardial infarction, ischemic heart failure," }, { "id": "wiki20220301en012_132177", "title": "Green tea", "score": 0.009615384615384616, "content": "Glycemic control Green tea consumption lowers fasting blood sugar but in clinical studies the beverage's effect on hemoglobin A1c and fasting insulin levels was inconsistent. Hyperlipidemia Drinking green tea or taking green tea supplements decreases the blood concentration of total cholesterol (about 3–7 mg/dL), LDL cholesterol (about 2 mg/dL), and does not affect the concentration of HDL cholesterol or triglycerides. A 2013 Cochrane meta-analysis of longer-term randomized controlled trials (>3 months duration) concluded that green tea consumption lowers total and LDL cholesterol concentrations in the blood. Inflammation A 2015 systematic review and meta-analysis of 11 randomized controlled trials found that green tea consumption was not significantly associated with lower plasma levels of C-reactive protein levels (a marker of inflammation). Weight loss There is no good evidence that green tea aids in weight loss or weight maintenance." }, { "id": "pubmed23n0224_12696", "title": "The Bucharest Multifactorial Prevention Trial of Coronary Heart Disease--ten year follow-up: 1971-1982.", "score": 0.009523809523809525, "content": "The trial begun in 1971 and the paper brings the results after a ten-year follow-up. Both the intervention and control group contained 5000 men with a similar socioeconomic and professional structure; the intervention group was examined every six months in the first 5 years and annually in the second phase. The control group was examined \"only after\" 5 years and a second time at the final moment. The decreases of the cumulative ten-year incidences were: for hard events--26.7%; for myocardial infarction--20%; for fatal myocardial infarction--52%; for stroke--31%; for cardiovascular mortality--38%; for total mortality--14%. The trend of serum cholesterol and cigarettes/day was downward, but the blood pressure had a rather flat evolution in the intervention group. The control group disclosed also some downward trends." }, { "id": "pubmed23n0510_9159", "title": "Cardiovascular disease in women with diabetes mellitus: a review.", "score": 0.009433962264150943, "content": "To analyze cardiovascular disease (CVD) along wit it's contributing risk factors in women with diabetes mellitus (DM) and from this, to recommend prevention strategies. A review of pertinent studies serves as the basis for the analysis and recommendations of prevention strategies in this group. Women with (DM) show a higher morbidity and mortality from CVD. The presence of DM confers these individuals the same risk of having a coronary event as present in a non-diabetic person who has suffered a previous myocardial infarction. Arterial hypertension, a characteristic dyslipidaemia (hypertrigliceridemia, low level of high density lipoprotein cholesterol and elevated low density lipoprotein cholesterol), obesity, microalbuminuria, platelet hyperaggregability and endothelial dysfunction converge conferring the women with DM a higher susceptibility to atherosclerosis. Recommendations include: lifestyle intervention weight reduction, increase in physical activity and smoking cessation. Women with DM should target to lower the LDL-C to a level below 100 mg/dl, the blood pressure level to below 130/80 mm Hg and triglycerides to less than 150 mg/dl. The goal is to raise HDL-C to a level over 45 mg/dl and reduce hemoglobin A1c (HbAlc) levels to below seven (7%) percent. Women with DM should use aspirin on a daily basis, unless contraindicated. These actions may lead to the reduction of the burden of CVD in women with DM. This article summarizes the recent salient features of CVD in women with DM with emphasis on preventive measures as well as on the understanding of prevailing guidelines established under the principles of evidence based medicine." }, { "id": "pubmed23n0516_810", "title": "CARDS on the table: should everybody with type 2 diabetes take a statin?", "score": 0.009433962264150943, "content": "Vascular complications are a major cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). The recently published Collaborative Atorvastatin Diabetes Study (CARDS) showed that atorvastatin (10 mg, once daily vs. placebo) markedly reduces vascular events in this high-risk population. The participants (n = 2838) were fairly typical T2DM = 2838) patients without cardiovascular disease and with at least one other risk factor: hypertension, retinopathy, albuminuria or current smoking. In the treatment group, coronary events were reduced by 36% (p = 0.001) and stroke by 48% (p = 0.001). The trial was terminated two years early on ethical grounds. The number needed to treat (NNT) was 27 for four years to prevent one event. However, the benefit may have been greater since a proportion of the placebo group received statin therapy. The benefit from statin treatment was independent of sex, age, baseline lipid levels, was independent of sex, age, baseline lipid levels, systolic blood pressure, retinopathy, albuminuria, systolic blood pressure, retinopathy, albuminuria, smoking or HbA smoking or HbA(1c). The frequency of adverse events did not differ between the groups. These findings support those of other statin trials. CARDS does not comment on renal function. However, other trials suggest that statins preserve renal function in those with and without DM. We discuss the CARDS study in this context in this brief overview paper. the evidence shows that we need to control glucose to prevent microvascular complications, to lower cholesterol to prevent macrovascular disease and to lower blood pressure to prevent both. It may be that the benefit of statins extends beyond a threshold low-density lipoprotein cholesterol level in patients with T2DM. More trials are needed in this field." }, { "id": "pubmed23n0521_21355", "title": "Secondary prevention of coronary heart disease in elderly patients.", "score": 0.009345794392523364, "content": "Coronary heart disease remains a leading cause of mortality in the United States, with 84 percent of persons 65 years or older dying from this disease. Secondary preventive measures, including lifestyle modification and pharmacotherapy, are important for elderly patients because of the variable impacts on morbidity and mortality rates and quality of life. Participating in light to moderate activities significantly decreases mortality rates in elderly patients. Smoking cessation translates into a reduction in overall mortality and morbidity rates at least equal to that of other preventive measures such as aspirin or beta-blocker therapy. Recent studies on the effects of lowering low-density lipoprotein cholesterol levels to below 100 mg per dL have shown a substantial reduction in coronary heart disease mortality and nonfatal myocardial infarction rates, with a persistent effect in patients older than 75 years. Hypertension, manifesting mostly as isolated systolic blood pressure elevation, also should be treated aggressively. Conventional medical therapies for hypertension (e.g., diuretics, beta blockers) and newer agents (e.g., calcium channel blockers, angiotensin-converting enzyme inhibitors), together with sodium restriction, have had a positive effect on cardiovascular mortality and morbidity rates in older patients. With the increasing prevalence of obesity, insulin resistance, and type 2 diabetes, interventions targeting weight reduction and glucose control should be emphasized. Whereas weight-loss strategies are poorly defined in this population, the management of diabetes through dietary modification, exercise, and medications is similar across age groups. The target hemoglobin A1C level is less than 7 percent. Elderly patients are prone to depression and social isolation, and they are more likely to have a lower socioeconomic status than younger patients, which may negatively affect participation in rehabilitation programs and compliance with medical advice and therapy. Strategies aimed at these factors have shown variable results and remain ill-defined." }, { "id": "wiki20220301en067_58690", "title": "Type 1 diabetes", "score": 0.009259259259259259, "content": "Monoclonal antibodies used for the treatment of cancer (checkpoint inhibitors inhibiting PD-1 and PD-L1), especially nivolumab and pembrolizumab have been reported to occasionally induce autoimmune diabetes. Diagnosis Diabetes is typically diagnosed by a blood test showing unusually high blood sugar. The World Health Organization defines diabetes as blood sugar levels at or above 7.0 mmol/L (126 mg/dL) after fasting for at least eight hours, or a glucose level at or above 11.1 mmol/L (200 mg/dL) two hours after an oral glucose tolerance test. The American Diabetes Association additionally recommends a diagnosis of diabetes for anyone with symptoms of hyperglycemia and blood sugar at any time at or above 11.1 mmol/L, or glycated hemoglobin (hemoglobin A1C) levels at or above 48 mmol/mol." }, { "id": "pubmed23n0405_6439", "title": "Atherosclerotic Risk Factors in Patients with Ischemic Cerebrovascular Disease.", "score": 0.009259259259259259, "content": "Aggressive treatment of atherosclerotic risk factors can substantially reduce stroke risk in patients with a history of stroke or transient ischemic attack. Data from several recent large clinical trials provide convincing evidence of benefit for a number of specific therapies directed at this population. The authors recommend treatment with ramipril alone or perindopril plus indapamide regardless of blood pressure, provided there is no contraindication. For patients already taking a different angiotensin- converting enzyme (ACE) inhibitor, the authors do not routinely switch agents. The authors recommend use of simvastatin 40 mg per day in patients with a total cholesterol level of 135 mg/dL or greater, provided no contraindication exists. The authors also recommend consideration of gemfibrozil in patients with isolated low high- density lipoprotein levels. In patients with diabetes mellitus, tight glycemic control has not been shown to reduce macrovascular complications such as stroke, but does reduce microvascular complications. However, diabetics should receive especially aggressive treatment of other vascular risk factors. There is no role for post-menopausal hormone replacement therapy in prevention of stroke. Weight loss for overweight patients, regular exercise, and a diet rich in fruits, vegetables, cereals, and fish, as well as low in fat and cholesterol, should be a standard recommendation for this group of patients. Treatment with folic acid, B(6), and B(12) for patients with elevated homocysteine appears rational, though this is unproven. However, there is no benefit to vitamin E, vitamin C, or beta-carotene supplementation. Smokers should stop. For every 43 smokers who quit, one stroke is prevented. Moderate consumption of alcohol (one to two drinks a day) may be beneficial, but heavy alcohol use (more than five drinks a day) increases stroke risk." }, { "id": "pubmed23n0629_14668", "title": "Relative and cumulative effects of lipid and blood pressure control in the Stroke Prevention by Aggressive Reduction in Cholesterol Levels trial.", "score": 0.009174311926605505, "content": "The relative contributions of on-treatment low- and high-density lipoprotein cholesterol (LDL-C, HDL-C), triglycerides, and blood pressure (BP) control on the risk of recurrent stroke or major cardiovascular events in patients with stroke is not well defined. We randomized 4731 patients with recent stroke or transient ischemic attack and no known coronary heart disease to atorvastatin 80 mg per day or placebo. After 4.9 years, at each level of LDL-C reduction, subjects with HDL-C value above the median or systolic BP below the median had greater reductions in stroke and major cardiovascular events and those with a reduction in triglycerides above the median or diastolic BP below the median showed similar trends. There were no statistical interactions between on-treatment LDL-C, HDL-C, triglycerides, and BP values. In a further exploratory analysis, optimal control was defined as LDL-C &lt;70 mg per deciliter, HDL-C &gt;50 mg per deciliter, triglycerides &lt;150 mg per deciliter, and SBP/DBP &lt;120/80 mm Hg. The risk of stroke decreased with as the level of control increased (hazard ratio [95% confidence interval] 0.98 [0.76 to 1.27], 0.78 [0.61 to 0.99], 0.62 [0.46 to 0.84], and 0.35 [0.13 to 0.96]) for those achieving optimal control of 1, 2, 3, or 4 factors as compared to none, respectively. Results were similar for major cardiovascular events. We found a cumulative effect of achieving optimal levels of LDL-C, HDL-C, triglycerides, and BP on the risk of recurrent stroke and major cardiovascular events. The protective effect of having a higher HDL-C was maintained at low levels of LDL-C." }, { "id": "pubmed23n0395_13059", "title": "The HOPE Study (Heart Outcomes Prevention Evaluation).", "score": 0.009174311926605505, "content": "The Heart Outcomes Prevention Evaluation (HOPE) study was designed to test the hypotheses that two preventive intervention strategies, namely angiotensin-converting enzyme (ACE) inhibition or vitamin E, would improve morbidity and mortality in patients at high risk of cardiovascular events compared with placebo. This review addresses the ACE inhibitor (ACE-I) (ramipril) arm of the study, both on the trial population as a whole, and on the large diabetic subgroup. Patients were included in the study who were considered to be at high risk of future fatal or non-fatal cardiovascular events, by virtue of their age (&gt;55 years), existing or previous cardiovascular disease, or diabetes. Diabetics had at least one other risk factor, either known vascular disease or other factors such as cigarette smoking, high cholesterol or hypertension. Ramipril or placebo was added to concomitant medication, which included, in a substantial proportion of patients, antihypertensive drugs (excluding ACE-I), lipid-lowering agents or aspirin. As a result, despite a history of hypertension in nearly 50% of patients, blood pressure (BP) at baseline was normal and the reduction in BP attributable to ramipril modest (a fall of 3-4 mmHg systolic BP and 1-2 mmHg diastolic). The trial was stopped early on the advice of the Data Monitoring Committee because of convincing evidence of the benefit of ramipril treatment on the combined primary endpoint of cardiovascular death, non-fatal myocardial infarct (MI) and non-fatal stroke (14% vs. 17.8% on ramipril and placebo, respectively; relative risk reduction 22%, p&lt;0.001). This comprised a risk reduction of 32% for stroke, 20% for MI, 26% for cardiovascular death and 16% for all-cause mortality, as well as a reduction in the risk of several other endpoints including heart failure and revascularisation procedures. The results among the 3577 diabetic subjects were even more striking, with a reduction of 25% in the combined primary endpoint. This reduction in the combined endpoint and in particular the reduction in MI far exceeded that which would be expected from the modest fall in BP. Furthermore, a multiple regression analysis of the diabetic subgroup showed similar relative risk reductions even after allowing for the effects of the fall in BP. Possible explanations for the non BP-mediated benefits of ramipril include reduction of angiotensin II-induced intimal and vascular smooth muscle proliferation and possible plaque stabilisation. The HOPE study results show that it is both safe and beneficial to lower BP that is already within the 'normal' range, particularly in patients with known vascular risk factors. This should greatly extend the use of ACE-I to a wider group of patients - not only those with left ventricular dysfunction, hypertension or diabetic microalbuminuria, but to the sort of high-risk patients who are currently given prophylactic treatment with aspirin." }, { "id": "pubmed23n0783_2102", "title": "How to prevent and treat pharmacological hypoglycemias.", "score": 0.00909090909090909, "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": "pubmed23n0397_7210", "title": "Stroke prevention: management of modifiable vascular risk factors.", "score": 0.00909090909090909, "content": "Stroke prevention is a crucial issue because (i) stroke is a frequent and severe disorder, and (ii) acute stroke therapies that are effective at the individual level have only a little impact in term of public health. Stroke prevention consists of the combination of 3 strategies: an optimal management of vascular risk factors, associated when appropriate with antithrombotic therapies, carotid surgery, or both. Primary prevention trials have shown that reducing blood pressure in hypertensive subjects reduces their vascular risk, including stroke. The association of perindopril plus indapamide reduces the vascular risk in patients who have had a stroke or TIA during the last 5 years, irrespective of their baseline blood pressure. Lowering serum cholesterol with statins or gemfibrozil in patients with hypercholesterolemia or coronary heart disease (CHD), reduces the risk of stroke. However, no trial of cholesterol-lowering therapy has been completed in stroke patients. A strict control of high cholesterol levels should be encouraged, because of benefits in terms of CHD. Statins should be prescribed for stroke patients with CHD, or increased cholesterol levels. Cigarette smoking is associated with an increased risk of stroke and should be avoided. Careful control of all risk factors, especially arterial hypertension in type 1 and type 2 diabetics is recommended, together with a strict glycemic control to reduce systemic microvascular complications. Estrogens prescribed in hormone replacement or oral contraceptive therapies are not recommended after an ischemic stroke. It is also recommended to reduce alcohol consumption and obesity, and to increase physical activity in patients at risk for first-ever or recurrent stroke. An optimal management of risk factors for stroke is crucial to reduce the risks of first-ever stroke, recurrent stroke, any vascular event after stroke and vascular death. One of the major public health issues for the coming years will be to focus more on risk factor recognition and management." }, { "id": "wiki20220301en008_126427", "title": "Type 2 diabetes", "score": 0.009013134995511752, "content": "Management of type 2 diabetes focuses on lifestyle interventions, lowering other cardiovascular risk factors, and maintaining blood glucose levels in the normal range. Self-monitoring of blood glucose for people with newly diagnosed type 2 diabetes may be used in combination with education, although the benefit of self-monitoring in those not using multi-dose insulin is questionable. In those who do not want to measure blood levels, measuring urine levels may be done. Managing other cardiovascular risk factors, such as hypertension, high cholesterol, and microalbuminuria, improves a person's life expectancy. Decreasing the systolic blood pressure to less than 140 mmHg is associated with a lower risk of death and better outcomes. Intensive blood pressure management (less than 130/80 mmHg) as opposed to standard blood pressure management (less than 140-160 mmHg systolic to 85–100 mmHg diastolic) results in a slight decrease in stroke risk but no effect on overall risk of death." }, { "id": "pubmed23n0862_17414", "title": "Maintenance of Clinical Endpoints After Discharge from a Pharmacist-Managed Risk Reduction Clinic at a Veterans Affairs Medical Center.", "score": 0.009009009009009009, "content": "Diabetes, dyslipidemia, and hypertension are complex chronic disease states that often require close monitoring and frequent follow-up to achieve and maintain therapeutic control as determined by hemoglobin A1c (A1c), low-density lipoprotein (LDL), and blood pressure (BP). At the Charles George Veterans Affairs Medical Center (CGVAMC), physicians may refer their patients to the on-site pharmacist-managed Risk Reduction Clinic (RRC). Patients are discharged from the RRC once patient-specific therapeutic goals have been met for diabetes, dyslipidemia, and/or hypertension. This study investigated the change in A1c, LDL, and systolic blood pressure (SBP) after discharge from the CGVAMC RRC. To investigate (a) how clinical endpoints for diabetes, dyslipidemia, and hypertension change after discharge from the pharmacist-managed RRC at the CGVAMC; (b) the factors associated with worsening of monitoring parameters; and (c) the frequency of reconsultation to the RRC. In this single-center retrospective quality management study, patients were included if they had a completed consultation to the CGVAMC RRC between August 11, 2008, and January 1, 2011, for the management of type 2 diabetes, dyslipidemia, and/or hypertension. Patients were included if they were discharged from the RRC prior to October 1, 2011, due to goal attainment. Furthermore, it was required that patients have A1c, LDL, and SBP measurements, as applicable based on diagnoses, at least yearly during the first 2 years following discharge. Patients were excluded if they were discharged for any reason other than goal attainment or if they were followed by a specialty clinic related to the RRC, including the Diabetes PharmD, Diabetes MD, MIDAS (group diabetes), or MAGIC (group dyslipidemia) clinics. Data collection included patient demographics; date of and indication for consultation to the RRC; date of first RRC visit; date of discharge from the RRC; number of visits to the RRC; A1c, LDL, SBP, and weight at consultation to the RRC, at discharge, and during the 2 years following discharge from the RRC; and date of and indication for reconsultation to the RRC, as applicable. Two-tailed paired t-tests were used to compare A1c, LDL, and SBP at discharge from the RRC to A1c, LDL, and SBP during the follow-up period. Two-tailed unpaired t-tests were performed to determine which variables were associated with changes in the monitoring parameters after discharge from the RRC. One hundred forty-nine patients were included in this study. For all patients with a diagnosis of diabetes (N = 82), A1c rose from 6.49% to 6.79% (P &lt; 0.001) during the first year and to 7.04% (P &lt; 0.001) during the second year following discharge. For patients diagnosed with dyslipidemia (N = 137), LDL rose after discharge from 81.5 mg/dL to 90.8 mg/dL (P &lt; 0.001) and to 90.9 mg/dL (P &lt; 0.001), respectively. For patients diagnosed with hypertension (N = 132), SBP rose from 126.2 mm Hg to 131.5 mm Hg (P &lt; 0.001) and to 133.9 mm Hg (P &lt; 0.001), respectively. An increase in A1c after discharge was associated with lower discharge A1c (P = 0.014), higher consultation weight (P = 0.009), and higher discharge weight (P = 0.042). A rise in LDL was correlated to higher consultation LDL (P = 0.006), while higher SBP was associated with lower discharge SBP (P &lt; 0.001). Twelve percent of patients were reconsulted to the RRC. A1c, LDL, and SBP rose after discharge from the pharmacist-managed risk reduction clinic, but these changes may not have been clinically significant based on the low reconsultation rate and values remaining close to generally accepted therapeutic goals. Patients likely to benefit from extending RRC services past goal attainment include those with higher A1c and LDL at the time of consultation and those with higher weight. As a result of this study, recommendations have been made to consider following up every 3-4 months for 2-3 additional visits for patients with baseline A1c &gt; 8% and LDL &gt; 115 mg/dL and those with weight &gt; 220 pounds prior to discharging them from the CGVAMC RRC. Furthermore, we believe that all patients could benefit from extending follow-up to 6 months for 1-2 additional visits or as needed after their therapeutic goals have been reached." }, { "id": "pubmed23n0637_18409", "title": "[Treatment of diabetes in metabolic syndrome].", "score": 0.009009009009009009, "content": "Hyperglycaemia is a typical feature of metabolic syndrome (MeTS) and one of its independent diagnostic criteria. The term includes impaired glucose homeostasis (impaired fasting glucose and impaired glucose tolerance) and type 2 diabetes mellitus. Although glycaemic control has been shown to lower the risk of microvascular events, the effect of intensive glycaemic control on macrovascular outcomes is less clear. Epidemiological studies show hyperglycaemia, particularly the postprandial one, to be a clear risk factor for cardiovascular (CV) mortality and morbidity. However, the intervention studies are less conclusive. The large interventional studies published in 2008 and 2009 (UKPDS, VADT, ACCORD, ADVANCE, RECORD) advocate the controlling of nonglycemic risk factors (through blood pressure control, lipid lowering with statin therapy, aspirin therapy, and lifestyle modifications) as the primary strategies for reducing the burden of CV disease in people with diabetes, and demonstrated the need for individualized approach to the patients' care in terms of blood glucose control. The patients with shorter duration of type 2 diabetes and without established atherosclerosis might reap CV benefit from intensive glycemic control. Conversely, it is possible that potential risks of intensive glycaemic control (hypoglycaemia) may outweigh its benefits in other patients, such as those with a very long duration ofdiabetes, known history of severe hypoglycemia, advanced atherosclerosis, and advanced age/frailty. According to the latest recommendations of the Czech Diabetes Society that are in line with the European and US standards the best way to protect type 2 diabetic patients against coronary and cerebrovascular disease is to target all cardiovascular risk factors (blood pressure treatment, including lipid-lowering with statins, aspirin prophylaxis, smoking cessation, and healthy lifestyle behaviors hypertension, dyslipidemia, obesity and other symptoms of metabolic syndrome. The target HbA1c levels in patients with the low CV risk shoul be below 4.5%. Less strict goals (HbA1c below 6%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions or those with long-standing diabetes. The individual targets should be achieved safely (without hypoglycaemias). Slow advancing in diabetes compensation is preferred. Lifestyle changes are the cornerstone of therapy. Metformin is the drug of choice; its administration, together with lifestyle changes, should be initiated immediately after the diagnoses of diabetes. If monotherapy does not provide satisfactory glucose control, other oral antidiabetic agents or insulin are added to the combination. Since it is not known which hypoglycaemic agents are beneficial from the perspective of long-term patient prognosis, the selection is liberal. Contraindication of the various farmaceuticals must be respected. It is possible to use a range of different combinations, metformin is administered with a glitazone (zero risk of hypoglycaemias is the advantage) with sulphonylurea derivatives (low price is the advantage) with glinides, with incretins, acarbose, antiobesity agents or insulin. The next step is a triple combination of hypoglycaemic agents with different mechanisms of action. Therapy also includes education focusing on changes to dietary and lifestyle habits, including smoking cessation, and education related to the prevention of complications, with particular regard to prevention of diabetic foot and atherosclerosis." }, { "id": "pubmed23n0565_6136", "title": "[The best of epidemiology and cardiovascular prevention in 2006].", "score": 0.008928571428571428, "content": "The recent analysis of the French MONICA registries report a reduction in the incidence of fatal MI related to improvement of care whereas the overall incidence of coronary events remain stable, suggesting the need for a better primary prevention. The extensive review of the death certificates and the analysis of the death classification from the same registries indicate an under estimation of MI-related death in the national death registry. It is also confirmed that instead of 50%, approximately 80% of coronary death are explained by the four major risk factors including smoking, hypercholesterolemia, hypertension and diabetes. The international REACH registry has enrolled more than 67 000 individuals including patients with symptomatic atherothrombotic disease and patients with multiple risk factors. The analysis of baseline characteristics and of the one year FU shows a high residual risk and a lack of efficacy of secondary prevention. The existence of a symptomatic disease and the number of symptomatic localization of atherothrombosis are critical factors to predict recurrence of major vascular events Secondary analysis of the INTERHEART study provide the essence of what should any physician know about the relationship between coronary heart disease and smoking, either active or passive. Prevention with respect to this risk factor remains very insufficient. Varenicline, a new nicotinic receptor partial agonist, should help patients involved in smoking cessation program. The established detrimental effects of perioperative smoking represent a unique opportunity to promote smoking cessation in individuals scheduled for surgery. The major cardiovascular impact of second hand smoking has been recently demonstrated by the short-term effects of banning smoking in public places on the incidence of acute coronary events. The SPARCL study has demonstrated the benefit of high dose of atorvastatine to prevent recurrent acute ischemic cerebrovascular event in patients with a prior history of stroke or TIA. In the open ASTEROID study, high doses of rosuvastatine confirm the possibility of reducing the volume of coronary atheroma analyzed by IVUS. The expected benefit of glitazones to reduce the incidence of death, MI and stroke in diabetes patients with a prior history of vascular event has been confirmed in the PROactive study. Pioglitazone provided a clear reduction of recurrent vascular events in diabetes patient with a prior MI at a cost of a significant increase of the risk of heart failure. In the DREAM study, neither ramipril nor rosiglitazone have reduced the incidence of cardiovascular events significantly. The moderate benefit of the fenofibrate to prevent cardiovascular events in the FIELD study, which was carried out in diabetics mostly in primary prevention, needs to be considered after adjustment on statin use in a higher proportion of patients of the placebo group. Postprandial hyperglycaemia, analyzed by the peak of glycaemia after a load in glucose, has been confirmed as a more powerful independent predictive factor of the risk of cardiovascular event than fasting glycaemia. The systematic screening postprandial hyperglycaemia represents an interesting strategy for primary prevention which warrants further investigation. If obesity is a risk factor whose impact on morbi-mortality is well established, a French study shows that body mass index has an unfavourable influence on the cognitive functions in middle-aged men and women." } ] } } }

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{ "1": "Do not perform treatment and annual Rx control.", "2": "Sputum culture for mycobacteria and treat only if positive.", "3": "Isoniazid for 9 months.", "4": "Treatment with 4 drugs 4 months.", "5": "Treatment with RIF and PRZ for 2 months." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en039_79799", "title": "Tuberculosis management", "score": 0.01409470277635837, "content": "Deviations from the standard regimen There is evidence supporting some deviations from the standard regimen when treating pulmonary TB. Sputum culture-positive patients who are smear-negative at the start of treatment do well with only 4 months of treatment (this has not been validated for HIV-positive patients); sputum culture-negative patients do well on only 3 months of treatment (possibly because some of these patients never had TB at all). It is unwise to treat patients for only three or four months, but all TB physicians will have patients who stop their treatment early (for whatever reason), and it can be reassuring to know that sometimes retreatment is unnecessary. Elderly patients who are already taking a large number of tablets may be offered 9HR, omitting PZA which is the bulkiest part of the regimen." }, { "id": "wiki20220301en022_111616", "title": "Isoniazid", "score": 0.013660388595250502, "content": "Isoniazid has been approved as prophylactic therapy for the following populations: People with HIV infection and a PPD (purified protein derivative) reaction of at least 5 mm induration Contacts of people with tuberculosis and who have a PPD reaction at least 5 mm induration People whose PPD reactions convert from negative to positive in a two-year period – at least 10 mm induration for those up to 35 years of age, and at least 15 mm induration for those at least 35 years old People with pulmonary damage on their chest X-ray that is likely to be due to healed tuberculosis and also have a PPD reaction at least 5 mm induration Injection drug users whose HIV status is negative who have a PPD reaction at least 10 mm induration People with a PPD of greater than or equal to 10 mm induration who are foreign-born from high prevalence geographical regions, low-income populations, and patients residing in long-term facilities" }, { "id": "pubmed23n0659_18386", "title": "[Consensus document on the diagnosis, treatment and prevention of tuberculosis].", "score": 0.013006756756756757, "content": "Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest x-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when &gt;or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained." }, { "id": "pubmed23n0660_488", "title": "[Consensus document on the diagnosis, treatment and prevention of tuberculosis].", "score": 0.013000717572073783, "content": "Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest X-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when &gt;or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained." }, { "id": "pubmed23n0007_2489", "title": "[Chemotherapy of the source and the risk of infection in home contacts].", "score": 0.011407214819629509, "content": "An attack treatment with 3 drugs during 4-6 months and a consolidation treatment with 2 drugs then INH was applied in 595 cases detected between July 1, 1968 and June 30, 1972, i.e. 264 group A (positive), 200 group B (negative cultures) and 131 group C (pleuretics). The contacts had been in close contact with the source for at least three months before establishing the diagnosis; 549 had been vaccinated at birth with BCG and 209 revaccinated; 413 had undergone chemoprophylaxis with INH. The control group comprised 1008 subjects, the mean age of the groups being very close; they were followed up for 2 years and 1 month and 2 years and 7 months. Testing was done every year with 1 u PPD IC 65. The contacts were controlled annually by radiophotography and X-ray and the controls only in case of shifting of the test. Among the contacts there were 44 conversions in the subjects with an initial tuberculin reaction of 0-5 mm and 4 in those with an initial tuberculin reaction of 6-9 mm, representing 15.1% (group A 27.7%, group B 9,8%, group C 10.5%). Three months after the initiation of chemotherapy the proportion of conversions in the three groups (group A 12.3%, group B 5.9%, group C 10.5%) was equal to that of the controls (8.8%). The next year there were 11.2% conversions among the contracts (group A 11.4%, group B 9.6% and C 17.7%) as against 11.9% among the controls. In the first year 8.3% of the contacts contracted tuberculosis (A 15.6%, B 2.4%, C 4.0%) and 0.32% of the controls. The next year 2.8% of the contacts fell ill (A 4.3%, B 2%, C 0%) and 0.5% of the controls. Among group A contacts aged 0 to 6 years there were 31.7% conversions and 30.7% cases of tuberculosis in the first year, and 7.1% and 1.8% respectively in the following year. Group B and C presented 10.9% conversions and 6% cases of disease in the first year, and no case of tuberculosis in the second year. Chemotherapy reduced conversions and sickness in this group three months after the diagnosis was established." }, { "id": "article-22941_50", "title": "HIV-1–Associated Opportunistic Infections -- Treatment / Management", "score": 0.010761238337574214, "content": "Mycobacterium tuberculosis: Drug-susceptible TB infection is treated for 6 months using a combination of isoniazid (INH), pyrazinamide (PZA), rifampin (RIF) or rifabutin, and ethambutol (EMB) for 2 months by directly observed therapy (DOT), followed by INH and RIF for 4 months. In patients with cavitary disease noted on chest X-ray or those with positive cultures, the treatment should be for a total of 9 months with an additional 3 more months of INH and RIF. All patients receiving INH therapy must be prescribed pyridoxine supplements. Extrapulmonary TB except for CNS disease, bone, and joint involvement, should be treated for 6 to 9 months (2 months of INH, PZA, RIF, and EMB, followed by 4 to 7 months of INH and RIF). In patients with CNS, bone, and joint diseases, treatment must be for 9 to 12 months. Intermittent dosing has better medication compliance rates when administered by DOT and achieves higher peak serum concentration. [21]" }, { "id": "InternalMed_Harrison_13594", "title": "InternalMed_Harrison", "score": 0.010285890489405753, "content": "Culture Results Intensive Phase Continuation Phase Extension of Total Treatment Culture positive HRZE for 2 months, daily or intermit-HR for 4 months, daily or 5 d/wk To 9 months, if 2 months of Z is not completed or culture tent (with dose adjustment) or conversion is prolonged and cavitation is evident on plain radiographa HR for 4 months, intermittent (with dose adjustment) Culture negative HRZE for 2 months 2 months To 6 months, if patient is infected with HIV Extrapulmonary HRZE for 2 months HR for 4–7 months, daily or 5 d/wkb To 9–12 months in TB meningitis. Some recommend 9 months for bone/joint TB. Resistant to H QRZEc or, less often, RZES for 6 months … Prolonged culture conversion, cavitation Resistant to R HZEQc (IAd) for 2 months HEQ(S) for 10–16 months Prolonged culture conversion, delayed response" }, { "id": "Surgery_Schwartz_4788", "title": "Surgery_Schwartz", "score": 0.009966535719482032, "content": "when 2 months of treatment has been completed. If cavities were seen on the initial chest radiograph (CXR) or the acid-fast bacillus (AFB) smear results are positive at completion of 2 months of treatment, the continuation phase of treatment should consist of INH and RIF daily or twice daily for 4 months to complete a total of 6 months of treatment. If cavitation was present on the initial CXR and the culture results at the time of completion of 2 months of therapy are positive, the continuation phase should be lengthened to 7 months (total of 9 months of treatment). If the patient has HIV infection and the CD4+ cell count is <100/µL, the continuation phase should consist of daily or three times weekly INH and RIF. In HIV-uninfected patients with no cavitation on CXR and negative results on AFB smears at completion of 2 months of treatment, the continuation phase may consist of either once weekly INH and rifapentine (RPT) or daily or twice weekly INH and RIF to complete a total of 6" }, { "id": "pubmed23n0694_17714", "title": "Results at 30 months of a randomised trial of two 8-month regimens for the treatment of tuberculosis.", "score": 0.009900990099009901, "content": "An 8-month isoniazid (INH, H) and ethambutol (EMB, E) based regimen recommended by the World Health Organization (WHO) had never been evaluated in a randomised controlled multicentre trial. To compare, in a non-inferiority study design, two 8-month INH+EMB-based regimens with a standard INH and rifampicin (RMP, R) based regimen. A total of 1355 patients with newly diagnosed smear-positive pulmonary tuberculosis were randomly allocated to receive 1) daily EMB, INH, RMP and pyrazinamide (PZA, Z) for 2 months, followed by EMB+INH for 6 months (2EHRZ/6HE); 2) the same drugs in the intensive phase but given three times weekly, followed by the same continuation phase of daily EMB+INH (2(EHRZ)(3)/6HE); or 3) a control regimen with the same intensive phase as in regimen 1, followed by 4 months of daily RMP+INH (2EHRZ/4HR). All patients were to be seen and sputum examinations for microscopy and culture carried out at regular intervals up to 30 months after randomisation. At 30 months, failure/relapse rates were 11.7% of 281 2EHRZ/6HE, 15.3% of 301 2(EHRZ)(3)/6HE and 6.0% of 282 2EHRZ/4HR patients (χ(2), 2 degrees of freedom = 12.8, P = 0.002). These results confirm earlier findings demonstrating the inferiority of the INH+EMB-based regimens to the standard 6-month regimen. The WHO has withdrawn its recommendation of these regimens." }, { "id": "wiki20220301en029_96904", "title": "Heaf test", "score": 0.009828904259191846, "content": "The reading of the Heaf test was defined by a scale: Negative - No induration, maybe six minute puncture scars Grade 1 - four to six papules (also considered negative) Grade 2 - Confluent papules form indurated ring (positive) Grade 3 - Central filling to form disc (positive) Grade 4 - Disc >10 mm with or without blistering (strongly positive) Grades 1 and 2 could result from previous BCG or avian tuberculosis, rather than human TB infection. Children who were found to have a grade 3 or 4 reaction were referred for X-ray and follow-up. For interpretation of the test, see Tuberculosis diagnosis. Other tests The equivalent Mantoux test positive levels done with 10 TU (0.1 mL 100 TU/mL, 1:1000) are 0–4 mm induration (Heaf 0-1) 5–14 mm induration (Heaf 2) >15 mm induration (Heaf 3-4) The Mantoux test is preferred in the United States for the diagnosis of tuberculosis; multiple puncture tests, such as the Heaf test and Tine test, are not recommended. References" }, { "id": "pubmed23n0368_18354", "title": "Tuberculosis verrucosa cutis associated with tuberculous lymphadenitis.", "score": 0.00980392156862745, "content": "A 34-year-old man presented with a large cutaneous lesion on his left thigh that had started as a small papule when he was 13 years of age. The lesion had enlarged slowly over the last 21 years. The patient had received bacillus Calmette-Guérin (BCG) vaccination in childhood. The family history was significant for tuberculosis. Clinical examination revealed a large, purplish-red, indurated plaque measuring 30 x 29 cm on the left thigh, extending to the buttock area. The edges of the lesion had a serpiginous contour with an involuted center (Fig. 1). A left inguinal lymph node was palpated. Chest X-ray and blood cell count were normal. No other focus of disease was identified. Laboratory testing for human immunodeficiency virus (HIV) infection was negative. Purified protein derivative (PPD) intradermal injection disclosed a 19-mm skin induration. Both the cutaneous lesion and the inguinal lymph node were biopsied. Histopathologic sections of the skin fragment showed epidermal hyperkeratosis, neovascular proliferation, and a dense dermal lymphocytic infiltrate. The histopathology of the lymph node demonstrated few granulomas with focal areas of central necrosis. Staining for fungus was negative. Ziehl-Neelsen staining was negative on both the skin and lymph node specimens. Culture for fungus and Leishmania sp. was negative. Tissue culture on Lowenstein-Jensen medium from skin and lymph node was positive for Mycobacterium colonies after 5 and 7 weeks, respectively. Multidrug therapy was instituted with rifampin 600 mg/day, isoniazid 400 mg/day, and pyrazinamide 2 g/day for 2 months, and then rifampin 600 mg/day and isoniazid 400 mg/day alone for the next 4 months. An excellent response was obtained at the end of treatment (Fig. 2)." }, { "id": "pubmed23n0788_11417", "title": "HIV-infected patients retreated for tuberculosis with intermittent Category II regimen--treatment outcome at 24-month follow-up.", "score": 0.00980392156862745, "content": "The management of tuberculosis re-treatment in HIV-infected individuals is complex. The clinical and radiological manifestations in this group and response to Category II treatment is not well described. We performed a prospective cohort study of HIV-infected patients retreated for TB due to failure, relapse or default after treatment, at Tuberculosis Research Centre, Chennai, between February 2001 to September 2005. The Category II regimen followed in the TB programme in India (RNTCP) was administered (2 months of Streptomycin (S), Ethambutol (E), INH (H), Rifampicin (R), Pyrazinamide (Z)/1 month of EHRZ/5 months of HRE all given thrice weekly). Antiretroviral treatment was not routinely available at that time. Of the 42 patients enrolled, 35 (83%) were males. The mean age was 33.2 (SD-6.3) years. Cough was the commonest (67%) presenting symptom and opacities were the commonest (48%) radiographic occurrence. 31 patients were culture-positive at baseline, drug susceptibility results showed that 21 (68%) were fully susceptible to all first line drugs, four patients (13%) had MDR TB and four had resistance to INH alone. Among the 31 culture-positive patients, 15 patients (48.4%) completed treatment and were declared cured, of whom two subsequently relapsed. All four MDR patients died. Six patients who received ART, survived. Only 50% of HIV-infected, ART-naive patients who were retreated for tuberculosis using an intermittent Category II regimen had a favourable response to treatment. Early detection of MDRTB and concurrent antiretroviral therapy could contribute to improved outcomes." }, { "id": "Surgery_Schwartz_4781", "title": "Surgery_Schwartz", "score": 0.009766522658332567, "content": "accuracy. Chest CT scan can delineate the extent of parenchymal disease.Management Medical therapy is the primary treatment of pul-monary tuberculosis and is often initiated before a mycobacte-rial pathogen is definitively identified. Combinations of two or more drugs are routinely used in order to minimize resistance, which inevitably develops with only single-agent therapy. A current treatment algorithm is outlined in Fig. 19-32. Gener-ally, therapy lasts about 26 weeks (2 months intensive therapy followed by 4 months continuation therapy). A 7-month con-tinuation phase should be considered for patients with cavitary pulmonary TB who remain positive on sputum culture after the 2-month intensive therapy, those patients who did not receive pyrazinamide during the intensive phase, HIV-positive patients who did not receive concomitant antiretroviral therapy, and patients treated with INH and rifapentine once weekly (not rec-ommended) who have persistent positive sputum after 2 months of" }, { "id": "pubmed23n0053_8671", "title": "[Controlled trial of short-term chemotherapy in pulmonary tuberculosis, final study].", "score": 0.009708737864077669, "content": "178 new cases of tuberculosis of the lungs and pleura have been treated within the period of four years (1985-1988) in military medical institutions of the Y.P.A. The patients were classified by random selection in two therapeutical groups. Two six-month regimens were applied with the same drugs except for the fourth one which was used in the initial period only (EHRZ and SHRZ). Both applied therapeutical combinations were equally successful. All patients achieved negative cultures at least three months after onset of chemotherapy. Relapses occurred in 4 (2.3%) of patients during the period of follow-up for at least 2 and the most 5.5 years after the end of therapy. The toxic effects were tolerable. The drug resistance was found in 25 of 134 (18.6%) patients, the most common to one drug." }, { "id": "pubmed23n0834_8898", "title": "Prevalence of latent tuberculosis infection in patients with moderate to severe psoriasis taking biologic therapies in a dermatologic private practice in Miami, Florida.", "score": 0.009615384615384616, "content": "The reactivation of a latent tuberculosis infection is one of the possible major events that may occur during biologic therapies for inflammatory chronic diseases such as psoriasis. Although its main screening test is regularly used in clinical practice, there are few studies about the prevalence of this silent mycobacterial infection and the rate of positive convertors during treatment. To assess the prevalence of latent tuberculosis infection (LTBI) in patients with moderate to severe psoriasis receiving biologic therapy by using tuberculin skin test as a screening method and to evaluate the rate of conversion of tuberculin skin test (TST) during the treatment with biologics. A total of 445 patients were included in our retrospective study, conducted from January 2006 to September 2012. Tuberculin skin test was performed in all patients prior to treatment and once a year during the follow-up. PPD was considered positive with an induration above 5 mm, following the recommendations of Centers for Disease Control and Prevention/ America Thoracic Society. Data analysis was obtained with SPSS 20.0. The prevalence of LTBI in our population before initiating the treatment was 4.5% by using TST screening method. During the treatment, 10 cases that were initially TST-negative became positive. Only one of the patients developed active tuberculosis infection. The other 9 TST-positive patients were detected during the regular annual screening, and no symptoms or findings on chest x-ray were seen. All the patients were treated with isoniazid (INH) for nine months, and biologic therapy was restarted after one month of treatment with INH without development of overt TB infection in any of them during the follow-up period of the study. The mean time to becoming TST positive from start date was 26.7 months (range from 8 months to 5 years). As the PPD was done annually, it is unknown exactly when the patients became TST positive. Prior to initiating treatment, 20 patients were found to be TST positive. All patients had clear chest x-rays and were treated with nine months of INH prior to initiating biologic therapy at least month later. The use of a screening tool for LTBI is mandatory in patients taking biologic therapies to avoid severe infectious complications. Periodic follow-up is also crucial as positive results may be seen after prolonged use of these agents." }, { "id": "pubmed23n0287_18051", "title": "[Efficacy and tolerance of the treatment of tuberculosis in the aged].", "score": 0.009615384615384616, "content": "We analyzed 55 confirmed cases of tuberculosis in patients over 65, a sample that amounted to 9% of all patients seen in our practice over a period of 5 years. Mean age was 72.4 and the male/female ratio was 4/1. The most frequently associated diseases were tobacco addiction (49%), chronic obstructive pulmonary disease (33%), alcoholism (25%) and prior diagnosis of tuberculosis (20%). Lung involvement was the most common clinical presentation (76%), followed by pleural (9%) and skeletal (7%) involvement. The clinical picture was non specific, with 13% remaining asymptomatic. Cough was the most frequent symptom (45%) and unilateral apical fibrosis with ulceration was the most frequent radiological finding. Pleural discharge and cavitation were demonstrated in 14 and 22%, respectively. Scarring was visible on X-rays in 44%. The tuberculin test was positive in 88% of the cases in which it was performed. Mean delay in diagnosis was 3.4 months; 62% were diagnosed by sputum test, 11% by culture, and 27% histology. In 4% death was directly caused by tuberculosis. Three patients withdrew from treatment, in one case treatment failed, and there was one relapse detected at follow-up. We observed adverse side effects in 33%, and found no statistically significant differences between the 2 therapeutic protocols used (2 months RHS/7 months RH and 2 months RHZS/4 months RH). The incidence of tuberculosis among the elderly is low in our practice and the entity behaves much as it does in the rest of the adult population. Both the efficacy and tolerance of treatment can be considered optimal." }, { "id": "pubmed23n0524_1388", "title": "[Two cases of Mycobacterium szulgai pulmonary disease in the elderly].", "score": 0.009523809523809525, "content": "The rate of pulmonary nontuberculous mycobacteriosis (NTM) in the total pulmonary mycobacteriosis has been continuously increasing. While M. avium complex is the most common cause of NTM, there are a few case reports of pulmonary infection due to M. szulgai. We described two cases of pulmonary NTM caused by M. szulgai. A 75-year-old male was admitted to our hospital because of dyspnea on effort, and productive cough. A chest X-ray showed an infiltrative shadow with cavity in the right upper lobe. A sputum smear for mycobacteria was positive, and a culture grew M. szulgai which was identified by DNA-DNA hybridization. He was treated with isoniazid, rifampicin, and ethambutol. His symptoms and CT and X-ray findings improved, and his sputum smear and culture converted to negative for mycobacteria. Second case was a 73-year-old male who had previously been diagnosed as MAC and pulmonary aspergillosis, and had been treated with antituberculous and antifungal drugs. He was readmitted to our hospital, because of general fatigue and hemoptysis. A chest X-ray revealed a consolidation with bronchiectasis and cavity in the both upper lung fields. A sptum smear for mycobacteria was positive, and a grown culture was identified as M. szulgai. He was treated with rifampicin, ethambutol and kanamycin based on the results of susceptibility testing. After 3 months of this treatment his sputum smear and culture converted to negative for mycobacteria, and his symptoms, and CT and X-ray findings improved." }, { "id": "pubmed23n0375_14274", "title": "Evaluation of tuberculosis control by periodic or routine susceptibility testing in previously treated cases.", "score": 0.009523809523809525, "content": "A national tuberculosis control programme (NTP) disposing of baseline drug resistance rates and using 2EHRZ/6TH in the treatment of new cases. To estimate the extent of drug resistance created by the NTP. Resistance rates in 2EHRZ/6TH failure and relapse cases were compared to baseline, and resistance profiles of repeat isolates were checked. Numbers of observed resistant failures were compared to numbers expected due to pre-existing resistance. Trends of resistance in combined new and previously treated cases were extrapolated. High drug resistance rates were observed. Changes in resistance to streptomycin, the virtual absence of documented acquired resistance and a close match of observed with expected resistant failures all indicated accumulation of primary drug resistance as the main mechanism. Resistance in relapse/failure cases showed a significantly declining trend, and estimated combined drug resistance decreased rapidly. Drug resistance in previously treated cases seems to consist of passed-on primary rather than true acquired resistance. A one-time survey is thus confusing, but continuous routine testing may constitute the best drug resistance monitoring method. Cases previously treated with short-course chemotherapy may show drug resistance much more frequently than generally assumed, and all should receive a re-treatment regimen. The 2EHRZ/6TH regimen proved very safe under field conditions, causing no 'amplification' towards multidrug resistance and almost no acquired isoniazid resistance. Implementation of this regimen, together with a standardised re-treatment regimen, seemed to rapidly reduce isoniazid as well as multidrug resistance levels, despite the fact that directly observed treatment was not strictly applied." }, { "id": "pubmed23n0047_1164", "title": "[A case of sarcoidosis with primary acute pulmonary cavitation].", "score": 0.009433962264150943, "content": "A 23-year-old man was admitted to our hospital on June 24, 1991, because of worsening chest X-ray findings of sarcoidosis. In August 1990, he was referred to our outpatient office, because of BHL and nodular lesions on chest X-ray film performed at his company 4 months earlier. At that time, serum ACE was elevated to 34.0 IU/l, and Ga scintigraphy showed abnormal uptake in bilateral lacrimal and salivary glands, mediastinal and hilar lymph nodes, and in the lung fields. TBLB specimen showed noncaseating epithelioid granuloma with giant cells and negative stains for acid-fast bacilli. Although it was planned to follow this patient without medication, he did not return to our outpatient department. In June 1991, because of worsening of lesions in the lung at annual checkup at his company, he was referred and admitted for steroid therapy. Chest X-ray film on admission showed BHL, multiple nodular lesions in both lung fields, and bullous change in the left upper lobe. Chest CT on admission showed three cavitating lesions within preexisting nodules. PPD skin test was negative, and sputum smears and cultures were repeatedly negative for pyogenic bacteria and acid-fast bacilli. Therapy was initiated with prednisolone 30 mg daily. Four months later, there was marked resolution of BHL and nodular lesions, and the cavitating lesions were no longer visible on chest X-ray film. From the clinical and radiological observations, it is concluded that the cavitating lesions in the present case were primary acute pulmonary cavitation in sarcoidosis, distinct from infection, bullae, or cystic bronchiectasis which are seen in the chronic and fibrotic stages of sarcoidosis." }, { "id": "pubmed23n0560_22425", "title": "[Familial tuberculosis: tracing the contacts of an infectious case].", "score": 0.009433962264150943, "content": "This is a prospective study of 30 cases of smear positive pulmonary tuberculosis, with at least two sputum positive members of the family, seen in the respiratory clinic between January 2003 and June 2004. They constitute the index cases who represent 3.5% of the cases of tuberculosis (n=850) and 2.9% of hospital admissions (n=1034) during the same period. Four patients were HIV positive. In the family circle, all contacts received an intradermal tuberculin test (IDTT) of 10 IU and/or a chest x-ray and/or sputum examination for AFB. Of the 601 contacts 359 (60%) had a positive IDTT with a mean diameter of 13 mm. Active pulmonary tuberculosis was found in 16 contacts giving a prevalence of 2.7% and an incidence of 4.5% (16/359). 67% of the contacts were adults aged 16-87 with a mean age of 35 years. The IDTT was positive with a mean diameter of 12.3 mm. The chest x-ray was abnormal in 40 adults (16.7%) and sputum examination confirmed pulmonary tuberculosis in 14 cases. 33% of the contacts were children (n=119) aged from 3 months to 15 years with the majority (85%) aged under 10. The IDTT was positive with a mean diameter of 12 mm and the chest x-ray was abnormal in 22 cases (18.5%). Two children of 15 years had active tuberculosis. The contacts identified were treated according to the tuberculosis protocol of Senegal (2RHEZ/6EH) with the intensive phase dispensed in hospital. It is of major importance therefore to develop effective strategies of information, education, diagnosis and management for cases of infectious pulmonary tuberculosis." }, { "id": "pubmed23n0871_22379", "title": "Primary Cutaneous Coccidioidomycosis Presenting as a Recurrent Preauricular Cyst.", "score": 0.009345794392523364, "content": "A 31-year-old Filipino active duty marine presented with a 2-year history of a waxing and waning nodule on his left cheek that had been incised and drained on multiple occasions. The patient had no significant medical history other than a positive purified protein derivative test with negative chest x-ray finding treated with a 9-month course of isoniazid in 2010. He denied cough, fever, chills, night sweats, weight loss, joint/bone pain, or prior trauma to the area. On initial examination, there was a 1×1-cm erythematous indurated nodule associated with an overlying violaceous scar on his left preauricular cheek. Since the lesion was presumed to be an inflamed epidermal cyst, it was initially treated with 0.1 cc of interlesional triamcinolone acetonide (10 mg/cc). At 1-month follow-up, the lesion was slightly less indurated, but an excisional biopsy was performed to remove the residual nodule. The biopsy showed an essentially normal epidermis with focal dermal fibrosis below which were multiple collections of histiocytes and multinucleated giant cells surrounded by a dense lymphoplasmacytic infiltrate with numerous eosinophils (Figure 1). A few multinucleated giant cells contained large thick-walled spherules, some with endospores, consistent with Coccidioides immitis (Figure 2). Serological tests showed positive serum for C immitis IgG antibodies with low levels of complement-fixing antibodies (1:2). IgM antibodies were negative. Findings from chest x-ray and bone scan failed to reveal evidence of systemic disease. Although the infectious disease physician felt that the patient most likely had primary cutaneous coccidioidomycosis (PCC), since the duration of the infection was unknown and the patient was Filipino, thereby increasing his risk of dissemination, he was placed on a daily regimen of 400 mg of oral fluconazole until his complement fixation titers became undetectable. " }, { "id": "pubmed23n0044_24686", "title": "[The efficacy of ethambutol compared to streptomycin in the initial quadruple phase of short-term regimens].", "score": 0.009345794392523364, "content": "In order to test comparatively SM and EMB efficacies within quadruple regimens of short-term chemotherapy, two groups of patients with pulmonary tuberculosis at first treatment, sputum positive under microscopic examination, were constituted through randomization. One group (59 cases) was submitted to the standard regimen RHSZ 2/7, and the other (61 cases) to RHZE 2/7. Group structure was homogeneous from the standpoint of case repartition, according to the anatomo-radiological form, therapeutical regimen, and sensitivity to Tb drugs. Both bacteriological and radiological clinical evolutions show, even in the conditions of a short-time interval (2 months), a similar efficacy of SM and EMB within the quadruple regimens in the initially intensive phase of anti-Tb treatment. It is possible that the results may be dependent upon the concomitantly bactericidal action of: rifampicin, hydrazide and pyrazinamide. Therefore, a further testing of the comparative efficacy of the triple regimen RHZ 2/7 with the quadruple RHSZ 2/7 and RHZE 2/7 during a longer follow-up is required." }, { "id": "wiki20220301en039_79869", "title": "Tuberculosis management", "score": 0.009305546538553096, "content": "There are several treatment regimens available: 9H—Isoniazid for 9 months is the gold standard and is 93% effective. 6H—Isoniazid for 6 months might be adopted by a local TB program based on cost-effectiveness and patient compliance. This is the regimen currently recommended in the UK for routine use. The US guidance exclude this regimen from use in children or persons with radiographic evidence of prior tuberculosis (old fibrotic lesions). (69% effective) 6 to 9H2—A twice-weekly regimen for the above two treatment regimens is an alternative if administered under Directly observed therapy (DOT). 4R—Rifampicin for 4 months is an alternative for those who are unable to take isoniazid or who have had known exposure to isoniazid-resistant TB. 3HR—Isoniazid and rifampicin may be given for 3 months. 2RZ—The 2-month regimen of rifampicin and pyrazinamide is no longer recommended for treatment of LTBI because of the greatly increased risk of drug-induced hepatitis and death." }, { "id": "pubmed23n0480_3917", "title": "[Agranulocytosis due to anti-tuberculosis drugs including isoniazid (INH) and rifampicin (RFP)--a report of four cases and review of the literature].", "score": 0.009259259259259259, "content": "We experienced 4 cases of agranulocytosis due to anti-tuberculosis drugs (rifampicin [RFP], isoniazid [INH], ethambutol [EB], streptomycin [SM] or pyrazinamide [PZA]) among some 6,400 tuberculosis patients who underwent chemotherapy over the past 20 years from 1981 to 2002 in our hospital, and the incidence rate of agranulocytosis was estimated at 0.06%. The 4 cases of agranulocytosis were as follows. CASE 1: A 51-year-old woman with right chest pain and fever was admitted to our hospital on Jan 4, 2001. The white blood cell (WBC) count was 5,200/microliter. The tubercle bacilli were cultured in her sputum. The treatment with INH 0.3, RFP 0.45, EB 0.75, PZA 1.2 g/day, allopurinol and teprenone was started on Jan 13. Pyrazinamide and allopurinol were stopped because of hyper-uric acidemia on Feb 7. Agranulocytosis and eosinophilia (WBC 1,300 [Neut 1%, Ly 57%, Eos 35%]) developed on Feb 13. All drugs were withdrawn and G-CSF drug nartograstim 100 micrograms was injected subcutaneously for 3 days. The WBC recovered to normal level and she was thereafter treated with INH, EB and Levofloxacin (LVFX) without any further trouble. Agranulocytosis in this case was supposed to be due to RFP. CASE 2: A 66-year-old man who had had nephrotic syndrome and hypothyroidism and has been treated with prednisolone 10 mg/day was admitted to our hospital on Aug 9, 2000 because of miliary tuberculosis. The tubercle bacilli were cultured in his sputum and the treatment with INH 0.3, RFP 0.45, and EB 0.75 g/day were started on Aug 10, but it was withdrawn on Aug 17 because of general skin eruption. After re-starting treatment with EB and INH on Aug 24, RFP was added in small dosage (0.05 g) on Oct 12, but agranulomatosis (WBC 2,300/microliter [Neut 2%]) developed on Nov 21, and all drugs were withdrawn again. The G-CSF drug filgrastim was used once subcutaneously, and WBC recovered immediately. He was thereafter treated with INH, EB, LVFX successfully. Agranulocytosis was supposed to be due to RFP. CASE 3: A 60-year-old woman without symptoms had abnormal chest roentgenograph, and consulted with our hospital on Aug 26, 2002. The broncho-alveolar lavage fluid was smear and culture-negative, but PCR-TB positive, and the case was diagnosed as pulmonary tuberculosis. Treatment with INH 0.3, RFP 0.45, EB 0.75, PZA 1.2 g/day, alloprinol 300 mg and rebamipide 300 mg/day was started on Sept. 5, 2002. Late in September, she complained of appetite loss. The laboratory data on Oct 3 revealed WBC 900/microliter (Neut 1%, Ly 94%), aspartate aminotransferase (AST) 199 IU/l, and alanine aminotransferase (ALT) 253 IU/l, showing agranulocytosis and drug-induced hepatitis. The chemotherapy was immediately withdrawn and she was admitted to our hospital on the next day. Glycyrrhizin derivative (SNMC) 40 ml was injected for 5 days, and WBC recovered, and AST and ALT also became normal. CASE 4: A 60-year-old man was admitted to our hospital on March 11, 1981 because pulmonary tuberculosis had recurred. He had been treated with SM, PAS and INH in 1973 for pulmonary tuberculosis. On admission examination of blood count and blood chemistry were normal. Treatment with RFP, INH and SM was started on March 11. He stopped out from the hospital on April 17, but in a few days he returned back with sore throat, lower lip swelling and gingival bleeding. Blood cell count on April 24 showed pancytopenia with RBC 226, Hb 7.5, WBC 800 (Ly 96%, Eos 4%) and Plt 10,000/microliter. The bone-marrow showed NCC (nuceated cell count) of 5,500, and megakaryocyte 0. Thereafter ground glass appearance shadows were seen on the whole lung field, and he died May 26. Autopsy showed generalized aspergillosis. It was strongly suspected that either of RFP, INH or SM was responsible for his pancytopenia. We collected another 10 cases of agranulocytosis due to anti-tuberculosis drugs in the world wide literature, and found men/women ratio 5/8 (in one case gender was not known), the duration of chemotherapy before appearance of agranulocytosis 1-3 months, no change in the lymphocyte count of the peripheral blood, and the accompanying of another allergic signs such as skin eruption, blood eosinophilia or drug-induced hepatitis in some cases, and these findings suggest that the mechanism of agranulocytosis due to anti-tuberculosis drugs was allergic in nature." }, { "id": "pubmed23n0317_14250", "title": "Should we take a history of prior treatment, and check sputum status at 2-3 months when treating patients for tuberculosis?", "score": 0.009259259259259259, "content": "Pinetown, South Africa (1975-1983). To determine the value of previous treatment history and sputum smear examination at 2-3 months in predicting treatment failure and relapse in tuberculosis patients treated with four drugs given twice weekly for six months under direct observation. Four cohort studies among 562 ambulant adults with culture positive pulmonary tuberculosis, designed to test the effectiveness of isoniazid 600-900 mg, rifampicin 600 mg, pyrazinamide 2-3 g, and streptomycin 1-2 g, given twice weekly. The same drug regimen was given to all patients irrespective of previous treatment history. Therapy was not changed if smears remained positive at 2-3 months. Positive predictive values of a history of previous treatment for a positive smear at 2-3 months (18.3%), treatment failure (5.2%), and relapse (9.4%) were poor. Although patients with positive smears at 2-3 months were more likely to fail therapy than patients with negative smears (relative risk=4.5, 95% Confidence Interval [CI]: 1.6-12.8), positive predictive value for treatment failure was only 12.5%. Although relapse was more frequent in patients with positive smears than those with negative smears (9.7% vs 6.2%; P=0.4), most patients who relapsed had been smear negative at 2-3 months (18/21). A four-drug rifampicin-containing regimen can safely be given twice weekly under direct observation to both new and retreatment cases, and the 2-3 month smear examination can safely be omitted." }, { "id": "wiki20220301en089_38450", "title": "Latent tuberculosis", "score": 0.009238318754000427, "content": "There are several treatment regimens currently in use: 9H — isoniazid for 9 months is the gold standard (93% effective, in patients with positive test results and fibrotic pulmonary lesions compatible with tuberculosis). 6H — Isoniazid for 6 months might be adopted by a local TB program based on cost-effectiveness and patient compliance. This is the regimen currently recommended in the UK for routine use. The U.S. guidance excludes this regimen from use in children or persons with radiographic evidence of prior tuberculosis (old fibrotic lesions) (69% effective). 6 to 9H2 — An intermittent twice-weekly regimen for the above 2 treatment regimens is an alternative if administered under Directly observed therapy (DOT). 4R — rifampicin for 4-months is an alternative for those who are unable to take isoniazid or who have had known exposure to isoniazid-resistant TB. 3HR — Isoniazid and rifampin may be given daily for three months." }, { "id": "Surgery_Schwartz_4789", "title": "Surgery_Schwartz", "score": 0.009193073300688543, "content": "on AFB smears at completion of 2 months of treatment, the continuation phase may consist of either once weekly INH and rifapentine (RPT) or daily or twice weekly INH and RIF to complete a total of 6 months of treatment (bottom). For patients receiving INH and RPT whose 2-month culture results are positive, treatment should be extended by an additional 3 months (total of 9 months). *EMB may be discontinued when results of drug susceptibility testing indicate no drug resistance. †PZA may be discontinued after it has been taken for 2 months (56 doses). ‡RPT should not be used in HIV-infected patients with tuberculosis or in patients with extrapulmonary tuberculosis. §Therapy should be extended to 9 months if results of 2-month culture are positive. (Reproduced with permission from Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis, Am J Respir Crit Care Med." }, { "id": "pubmed23n0697_18552", "title": "Cutaneous manifestations of Strongyloides stercoralis hyperinfection in an HIV-seropositive patient.", "score": 0.009174311926605505, "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": "pubmed23n0380_4038", "title": "[Efficacy of regimens containing INH, RFP with varied chemotherapy courses on retreated culture positive pneumoconio-tuberculosis].", "score": 0.009174311926605505, "content": "To evaluate the short and long-term effects of regimens containing INH, RFP with varied chemotherapy courses on culture-positive pneumoconio-tuberculosis. 79 patients with culture-positive pneumoconio-tuberculosis were divided into three groups according to chemotherapy duration: 9-months group (M9: 2SHRZ/7HRE) 28 cases, 12-month group (2SHRZ/10HRE) 25 cases, 18-month group (M18: 2SHRZ/10HRE/6HR) 26 cases. Evaluating the efficacy of regimens depended predominantly on sputum bacteriological conversion, and the patients who completed the regimens were followed up for 5-8 years. Sputum negative conversion rates of three groups at the end of chemotherapy were 83%, 96%, 95%, and their recurrent rates in follow-up period 41%, 4% and 5% respectively. Of all patients who completed the regimens bacteriological relapse rates from the first to fourth year are 6%, 8%, 2%, 2% in the follow-up period. There was no bacteriological relapse from fifth to eighth year. It is effective for SHRZ/HRE combination with 12-months course to retreated tubercle bacillus positive pneumoconio-tuberculosis, and it is appropriate for such patients to be followed up for 4-5 years." }, { "id": "pubmed23n0539_8932", "title": "Reversion of the ELISPOT test after treatment in Gambian tuberculosis cases.", "score": 0.00909090909090909, "content": "New tools are required to improve tuberculosis (TB) diagnosis and treatment, including enhanced ability to compare new treatment strategies. The ELISPOT assay uses Mycobacterium tuberculosis-specific antigens to produce a precise quantitative readout of the immune response to pathogen. We hypothesized that TB patients in The Gambia would have reduced ELISPOT counts after successful treatment. We recruited Gambian adults with sputum smear and culture positive tuberculosis for ELISPOT assay and HIV test, and followed them up one year later to repeat testing and document treatment outcome. We used ESAT-6, CFP-10 and Purified Protein Derivative (PPD) as stimulatory antigens. We confirmed the reliability of our assay in 23 volunteers through 2 tests one week apart, comparing within and between subject variation. We performed an ELISPOT test at diagnosis and 12 months later in 89 patients. At recruitment, 70/85 HIV-negative patients (82%) were ESAT-6 or CFP-10 (EC) ELISPOT positive, 77 (90%) were PPD ELISPOT positive. Eighty-two cases (96%) successfully completed treatment: 44 (55%; p &lt; 0.001) were EC ELISPOT negative at 12 months, 17 (21%; p = 0.051) were PPD ELISPOT negative. Sixty (73%) cured cases had a CFP-10 ELISPOT count decrease, 64 (78%) had an ESAT-6 ELISPOT count decrease, 58 (70%) had a PPD ELISPOT count decrease. There was a mean decline of 25, 44 and 47 SFU/2 x 105 cells for CFP-10, ESAT-6 and PPD respectively (p &lt; 0.001 for all). Three of 4 HIV positive patients were cured, all 3 underwent ELISPOT reversion; all 4 not cured subjects (3 HIV-negative, 1 HIV positive) were ESAT-6, CFP-10 and PPD ELISPOT positive at 12 months. Successful tuberculosis treatment is accompanied by a significant reduction in the M. tuberculosis-specific antigen ELISPOT count. The ELISPOT has potential as a proxy measure of TB treatment outcome. Further investigation into the decay kinetics of T-cells with treatment is warranted." }, { "id": "pubmed23n0818_14184", "title": "[The therapeutic effect of regimens containing isoniazid and rifampicin for pulmonary tuberculosis with single isoniazid or rifampicin resistance].", "score": 0.00909090909090909, "content": "To study regimens containing isoniazid and rifampicin for the treatment of pulmonary tuberculosis with isoniazid or rifampicin resistance. Eighty patients with isoniazid or rifampicin resistance, and whose sputum were still positive at the end of 2-month therapy with isoniazid (H), rifampicin (R), pyrazineamide (Z) and ethambutol (E), were retrospectively analyzed from Jan.2009 to Dec.2012 in Guangzhou Chest Hospital. According to the Mycobacterium drug sensitive test (DST) before the treatment with isoniazid and rifampicin, the patients were divided into the sensitive group (either H or R sensitive), the multidrug-resistance group (both H and R resistance) and the single-resistance group (H or R resistance). There were 80 patients (57 females, 23 males) whose sputum was still positive at the end of 2 month treatment. Their ages ranged from 16-80 (average 45) years. Among them, 29 received the first-treatment, while 51 received retreatment. There were 37 cases in the sensitive group, with 18 first-treatment patients and 19 retreatment patients. There were 15 cases in the single-resistance group, with 3 first-treatment patients and 12 retreatment patients. There were 28 cases in the multidrug-resistance group, with 8 first-treatment patients and 20 retreatment patients. After treatment, mycobacterial conversion to MDR-TB occurred in 2 patients in the sensitive group, and in 6 patients in the single-resistance group. The rate of conversion to MDR-TB was higher in the single-resistance group than that in the sensitive group (χ² = 12.849, P = 0.000).Six patients with single H resistance converted to MDR-TB and 2 patients with single R resistance converted to MDR-TB (P &lt; 0.05, RR = 18.0). Single H or R drug-resistance was more common in retreated patients with pulmonary tuberculosis.If regimens containing isoniazid and rifampicin was used to treat patients with single H or R drug-resistance, resistant enlarging effect may appear and lead to MDR-TB. The retreated patients should be monitored as soon as possible for detection of Mycobacterium resistance to H and R, and regimens for H or R-resistance should be used to prevent resistant enlarging effect." }, { "id": "pubmed23n0748_617", "title": "Pearls and oy-sters: tuberculous meningitis: not a diagnosis of exclusion.", "score": 0.009009009009009009, "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." } ] } } }

{ "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": [ [ 37, 143 ] ], "word_ranges": [ [ 8, 23 ] ], "text": "the most frequent cause of acute uncompensated respiratory acidosis in a young person is bronchopneumonia." } }

{ "1": "PET SCAN.", "2": "Lobar pneumonia.", "3": "EAP.", "4": "Alveolar hypoventilation.", "5": "Bronchopneumonia." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0580_1206", "title": "Using 99mTc-DTPA radioaerosol inhalation lung scan as compared with computed tomography to detect lung injury in blunt chest trauma.", "score": 0.012928194993412384, "content": "Detection of pulmonary contusion in patients with blunt chest trauma is very important so as to commence therapy immediately to avoid irreversible damage. The purpose of our study was to evaluate the efficacy of technetium-99m diethylene triamine pentaacetic acid (99mTc-DTPA) aerosol inhalation lung scintigraphy in comparison with chest computed tomography (CT) in the diagnosis of pulmonary contusion at acute blunt chest trauma. Twenty-nine patients with isolated blunt chest trauma were referred to the emergency department of our hospital, and nine healthy people participated in this study. Sixteen patients who had pulmonary contusion on CT scans were referred to as group 1, and 13 patients who had normal CT scans as group 2. Nine healthy people comprised a control group. 99mTc-DTPA aerosol inhalation lung scintigraphy was performed on the first day in all patients. The mean half time (T1/2) and penetration index values of 99mTc-DTPA clearance were significantly lower in groups 1 and 2 compared with the control group. Among the three groups, there were no significant differences in arterial blood gas analysis except for PO2. The mean T1/2 value of 99mTc-DTPA clearance did correlate with PO2 values but not with pH, PCO2, or HCO3 values. 99mTc-DTPA radioaerosol inhalation lung imaging may serve as a useful adjunct and supportive method to chest CT scanning for detecting mild pulmonary contusion." }, { "id": "pubmed23n1131_20894", "title": "Amphetamine toxicity masked by concomitant γ-hydroxybutyrate (GHB) ingestion.", "score": 0.009900990099009901, "content": "We report a case of a young male with amphetamine toxicity initially obscured by concomitant use of gamma-hydroxybutyrate (GHB), and the sympathomimetic symptoms emerged after GHB's effects receded. A 24-year-old unconscious man presented to emergency department showed the following vital signs upon admission: blood pressure 136/58 mmHg; heart rate 79 bpm; SpO2 87% under ambient air; body temperature 36.1 °C; Glasgow Coma Scale score 3. The pupils were not dilated. Arterial blood gas test revealed respiratory acidosis (pH = 7.229, pCO2 = 64.4 mmHg, pO2 = 42.3 mmHg, HCO3 = 26.3 mmol/L). Intubation was performed and the patient was transferred to intensive care unit. The patient regained consciousness and became agitated in association with sinus tachycardia (heartrate 143 bpm; blood pressure 173/61 mmHg). A few hours later, he experienced abrupt desaturation (SpO2 65%) and profuse, pinkish, frothy sputum. Chest radiography revealed a bat-wing perihilar shadowing, and computed tomography showed bilateral ground-glass opacity and an alveolar pattern from acute pulmonary edema. A high dose of benzodiazepine with a midazolam pump at 50 mg/h was administered to relieve symptoms. The patient's friends confessed to concomitant use of amphetamine and GHB. The urine toxicology result was positive for amphetamine (≧500 ng/mL). The patient improved later and was extubated at 4 days after the mitigation of pneumonia and discharged uneventfully 8 days later. In our patient, amphetamine intoxication was initially masked by concomitant use of GHB but appeared as GHB's effect attenuated. We wish to remind clinicians of variable clinical presentations of polydrug abuse." }, { "id": "pubmed23n0252_4997", "title": "[Intra-alveolar hemorrhage. An uncommon accident in a breath holding diver].", "score": 0.009900990099009901, "content": "To date, pulmonary oedema in breath hold divers has only been reported after dives below 50 meters, hypoxaemic syncope being the most common risk. We recently observed a 35-year-old well-trained breath hold diver who was unable to achieve deep inspiration during a high-level competition. After two hours of repeated dives to a depth of 25 meters for approximately 2-minute periods with intermittent recovery the patient developed cough and haemoptysis. The chest X-ray revealed lung images suggestive of intra-alveolar haemorrhage. The patient had taken 1 g of aspirin per os for three days prior to diving. Symptoms subsided spontaneously in 48 hours and one month later all haematology tests were normal except for minimal alteration of platelet aggregation. Pulmonary oedema in breath hold divers is usually attributed to blood shift to the pulmonary circulation related to the lowered intra-thoracic pressure. In our case, oedema was secondary to intra-alveolar haemorrhage favoured by aspirin which should be avoided before breath hold diving." }, { "id": "pubmed23n0071_5569", "title": "[Changes in Po2, Pco2, pH, and HCO3 concentration and flow rates in human parotid saliva by tongue sour stimulation at various intervals].", "score": 0.00980392156862745, "content": "The PO2, PCO2, pH, and HCO3- concentration and flow rates of parotid saliva were observed by tongue stimulation with 3% tartaric acid at various intervals in a human subject after about a one hour rest. The PO2, PCO2, pH, and HCO3- concentrations in parotid saliva were measured with a Blood Gas Analyzer System. The results are summarized as follows: 1) The mean PO2 and PCO2 of parotid saliva immediately before tongue stimulation were about 40 mmHg (range 33-44 mmHg) and 45 mmHg (41-48). There values were similar to those of venous blood. 2) PO2 increased to about 50 mmHg (46-54) 5 to 10 sec. after stimulation, and then 3 to 8 min. later, it decreased to a minimum value of about 28 mmHg (26-29) before returning to the resting level 15 min. after stimulation, when the intervals between stimulations were longer than 2 min., similar changes in PO2 were observed, whereas stimulations every 30 sec. or 1 min. had no effect on PO2. 3) PCO2 increased to about 98 mmHg (85-120) from the resting level of 45 mmHg (41-48) 5 to 10 sec. after stimulation, and returned to the resting level 1 min. after stimulation. When the intervals between stimulations were shorter than 20 min., the peak value of PCO2 by the first stimulation was higher than those induced by the following stimulations. When the interval was 30 sec. or 1 min., only the peak after the first stimulation was observed. 4) The pH of parotid saliva was about 7.4 (7.35-7.5) 30 to 50 sec. after stimulation, and it decreased below 6.5 about 12 min. after stimulation. When the interval between stimulations was 5 min., the pH of the parotid saliva after stimulation was always above 6.5. When the interval between stimulations was 1 min. or 30 sec., it remained at about 7.5. 5) The HCO3- concentration in parotid saliva depends almost exclusively on the pH when Pco2 remained unchanged. When Pco2 was high, however, the HCO3- concentration was affected by the change in Pco2. 6) There was no relationship between changes in the flow rate of parotid saliva and Po2, Pco2, pH, and the HCO3- concentration. Particularly, when the interval between stimulations was shorter than 5 min., the changes in flow rate had no effect on Po2, Pco2, pH, and the HCO3- concentration." }, { "id": "pubmed23n0621_8196", "title": "[A case of traumatic pneumatocele revealed by CT 36 years after blunt chest trauma].", "score": 0.00980392156862745, "content": "An 82-year-old male farmer who came to our clinic in November 2004 had an abnormal mass shadow of soft tissue density in the left lower lobe on his chest radiography. He had once received sudden blunt chest trauma to his left anterior chest wall by heavy farm equipment and this had produced a relative large pulmonary laceration on the basal segment near aorta at age 47 in 1970. One month after the accident, he went to a local hospital for chest radiographic examination. Initially tuberculosis was suspected, but was denied after one year. In 1972 when he was 61-years-old, he had consulted our clinic on the first vivit, for evaluation the findings of the thin-walled parenchymal dead space with air-fluid level at the left basal segment which was confused with pleural effusion for a long time. Needle aspiration performed to the dead space yielded, whitish turbid fluid without tubercule bacillus was obtained. In November 2006, when he was 84-years-old, he again came to our clinic. By chest CT, the abnormal shadow was disclosed as a relatively large unilocular traumatic paneumatocele, 4 x 7cm in size, with an air-fluid level, encircled by a thick wall with noticeable calcification, located in the basal segment of the entirely collapsed lower lobe. From the findings of leucocytes are still found in the fluid of the site of laceration, and both elevation of CRP and the blood sedimentation rate, persistent inflammatory reaction in the lacerated space was suspected. We report a rare case in which a traumatic pneumatocele existed for 36 years. This case suggests the importance of chest CT in the diagnostic procedure of traumatic pneumatocele." }, { "id": "pubmed23n0226_13286", "title": "Long-term submergence at 3 degrees C of the turtle Chrysemys picta bellii in normoxic and severely hypoxic water. III. Effects of changes in ambient PO2 and subsequent air breathing.", "score": 0.009708737864077669, "content": "Western Painted Turtles, Chrysemys picta bellii (N = 5), were maintained submerged and apneic for 90 days: days 0-21 in severely hypoxic water (PO2 = 0-5 mmHg), days 22-43 in aerated water (PO2 approximately 160 mmHg), and days 44-90 again in hypoxic water. From day 90 onward, the water was aerated and the turtles were allowed access to the air; water and air temperatures were maintained at 3 degrees C. Arterial blood samples were taken periodically and analysed for PO2, PCO2, pH, [Na+], [K+] [Cl-], [lactate-], [glucose] and haematocrit. Plasma [HCO3-] was calculated for all samples and total plasma calcium was measured on samples from two animals. Each exposure to low PO2 water caused progressive lactic acidosis and a transient respiratory acidosis with an accompanying fall in plasma [Cl-] and rise in plasma [K+] and [calcium]. During the intervening period in aerated water, blood pH recovered significantly (from 7.33 to 7.74 in 7 days), due primarily to a fall in PCO2 (from 23.5 to 10.6 mmHg), while [lactate-] remained unchanged (at about 50 mM), and [HCO-3] rose slightly. Plasma [K+] promptly returned to nearly normal values. When permitted to breathe on day 90, the three surviving turtles rapidly restored pH to normal by pronounced hyperventilation (PCO2 less than 5 mmHg). Metabolic acidosis, however, disappeared slowly with a t1/2 for [lactate-] and [HCO-3] restoration of about 2 weeks. We conclude that a wintering turtle can stabilize or even slightly improve its acid-base and ionic status by moving from an anoxic environment to well-oxygenated water. Further improvements can be gained by breathing air, but recovery proceeds at a very slow rate if the animal remains at 3 degrees C." }, { "id": "pubmed23n0001_3535", "title": "[Examinations to phenomenon of shock-lung (author's transl)].", "score": 0.009708737864077669, "content": "The pathogenesis of shock lung as well as the success of therapy in this condition was studied in 79 cases of extrathoracic trauma. The water-, hemoglobin-, and DNA contents of the lungs were measured in order to determine the extent of edema, the rate of perfusion, and proliferation. The cases were divided into two groups according to whether they had or had not received medical therapy before death. The data from these two groups were compared using statistical methods in which time of survival was especially taken into account. The fluid balance, pO2, pCO2, central venous pressure, pH of the serum, total serum protein and serum creatinine were also studied in these cases. Results of the study are as follows. Three phases of the posttraumatic syndrome of shock-lung could be distinguished: phase I (initial phase): blood perfusion is increased, edema is beginning to form, and medical treatment has not yet begun. Phase II (early phase = sydrome of early respiratory failure): pulmonary edema is developing rapidly while perfusion is decreasing. Phase III (late phase = syndrome of late respiratory failure): proliferative changes predominante and the edema is still increasing. The mean weight of the lungs was 397 g (s = 170) in phase I, 774 G (S = 361) In phase II, and 1124 g (s = 310) in phase III. The survival times correlated significantly and positively with the amount of water and DNS in the lungs and significantly and negatively to the amount of hemoglobin in the lungs. Thus, increasing pulmonary edema and increasing proliferative changes occurred with decreasing pulmonary perfusion. This correlation was even noted in groups of patients who had not received medical treatment and whose survival times were short. In treated cases, the fluid balance was significantly and negatively correlated to the total serum protein." }, { "id": "pubmed23n0763_17465", "title": "Phosgene exposure: a case of accidental industrial exposure.", "score": 0.009615384615384616, "content": "Phosgene is a rare exposure with strong clinical implications. We report a phosgene exposure that resulted in the patient's death. A 58 year-old man arrived to the emergency department 1 hour after exposure to phosgene with complaints of a sore throat. Initial vital signs were blood pressure 175/118 mmHg, heart rate 98/min, respirations 12/min, and oxygen saturation of 93% on room air. Physical exam revealed few scattered rhonchi, without signs of distress. Initial arterial blood gases (ABG's) revealed pH 7.42, pCO2 43 mmHg, pO2 68 mmHg, HCO3 27 meq/L, and oxygen saturation of 93% on room air. Initial chest x-ray 2 hours after the exposure demonstrated clear lung fields. Approximately 2.5 hours after the exposure, he began complaining of dyspnea, restlessness and his oxygen saturation dropped below 90%. He received nebulized albuterol, 1 gram intravenous methylprednisolone, and 100 % oxygen via face mask. Minimal improvement was noted and he was intubated. The post intubation chest x-ray, 3.5 hours after the exposure, revealed diffuse alveolar infiltrates. Acetylcysteine, terbutaline, and IV steroids were administered without improvement. The patient died 30 hours after exposure. There are many misunderstandings concerning phosgene due to its rare presentation. Traditional treatment modalities are often unproven in human trials and were unsuccessful in this case. This case highlights the significant toxicity that results from phosgene exposure and the challenges of the limited treatment modalities. There is concern for the use of this agent in chemical terrorism." }, { "id": "pubmed23n0375_4914", "title": "[Bronchiolitis obliterans with idiopathic organizing pneumonia. Usefulness and yield of diagnostic techniques and procedures in a series of 20 patients].", "score": 0.009615384615384616, "content": "To assess retrospectively the utility and the profitableness of the diagnostic procedures and techniques in patients with idiopathic BOOP. We studied epidemiological features, clinical manifestations, respiratory function tests, chest radiology, and other diagnostic procedures and techniques, as well as the evolution and the mortality rates in patients with histological diagnosis of idiopathic BOOP during the period 1992-1999. 20 patients (55% F, 45% M). Age: 64 +/- 15 years old, 50% smokers. The mean period elapsed since the beginning of the symptoms and the time of diagnosis was 51 +/- 30 days. The clinical presentation is of a subacute influenza-like illness, with fever, cough, dyspnea and crackles. The more common abnormalities were. WBC (10,949 +/- 2,6429 mm3, ESR 85 +/- 86 UI/L, LDH 309 +/- 86 UI/L. Arterial blood gas: PaO2 64 +/- 9, PaCO2 35 +/- 3 mmHg. Pulmonary function tests: VCF 81 +/- 25%, FEV1/VCF 78 +/- 17%, TLCO 74 +/- 9%, TLCO sb 77 +/- 4%. Radiological evaluation: bilateral multiple patchy alveolar opacities 75%), solitary focal lesion (15%) and interstitial opacities (10%). The bronchoscopy and BAL 10/20 (50%). Transbronchial biopsy 12/20 wit diagnosis (60%). The video assisted thoracoscopic lung biopsy 1/20 (5%) and open lung biopsy 7/20 (35%). Recurrences 8/20 (40%). Mortality rate 3/20 (15%). The idiopathic BOOP is a benign entity clinic inespecific, associated to hypoxemia and bilateral alveolar opacities. The transbronchial biopsy is a diagnostic procedure alternative to the open lung biopsy, in a compatible clínico-radiological context. The response to treatment is acceptable although it presents frequent exacerbations, and low mortality rate." }, { "id": "pubmed23n0353_584", "title": "Continuous monitoring of cerebrospinal fluid acid-base balance and oxygen metabolism in patients with severe head injury: pathophysiology and treatments for cerebral acidosis and ischemia.", "score": 0.009523809523809525, "content": "Continuous monitoring of cerebral acid-base balance and oxygen metabolism has been introduced in neurointensive care settings. The hypothesis of this study utilizing multimodal neuromonitoring modalities is that hyperventilation and hypothermia improve cerebral acidosis through prevention of cerebral ischemia aggravation in patients with severe head injury. Continuous monitoring of cerebrospinal fluid (CSF) pH, PCO2, HCO3-, base excess (BE), PO2, SO2, temperature, lactate and pyruvate (La and Py) measurements were conducted in 8 patients with severe head injury. Temperature-corrected CSF parameters were correlated with those in the jugular blood including oxygen saturation (SjO2), regional oxygen saturation (rSO2), intracranial pressure (ICP) and cerebral perfusion pressure (CPP), jugular blood temperature (Tjb), and endtidal PCO2 (PetCO2). Therapeutic significance of hyperventilation and hypothermia was evaluated. 1) CSF acidosis was observed in all cases (minimum pH 6.59-7.17) due to increased CSF PCO2 and/or decreased CSF HCO3- and tended to associate with abnormal ICP and/or CPP or ischemic episodes indicated by CSF PO2 and SO2, rSO2, and/or SjO2 during monitoring. 2) It was more obvious in CSF than in jugular blood that increased PCO2, La and Py, and/or decreased HCO3- resulted in decreased BE and pH. 3) Decreased CSF PO2 and SO2 only correlated with severe CSF acidosis. 4) Hyperventilation: Decreased PetCO2 did not always closely correlate with CSF PCO2 decrease and CSFpH increase. 5) Hypothermia: There were negative correlations of Tjb with CSF pH and SO2 in all cases, though correlation coefficients were not always high. CSF acidosis caused by increased CSF PCO2, La and Py, and/or decreased HCO3- tended to associate with abnormal ICP and CPP, and desaturation indicated by CSF SO2, rSO2, and/or SjO2. Hypothermia rather than hyperventilation tends to improve cerebral acidosis and ischemia." }, { "id": "pubmed23n0361_3012", "title": "[Preflight assessment by hypoxic inhalation test in cardiopulmonary patients].", "score": 0.009523809523809525, "content": "Flying may expose passengers to hypoxic conditions, which may induce hypoxemia, particularly in those with chronic heart and/or lung disease. Onset of dyspnea, wheezing, chest pain, cyanosis and right heart failure can lead to urgent need for oxygen during flight. The hypoxia inhalation test (HIT) provides a safe and simple means of identifying those who may develop hypoxemia during flight. We report our experience with 48 self-reporting patients who underwent HIT prior to pre-planned air travel. They inhaled for 15-minute periods a reduced oxygen concentration (F1O2 15%) under normobaric conditions, during which O2 saturation was monitored by pulse oximeter; electrocardiogram, blood pressure and symptoms were also monitored. O2 saturation of &lt; 85% (PaO2 50 mm Hg) was considered a positive test. In the 8 cases (17%) with a positive test, 5 had chronic obstructive pulmonary disease and 3 had cardiovascular and/or combined heart-lung disease. We calculated predicted O2 partial pressure in altitude (PaO2ALT) and compared it to actual results in the 8 patients with a positive HIT. In 5, use of the predicted formula would have under-diagnosed the hypoxemia that developed during the HIT. Thus, the results of the HIT changed treatment strategy in these patients. We recommend that patients with positive tests use O2 (2LPM or 4LPM) during flight. HIT is practical and of potential benefit in the objective assessment of patients with various degrees of heart, lung or combined heart-lung disease. Clinicians should be aware of the relative risk of hypoxia during flight in such patients, and of the value of HIT in identifying them, leading to increase in its use." }, { "id": "pubmed23n0525_4588", "title": "Mystery in the basement.", "score": 0.009433962264150943, "content": "56 year-old male presented to the University of Mississippi Medical Center emergency department (ED) with complaints of progressive shortness of breath, productive cough, fever, and malaise. His past medical history was significant for hypertension as well as a 60 pack-year history of smoking. Upon arrival to the ED he had a temperature of 103.6 degrees F, blood pressure of 80/40 mm Hg, a pulse of 110 beats per minute, respirations of 28 per minute, and an oxygen saturation of 50% on room air. He appeared to be in significant respiratory distress. Lung examination revealed diffuse bilateral rhonchi and wheezes in all lung fields. He was emergently intubated. Chest radiograph demonstrated a miliary pattern scattered throughout all lung fields in addition to parenchymal opacities. A complete blood count revealed a white blood cell count of 33,500 10(3)/microL, hematocrit of 37%, and platelets of 906,000 10(3)/uL. Blood urea nitrogen and creatinine were 27 mg/dL and 1.0 mg/dL, respectively. Initial ABG on 100% oxygen showed pH 7.15, pCO2 82 mm Hg, and pO2 62 mm Hg. Troponin I was negative. An electrocardiogram demonstrated sinus tachycardia. Blood and urine cultures were obtained." }, { "id": "pubmed23n0536_698", "title": "[Fire-eater's lung. Two cases and review of the literature].", "score": 0.009433962264150943, "content": "Two men were hospitalized (three years apart) after aspirating petroleum on their fist attempt at \"fire-eating\". Pt.1 (aged 25 years) complained of chest pain, dyspnea and dizziness. The other (Pt. 2; aged 29 years) had a hemoptysis. Pt. 1 had a normal body temperature, but the breath sounds were decreased over the left base. The breath sounds in Pt. 2 were normal, but he had a fever of 38.8 degrees C. Routine physical examination was unremarkable. Laboratory tests in both patients revealed increased inflammatory parameters. Chest radiographs showed that Pt. 1 had a left basal alveolar infiltrate, while Pt. 2 had an infiltrate in the right middle and upper lobe, which on computed tomography after a few days showed signs of cavitation in the left infrahilar region and the middle lobe, respectively. Pneumococci were found in the sputum of Pt. 2. Both patients were given antibiotics, Pt. 1 also had salbutamol inhalation treatment. The patients were discharged symptom-free after 8 and 10 days, respectively. A follow-up chest radiograph four weeks later in Pt. 1 merely showed streaky-fibrotic residues. These two case reports and detailed literature search indicate that immediate administration of antibiotics is important, while routine steroid treatment is not necessary." }, { "id": "pubmed23n0286_14099", "title": "Oxygen status algorithm, version 3, with some applications.", "score": 0.009345794392523364, "content": "The Oxygen Status Algorithm is a computer program which uses measurements from a pH &amp; blood gas analyser and a hemoximeter to calculate the oxygen status and the acid-base status of the arterial blood. Version 3 features on-line data collection from the analyser; storage of up to 2000 patient cases in a Lotus 123 file format; printing of a Cumulated Patient Report in addition to the Patient Status Report; combination of arterial and mixed venous data for calculation of the shunt and the oxygen consumption rate (when cardiac output is keyed in); calculation of reference values for fetal haemoglobin for newborns (when gestational age is keyed in). Examples of applications answer the following questions: 1) Does hyperventilation improve the oxygen supply to the tissues? No, for a normal person a slight hypoventilation with a pCO2 of 8.5 kPa provides a maximal oxygen extraction tension. 2) What is the optimal hyperventilation at the top of Mt. Everest (ambient pressure 33 kPa)? Hyperventilation to a pCO2 of about 1.4 kPa provides a maximal oxygen extraction tension of 2.4 kPa for an unacclimatized person. 3) Which change in haemoglobin oxygen affinity would be equivalent to a decrease in arterial pO2 to 6.3 kPa? The oxygen extraction tension would decrease to 4.0 kPa and the same value would be caused by a decrease in half-saturation tension to 2.8 kPa, a decrease which could be due to a moderate alkalaemia (pH = 7.54) combined with a moderately decreased 2,3-diphosphoglycerate concentration (3.4 mmol/L). 4) Is temperature correction of the measured pO2 and pCO2 to the actual body temperature needed? Yes, for example, omitting temperature correction even when the patient temperature is only slightly decreased to 36 degrees C would result in a negative value for the calculated arterio-venous shunt fraction when the actual value, using temperature correction, is 11%. 5) Does the alpha-stat approach of pCO2 and pH regulation in hypothermia, where pH is allowed to rise as in blood in vitro, cause a fall in mixed venous pO2 below the critical value? No, although the mixed venous pO2 will be lower than with the pH-stat approach (constant pH at body temperature), it remains above the critical mixed venous pO2 level. The program is intended for clinical routine use as well as teaching purposes. It has context sensitive help as well as an extensive help index. A number of \"demo\" cases are provided with annotations in a separate file." }, { "id": "pubmed23n0263_7108", "title": "[The significance of maximal expiratory concentrations of CO2 (MEC CO2) in the negative diagnosis of acute pulmonary embolism in chronic obstructive bronchopneumopathies].", "score": 0.009345794392523364, "content": "The aim of this prospective study was to analyse the contribution of the measurement of alveolar arterial gradients of CO2 during forced expiration in the diagnosis of pulmonary emboli occurring in chronic airflow obstruction (COPD) as a result of smoking. The study was carried out on 178 patients: Group 1: 54 subjects without emboli (14 controls, 33 COPD and 7 patients with chest pain); Group 2: 72 patients with proved emboli (49 non COPD, 23 COPD); Group 3: 52 patients COPD presenting with varied non-embolic broncho-pulmonary pathology (pneumonia, bronchospasm, pulmonary oedema, bronchial neoplasm). The diagnosis of pulmonary emboli was confirmed by scintigraphy in patients with non COPD or angiography (in patients with COPD). The maximal fraction of CO2 was measured using a capnologue during a forced expiration which was long and prolonged until residual volume was achieved. The PaCO2 was measured simultaneously by an analysis of arterial blood gases. The D index was calculated according to the formula [(PaCO2-PEM CO2)/PaCO2] x 100. The D index was significantly lower in Group 1 (3.42 +/- 3.8% p &lt; 0.0001) than in Group 2 (20.8 +/- 10%) and Group 3 (17.6 +/- 11.7%) (not significant between Groups 2 and 3). In patients with COPD the specificity and sensitivity and the predicted positive and negative value were 100% for a D limit of 7%. In COPD patients these values were respectively 82, 95, 75 and 96% for a D limit of 7%; on the other hand for a D below 5% the values were 60, 100, 64 and 100% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "wiki20220301en000_201697", "title": "Hypoxia (medical)", "score": 0.009259259259259259, "content": "Hypoxia exists when there is a reduced amount of oxygen in the tissues of the body. Hypoxemia refers to a reduction in PO2 below the normal range, regardless of whether gas exchange is impaired in the lung, CaO2 is adequate, or tissue hypoxia exists. There are several potential physiologic mechanisms for hypoxemia, but in patients with COPD the predominant one is V/Q mismatching, with or without alveolar hypoventilation, as indicated by PaCO2. Hypoxemia caused by V/Q mismatching as seen in COPD is relatively easy to correct, so that only comparatively small amounts of supplemental oxygen (less than 3 L/min for the majority of patients) are required for LTOT. Although hypoxemia normally stimulates ventilation and produces dyspnea, these phenomena and the other symptoms and signs of hypoxia are sufficiently variable in patients with COPD as to be of limited value in patient assessment. Chronic alveolar hypoxia is the main factor leading to development of cor pulmonale—right ventricular" }, { "id": "pubmed23n0070_1445", "title": "[Traumatic respiratory distress syndrome on plateau: diagnosis and treatment].", "score": 0.009259259259259259, "content": "Twenty-seven adult patients, living at plateau, developed acute respiratory syndrome after severe trauma or major operation, were reported. Seven of them died. The clinical pictures were also of severe air-hunger, cyanosis and hypoxemia associated with diffusive interstitial edema of lungs, while the mean values of blood gases were much less compared with those of patients on plain, being P-a O2 33 mm Hg, Sat. O2 71%, PaCO2 31 mmHg, A-aDO2 426 mm Hg. The diagnostic points of ARDS of patient on plateau have been suggested and the urgent requirement of management for these patients on plateau has been emphasized and described." }, { "id": "pubmed23n0805_1338", "title": "Successful management of drug-induced hypercapnic acidosis with naloxone and noninvasive positive pressure ventilation.", "score": 0.009174311926605505, "content": "A 74-year-old man was referred to our hospital due to deteriorating level of consciousness and desaturation. His Glasgow Coma Scale was 6, and his pupils were constricted but responded to light. Chest radiograph was negative for significant findings. Arterial blood gas evaluation on supplemental oxygen revealed severe acute on chronic respiratory acidosis: pH 7.15; PCO2, 133 mm Hg; PO2,64 mm Hg; and HCO3, 31 mmol/L. He regained full consciousness (Glasgow Coma Scale, 15) after receiving a 0.4 mg dose of naloxone, but because of persistent severe respiratory acidosis (pH 7.21; PCO2, 105 mm Hg), he was immediately commenced on noninvasive positive pressure ventilation (NIV) displaying a remarkable improvement in arterial blood gas values within the next few hours. However, in the days that followed, he remained dependent on NIV, and he was finally discharged on a home mechanical ventilation prescription. In cases of drug-induced respiratory depression, NIV should be regarded as an acceptable treatment, as it can provide ventilatory support without the increased risks associated with invasive mechanical ventilation." }, { "id": "pubmed23n0311_20682", "title": "[Clinical pathological study on 23 pulmonary embolism proved by autopsy].", "score": 0.009174311926605505, "content": "To improve the early diagnosis of pulmonary embolism. The clinical and pathological data of 23 cases of autopsy-proved pulmonary embolism in Beijing hospital from 1951 to 1994 were reviewed. 23 patients: male 18, female 5, age ranged from 34 to 82 years. Misdiagnosis rate was 87%. The unexplained dyspnea, chest pain, sudden onset dyspnea and sudden death were the most frequent symptoms. Arterial blood gas data frequently demonstrated hypoxia and hypocapnia. The most important causes of an incorrect diagnosis could be the failure of suspecting pulmonary embolism, because of the variability of clinical manifestation and the presence of other concomitant diseases. All patients with otherwise severe unexplained dyspnea or chest pain have to be sent for perfusion lung scintigraphy, accordingly, underdetection of pulmonary embolism and mortality of pulmonary embolism could be reduced." }, { "id": "wiki20220301en000_51932", "title": "Blood", "score": 0.00909090909090909, "content": "The term serum refers to plasma from which the clotting proteins have been removed. Most of the proteins remaining are albumin and immunoglobulins. pH values Blood pH is regulated to stay within the narrow range of 7.35 to 7.45, making it slightly basic. Blood that has a pH below 7.35 is too acidic, whereas blood pH above 7.45 is too basic. Blood pH, partial pressure of oxygen (pO2), partial pressure of carbon dioxide (pCO2), and bicarbonate (HCO3−) are carefully regulated by a number of homeostatic mechanisms, which exert their influence principally through the respiratory system and the urinary system to control the acid–base balance and respiration. An arterial blood gas test measures these. Plasma also circulates hormones transmitting their messages to various tissues. The list of normal reference ranges for various blood electrolytes is extensive. In non-mammalian vertebrates" }, { "id": "pubmed23n0058_6842", "title": "[The diagnosis of pulmonary embolism: the role of noninvasive technics].", "score": 0.00909090909090909, "content": "Today a large group of patients with pulmonary embolism is still undetected because this disease is not suspected. We evaluated the role of routine clinical procedures such as history, chest x-ray, electrocardiogram and blood gas analysis in the diagnosis of this disease. We studied 177 patients sent to our observation with suspicion of pulmonary embolism, which was later confirmed in 97 and excluded in 80. Prolonged immobilization, surgical procedures and deep vein thrombosis are the most frequent predisposing factors (P less than 0.05 or less) in patients with pulmonary embolism with respect to patients with unconfirmed suspicion of embolism. Among symptoms and signs, pleuritic chest pain, sudden onset of dyspnea, tachypnea, fever, enlarged jugular veins, enhanced pulmonary component of the second heart sound, pulmonary systolic murmur and basal hypophonesis were the most frequent signs (P less than 0.005 or less) in patients with embolism. Among radiographic signs \"sausage\" descending pulmonary artery, diaphragmatic elevation, pulmonary infarction, Westermark sign and azygos vein enlargement were more frequent (P less than 0.05 or less) in patients with embolism with respect to patients with unconfirmed suspicion of embolism. Among electrocardiographic signs, tachycardia, P-R segment displacement and negative T wave in V1-V2 were more frequent in patients with embolism with respect to patients with unconfirmed suspicion of embolism (P less than 0.05 or less). PO2, standard pO2 and pCO2 were significantly lower (P less than 0.001) in patients with embolism. After discriminant analysis of the whole data set most patients were correctly classified as embolic (90/97) and non-embolic (75/80).(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0419_17156", "title": "[Acute encephalopathy due to thiamine deficiency with hyperammonemia in a chronic hemodialysis patient: a case report].", "score": 0.009009009009009009, "content": "Hemodialysis(HD) patients are at risk for thiamine deficiency because of low intake and accelerated loss of thiamine during HD. We report here an HD patient, an 82-year-old woman, who developed acute encephalopathy due to thiamine deficiency with hyperammonemia. She was admitted to Nishikawa Town Hospital due to pneumonia and was treated with ABPC/SBT for one week. While she was cured of pneumonia, she had a persistently poor appetite. On the twenty-fourth day after admission, HD with intradialytic parenteral nutrition(IDPN), which consisted of 10% glucose 500 ml, in order to correct her malnutrition, was started. She suddenly presented confusion, speech disturbance and ophthalmoplegia. HD with IDPN was stopped after two hours because of her symptoms. Laboratory studies disclosed plasma glucose of 186 mg/dl and serum ammonium of 155 micrograms/dl. Arterial blood gas analysis(inhaling 3 l/min O2) showed severe metabolic acidosis and respiratory acidosis (pH 7.138, pCO2 44.8 mmHg, pO2 108.9 mmHg, HCO3- 15.1 mmol/l). Her malnutrition, unexplained metabolic acidosis and neurological presentation raised the suspicion of acute encephalopathy due to thiamine deficiency. Fursultiamine 100 mg was administered intravenously. After two hours, metabolic acidosis disappeared (pH 7.437, pCO2 33.9 mmHg, pO2 161.0 mmHg, HCO3- 22.9 mmol/l), and she regained her clear consciousness and serum ammonium decreased at 16 micrograms/dl on the next morning. Serum lactate and thiamine level were shown later to be 57.5 mg/dl and 27 nmol/l, respectively. Her clinical course suggests that the glucose load including IDPN may have caused deterioration of the neurological disorder under the condition of thiamine deficiency. Furthermore, it is possible that a relationship exists between thiamine deficiency and hyperammonemia." }, { "id": "wiki20220301en061_14330", "title": "Tony Bland", "score": 0.009009009009009009, "content": "Although Bland survived the initial crush, he had suffered severe brain damage and eventually became the disaster's 96th victim on 3 March 1993, aged 22, after being in a coma for nearly four years. He never regained consciousness and a legal ruling in November 1992 allowed doctors to withdraw his treatment at the request of his family, as there had been no sign of improvement in his condition and the doctors treating him advised that there was no reasonable possibility that he would ever emerge from his persistent vegetative state, and was unlikely to survive more than five years. Injuries and prognosis Bland suffered serious injuries in the crush at the Leppings Lane terrace. He suffered crushed ribs and two punctured lungs, causing an interruption in the supply of oxygen to his brain. As a result, he sustained catastrophic and irreversible damage to the higher centres of the brain, which had left him in a persistent vegetative state (PVS)." }, { "id": "pubmed23n0239_5454", "title": "Pulmonary gas exchange and ventilation during hemodialysis.", "score": 0.008928571428571428, "content": "Hemodialysis-induced hypoxemia has been explained by several mechanisms: pulmonary microembolization, decreased pulmonary diffusing capacity, fall in alveolar oxygen tension, hypoventilation and ventilation/perfusion abnormalities. The objective of this study was to analyze the factors influencing pulmonary ventilation and gas exchange of 20 patients with chronic renal failure during hemodialysis performed under the following conditions: Group 1 (9 patients) dialyzed against an acetate dialysate with a cuprophan membrane; Group 2 (7 patients) dialyzed against acetate bubbled with CO2 with a cuprophan membrane; Group 3 (4 patients) similar to Group 1, but using a polyacrylonitrile membrane. Arterial and venous blood samples were obtained from the respective lines during the predialysis period (zero), at 30, 60, 120 180 and 240 min of hemodialysis, and 60 min post dialysis (300 min) for the measurement of pH, PCO2, PO2, HCO-3 and total CO2. The minute expired volume (VE), expired fractions of O2 (FEO2) and CO2 (FECO2), O2 consumption (VO2), CO2 elimination through the lungs (VCO2) and dialyzer, respiratory exchange ratio (R), dead space to tidal volume ratio (VD/VT), alveolar ventilation (VA) and alveolar-arterial O2 difference (delta AaPO2) were measured and a leukocyte count was performed for each period of hemodialysis. The patients in Groups 1 and 3 showed a significant drop in ventilation and PaO2, a slight decrease in PAO2 and a significant increase in delta AaPO2. The patients in Groups 1 and 2 showed a significant leukopenia at 30 min of hemodialysis. The volume of CO2 eliminated across the dialyzer was very similar for the three groups of patients. Group 2 did not show any drop in ventilation or PaO2. For Group 2 venous line pH was very low and PCO2 was within the normal range, in contrast to the normal or high pH and low PCO2 shown by Groups 1 and 3. This study indicates that the drop in PaO2 was partially the consequence of a slight decrease in PAO2, but mainly due to the increase in delta AaPO2. Thus the most likely cause of the decrease in PaO2 was the VA/Q imbalance brought about by a drop in ventilation. The drop in ventilation was linked not only to the volume of CO2 eliminated across the dialyzer, but also to the amount of CO2 delivered to the lungs, and to the pH and PCO2 of the venous line." }, { "id": "pubmed23n0956_17636", "title": "[Analysis on treatment of extremely severe burn patients with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident].", "score": 0.008928571428571428, "content": "<bObjective:</b To summarize the measures and experience in diagnosis and treatment of extremely severe burn patients with severe inhalation injury in dust explosion accident. <bMethods:</b The medical records of 13 patients with extremely severe burn complicated with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident who were treated at the First Affiliated Hospital of Soochow University (hereinafter referred to as our hospital) on August 2nd, 2014, were retrospectively analyzed. All the patients were transferred to our hospital 3-8 hours after injury under the condition of inhalation of pure oxygen. Twelve patients underwent tracheotomy within 5 hours after admission, while 1 patient underwent tracheotomy before admission. All the patients were in ventilator-assisted respiration, with synchronized intermittent mandatory ventilation combined with positive end expiratory pressure. All the patients underwent thorax or limbs escharotomy on the second day after admission, so as to reduce the restrictive ventilatory dysfunction caused by the contraction of thorax eschar and the terminal circulation disorder caused by the contraction of limbs eschar. All the patients underwent electronic bronchoscopy within 48 hours after admission, airway secretion were cleared and airway lavage were carried out under electronic bronchoscope according to the patients' condition, and the sputum, lavage solution, pathological tissue were collected for microbiological culture. All the patients underwent chest X-ray examination on the second day after admission and reexamination as required. Patients were all treated with a combination of broad-spectrum antibiotics early after admission to control lung and systemic infection. One patient was treated with extracorporeal membrane oxygenation for acute respiratory distress syndrome 1 week after admission. <bResults:</b One patient suffered from cardiopulmonary arrest during tracheotomy, which recovered autonomous respiration and cardiac impulse after cardiopulmonary resuscitation. Three patients showed decreased pulse oxygen saturation (SpO(2)) within 48 hours after injury, and the SpO(2) returned to normal after sputum aspiration, scab removal and lavage under electronic bronchoscope. During the course of disease, bacteria were cultured from wound exudate of 7 patients, bacteremia occurred in 10 patients, and sputum microbiological culture results of 13 patients were positive. Eight of the 13 patients in this group survived, and 5 died. One patient died 19 days after injury, and 4 patients died 33-46 days after injury. The main cause of death was multiple organ dysfunction syndrome induced by severe septic shock eventually. <bConclusions:</b For this batch of patients with extremely severe burn complicated with severe inhalation injury caused by dust explosion accident, the treatment and cure measures including early definite diagnosis and timely tracheotomy, the application of effective ventilation, the effective treatment of respiratory system complications, and rational use of antibiotics for the control of lung infection obtained quite good curative effect." }, { "id": "pubmed23n0501_2843", "title": "Cases from the Osler Medical Service at Johns Hopkins University. Diagnosis: P. carinii pneumonia and primary pulmonary sporotrichosis.", "score": 0.008849557522123894, "content": "PRESENTING FEATURES: A 53-year-old man who had human immunodeficiency virus (HIV) presented to the Johns Hopkins Hospital with a 3-month history of increasing dysphagia, cough, dyspnea, chest pain, and an episode of syncope. His past medical history was notable for oral and presumptive esophageal candidiasis that was treated with fluconazole 6 months prior to presentation. Three months prior to presentation, he discontinued his medications, and his symptoms of dysphagia recurred. During that time he developed intermittent fevers and chills, progressively worsening dyspnea on exertion, and a cough productive of white sputum. He also reported a 40-lb weight loss over the past 3 months. On the day prior to presentation, he had chest pain and shortness of breath followed by weakness, dizziness, and a brief syncopal episode. He denied orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, jaundice, hemoptysis, hematemesis, melena, hematochezia, or diarrhea. There was no history of alcohol use, and he stopped smoking tobacco approximately 1 month previously. He smoked cocaine but denied injection drug use. The patient had never been on antiretroviral therapy and had never had his CD4 count or viral load measured. On physical examination, the patient was a thin, cachectic man who appeared older than his stated age. His vital signs were notable for blood pressure of 102/69 mm Hg, resting tachycardia of 102 beats per minute, resting oxygen saturation of 92% on room air, normal resting respiratory rate, and a temperature of 38.1 degrees C. His oropharynx was clear, with no signs of thrush or mucosal ulcers. His pulmonary examination was notable for diminished breath sounds in the lower lung fields bilaterally. Cardiac, abdominal, and neurologic examinations were normal. His skin was intact, with no visible petechiae, rashes, nodules, or ulcers. Laboratory studies showed a total white blood cell count of 3.2 x 10(3)/microL, with a total lymphocyte count of 330/microL, hematocrit of 30.2%, a serum sodium level of 129 mEq/L, and a serum lactate dehydrogenase level of 219 IU/L. The patient had an absolute CD4 count of 8 cells/mm3 and a HIV viral load of 86,457 copies/mL. His arterial blood gas on room air had a pH of 7.51, a PCO2 of 33 mm Hg, and a PO2 of 55 mm Hg. Electrocardiogram and serial serum cardiac enzymes were normal. A chest radiograph showed bilateral upper lobe patchy infiltrates with left upper lobe consolidation. Computed tomographic (CT) scan of the chest with contrast showed bilateral ground glass infiltrates with focal consolidation (Figure 1) and no evidence of pulmonary embolism. Induced sputum was negative for Pneumocystis carinii, fungi, or acid-fast bacilli. A bronchoalveolar lavage was performed. What is the diagnosis?" }, { "id": "pubmed23n0247_7515", "title": "[Exercise tests in pneumopathy patients].", "score": 0.008849557522123894, "content": "In this prospective work eleven pneumopathes patients were studied, ten of them with HAP, which were subjected to effort prove in endless band, in order to know the electrocardiographic alterations presented during the exercise. The VO2 máx was determined simultaneously in four patients. In the four, the value of this parameter was found under the normal value, which showed us a poor increase of the cardiac expense for the demands in the exercise. If the effort proves had not been practiced, this fact could not have been known. Related to the electrocardiographic alterations, cellular diastolic depolarization signs (cellular damage), product of the cellular damage, were found. The mechanics of this cellular damage, as well as the one of the poor increase of cardiac expense, are mentionned in the discussion." }, { "id": "pubmed23n0054_18310", "title": "[Dynamics of the acid-base balance of venous and arterial blood in clinically healthy calves].", "score": 0.008771929824561403, "content": "Values of the acid base balance were examined in both venous and arterial blood of healthy calves (n = 6) of the Slovak Spotted breed aged, 3, 6, 8, 10, 12, 14, 18, and 24 weeks, respectively. Until week 4 of age the animals were fed milk only, until the age of 9 weeks a milk-roughage transition fodder and from week 10 on they were given classical herbage. Blood samples were taken from the V. jugularis and A. carotis communis or A. axillaris, respectively. The results achieved were corrected to a body temperature of 39 degrees C. During the examination period the following values were stated for both arterial and venous blood: actual acidity (pH) 7.391 +/- 0.014 and 7.362 +/- 0.013 logmolc, pCO2 6.35 +/- 0.15 and 7.35 +/- 0.11 kPa, HCO3-28.38 +/- 1.42 and 30.32 +/- 1.02 mmol. l(-1), ABE 3.57 +/- 1.44 and 4.34 +/- 1.09 mmol. l(-1); pO2 12.63 +/- 1.15 and 5.21 +/- 0.73 kPa, SAT 95.8 +/- 1.03 and 61.2 +/- 9.59%, respectively. A gradual increase in most indices of the acid base balance could be stated both in arterial and venous blood. The trends either revealed a parallel increase (HCO3-, pH) or they were more pronounced either in venous blood (SAT) or in arterial blood (ABE, pO2). Some trends were almost balanced (pCO2 and pO2 in venous blood and SAT and pCO2 in arterial blood). Thus pH, pO2 and SAT indices of the acid base balance were higher in arterial blood as compared to venous blood while pCO2, HCO3- and ABE values were higher in venous blood.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "article-24509_11", "title": "Lung Torsion -- History and Physical", "score": 0.008771929824561403, "content": "No specific clinical signs or physical exam findings suggest lung torsion as the diagnosis. Nonspecific clinical signs include fever, chest pain, shortness of breath, and cough. [16] The most common symptom, however, are dyspnea, fever, and chest pain, respectively. [16] Most of these symptoms appear 4 to 14 days after a thoracic procedure, trauma, or any other triggering effect. Some patients were even asymptomatic and showed no clinical signs. Physical exam findings can reveal hypoxia, respiratory discomfort, and tachypnea. [13] [16] [21] [18] [1] Radiological imaging, however, is required to confirm the diagnosis of lung torsion. [22]" }, { "id": "wiki20220301en021_11805", "title": "Carotid body", "score": 0.008695652173913044, "content": "Stimulus The carotid body peripheral chemoreceptors are primarily sensitive to decreases in the partial pressure of oxygen (PO2). This is in contrast to the central chemoreceptors in the medulla oblongata that are primarily sensitive to changes in pH and PCO2 (a decrease in pH and an increase in PCO2). The carotid body chemoreceptors are also sensitive to pH and PCO2, but only secondarily. More specifically, the sensitivity of carotid body chemoreceptors to decreased PO2 is greater when pH is decreased and PCO2 is increased. Impulse rate for carotid bodies is particularly sensitive to changes in arterial PO2 in the range of 60 down to 30 mm Hg, a range in which hemoglobin saturation with oxygen decreases rapidly. The output of the carotid bodies is low at an oxygen partial pressure above about 100mmHg (13,3 kPa) (at normal physiological pH), but below 60mmHg the activity of the type I (glomus) cells increases rapidly due to a decrease in hemoglobin-oxygen saturation below 90%." }, { "id": "pubmed23n0214_4373", "title": "Clinical aspects of farmer's lung: airway reactivity, treatment and prognosis.", "score": 0.008695652173913044, "content": "This study reviews the results of five clinical studies dealing with farmer's lung (FL). The total number of patients included was 107, with a mean age of 49 years. All patients were farmers with dairy cattle. The clinical symptoms, auscultatory findings, chest radiography, laboratory data, partial pressure of oxygen in arterial blood at rest (PaO2), dynamic spirometry (FVC and FEV1) and lung diffusing capacity of carbon monoxide (DLco) were recorded at the first visit to the hospital and one, three, six and twelve months later during the follow-up and every six months after that. Half of the patients with FL reported insidious onset of the disease, and 28% reported acute onset. Dyspnoea was reported by all patients, coughing was almost as common. A considerable proportion of the patients reported muscle and joint pains. Diffuse opacities were detected in the chest radiograms of 99 patients (93%): the more severe the radiological change, the more impaired the DLco value. A normal chest radiogram was seen in eight of the 107 patients at the first evaluation. Half of the patients showed a restrictive type of impairment of ventilatory function at the first evaluation. Lung diffusing capacity was less than 80% of the predicted value in 89% of the patients. Ninety-nine patients were initially challenged with histamine and twenty-two of them (22%) showed increased bronchial responsiveness. Bronchial hyper-reactivity was transient in most of the patients and might also fluctuate with exacerbation of FL symptoms. Specimens of the airway epithelium of FL patients were taken by rigid bronchoscope from five patients for electronmicroscope studies. Extensive bronchial damage to the airway epithelium associated with the presence of spore-like fungi was observed. Aspiration biopsy of the spleen was carried out on ten FL patients during their first visit to the hospital. Granuloma-like reactions were detected in the aspiration biopsy material of five FL patients. The granulomatous changes in the spleen had disappeared when the procedure was repeated on two patients at an asymptomatic stage of the disease. Ninety-three patients were included in a follow-up study with a mean follow-up period of 18.6 months. The patients with clinically less severe disease were observed without medication. It appeared that corticosteroid medication was usually started if the DLco value was less than 65% of the predicted value. Fourteen patients with a DLco value less than 65% were observed without medication and served as a control group for those on medication.(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "pubmed23n0884_15856", "title": "Spontaneous pneumomediastinum following pneumonia in a 23-year-old male patient.", "score": 0.008620689655172414, "content": "Spontaneous pneumomediastinum (SPM) is defined as the presence of interstitial air in the mediastinum without any apparent precipitating factor. We present a case of 23 year old male patient, who has been referred to our outpatient clinic with the complaints of sudden chest pain, dyspnea followed by pneumonia and was diagnosed as SPM. The patient was treated with ampicillin sulbactam (4 gr/day) and methylprednisolon (20 mg/day) for 4 days. and oral intake was stopped during treatment. Post treatment, it was observed that the crepitations were disappeared thoroughly and vesicular sounds were heard by oscultation. The control values of arterial blood gas was as following: pH:7,39 pO2:95 mmHg, pCO2:37 mmHg, SaO2: %97. In the 5th day his oral intake was started and he was discharged." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 214 ] ], "word_ranges": [ [ 0, 40 ] ], "text": "The closest answer is 1. If we are strict we would be talking about a pure motor lacunar infarction (with mild dysarthria). Since the other 3 options do not give us a clinical picture like the one in the statement." }, "2": { "exist": true, "char_ranges": [ [ 215, 294 ] ], "word_ranges": [ [ 40, 55 ] ], "text": "Both options 2 and 3 give us a much more florid and extensive clinical picture." }, "3": { "exist": true, "char_ranges": [ [ 215, 294 ] ], "word_ranges": [ [ 40, 55 ] ], "text": "Both options 2 and 3 give us a much more florid and extensive clinical picture." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Left capsular lacunar lacunar infarction.", "2": "A cortico-subcortical left frontotemporal sylvian infarction.", "3": "Brain stem infarction.", "4": "A left lenticular hemorrhage.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0475_5034", "title": "[Aphasias for verbal and sign languages are due to lesions of nearly localised but not identical brain regions of the left hemisphere].", "score": 0.0178585665311329, "content": "To study the characteristics of verbal and sign language aphasia in a patient fluent in both languages, who had had a recent left hemisphere stroke as well as to localise the site responsible for Spanish sign language aphasia. 56 years old male, with risk factors for stroke, who presented an episode of sudden onset aphasia and right hemiplegia that partially recovered in a few hours. The residual deficit of language was explored with a detailed protocol that included comprehension, denomination, oral and phonetic praxis, propositional and automatic spontaneous language, reading and writing tasks. The examination of verbal and sign language was video-recorded. The lesion was localised by magnetic resonance imaging 24 days after the stroke. The patient, whose infarction involved the superior temporal gyrus and sylvian operculum, presented similar abnormalities for comprehension of complex sentences, many phonemic paraphasias and no trouble to repeat single words. Oral language was not fluent, but sign language was quite fluent with a rich vocabulary, but with semantic paraphasias, agrammatism and without self-criticism for his own mistakes. The pattern of oral and sign language alterations is partially different, more for expressive than perceptive discourse, although both types of aphasias are caused by lesions of the left hemisphere. The regions responsible for these abnormalities of both symbolic languages are localised close to each other, but not in the same place." }, { "id": "wiki20220301en140_52073", "title": "Lacunar stroke", "score": 0.016464699683877766, "content": "Signs and symptoms Each of the five classical lacunar syndromes has a relatively distinct symptom complex. Symptoms may occur suddenly, progressively, or in a fluctuating (e.g., the capsular warning syndrome) manner. Occasionally, cortical infarcts and intracranial hemorrhages can mimic lacunar infarcts, but true cortical signs (aphasia, visuospatial neglect, gaze deviation, and visual field defects) are always absent in lacunar strokes. The classic syndromes are as follows: Silent lacunar infarction" }, { "id": "Neurology_Adams_6343", "title": "Neurology_Adams", "score": 0.013646308451069827, "content": "As mentioned, in the ventral pons, the lacunar syndrome may be one of pure motor hemiplegia, mimicking that of internal capsular infarction except at times for relative sparing of the face and the presence of an ipsilateral paresis of conjugate gaze in some cases; or there is another highly characteristic lacunar syndrome of a combination of dysarthria and clumsiness of one hand. This “clumsy hand–dysarthria” stroke is usually located in the paramedian midpons or in the posterior portion of the internal capsule opposite the affected limb. Occasionally, a lacunar infarction of the pons, midbrain, internal capsule, or parietal white matter gives rise to a hemiparesis with ataxia on the same side as the weakness (Fisher, 1965a; Sage and Lepore). Some of the brainstem syndromes may blend with basilar branch syndromes." }, { "id": "Neurology_Adams_6339", "title": "Neurology_Adams", "score": 0.013410835042929867, "content": "Lacunar strokes tend to evolve quickly but not typically as suddenly as an embolus, for example. These clinical aspects are discussed extensively in the earlier section “Lacunar TIA.” In broad terms, the essential feature of these deep strokes is the striking absence of cortical deficits; that is, seizures, aphasia or amnesia (except in limited circumstances of small thalamic infarction), agnosia, apraxia, dysgraphia, alexia, and a number of cognitive changes. Multiple deep strokes can result in a dementia of the type discussed in Chap. 20. Furthermore, because of the small size of the strokes, certain clinical syndromes that might be expected to result from deep lesions, such as hemianopia, also do not occur. Fisher, in several papers (1965a, 1967, 1979) and in an iconic review 1965b, delineated the most frequent symptomatic forms of lacunar stroke: 1. Pure motor hemiplegia 2. Pure sensory stroke 3. Clumsy hand–dysarthria 4. Ipsilateral hemiparesis–ataxia" }, { "id": "article-113551_23", "title": "Lacunar Stroke -- History and Physical", "score": 0.011398293336619328, "content": "Clinical presentation depends on the area of brain involvement. Lacunar infarcts in the centrum semiovale may present without symptoms and can be found incidentally on brain imaging for some other cause. However, certain lacunar infarcts, like in the posterior limb of the internal capsule or the pons, can present with severe hemiplegia. Often, cortical findings, such as neglect, visual disturbances, aphasia, and behavioral changes, are absent in the clinical presentation of lacunar stroke as they occur in subcortical areas of the brain." }, { "id": "article-44336_17", "title": "Lacunar Syndromes -- History and Physical", "score": 0.010755860128434954, "content": "Sensorimotor Stroke : Patients present with weakness and numbness of the face, arm, and leg without cortical signs. Cortical function testing should distinguish between a frontoparietal lobe (MCA) stroke and a subcortical stroke (posterior thalamus and internal capsule). Dysarthria-Clumsy Hand Syndrome : This is a less common form of the lacunar syndrome. Patients present with facial weakness, dysarthria, dysphagia, and dysmetria or clumsiness of one upper extremity." }, { "id": "Neurology_Adams_6200", "title": "Neurology_Adams", "score": 0.010456187895212285, "content": "It has been recognized that strokes caused by occlusion of small penetrating vessels of the brain—lacunes—have a propensity to be intermittent (“stuttering”) at their onset and occasionally to allow virtually complete restitution of function between discrete episodes. Whether this constitutes a “lacunar TIA” has been debated, but it seems to us that the more important problem is our inability to distinguish a transitory occlusion of a small vessel from that of a larger vessel. Donnan and colleagues (1993) speak of a “capsular warning syndrome,” which we have seen a number of times, consisting of escalating episodes of weakness in the face, arm, and leg and culminating in a capsular lacunar stroke. Nevertheless, the basic pattern of a small deep stroke remains identifiable in mild form; partial syndromes that simulate cortical TIA are less common. Lacunar stroke is discussed extensively further on." }, { "id": "pubmed23n0536_13340", "title": "Clinical study of 39 patients with atypical lacunar syndrome.", "score": 0.01037106524911403, "content": "The aim of this study was to describe the clinical characteristics of atypical lacunar syndrome (ALS) based on data collected from a prospective acute stroke registry. In total, 2500 acute stroke patients were included in a hospital based prospective stroke registry over a 12 year period, of whom 39 were identified as having ALS and radiologically proven (by computed tomography or magnetic resonance imaging) lacunes. ALS accounted for 1.8% of all acute stroke patients, 2.1% of acute ischaemic stroke, and 6.8% of lacunar syndromes. ALS included dysarthria facial paresis (n = 12) or isolate dysarthria (n = 9), isolated hemiataxia (n = 4), pure motor hemiparesis with transient internuclear ophthalmoplegia (n = 4), pure motor hemiparesis with transient subcortical aphasia (n = 3), unilateral (n = 2) or bilateral (n = 3) paramedian thalamic infarct syndrome, and hemichorea hemiballismus (n = 2). Atypical lacunar syndromes were due to small vessel disease in 96% of patients. Atherothrombotic infarction occurred in one patient and cardioembolic infarct in another, both presenting pure dysarthria. Outcome was good (in hospital mortality 0%, symptom free at discharge 28.2%). After multivariate analysis, the variables of speech disturbances, nausea/vomiting, ischaemic heart disease, and sensory symptoms were found to be significantly associated with ALS. In conclusion, atypical lacunar syndrome is an infrequent stroke subtype (one of each 14 lacunar strokes). ALS occurred in 6.8% of lacunar strokes. Isolated dysarthria or dysarthria facial paresis were the most frequent presenting forms. The prognosis of this infrequent non-classic lacunar syndrome is good." }, { "id": "article-113551_25", "title": "Lacunar Stroke -- History and Physical", "score": 0.010197820797630382, "content": "Pure motor hemiparesis involves the posterior limb of the internal capsule, corona radiata. This type presents with contralateral hemiparesis of the face, arm, and leg. Mild dysarthria may be present with the absence of sensory symptoms. These are the most common lacunar syndromes. They account for 45% of cases of lacunar strokes. Cortical signs like aphasia, cognitive deficit, or visual symptoms are always absent. Pure motor stroke can be a combination of weakness in the arm, leg, or face on one side or any of these parts alone." }, { "id": "Neurology_Adams_3839", "title": "Neurology_Adams", "score": 0.00994595073542442, "content": "Many diseases and focal cerebral lesions mute or reduce the prosody of speech, the most dramatic examples being the hypophonic monotone of Parkinson disease and the effortful utterances of Broca’s aphasia. Largely through the work of Ross, it has become apparent that prosody is also greatly disordered in patients with strokes involving portions of the nondominant hemisphere that mirror the language areas of the left hemisphere. In these cases, there is impairment both of comprehension and of production of the emotional content of speech and its accompanying gestures. A prospective study of middle cerebral artery infarctions by Darby corroborated this view: aprosodia, as it has come to be called, was present only in those patients with lesions in the territory of the inferior division of the right middle cerebral artery. The deficit was most prominent soon after the stroke and was not found with lacunar lesions. In our patients, using bedside tests, we have had difficulty in" }, { "id": "wiki20220301en140_52080", "title": "Lacunar stroke", "score": 0.009900990099009901, "content": "Treatment and prognosis Typically, tissue plasminogen activator may be administered within 3 to 4.5 hours of stroke onset if the patient is without contraindications (i.e. a bleeding diathesis such as recent major surgery or cancer with brain metastases). High dose aspirin can be given within 48 hours. For long term prevention of recurrence, medical regimens are typically aimed towards correcting the underlying risk factors for lacunar infarcts such as hypertension, diabetes mellitus and cigarette smoking. Anticoagulants such as heparin and warfarin have shown no benefit over aspirin with regards to five-year survival. Patients who suffer lacunar strokes have a greater chance of surviving beyond thirty days (96%) than those with other types of stroke (85%), and better survival beyond a year (87% versus 65-70%). Between 70% and 80% are functionally independent at 1 year, compared with fewer than 50% otherwise." }, { "id": "pubmed23n0686_1865", "title": "[Case of ipsilateral monoparesis by lacunar infarction: a consideration on the pathological mechanism].", "score": 0.00980392156862745, "content": "An 81-year-old man had sudden-onset dysarthria and weakness in the right leg, and was admitted to our hospital in July 2009. Neurological examination showed right leg monoparesis, sensory disturbance on the right limbs, dysarthria, and decreased deep tendon reflexes. Brain MRI revealed an acute lacunar infarction in the right corona radiata and an old lacunar infarction in the left centrum semiovale, which occurred 4 years before. MR tractography disclosed impaired motor fibers in the right corona radiata, and transcranial magnetic stimulation (TMS) suggested diminished innervation from the bilateral cerebral cortices to the right leg. These results collectively indicated that reorganization of the pyramidal fibers were responsible for the monoparesis ipsilateral to the lacunar infarction, although anomalous pyramidal fibers with ipsilateral innervation were responsible for ipsilateral hemiplegia a previous study." }, { "id": "Neurology_Adams_3909", "title": "Neurology_Adams", "score": 0.00980392156862745, "content": "This rare and somewhat amusing condition defies classification but is worthy of comment because it may be mistaken for hysteria or psychosis. An accent that is distinctly foreign but vague in actual region of origin replaces the patient’s native speech pattern. The syndrome arises after a left-sided lesion, most often a stroke with a mild associated Broca aphasia. Although the accent may be interpreted by the listener as compatible with German, Spanish, French, Asian, or another nationality, authoritative analysis indicates that the alterations are not specific to any genuine language and are simply attributed by the listener to a known foreign accent. The syndrome is also encountered as a transient phenomenon during recovery from stroke. The relation to disorders of prosody, which is produced by lesions of the nondominant hemisphere, is unclear. LeCours and Lhermitte made an analysis of the disorder based on the obligate use of diphthongs in certain languages; these were not properly" }, { "id": "wiki20220301en230_12251", "title": "Lipohyalinosis", "score": 0.009708737864077669, "content": "Furthermore, \"In the microscopic level of small arteries or arterioles, hypertension also generates specific vasculopathies such as lipohyalinosis and thus causing lacunar infarctions\". Hypertensions and lacunar infarcts and lacunar stroke are related. This means hypertension is a start to a chain reaction. From lipohyalinosis to lacunar infarctions that may eventually lead to stroke, hypertension, uncontrolled, can cause a lot of damage to the brain. Lacunar infarcts Lacunar infarcts are a result of atherosclerosis (microthrombi) and lipohyalinosis. These affect the deep structures of the brain and may leave small (~5mm) cavity lesions. Small lacunar infarcts are \"caused by various arterial disorders, the most frequent of which include microatheroma, lipohyalinosis, fibrinoid necrosis, and Charcot-Bouchard aneurysm\"." }, { "id": "wiki20220301en398_27616", "title": "Sign language in the brain", "score": 0.009708737864077669, "content": "damage in Broca's area have problems producing signs. Those with damage in the Wernicke's area (left hemisphere) in the temporal lobe of the brain have problems comprehending signed languages. Early on, it was noted that Broca’s area was near the part of the motor cortex controlling the face and mouth. Likewise, Wernicke's area was near the auditory cortex. These motor and auditory areas are important in spoken language processing and production, but the connection to signed languages had yet to be uncovered. For this reason, the left hemisphere was described as the verbal hemisphere, with the right hemisphere deemed to be responsible for spatial tasks. This criteria and classification was used to denounce signed languages as not equal to spoken language until it was widely agreed upon that due to the similarities in cortical connectivity they are linguistically and cognitively equivalent. In the 1980s research on deaf patients with left hemisphere stroke were examined to explore" }, { "id": "wiki20220301en031_63946", "title": "Global aphasia", "score": 0.009650234585195561, "content": "subcortical regions. It is well known that a lesion to the cortex can cause aphasia. However, a study by Kumar et al. (1996) suggests that lesions to the subcortical regions of the cortex such as the thalamus, basal ganglia, internal capsule, and paraventricular white matter can also cause speech and language deficits. This is due to the fact that the subcortical regions are closely associated with the language centers in the brain. Kumar et al. state that while lesions to the subcortical regions could cause certain types of aphasia, a lesion to these regions would rarely cause global aphasia. In a study performed by Ferro (1992), it was found that five different brain lesion locations were linked to aphasia. These locations include: \"fronto-temporo-parietal lesions\", \"anterior, suprasylvian, frontal lesions\", \"large subcortical infarcts\", \"posterior, suprasylvian, parietal infarcts\", and \"a double lesion composed of a frontal and a temporal infarct\"." }, { "id": "Neurology_Adams_3963", "title": "Neurology_Adams", "score": 0.009615384615384616, "content": "Levine DN, Mohr JP: Language after bilateral cerebral infarctions: Role of the minor hemisphere in speech. Neurology 29:927, 1979. Lundgren K, Helm-Estabrooks N, Klein R: Stuttering following acquired brain damage: A review of the literature. J Neurolingustics 23:447, 2010. Martin N, Saffran EM: A computational account of deep dysphasia: Evidence from a single case study. Brain Lang 43:240, 1992. Milner B, Branch C, Rasmussen T: Evidence for bilateral speech representation in some non-right-handers. Trans Am Neurol Assoc 91:306, 1966. Mohr JP: The vascular basis of Wernicke aphasia. Trans Am Neurol Assoc 105:133, 1980. Mohr JP, Pessin MS, Finkelstein S, et al: Broca aphasia: Pathologic and clinical. Neurology 28:311, 1978. Naeser MA, Alexander MP, Helm-Estabrook N, et al: Aphasia with predominantly subcortical lesion sites. Arch Neurol 39:2, 1982. Ojemann G: Cortical organization of language. J Neurosci 11:2281, 1991." }, { "id": "article-886_18", "title": "Neuroanatomy, Internal Capsule -- Clinical Significance -- Ischemic Strokes Involving the Internal Capsule", "score": 0.009573658165207461, "content": "Lacunar strokes primarily affect the deep structures of the brain, such as the putamen, caudate nucleus, thalamus, and internal capsule. Depending on the location of a lesion, the symptoms of lacunar strokes will require differentiation from cortical strokes. These deep strokes usually have an absence of cortical deficits such as seizures, aphasia, agnosia, and dysgraphia. Other cortical deficits include apraxia, alexia, and amnesia. The progression of symptoms of lacunar strokes are abrupt in onset and evolve within minutes. [20] In some cases, the symptoms may develop over several hours. Many variations of lacunar stroke syndromes exist. Classic lacunar stroke syndrome that arises from internal capsule lesions are pure motor strokes, ataxic hemiparesis, and clumsy hand-dysarthria. [21]" }, { "id": "wiki20220301en140_52072", "title": "Lacunar stroke", "score": 0.009523809523809525, "content": "Lacunar stroke or lacunar cerebral infarct (LACI) is the most common type of ischemic stroke, resulting from the occlusion of small penetrating arteries that provide blood to the brain's deep structures. Patients who present with symptoms of a lacunar stroke, but who have not yet had diagnostic imaging performed, may be described as suffering from lacunar stroke syndrome (LACS). Much of the current knowledge of lacunar strokes comes from C. Miller Fisher's cadaver dissections of post-mortem stroke patients. He observed \"lacunae\" (empty spaces) in the deep brain structures after occlusion of 200–800 μm penetrating arteries and connected them with five classic syndromes. These syndromes are still noted today, though lacunar infarcts are diagnosed based on clinical judgment and radiologic imaging. Signs and symptoms" }, { "id": "Neurology_Adams_3962", "title": "Neurology_Adams", "score": 0.009523809523809525, "content": "Kurowski KM, Blumstein SE, Alexander M: The foreign accent syndrome: A reconsideration. Brain Lang 54:1, 1996. LeCours H, Lhermitte F: Aphasiology. Eastbourne, UK, Ballière-Tindall, 1989. LeCours H, Lhermitte F: The pure form of the phonetic disintegration syndrome (pure anarthria). Brain Lang 3:88, 1976. Leiner HC, Leiner SL, Dow RS: Cognitive and language functions of the human cerebellum. Trends Neurosci 16:444, 1993. Leischner A: The agraphias. In: Vinken PJ, Bruyn GW (eds): Handbook of Clinical Neurology. Vol 4: Disorders of Speech, Perception and Symbolic Behavior. Amsterdam, North-Holland, 1969, pp 141–180. LeMay M, Culebras A: Human brain morphologic differences in the hemispheres demonstrable by carotid angiography. N Engl J Med 287:168, 1972. Levine DN, Mohr JP: Language after bilateral cerebral infarctions: Role of the minor hemisphere in speech. Neurology 29:927, 1979." }, { "id": "wiki20220301en140_52074", "title": "Lacunar stroke", "score": 0.009433962264150943, "content": "A silent lacunar infarction (SLI) is one type of silent stroke which usually shows no identifiable outward symptoms, and is thus termed \"silent.\" Because stroke is a clinical diagnosis (that is, it is defined by clinical symptoms), there is debate about whether SLI are considered to be strokes, even though the pathophysiology is presumably the same. Individuals who suffer a SLI are often completely unaware they have suffered a stroke. This type of stroke often causes lesions in the surrounding brain tissue that are visibly detected via neuroimaging techniques such as MRI and computed axial tomography (CT scan). Silent strokes, including silent lacunar infarctions, have been shown to be much more common than previously thought, with an estimated prevalence rate of eleven million per year in the United States. Approximately 10% of these silent strokes are silent lacunar infarctions. While dubbed \"silent\" due to the immediate lack of classic stroke symptoms, SLIs can cause damage to the" }, { "id": "pubmed23n0906_10685", "title": "Selective associative phonagnosia after right anterior temporal stroke.", "score": 0.009433962264150943, "content": "We report the case of a 48 year old men who developed a selective impairment in famous voice recognition after ischemic stroke in right subcortical structures (lenticular nucleus and head of the caudate) and right anterior temporal lobe. He underwent fibrinolytic treatment. During the following days he progressively recovered and was discharged without neurological focal sign. Patent foramen ovale was found. When he got back to his house he noticed that he was unable to recognize the voice of his favoured singers and needed to ask who was the singer to his relatives. Neuropsychological examination revealed a selective impairment in famous voice recognition in the absence of alteration of voice perception, face perception and famous face recognition. All other neuropsychological domains were spared. In particular language, memory and executive functions were intact. Neuroimaging carried out by means of PET and MRI revealed two small ischemic lesions in the right subcortical region, involving lenticular and caudate nuclei and in the right temporal pole. To our knowledge, this is the first case described in literature of a patient showing a selective associative phonagnosia after right anterior temporal stroke. The present case helps to clarify the brain circuits underlying famous voice recognition and adds evidence in favour of a right hemisphere involvement in processing knowledge of familiar voices. These findings are discussed in relation to current models of brain organization of person-specific and general semantic knowledge." }, { "id": "pubmed23n0516_11572", "title": "Cerebral small vessel disease in pseudoxanthoma elasticum: three cases.", "score": 0.009345794392523364, "content": "Cerebral small vessel disease is rarely described in association with pseudoxanthoma elasticum (PXE), a hereditary connective tissue disorder with skin, eye and vascular manifestations. This autosomally inherited elastic tissue disease has been attributed to mutations in the ABCC6 gene located on chromosome 16p13.1. Different stroke mechanisms are suggested in PXE patients, arterial hypertension and accelerated atherosclerosis being the leading ones. Case 1: A 49-year-old man with history of mild hypertension presented with recurrent transient ischemic attacks. At the age of 42, evaluation for progressive visual loss and skin changes led to diagnosis of PXE. Brain magnetic resonance imaging (MRI) disclosed multiple lacunar infarctions and confluent periventricular white matter lesions (WML). Case 2: A 71-year-old woman with history of mild hypertension suffered right-sided stroke. Diagnosis of PXE was made at the age of 48 due to severe visual loss and skin changes. Brain MRI revealed multiple lacunar infarctions and subcortical ischemic leukoencephalopathy. Case 3: A 47-year-old woman with prominent skin changes and bilateral amblyopia developed right-sided weakness. Skin biopsy confirmed PXE. Several lacunar infarcts in deep white matter and pons were revealed on MRI. We present three patients with clinical and histopathological features of PXE who presented with multiple lacunar strokes, two with extensive confluent WML. These cases illustrate that PXE is a rare but significant risk factor for small vessel disease and stroke in patients of all age groups. Occlusive small vessel disease and subsequent lacunar infarcts and WML represent important PXE manifestations." }, { "id": "pubmed23n0334_1621", "title": "[A 96-year-old man with consciousness disturbance, convulsion, and left hemiplegia of acute onset].", "score": 0.009259259259259259, "content": "We report a 96-year-old Japanese man who developed a sudden onset of left hemiplegia and coma. He was found to have diabetes mellitus, hypertension, and atrial fibrillation since 1996 with occasional episodes of congestive heart failure. He was otherwise apparently well until July 5 of 1997 when he developed a sudden onset of unresponsiveness and convulsion involving his right hand and was admitted to our hospital. On admission, his BP was 210/120 mmHg, heart rate 76/min and irregular, BT 36.5 degrees C, and Cheyne-Stokes respiration. General medical examination was otherwise unremarkable. Neurologic examination revealed semicoma, conjugated deviation to the right, loss of oculocephalic response, left facial paresis of central type, flaccid left hemiplegia, and bilateral Babinski sign. Pertinent laboratory findings are as follows: BUN 47 mg/dl, creatinine 1.46 mg/dl, GPT 69 IU/l, LDH 1,142 IU/l, and CK 385 IU/l. A chest x-ray film revealed cardiac enlargement and EKG showed left ventricular hypertrophy and atrial fibrillation. Cranial CT scan revealed low density areas involving the right anterior cerebral and the right posterior cerebral artery territories. He was treated with an intravenous osmotic agent and short course of intramuscular steroid. He remained unconscious despite these treatment and developed sudden cardiopulmonary arrest three weeks after the admission. The patient was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had suffered from cerebral embolism of cardiac origin. The cause of the death was ascribed to acute subendocardial myocardial infarction. Most of the participants agreed with this conclusion. Postmortem examination revealed an old subendocardial myocardial infarction involving the posterior septal region and posterolateral wall of the left ventricle. Neuropathologic examination revealed hemorrhagic infarctions involving the territories of the right anterior cerebral, right middle cerebral, right posterior cerebral, and left anterior cerebral arteries. The left A1 portion of the anterior cerebral artery was hypoplastic, and the left pericallosal artery appeared to have been receiving blood supply from the right anterior cerebral artery through the anterior communicating artery. The large arteries in the base showed marked arteriosclerosis; particularly, the initial portion of the right posterior artery showed near complete arteriosclerotic occlusions. These characteristic arterial changes appeared to be the reason why this patient suffered from an extensive infarction from what appeared to have been a single episode of cerebral embolism probably initially involving the right internal carotid artery." }, { "id": "Neurology_Adams_3866", "title": "Neurology_Adams", "score": 0.009259259259259259, "content": "Motor speech disorders, both severe Broca aphasia and the more restricted and transient types, are most often a result of vascular lesions. Embolic stroke in the territory of the upper (rolandic, superior) division of the middle cerebral artery is the most frequent type and results in an abrupt onset of aphasia. Small strokes may give way to rapid improvement (hours to days); contrariwise, infarctions that extend beyond the central Broca region at times produce a more severe clinical syndrome than might be anticipated from the size of the lesion. It is these latter strokes, especially if the underlying frontal white matter is damaged, that tend to cause lasting speech difficulty. Because of the territory that is supplied by the superior branch of the middle cerebral artery, strokes that cause Broca aphasia are usually associated with right-sided brachiofacial paresis (face, proximal arm, and hand) as described earlier, and sometimes with a left-sided manual-brachial apraxia" }, { "id": "First_Aid_Step1_572", "title": "First_Aid_Step1", "score": 0.009215180193098175, "content": "Hypertensive hemorrhages (Charcot-Bouchard microaneurysm) most often occur in putamen of basal ganglia (lenticulostriate vessels G ), followed by thalamus, pons, and cerebellum H . Effects of strokes Anterior circulation Middle cerebral artery Motor and sensory cortices A —upper limb and face. Temporal lobe (Wernicke area); frontal lobe (Broca area). Contralateral paralysis and sensory loss—face and upper limb. Aphasia if in dominant (usually left) hemisphere. Hemineglect if lesion affects nondominant (usually right) hemisphere. Wernicke aphasia is associated with right superior quadrant visual field defect due to temporal lobe involvement. Lenticulo-striate artery Striatum, internal capsule. Contralateral paralysis. Absence of cortical signs (eg, neglect, aphasia, visual field loss). Pure motor stroke. Common location of lacunar infarcts B , due to hyaline arteriosclerosis (lipohyalinosis) 2° to unmanaged hypertension. Posterior circulation" }, { "id": "pubmed23n0397_10189", "title": "A 15-year-old boy with central nervous system vasculopathy presenting with dysarthria-clumsy hand syndrome.", "score": 0.009174311926605505, "content": "Dysarthria-clumsy hand stroke syndrome has been described frequently in adults but not in children. We report a 15-year-old right-handed boy with sudden onset of dysarthria, dysphagia, right facial weakness, and mild right-hand clumsiness. Computed tomographic scan and magnetic resonance imaging demonstrated infarction in the genu and posterior limb of the left internal capsule. Magnetic resonance angiography and conventional angiography demonstrated stenosis of the supraclinoid portion of the left internal carotid artery and the origin of the left ophthalmic artery. Lacunar infarction in an older adult is not the only mechanism leading to dysarthria-clumsy hand syndrome." }, { "id": "pubmed23n0318_3561", "title": "[Cerebrovascular disorder and the language areas].", "score": 0.009174311926605505, "content": "Recent progress of imaging techniques has achieved precise descriptions of aphasic syndromes associated with cerebrovascular disorders. Infarction of the left anterior cerebral artery brings about transcortical motor aphasia. Occlusion of each branches of the left middle cerebral artery produces characteristic language symptoms. Recently, cases with infarction of the areas of prefrontal and precentral arteries were reported to manifest fluent aphasia indistinguishable from the classical transcortical sensory aphasia. Rare cases with lesions restricted to the Broca's area (territory of the precentral artery) produces aphasia with normal fluency, word finding difficulty and deficit in sentence comprehension. Classical non-fluent Broca's aphasia is caused by infarctions which at least involves the areas of precentral and central arteries. Aphemia or pure word dumbness results from damages which involves territory of the central artery. Conduction aphasia is most often associated with lesions of the posterior parietal artery territory. As in the case of Broca's aphasia, Wernicke's aphasia is a composite of conduction aphasia, pure word deafness, transcortical sensory aphasia, and alexia with agraphia. The lesion of Wernicke's aphasia naturally involves the areas of all of these aphasic symptoms. Transcortical sensory aphasia is associated with lesions in the posteroinferior temporal region, and is often associated with watershed infarctions of the middle and posterior cerebral arteries. Aphasia which results from putaminal hemorrhage has ambiguous manifestation, and is difficult to be classified into Wernicke-Lichtheim's model. Assessment of its fluency is notoriously difficult. Thalamic aphasia is similar to either anomic aphasia or transcortical sensory aphasia. It was pointed out that classical aphasic syndromes are still valid as cerebral arterial occlusion syndromes, but are insufficient for the purpose of more precise anatomo-clinical correlation." }, { "id": "pubmed23n0479_15808", "title": "[Multiple intracerebral microhemorrhages associated with primary aldosteronism: a case report].", "score": 0.00909090909090909, "content": "We have observed dot-like low intensity spots (a dot-like hemosiderin spot: dotHS) on T2*-weighted (T2*-w) MRI, subsequently diagnosed histologically as previous microbleeds associated with lipohyalinosis, amyloid angiopathy and cerebral small vessel disease (SVD) including an intracerebral hematoma (ICH) and a lacunar infarction. According to the literature, primary aldosteronism (PA), characterized by hypertension, is related to SVD. A 49-year-old female with a long history of untreated hypertension secondary to PA was admitted to our hospital for medical examinations on July 18th, 2000. She had the stepwise development of dementia, dysarthria and gait disturbance (right hemiparesis). CT and MRI demonstrated multiple lacunar infarctions. She was readmitted to our hospital on Jan 23rd, 2002. A neurological examination revealed right hemiparesis, dysarthria and consciousness disturbance. CT on admission demonstrated ICH in the left midbrain. Six days after the hemorrhage, T2*-w MRI showed thirty-two dotHSs in the basal ganglias and the cortical-subcortical regions. The incidence of ICH in patients with hypertension secondary to PA is reported to be higher than in patients with essential hypertension. Multiple dotHS may be associated with ICH, lacunar infarction, and severe microangiopathy related to hypertension secondary to PA." }, { "id": "pubmed23n1088_24837", "title": "Hemisphere stroke: impact on the semantic lexical aspects of language.", "score": 0.00909090909090909, "content": "To investigate if right hemisphere stroke is associated with decreased lexical-semantic ability. We compared subjects with right hemisphere brain damage after stroke with healthy controls using the validated version of the Montreal Evaluation of Communication to assess lexical-semantic domains of language. Sixteen patients and thirty-two controls were included. The post-stroke group with right hemispheric brain lesions showed considerable limitations in metaphor interpretation, fluency, and semantic judgment. Individuals with right hemisphere damage after stroke may present with language changes in the lexical-semantic aspects." }, { "id": "InternalMed_Harrison_30005", "title": "InternalMed_Harrison", "score": 0.00908829140121657, "content": "Occlusion of a lenticulostriate vessel produces small-vessel (lacunar) stroke within the internal capsule (Fig. 4466). This produces pure motor stroke or sensory-motor stroke contralateral to the lesion. Ischemia within the genu of the internal capsule causes primarily facial weakness followed by arm and then leg weakness as the ischemia moves posterior within the capsule. Alternatively, the contralateral hand may become ataxic, and dysarthria will be prominent (clumsy hand, dysarthria lacunar syndrome). Lacunar infarction affecting the globus pallidus and putamen often has few clinical signs, but parkinsonism and hemiballismus have been reported." }, { "id": "article-43129_8", "title": "Aphasia -- Pathophysiology", "score": 0.009065749121101054, "content": "Aphasia is caused by lesions to the language areas of the brain, which are typically located in the dominant hemisphere. For the majority of the population, the dominant hemisphere is on the left side. [8] These areas are Wernicke area, Broca area, and arcuate fasciculus. The most common cause of aphasia is due to CVA. CVA occurs when the blood supply to a certain part of the brain is greatly diminished or stopped due to an ischemic event (i.e., embolism or thrombosis) or from a hemorrhagic event (i.e., intracerebral hemorrhage, subarachnoid hemorrhage). In some cases, aphasia can be caused by damage to subcortical structures deep within the left hemisphere, including the internal and external capsules, the thalamus, and the caudate nucleus. [9]" } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 33, 330 ] ], "word_ranges": [ [ 4, 54 ] ], "text": "Young patient, with no previous history, who after taking NSAIDs presents bleeding with hemodynamic instability requiring transfusion. Answer 1 is not in accordance with what has been said, this is an unstable patient who has bled a lot, who has a Forrest IIa ulcer with a high risk of rebleeding." }, "2": { "exist": true, "char_ranges": [ [ 332, 418 ] ], "word_ranges": [ [ 54, 68 ] ], "text": "Answer 2 speaks of somatostatin, which is used for bleeding due to portal hypertension." }, "3": { "exist": true, "char_ranges": [ [ 492, 644 ] ], "word_ranges": [ [ 79, 106 ] ], "text": "Between 3 and 5, since there is a high risk of bleeding, endoscopic therapy is recommended, preferably with 2 techniques, so the correct one would be 5." }, "4": { "exist": true, "char_ranges": [ [ 420, 490 ] ], "word_ranges": [ [ 68, 79 ] ], "text": "4 will only be considered if bleeding is not controlled endoscopically." }, "5": { "exist": true, "char_ranges": [ [ 492, 644 ] ], "word_ranges": [ [ 79, 106 ] ], "text": "Between 3 and 5, since there is a high risk of bleeding, endoscopic therapy is recommended, preferably with 2 techniques, so the correct one would be 5." } }

{ "1": "Since the patient is young, with no associated diseases and the ulcer has stopped bleeding, he can be discharged early with treatment with a PPI and H. Pylori eradication.", "2": "Remove the endoscope, place nasogastric tube for continuous aspiration and initiate treatment with a PPI and somatostatin.", "3": "Take biopsy for H. Pylori, remove the endoscope taking care not to dislodge the platelet thrombus and continue pharmacological treatment with i.v. PPI.", "4": "Consultation to the surgical service to consider urgent surgical treatment.", "5": "Endoscopic treatment by injection of adrenaline into the ulcer and placement of clips (metal staples) followed by i.v. administration of PPI." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0608_5566", "title": "[Diagnosis and treatment of bleeding peptic ulcer: our experience].", "score": 0.018375566370196342, "content": "Bleeding peptic ulcer (PU) is the commonest cause of an acute upper gastrointestinal bleed. Aim of this study was to present our data regard the management of acute bleeding from PU during urgent endoscopy (examination performed in 2-6 h by the call). This study is based on an observational retrospective protocol. Records of 259 consecutive patients with PU (92 F, 167 M; median age 71.5 years; range: 19-100 years), attending our GI Unit from February 1st 2004 to July 31st 2007, were analyzed. Out of 259 patients with PU, 170 (65.6%) were treated with endoscopic hemostasis followed by medical therapy (PPI 80 mg bolus within 12 h of endoscopy followed by 8 mg/for 72 h and then an oral PPI , 40 mg once daily for 30 days), while 89 (34.4%) patients received only medical therapy (PPI, 40 mg once daily for 30 days). All ulcerative lesions with endoscopic stigmata of acute bleeding, visible vessels or adherent clot (Forrest Ia-IIb) were treated during the gastroscopy. The endoscopic procedures used were: injection of 1:10000 adrenaline (about 10 mL) around the bleeding lesion in 93 cases (55%); injection therapy and thermal method (argon plasma coagulation) in 53 cases (31%); injection therapy and mechanical method (metallic clips) in 20 cases (12%); only mechanical method (metallic clips) in 4 cases (2%). Endoscopic hemostasis was achieved in 251 pts (97%), while 17 pts (6.5%) required second endoscopy for rebleeding. Three patients (1.16%) required immediate surgery for failure of primary endoscopic hemostasis. The mortality within 30 days from the bleeding episode was 3.9% (10 pts). The treatment of this condition has made important progress since the introduction of emergency endoscopy and endoscopic techniques for hemostasis. The application of specific protocols, significantly decreases rebleeding and the need for surgery, whereas mortality is still high. Our data are in keeping with previous studies of the literature." }, { "id": "wiki20220301en003_42443", "title": "Peptic ulcer disease", "score": 0.01796550622804216, "content": "Early endoscopic therapy can help to stop bleeding by using cautery, endoclip, or epinephrine injection. Treatment is indicated if there is active bleeding in the stomach, visible vessels, or an adherent clot. Endoscopy is also helpful in identifying people who are suitable for hospital discharge. Prokinetic agents such as erythromycin and metoclopramide can be given before endoscopy to improve endoscopic view. Either high- or low-dose PPIs are equally effective in reducing bleeding after endoscopy. High-dose intravenous PPI is defined as a bolus dose of 80 mg followed by an infusion of 8 mg per hour for 72 hours—in other words, the continuous infusion of PPI of greater than 192 mg per day. Intravenous PPI can be changed to oral once there is no high risk of rebleeding from peptic ulcer." }, { "id": "pubmed23n0735_2444", "title": "The efficacy of PPI after endoscopic hemostasis in patients with bleeding peptic ulcer and role of Helicobacter pylori.", "score": 0.017543859649122806, "content": "Nowadays PPI present cornerstone in the medical therapy of bleeding peptic ulcer. Controlled pantoprazole data in peptic ulcer bleeding are few. To compare the effect of intravenous (iv) pantoprazole (PPI) with iv ranitidine (H2RA) for bleeding peptic ulcers after endoscopic therapy. After endoscopic haemostasis, 122 patients were randomized to PPI 80 mg + 8 mg/h or H2RA 50 mg + 13 mg/h, both for 72 h and to continue with oral equivalent dose of these medicaments. Patients underwent second-look endoscopy on day 3 or earlier, if clinically indicated. The primary endpoint measure was rebleeding before discharge and &lt;14 days of enrollment. Secondary endpoint measures included number of surgeries performed, volume of blood transfusion, mortality rate and hospital stay. All data were statistically analyzed and a value of 0.05 or less was considered to indicate statistical significance. In the group who were treated with PPI, re-bleeding rate was evidenced in 5 patients (8.33%) and in the groups who were treated with H2RA, re-bleeding rate was found in 9 patients (14.5%) with RR 0.27 and CI 0.12-0.60 and P &lt; 0.05. The volume of transfused blood was lower in the group treated with PPI compared to the group treated with H2RA (930 ml vs. 1540 ml and P &lt; 0.05). In this study there was not statistically significant difference in the hospital stay 15.00 vs. 17.80% (9 vs. 11 patients and P&gt; 0.05), the need for surgical intervention 5.00 vs. 6.45% (3 vs. 4 patients and P= 1.00) and the mortality rate 1.66 vs. 3.22% (1 vs. 2 patients and P &gt; 0.05). A high-dose pantoprazole infusion is more effective than a ranitidine infusion for prevention of re-bleeding after endoscopic epinephrine injection in patients with peptic ulcers and active bleeding or non-bleeding visible vessels (P &lt; 0.05). In all bleeding peptic ulcer patients is needed to make the eradication of H. pylori infection with the aim to prevent re-bleeding in long term." }, { "id": "pubmed23n1151_11639", "title": "[Peptic ulcer disease and H. pylori gastritis: key advances in clinical management].", "score": 0.017220990391722098, "content": "Helicobacter pylori (H. pylori) gastritis and non-steroidal anti-inflammatory drug (NSAID) intake are the most important risk factors for peptic ulcer disease (PUD) and ulcer bleeding. H. pylori infection was shown to increase the risk of ulcer bleeding in patients with PUD who are taking NSAID, aspirin, or another antiplatelet drug. H. pylori-positive patients on combined platelet aggregation inhibition are at the highest risk of bleeding. Evidence-based interdisciplinary treatment recommendations for the safe use of NSAID have been released. For patients with a moderate risk of PUD, the combination of NSAID and a proton pump inhibitor (PPI) or a monotherapy with a selective cyclooxygenase-2 (COX-2) inhibitor is recommended, whereas patients with a high risk of bleeding should receive a combination of a selective COX-2 inhibitor and a PPI. According to a recent randomized trial, hemodynamically stable patients with signs of upper gastrointestinal bleeding and an increased risk of death (Glasgow-Blatchford Score ≥ 12) undergoing endoscopy 6-24 after consultation do not have any disadvantage in terms of 30-day mortality compared to patients receiving endoscopy within 6 hours. After successful endoscopic hemostasis, additional prophylactic angiographic embolization does not reduce the risk of recurrent bleeding. Successful H. pylori eradication reduces the risk of developing gastric cancer (GC) in first-degree relatives of patients with GC by 73 %. In patients with successful endoscopic treatment of early GC, H. pylori testing with subsequent eradication also halves the rate of metachronous GC. Clarithromycin-based triple therapy for H. pylori eradication shows a decreasing effectiveness due to increasing antibiotic resistance, especially against macrolides. Accordingly, bismuth-containing quadruple therapy is widely recommended as the standard empiric first-line therapy." }, { "id": "pubmed23n0657_25148", "title": "Proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding.", "score": 0.01676094699350513, "content": "Peptic ulcer bleeding is a common and potentially fatal condition. For patients with bleeding peptic ulcers that display major endoscopic stigmata of recent hemorrhage, a combination of endoscopic and pharmacologic therapy is the current standard management. To show our experience with management of peptic ulcer bleeding. Patients who presented with gastrointestinal bleeding caused by peptic ulcer or recent history (&lt; 24 h before presentation) of hematemesis and/or melena admitted to our hospital emergency departments, and patients whose ulcer hemorrhage started after hospitalization for an unrelated medical or surgical condition. Patients with actively bleeding ulcers and those with nonbleeding visible vessel or adherent clot were treated with epinephrine injection and/or endoscopic hemoclips, and randomized to receive intravenous pantoprasole according to the continuous regimen (dose of 5 x 40 mg in continuous infusion of 8 mg/h for 72 h) or the standard regimen (40 mg bolus of PPI twice daily for 3 days). After the infusion, all patients were given 40 mg PPI twice daily orally. The primary end point was the in-hospital rebleeding rate, as discovered by the repeated endoscopy. Bleeding recurred in 5 of 34 patients (14.7%) receiving the intensive regimen, and in 8 of 35 (22.8%) patients receiving the standard regimen. Hemoglobin (g/l) rate in standard regimen group was 93.5 +/- 23.8, and in intensive regimen group 106.6 +/- 22.4 (P = 0.042). Mean units of blood transfused for all patients in group were 71.8 +/- 45.8 in the intensive and 45.3 +/- 50.2 in the standard regimen group (P = 0.0257). The duration of hospital stay was 6.4 +/- 2.8 in standard group and 5.8 +/- 2.8 in the intensive group (P = 0.40). In patients with bleeding peptic ulcers with successful endoscopic hemostasis the standard PPI regimen had advantage on transfusion requirements, but no advantage with respect to in-hospital rates of rebleeding rates, need for surgery, length of hospital stay, or death, which corresponds with recent studies." }, { "id": "pubmed23n0870_16286", "title": "High-dose omeprazole infusion compared with scheduled second-look endoscopy for prevention of peptic ulcer rebleeding: a randomized controlled trial.", "score": 0.01552757793764988, "content": "Previous studies have shown that both scheduled second-look endoscopy and high-dose continuous omeprazole infusion are effective in preventing peptic ulcer rebleeding. The aim of this noninferiority trial was to compare the efficacy of these two strategies for the prevention of rebleeding following primary endoscopic hemostasis. Consecutive patients who received endoscopic treatment for bleeding peptic ulcers (actively bleeding, with nonbleeding visible vessels) were randomized to two treatment groups following hemostasis. One group (second-look endoscopy group) received the proton pump inhibitor (PPI) omeprazole as an intravenous bolus every 12 hours for 72 hours and a second endoscopy within 16 - 24 hours with retreatment for persistent stigmata of bleeding. The other group (PPI infusion group) received continuous high-dose omeprazole infusion for 72 hours. Patients who developed rebleeding underwent surgery if repeat endoscopic therapy failed. The primary outcome was the rebleeding rate within 30 days after initial hemostasis. The margin for noninferiority was set at 5 %. A total of 153 patients were randomized to the PPI infusion group and 152 to the second-look endoscopy group. Rebleeding occurred within 30 days in 10 patients (6.5 %) in the PPI infusion group and in 12 patients (7.9 %) in the second-look endoscopy group (P = 0.646). Surgery was required for rebleeding in six patients from the PPI infusion group and three patients in the second-look endoscopy group (P = 0.32). Intensive care unit stay, transfusion requirements, and mortality were not different between the groups. Patients in the second-look endoscopy group were discharged 1 day earlier than those in the PPI infusion group (P &lt; 0.001). After endoscopic hemostasis, high-dose PPI infusion was not inferior to second-look endoscopy with bolus PPI in preventing peptic ulcer rebleeding. ClinicalTrials.gov (NCT: 00164931)." }, { "id": "pubmed23n0568_15516", "title": "Oral proton pump inhibitors are as effective as endoscopic treatment for bleeding peptic ulcer: a prospective, randomized, controlled trial.", "score": 0.015185985667159594, "content": "In managing patients with bleeding peptic ulcers, it has been reported that pharmacologic treatment can be an alternative to endoscopic treatment. We compared the hemostasis rates of the endoscopic treatment, hemoclipping, and the pharmacologic treatment, oral proton pump inhibitors (PPIs), in bleeding peptic ulcer. A randomized prospective study was performed on 129 bleeding peptic ulcer patients with hematemesis or melena. Sixty-two patients were treated by endoscopic hemoclipping and subsequently H(2) receptor antagonists were injected intravenously (hemoclipping group), and 67 patients were treated with an oral PPI without endoscopic treatment (PPI group). The 24-hr gastric pH test was performed sequentially following the treatment. The initial hemostasis rate of the hemoclipping group was 93.5% (58/62) and the rebleeding rate was 6.9% (4/58), and the hemostasis rate of the PPI group was 92.5% (62/67) and the rebleeding rate was 7.5% (5/67), which were not different. The 24-hr gastric pH was 4.54+/-2.56 in the hemoclipping group and 5.97+/-1.30 in the PPI group (P&lt;0.037). In the bleeding peptic ulcer patients, the hemostasis rate with the oral administration of PPIs was not different from that with the endoscopic hemoclipping treatment." }, { "id": "pubmed23n0730_15701", "title": "Management of bleeding gastroduodenal ulcers.", "score": 0.014716075713143161, "content": "A multidisciplinary group of Danish experts developed this guideline on management of bleeding gastroduodenal ulcers. Sources of data included published studies up to March 2011. Quality of evidence and strength of recommendations have been graded. The guideline was approved by the Danish Society of Gastroenterology and Hepatology September 4, 2011. Recommendations emphasize the importance of early and efficient resuscitation. Endoscopy should generally be performed within 24 hours, reducing operation rate, rebleeding rate and duration of in-patient stay. When serious ulcer bleeding is suspected and blood found in gastric aspirate, endoscopy within 12 hours will result in faster discharge and reduced need for transfusions. Endoscopic hemostasis remains indicated for high-risk lesions. Clips, thermocoagulation, and epinephrine injection are effective in achieving endoscopic hemostasis. Use of endoscopic monotherapy with epinephrine injection is not recommended. Intravenous high-dose proton pump inhibitor (PPI) therapy for 72 hours after successful endoscopic hemostasis is recommended as it decreases both rebleeding rate and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 3 days after endoscopic hemostasis. Patients with peptic ulcer bleeding who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks. Patients in need of continued treatment with ASA or a nonsteroidal anti-inflammatory drug should be put on prophylactic treatment with PPI at standard dosage. The combination of 75mg ASA and PPI should be preferred to monotherapy with clopidogrel in patients needing anti-platelet therapy on the basis of indications other than coronary stents." }, { "id": "pubmed23n0643_25160", "title": "[Guidelines of treatment for bleeding peptic ulcer disease].", "score": 0.013621142184813105, "content": "Peptic ulcer (PU) bleeding is the main cause of non-variceal gastrointestinal bleeding. Negative outcomes include re-bleeding and death, and many of the deaths are associated with decompensation of coexisting medical conditions precipitated by acute bleeding event. Accurate analysis of risk for clinical features can help physician to decide treatment modality. Endoscopy can detect bleeding stigmata and perform therapeutic hemostasis. Proton pump inhibitor (PPI) compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings, and reduces re-bleeding rates and surgical intervention. PPI treatment initiated prior to endoscopy in upper gastrointestinal (UGI) bleeding significantly reduces the proportion of patients with stigmata of recent hemorrhage (SRH) at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with endoscopic hemostasis for those with major SRH, is likely to be the most cost-effective. The treatment of H. pylori infection was found to be more effective than anti-secretory therapy in preventing recurrent bleeding from PU. H. pylori eradication alone and eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies to prevent ulcer bleeding among H. pylori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective treatment. This review focuses specifically on the current treatment of patients with acute bleeding from a peptic ulcer." }, { "id": "pubmed23n0563_16478", "title": "Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer.", "score": 0.013543811484786089, "content": "To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process." }, { "id": "wiki20220301en003_42442", "title": "Peptic ulcer disease", "score": 0.01322841829170943, "content": "NSAIDs induced ulcers NSAID-associated ulcers heal in 6 to 8 weeks provided the NSAIDs are withdrawn with the introduction of proton pump inhibitors (PPI). Bleeding For those with bleeding peptic ulcers, fluid replacement with crystalloids is sometimes given to maintain volume in the blood vessels. Maintaining haemoglobin at greater than 7 g/dL (70 g/L) through restrictive blood transfusion has been associated with reduced rate of death. Glasgow-Blatchford score is used to determine whether a person should be treated inside a hospital or as an outpatient. Intravenous PPIs can suppress stomach bleeding more quickly than oral ones. A neutral stomach pH is required to keep platelets in place and prevent clot lysis. Tranexamic acid and antifibrinolytic agents are not useful in treating peptic ulcer disease." }, { "id": "wiki20220301en003_42410", "title": "Peptic ulcer disease", "score": 0.01305321946942884, "content": "Diet does not play an important role in either causing or preventing ulcers. Treatment includes stopping smoking, stopping use of NSAIDs, stopping alcohol, and taking medications to decrease stomach acid. The medication used to decrease acid is usually either a proton pump inhibitor (PPI) or an H2 blocker, with four weeks of treatment initially recommended. Ulcers due to H. pylori are treated with a combination of medications, such as amoxicillin, clarithromycin, and a PPI. Antibiotic resistance is increasing and thus treatment may not always be effective. Bleeding ulcers may be treated by endoscopy, with open surgery typically only used in cases in which it is not successful." }, { "id": "wiki20220301en030_8098", "title": "Gastrointestinal bleeding", "score": 0.012905655210187595, "content": "Peptic ulcers Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. Proton pump inhibitors (PPI) may reduce mortality in those with severe disease as well as the risk of re-bleeding and the need for surgery among this group. Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal. In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance. There is tentative evidence of benefit for tranexamic acid which inhibits clot breakdown. Somatostatin and octreotide, while recommended for varicial bleeding, have not been found to be of general use for non variceal bleeds. After treatment of a high risk bleeding ulcer endoscopically giving a PPI once or a day rather than as an infusion appears to work just as well and is less expensive (the method may be either by mouth or intravenously)." }, { "id": "wiki20220301en030_8104", "title": "Gastrointestinal bleeding", "score": 0.012609970674486803, "content": "The benefits versus risks of placing a nasogastric tube in those with upper GI bleeding are not determined. Endoscopy within 24 hours is recommended, in addition to medical management. A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found. Prokinetic agents such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view. They also decrease the amount of blood transfusions required. Early endoscopy decreases hospital and the amount of blood transfusions needed. A second endoscopy within a day is routinely recommended by some but by others only in specific situations. Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. High and low dose PPIs appear equivalent at this point. It is also recommended that people with high risk signs are kept in hospital" }, { "id": "Surgery_Schwartz_7500", "title": "Surgery_Schwartz", "score": 0.012473662031184156, "content": "surgeonResuscitateContinuous IV PPI dripEGDLifelong acid suppressionTest + Rx H. pyloriAvoid NSAIDs/ASA if possibleYesShock?NoYesTransfusion?NoYesActive bleeding on EGD?NoYesVisible vessel on EGD?NoYesAbnormal PT, PTT, or platelets?NoFigure 26-42. Algorithm for the treatment of bleeding peptic ulcer. ASA = acetylsalicylic acid; EGD = esophagogastroduodenoscopy; O.R. = operating room; PPI = proton pump inhibitor; PRBC = unit of packed red blood cells; PT = prothrombin time; PTT = partial throm-boplastin time; Rx = treatment.Brunicardi_Ch26_p1099-p1166.indd 113401/03/19 7:12 PM 1135STOMACHCHAPTER 26Operation for bleeding peptic ulcerYesYesNoGastric ulcerDuodenal ulcerType 1,2,3Distal gastrectomy**Hemodynamically unstable?OrHigh operative risk?Csendes procPauchet procKelling-Madlener proc(see text)*Add lifelong PPI**Add TV for type 2 + 3Oversew + TV/DOversew + TV/ABMI < 21? ordifficult duodenum?Type 4RebleedRebleedDuodenal ulcer*Gastric ulcer*1) Bx and oversew2) Wedge" }, { "id": "Surgery_Schwartz_7490", "title": "Surgery_Schwartz", "score": 0.012332512988788624, "content": "(1st ant. tier)Duod.Cushingseromuscularsuture (2nd ant. tier)Posteriorthrough &through sutureFigure 26-38. A through D. Jaboulay pyloroplasty. ant. = anterior; Duod. = duodenum; Stom. = stomach. (Reproduced with permission from Zuidema GD: Shackelford’s Surgery of the Alimentary Tract, 4th ed. Philadelphia, PA: Elsevier/Saunders; 1996.)Brunicardi_Ch26_p1099-p1166.indd 113101/03/19 7:12 PM 1132SPECIFIC CONSIDERATIONS PART IIresuscitated and started on IV PPI.125 Most patients will stop bleeding with these measures alone, but about 25% will continue to bleed or will rebleed in hospital. It is important to identify this high-risk group early with clinical and endoscopic parameters because, essentially, all the deaths from bleeding ulcer occur in this group. Surgical consultation is mandatory, and endoscopic hemostatic therapy (cautery, epinephrine injection, clipping) is indicated and usually successful in these high-risk patients.126 Indications for operation include massive" }, { "id": "pubmed23n0494_22487", "title": "Initial factors predicting rebleeding and death in bleeding peptic ulcer disease.", "score": 0.011947011490213991, "content": "Bleeding peptic ulcer constitutes approximately half of the cases admitted with upper gastrointestinal bleeding. Although the bleeding episode stops spontaneously in most of them, rebleeding occurs in as much as 10-30% of them and has a mortality rate of 5-10%. In this study, we have evaluated the possible significant predictors associated with this adverse outcome. The records of 205 patients admitted to gastrointestinal bleeding unit (GIBU) in Riyadh Central Hospital, during the period May 1996 through to April 1999, with endoscopic confirmed diagnosis of bleeding peptic ulcer disease were reviewed for demography, clinical presentation, hematology, biochemistry, initial blood pressure, nasogastric lavage color, co-morbid disease and endoscopic findings. All the significant factors found initially (P&lt;0.05) were entered into odds ratio and its 95% confidence interval and finally the unconditioned logistic regression model was used to find out the significant independent predictors for both rebleeding and mortality in these patients. The majority of patients (85%) were males and below the age of 60 (73%). Duodenal ulcer was the source of bleeding in 84%. Endoscopy was performed in all patients within 24 hours of admission. Only 15% were actively bleeding at the time of initial endoscopy. Thirty-six patients (17%) rebelled, majority within 72 hours of initial hemostasis. Overall, 11 patients (5%) died, 6 of them were rebleeders. Initial presentation of systolic blood pressure &lt;100 mm Hg, blood in nasogastric tube and visible vessel within the ulcer in endoscopy were independent predictors of rebleeding while initial systolic blood pressure &lt;100 mm Hg and age &gt;60-years were independent predictors of mortality. Improvement of outcome in patients with bleeding peptic ulcer disease can be achieved by early detection of those patients who are at risk of adverse outcome. Patients with the above mentioned independent predictors of rebleeding and mortality are best managed in the intensive care unit with endoscopic hemostasis and proton pump inhibitor (PPI) therapy for a minimum of 5-days of admission." }, { "id": "wiki20220301en159_20849", "title": "Endoclip", "score": 0.011083743842364532, "content": "Endoclips have found a primary application in hemostasis (or the stopping of bleeding) during endoscopy of the upper (through gastroscopy) or lower (through colonoscopy) gastrointestinal tract. Many bleeding lesions have been successfully clipped, including bleeding peptic ulcers, Mallory-Weiss tears of the esophagus, Dieulafoy's lesions, stomach tumours, and bleeding after removal of polyps. Bleeding peptic ulcers require endoscopic treatment if they show evidence of high risk stigmata of re-bleeding, such as evidence of active bleeding or oozing on endoscopy or the presence of a visible blood vessel around the ulcer. The alternatives to endoscopic clipping of peptic ulcers are thermal therapy (such as electrocautery to burn the vessel causing the bleeding), or injection of epinephrine to constrict the blood vessel. Comparative studies between endoclips and thermal therapy make the point that endoclips cause less trauma to the mucosa around the ulcer than electrocautery, but no" }, { "id": "Surgery_Schwartz_7470", "title": "Surgery_Schwartz", "score": 0.01086905925615603, "content": "be stopped after 3 months if the ulcerogenic stimulus (e.g., H pylori, NSAIDs, or aspirin) has been removed. However, long-term maintenance PPI therapy should be considered in all patients admitted to hospital with ulcer complications, all high-risk patients on NSAIDs or aspi-rin (the elderly or debilitated), and all patients requiring anti-coagulation or antiplatelet agents or those with a history of recurrent ulcer or bleeding. Consideration should also be given to maintenance PPI therapy in refractory smokers with a history of peptic ulcer. Sucralfate acts locally on mucosal defects and is well tolerated, and occasionally it is useful as a supplement to acid suppression.2Peptic ulcer40%24%6%4%6%5%10%5%No obvious causeOtherNeoplasmErosive diseaseMallory-Weiss syndromeOesophagitisVaricesFigure 26-31. Causes of upper GI bleeding. (Reproduced with permission from Dallal HJ, Palmer KR: ABC of the upper gastro-intestinal tract: Upper gastrointestinal haemorrhage, BMJ. 2001 Nov" }, { "id": "wiki20220301en030_8107", "title": "Gastrointestinal bleeding", "score": 0.010174198434738702, "content": "Prognosis Death in those with a GI bleed is more commonly due to other illnesses (some of which may have contributed to the bleed, such as cancer or cirrhosis) than the bleeding itself. Of those admitted to a hospital because of a GI bleed, death occurs in about 7%. Despite treatment, re-bleeding occurs in about 7–16% of those with upper GI bleeding. In those with esophageal varices, bleeding occurs in about 5–15% a year and if they have bled once, there is a higher risk of further bleeding within six weeks. Testing and treating H. pylori if found can prevent re-bleeding in those with peptic ulcers. The benefits versus risks of restarting blood thinners such as aspirin or warfarin and anti-inflammatories such as NSAIDs need to be carefully considered. If aspirin is needed for cardiovascular disease prevention, it is reasonable to restart it within seven days in combination with a PPI for those with nonvariceal upper GI bleeding." }, { "id": "wiki20220301en252_15438", "title": "Therapeutic endoscopy", "score": 0.009978221254277967, "content": "A number of different techniques have been developed to allow treatment to be carried out endoscopically, to treat disorders such as bleeding, strictures and polyps. Types of endoscopic therapy Endoscopic haemostasis Endoscopic injection of bleeding peptic ulcers with adrenaline has been practised since the 1970s, endoscopic heater probes have been used since the 1980s, and Argon plasma coagulation has been used since the 1990s. More recently, adrenaline injection tends to be combined with either heater probe coagulation or argon plasma coagulation to minimize the chance of an ulcer rebleeding. The disadvantage of this treatment is a low risk of perforation of the gastric wall and a low risk of peritonitis. Combined therapy may work better than epinephrine alone. However, there is no evidence that one kind of treatment is more effective than the other." }, { "id": "wiki20220301en001_70209", "title": "Proton-pump inhibitor", "score": 0.009932659932659934, "content": "Medical uses These medications are used in the treatment of many conditions, such as: Dyspepsia Peptic ulcer disease including after endoscopic treatment for bleeding As part of Helicobacter pylori eradication therapy Gastroesophageal reflux disease (GERD or GORD) including symptomatic endoscopy-negative reflux disease and associated laryngopharyngeal reflux causing laryngitis and chronic cough Barrett's esophagus Eosinophilic esophagitis Stress gastritis and ulcer prevention in critical care Gastrinomas and other conditions that cause hypersecretion of acid including Zollinger–Ellison syndrome (often 2–3x the regular dose is required)" }, { "id": "pubmed23n0844_2936", "title": "Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.", "score": 0.00980392156862745, "content": "This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (&lt; 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence). " }, { "id": "pubmed23n0678_18985", "title": "[Diagnosis of gastric ulcer in the elderly].", "score": 0.00980392156862745, "content": "It is well known that gastric ulcers are most often found at anglus and upper corpus in the elderly. The number of gastric ulcer found at upper corpus hold half of all cases in the elderly patients with bleeding ulcer. Sixty percent of the elderly patients with bleeding ulcer took NSAIDs including low-dose aspirin in authors' hospital. Now it is easy to treat and cure bleeding ulcers due to development of endoscopic hemostasis and antiulcer drugs such as proton pump inhibitor(PPI). However, the elderly patients sometimes result in fatal outcome on bleeding from gastric ulcer. Therefore, it is important to prevent ulcer complications by PPI for the high-risk group such as elderly patients taking NSAIDs." }, { "id": "article-22080_13", "title": "Gastric Ulcer -- Treatment / Management", "score": 0.009725247430165463, "content": "The goal of treatment and management of gastric ulcers is first to increase the gastric pH and allowing the gastric mucosa to heal, which is possible through administering proton pump inhibitors, such as pantoprazole. A decision to proceed with an EGD should be the next consideration. Alarm symptoms should be recognized, which would make the need for an EGD more urgent. Alarm symptoms include unintentional weight loss, bleeding, age over 50, nausea, and vomiting. If a gastric ulcer is present on EGD, biopsies of the mucosa surrounding the ulcer will b necessary to rule out gastritis, Helicobacter pylori infection, and malignancy. These patients need to be on PPI therapy twice daily for 8 weeks and then undergo a repeat endoscopy to confirm for healing. [4]" }, { "id": "pubmed23n0065_5967", "title": "[The role of endoscopy in the hemorrhagic complications of gastroduodenal ulcer].", "score": 0.009708737864077669, "content": "The hemorrhage is a fairly frequent event in the evolution of the gastroduodenal peptic ulcer syndrome. The mortality rate has remained approximately unchanged, in spite of the progress in instrumental diagnosis and medical therapy, in the last decade. The authors examine 163 cases of digestive hemorrhage from gastroduodenal ulcers, observed in the last five years (1984-1988), with particular reference to the medical or surgical treatment undertaken, and to the mortality rate. Gastroduodenal ulcers, in 340 cases of upper digestive hemorrhage, represented nearly half the lesions, registered in the same period. Duodenal ulcers (D.U.), were found in 124 patients (34.4%) and gastric ulcers (G.U.) in 39 patients (11.47%), 113 (91.1%) patients with D.U., and 33 (84.6%) patients with G.U. were treated by medical therapy. The mortality rate in this group was 6.16%. II patients (8.9%) with D.U. and 6 patients (15.3%) with G.U. were operated on. The surgical mortality rate was high at 35.2%. Total mortality rate was 9.2%. The endoscopic exam was useful for diagnostic bleeding investigation and contributed to therapeutic decisions. Active bleeding lesions were found in 38.4% of patients with G.U. and in 32.3% with D.U. In 61.6% of patients with G.U. and in 67.7% with D.U., the lesions had already stopped bleeding; but in both lesions nearly 40% of cases, presented signs of a recent hemorrhage. The prognosis and natural history of the hemorrhage, was not changed by an immediate exam. The clinical reports and the data furnished, especially from continuous bleeding and rebleeding lesions, could be useful in identifying a sub-group of patients who could obtain better results by surgical treatment within a suitable time. The endoscopy, besides selecting and contributing to a better therapeutic strategy, through haemostasis technic, could reduce mortality rate from gastroduodenal ulcer lesions." }, { "id": "pubmed23n1046_19539", "title": "Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding.", "score": 0.009654191891396074, "content": "No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots - with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation - MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician. 53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p = .017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH. 1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov, Number: NCT03065465)." }, { "id": "wiki20220301en253_6048", "title": "Marginal zone B-cell lymphoma", "score": 0.009615384615384616, "content": "Primary rectal EMZL, more commonly termed MALT lymphoma of the rectum, usually presents at an early stage of disease with anal bleeding and/or blood in the stool. Endoscopic examination reveals a rectal polyp, rectal mass, or, less commonly, a rectal ulcer. Some cases of this lymphoma have been reported to regress spontaneously. On examination, >90% of cases present with localized (i.e. stage I or II) disease. The lymphomas' lesions are characterized by reactive lymphoid follicles infiltrated with centrocyte-like or monocyte-like B cells (the latter cells may show features of plasma cells). The malignant cells in these lesions may contain the t(11;18) translocation and therefore express the API2-MALT1 chimeric protein (11% of cases). Some 22-45% of casests are associated with Helicobactor pylori GI tract infection. Treatments for the disease have included radiotherapy, surgical resection, endoscopic mucosal resection, various chemotherapies, and antibiotic-based eradication of" }, { "id": "pubmed23n0480_3617", "title": "[Treatment of gastroduodenal ulcer bleedings in a general hospital of emergency care].", "score": 0.009615384615384616, "content": "Treatment of patients with gastroduodenal ulcer bleedings in a general hospital of emergency care is a complex of measures including of endoscopic diagnosis and stopping of bleeding, use of effective antisecretory drugs with obligatory laboratory control of acid-producing function of the stomach, surgical treatment and eradication of H. pylori. Up-to-date methods of endoscopic hemostasis - spirituous infiltration, argon-plasma coagulation, clipping of vessels in ulcer and also their combination in difficult cases - provide reliable hemostasis and allow to avoid urgent surgery. Recently we succeeded in reducing the rate of urgent surgeries performed at the height of bleedings from 70 to 40%. These methods can be recommended for clinical practice because they reduce significantly lethality rates in patients with severe conditions." }, { "id": "pubmed23n0717_12878", "title": "Management of patients with ulcer bleeding.", "score": 0.009523809523809525, "content": "This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy." }, { "id": "pubmed23n0646_23810", "title": "A case of hypereosinophilic syndrome presenting with intractable gastric ulcers.", "score": 0.009433962264150943, "content": "We report a rare case of hypereosinophilic syndrome (HES) presenting with intractable gastric ulcers. A 71-year-old man was admitted with epigastric pain. Initial endoscopic findings revealed multiple, active gastric ulcers in the gastric antrum. He underwent Helicobacter pylori (H pylori) eradication therapy followed by proton pump inhibitor (PPI) therapy. However, follow-up endoscopy at 4, 6, 10 and 14 mo revealed persistent multiple gastric ulcers without significant improvement. The proportion of his eosinophil count increased to 43% (total count: 7903/mm(3)). Abdominal-pelvic and chest computed tomography scans showed multiple small nodules in the liver and both lungs. The endoscopic biopsy specimen taken from the gastric antrum revealed prominent eosinophilic infiltration, and the liver biopsy specimen also showed eosinophilic infiltration in the portal tract and sinusoid. A bone marrow biopsy disclosed eosinophilic hyperplasia as well as increased cellularity of 70%. The patient was finally diagnosed with HES involving the stomach, liver, lung, and bone marrow. When gastric ulcers do not improve despite H pylori eradication and prolonged PPI therapy, infiltrative gastric disorders such as HES should be considered." }, { "id": "pubmed23n0584_7279", "title": "Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding.", "score": 0.009345794392523364, "content": "To evaluate the clinical effectiveness and cost-effectiveness of proton pump inhibitors (PPIs) in the prevention and treatment of acute upper gastrointestinal (UGI) haemorrhage, as well as to compare this with H2-receptor antagonist (H2RA), Helicobacter pylori eradication (in infected patients) or no therapy, for the prevention of first and/or subsequent bleeds among patients who continue to use non-steroidal anti-inflammatory drugs (NSAIDs). Also to evaluate the clinical effectiveness of PPI therapy, compared with other treatments, for the prevention of subsequent bleeds in patients who had previously experienced peptic ulcer (PU) bleeding. Electronic databases and major conference proceedings were searched up to February 2006. Data were collected from the systematic reviews addressing each research objective. These were then entered into an economic model to compare the costs and quality-adjusted life-days of alternative management strategies over a 28-day period for patients who have had UGI bleeding. A Markov model with a Monte Carlo simulation used data from the systematic reviews to identify the most cost-effective treatment strategy for the prevention of UGI bleeding (first and subsequent) among NSAID users using an outcome of costs per quality-adjusted life-years (QALYs) over a lifetime from age 50 years. PPI treatment initiated after endoscopic diagnosis of PU bleeding significantly reduced re-bleeding and surgery compared with placebo or H2RA. Although there was no evidence of an overall effect of PPI treatment on all-cause mortality, PPIs significantly reduced mortality in subgroups when studies conducted in Asia were examined in isolation or when the analysis was confined to patients with high-risk endoscopic findings. PPI treatment initiated prior to endoscopy in UGI bleeding significantly reduced the proportion of patients with stigmata of recent haemorrhage (SRH) at index endoscopy compared with placebo or H2RA, but there was no evidence that PPI treatment affected clinically important outcomes. Giving oral PPI both before and after endoscopy, with endoscopic haemostatic therapy (EHT) for those with major SRH, is preferred to all others on cost-effectiveness grounds at any threshold over 25,000 pounds per QALY, even if only short-term effects are taken into account, and at any threshold over 200 pounds per life-year gained if long-term effects are included. The risk of NSAID-induced endoscopic gastric and duodenal ulcers was reduced by standard doses of PPI and misoprostol, and double doses of H2RAs. Standard doses of H2RAs reduced the risk of endoscopic duodenal ulcers. PPIs reduced NSAID-induced dyspepsia. PPIs were superior to misoprostol in preventing recurrence of NSAID-induced endoscopic duodenal ulcers, but PPIs were comparable to misoprostol in preventing the recurrence of NSAID-induced endoscopic gastric ulcers. Full-dose misoprostol reduced bleeding, perforation or gastric outlet obstruction due to NSAID-induced ulcers, but misoprostol was poorly tolerated and associated with frequent adverse effects. H. pylori eradication treatment was equally effective with PPI treatment for the primary or secondary prevention of endoscopic ulcers in NSAID users. H. pylori eradication treatment was more effective than placebo for the primary prevention of endoscopic PU and for the prevention of re-bleeding from PU in NSAID users. With regard to primary and secondary prevention of bleeding PU in NSAID users, the two most cost-effective strategies are H. pylori eradication alone, and H. pylori eradication followed by misoprostol (substituted by a PPI, if misoprostol is not tolerated) at an additional 4810 pounds per QALY. In patients who had previously experienced a bleed from a PU, re-bleeding was less frequent after H. pylori eradication therapy than after non-eradication antisecretory therapy, whether or not the latter was combined with long-term maintenance antisecretory therapy. PPI treatment compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings, and reduces re-bleeding rates and surgical intervention. PPI treatment initiated prior to endoscopy in UGI bleeding significantly reduces the proportion of patients with SRH at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with EHT for those with major SRH, is likely to be the most cost-effective. Treatment of H. pylori infection was found to be more effective than antisecretory therapy in preventing recurrent bleeding from PU. H. pylori eradication alone or eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies for preventing bleeding ulcers among H. pylori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective. Further large randomised controlled trials are needed to address areas such as PPI administration prior to endoscopic diagnosis, different doses and administration of PPIs, as well as the primary and secondary prevention of UGI bleeding." } ] } } }

{ "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": [ [ 565, 846 ] ], "word_ranges": [ [ 76, 128 ] ], "text": "We must take into account that, in this case, potassium is decreased, so the most frequent cause (supported by the stains on the dress) would be diarrhea, so it is most likely that their renal failure (although they do not give us urine ion data to confirm it) is of prerenal type." } }

{ "1": "The presenting acid-base disorder is a respiratory acidosis.", "2": "Compensation to correct the acidosis is inadequate.", "3": "With this exploration, we rule out that she is dehydrated.", "4": "In any case, we should not put bicarbonate.", "5": "She has an acute renal failure of prerenal cause." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en074_45830", "title": "Base excess", "score": 0.01695156695156695, "content": "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) Blood pH is determined by both a metabolic component, measured by base excess, and a respiratory component, measured by PaCO2 (partial pressure of carbon dioxide). Often a disturbance in one triggers a partial compensation in the other. A secondary (compensatory) process can be readily identified because it opposes the observed deviation in blood pH. For example, inadequate ventilation, a respiratory problem, causes a buildup of CO2, hence respiratory acidosis; the kidneys then attempt to compensate for the low pH by raising blood bicarbonate. The kidneys only partially compensate, so the patient may still have a low blood pH, i.e. acidosis. In summary, the kidneys partially compensate for respiratory acidosis by raising blood bicarbonate." }, { "id": "pubmed23n0088_10230", "title": "Simple acid-base disorders.", "score": 0.01544608778625954, "content": "The body regulates pH closely to maintain homeostasis. The pH of blood can be represented by the Henderson-Hasselbalch equation: pH = pK + log [HCO3-]/PCO2 Thus, pH is a function of the ratio between bicarbonate ion concentration [HCO3-] and carbon dioxide tension (PCO2). There are four simple acid base disorders: (1) Metabolic acidosis, (2) respiratory acidosis, (3) metabolic alkalosis, and (4) respiratory alkalosis. Metabolic acidosis is the most common disorder encountered in clinical practice. The respiratory contribution to a change in pH can be determined by measuring PCO2 and the metabolic component by measuring the base excess. Unless it is desirable to know the oxygenation status of a patient, venous blood samples will usually be sufficient. Metabolic acidosis can result from an increase of acid in the body or by excess loss of bicarbonate. Measurement of the \"anion-gap\" [(Na+ + K+) - (Cl- + HCO3-)], may help to diagnose the cause of the metabolic acidosis. Treatment of all acid-base disorders must be aimed at diagnosis and correction of the underlying disease process. Specific treatment may be required when changes in pH are severe (pH less than 7.2 or pH greater than 7.6). Treatment of severe metabolic acidosis requires the use of sodium bicarbonate, but blood pH and gases should be monitored closely to avoid an \"overshoot\" alkalosis. Changes in pH may be accompanied by alterations in plasma potassium concentrations, and it is recommended that plasma potassium be monitored closely during treatment of acid-base disturbances." }, { "id": "wiki20220301en040_1095", "title": "Metabolic acidosis", "score": 0.013123061795628168, "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": "wiki20220301en040_1128", "title": "Respiratory acidosis", "score": 0.012538679731820525, "content": "Types Respiratory acidosis can be acute or chronic. In acute respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range (over 6.3 kPa or 45 mm Hg) with an accompanying acidemia (pH <7.36). In chronic respiratory acidosis, the PaCO2 is elevated above the upper limit of the reference range, with a normal blood pH (7.35 to 7.45) or near-normal pH secondary to renal compensation and an elevated serum bicarbonate (HCO3− >30 mEq/L). Causes Acute Acute respiratory acidosis occurs when an abrupt failure of ventilation occurs. This failure in ventilation may be caused by depression of the central respiratory center by cerebral disease or drugs, inability to ventilate adequately due to neuromuscular disease (e.g., myasthenia gravis, amyotrophic lateral sclerosis, Guillain–Barré syndrome, muscular dystrophy), or airway obstruction related to asthma or chronic obstructive pulmonary disease (COPD) exacerbation." }, { "id": "Physiology_Levy_3708", "title": "Physiology_Levy", "score": 0.012533596621139816, "content": "Table 37.2 ). In an appropriately compensated metabolic acidosis, the PCO2 is decreased, whereas it is elevated in compensated metabolic alkalosis. With respiratory acidosis, compensation results in an elevation of the [HCO3 −]. Conversely, ECF [HCO3 −] is reduced in response to respiratory alkalosis. In this example, the PCO2 is reduced from normal, and the magnitude of this reduction (10 mm Hg decrease in PCO2 for an 8 mEq/L decrease in ECF [HCO3 −]) is as expected (see Table 37.2 ). Therefore the acid-base disorder is a simple metabolic acidosis with appropriate respiratory compensation. A mixed acid-base disorder reflects the presence of two or more underlying causes for the acid-base disturbance. For example, consider the following data: pH = .6 96" }, { "id": "wiki20220301en071_55445", "title": "Metabolic alkalosis", "score": 0.011796774784680226, "content": "To calculate the expected pCO2 in the setting of metabolic alkalosis, the following equations are used: pCO2 = 0.7 [HCO3] + 20 mmHg ± 5 pCO2 = 0.7 [HCO3] + 21 mmHg Treatment To effectively treat metabolic alkalosis, the underlying cause(s) must be corrected. A trial of intravenous chloride-rich fluid is warranted if there is a high index of suspicion for chloride-responsive metabolic alkalosis caused by loss of gastrointestinal fluid (e.g., due to vomiting). Terminology Alkalosis refers to a process by which the pH is increased. Alkalemia refers to a pH which is higher than normal, specifically in the blood. See also Hypokalemia Metabolic acidosis Respiratory acidosis Respiratory alkalosis References External links Acid–base disturbances" }, { "id": "pubmed23n0032_12537", "title": "Acute acid-base disorders. 2. Specific disturbances.", "score": 0.011632341723874905, "content": "Evaluation of the acid-base status of the body requires measurement of bicarbonate (total carbon dioxide) concentration, pH, and partial pressure of CO2 in arterial blood. Calculation of standard bicarbonate and base excess or deficit is not necessary. The normal concentration of free hydrogen ions (H+) is approximately 40 millimoles/liter, which is equivalent to a pH of 7.4. The normal load of fixed acids is 50 to 80 millimoles in 24 hours. A steady state is maintained by excretion of an equal amount of H+ by the kidneys, which at the same time regenerate bicarbonate to replenish buffer stores. Renal excretion of H+ is in the form of titratable acid and ammonium. Synthesis of ammonia can increase severalfold under the stimulus of acidosis. This is the chief mechanism of long-term compensation. Metabolic acidosis can be due to an excessive acid load (endogenous or exogenous), impaired renal excretion of H+, or bicarbonate loss. Determination of the \"anion gap\" (unmeasured anions) helps to establish the mechanism of acidosis. Acidosis with a normal anion gap is due to either bicarbonate loss or ingestion of certain chloride salts. A gap larger than normal indicates the presence in the body of acids other than acidfying chloride salts. Management of metabolic acidosis requires accurate diagnosis, clear understanding of the mechansim, and individualized treatment. Metabloic alkalosis is due to loss of H+ (usually from stomach or kidneys) or ingestion of alkali. Measurement of urinary chloride helps establish the mechanism of alkalosis. In saline-responsive alkalosis, the urinary chloride level is very low. This is usually due to gastric loss of H+, and the condition responds to administration of saline solution. When the urinary chloride level is only moderately low, the alkalosis is probably not due to gastric loss of H+. This form of alkalosis (saline-resistant) does not respond well to administration of saline solution and requires use of potassium in treatment. Apprpriate compensatory responses to acidosis or alkalosis are critical to survival. Compensation for metabloic acidosis consists of hyperventilation and enhanced renal excretion of H+, chiefly as ammonium. In metabolic alkalosis, compensation is mainly renal excretion of bicarbonate. Respiratory acidosis is due to alveolar hypoventilation. In chronic situations, a compensatory rise in serum bicarbonate concentration is expected. Management consists of treatment of the cause of hypoventilation. Respiratory alkalosis is due to hyperventilation. Treatment requires identification and correction of the cause of hyperventilation." }, { "id": "wiki20220301en040_1133", "title": "Respiratory acidosis", "score": 0.011598081855693098, "content": "Diagnosis Diagnoses can be done by doing an ABG (Arterial Blood Gas) laboratory study, with a pH <7.35 and a PaCO2 >45 mmHg in an acute setting. Patients with COPD and other Chronic respiratory diseases will sometimes display higher numbers of PaCO2 with HCO3- >30 and normal pH. Terminology Acidosis refers to disorders that lower cell/tissue pH to < 7.35. Acidemia refers to an arterial pH < 7.36. See also Acidosis Alkalosis Arterial blood gas Chemical equilibrium pCO2 pH pKa Metabolic acidosis Metabolic alkalosis Respiratory alkalosis References External links Acid–base disturbances" }, { "id": "wiki20220301en074_45831", "title": "Base excess", "score": 0.011532083173874219, "content": "A high base excess, thus metabolic alkalosis, usually involves an excess of bicarbonate. It can be caused by Compensation for primary respiratory acidosis Excessive loss of HCl in gastric acid by vomiting Renal overproduction of bicarbonate, in either contraction alkalosis or Cushing's disease A base deficit (a below-normal base excess), thus metabolic acidosis, usually involves either excretion of bicarbonate or neutralization of bicarbonate by excess organic acids. Common causes include Compensation for primary respiratory alkalosis Diabetic ketoacidosis, in which high levels of acidic ketone bodies are produced Lactic acidosis, due to anaerobic metabolism during heavy exercise or hypoxia Chronic kidney failure, preventing excretion of acid and resorption and production of bicarbonate Diarrhea, in which large amounts of bicarbonate are excreted Ingestion of poisons such as methanol, ethylene glycol, or excessive aspirin" }, { "id": "wiki20220301en040_1131", "title": "Respiratory acidosis", "score": 0.011426564178857757, "content": "In acute respiratory acidosis, compensation occurs in 2 steps. The initial response is cellular buffering (plasma protein buffers) that occurs over minutes to hours. Cellular buffering elevates plasma bicarbonate (HCO3−) only slightly, approximately 1 mEq/L for each 10-mm Hg increase in PaCO2. The second step is renal compensation that occurs over 3–5 days. With renal compensation, renal excretion of carbonic acid is increased and bicarbonate reabsorption is increased. For instance, PEPCK is upregulated in renal proximal tubule brush border cells, in order to secrete more NH3 and thus to produce more HCO3−. Estimated changes In renal compensation, plasma bicarbonate rises 3.5 mEq/L for each increase of 10 mm Hg in PaCO2. The expected change in serum bicarbonate concentration in respiratory acidosis can be estimated as follows:" }, { "id": "Physiology_Levy_3706", "title": "Physiology_Levy", "score": 0.01122770001695458, "content": "The acid-base disorder represented by these values or any other set of values can be determined using the following three-step approach: 1. Examination of the pH. When pH is considered first, the underlying disorder can be classified as either an acidosis or an alkalosis. The defense mechanisms of the body cannot correct an acid-base disorder by themselves. Thus even if the defense mechanisms are completely operative, the change in pH indicates the acid-base disorder. In the example provided, the pH of 7.35 indicates acidosis. 2. Determination of metabolic versus respiratory disorder. Simple acid-base disorders are either metabolic or" }, { "id": "Physiology_Levy_3696", "title": "Physiology_Levy", "score": 0.011205019848892304, "content": "Table 37.1 summarizes the primary alterations and the subsequent compensatory or defense mechanisms of the various simple acid-base disorders. In all acid-base disorders the compensatory response does not correct the underlying disorder but simply reduces the magnitude of the change in pH. Correction of the acid-base disorder requires treatment of its cause. Types of Acid-Base Disorders Metabolic acidosis is characterized by a decreased ECF [HCO3 −] and pH. It can develop via the addition of nonvolatile acid to the body (e.g., diabetic ketoacidosis), the loss of nonvolatile base (e.g., HCO3 − loss caused by diarrhea), or failure of the kidneys to excrete titratable acid and NH4 + (e.g., renal failure). As previously described, the buffering of H+ occurs in both the ECF and ICF compartments. When the pH falls, the respiratory centers are stimulated and the ventilatory rate is increased (respiratory compensation)." }, { "id": "wiki20220301en019_114896", "title": "Acidosis", "score": 0.01115819209039548, "content": "Acid consumption from poisoning such as methanol ingestion, elevated levels of iron in the blood, and chronically decreased production of bicarbonate may also produce metabolic acidosis. Metabolic acidosis is compensated for in the lungs, as increased exhalation of carbon dioxide promptly shifts the buffering equation to reduce metabolic acid. This is a result of stimulation to chemoreceptors, which increases alveolar ventilation, leading to respiratory compensation, otherwise known as Kussmaul breathing (a specific type of hyperventilation). Should this situation persist, the patient is at risk for exhaustion leading to respiratory failure. Mutations to the V-ATPase 'a4' or 'B1' isoforms result in distal renal tubular acidosis, a condition that leads to metabolic acidosis, in some cases with sensorineural deafness." }, { "id": "wiki20220301en147_46230", "title": "Renal compensation", "score": 0.011150935882118677, "content": "Renal compensation is a mechanism by which the kidneys can regulate the plasma pH. It is slower than respiratory compensation, but has a greater ability to restore normal values. In respiratory acidosis, the kidney produces and excretes ammonium (NH4+) and monophosphate, generating bicarbonate in the process while clearing acid. In respiratory alkalosis, less bicarbonate (HCO3−) is reabsorbed, thus lowering the pH. References Acid–base disturbances" }, { "id": "wiki20220301en267_19616", "title": "Winters' formula", "score": 0.011011904761904763, "content": "Winters' formula, named for Dr. R.W. Winters, is a formula used to evaluate respiratory compensation when analyzing acid–base disorders and a metabolic acidosis is present. It can be given as , where HCO3− is given in units of mEq/L and pCO2 will be in units of mmHg. Winters' formula gives an expected value for the patient's PCO2; the patient's actual (measured) PCO2 is then compared to this: If the two values correspond, respiratory compensation is considered to be adequate. If the measured PCO2 is higher than the calculated value, there is also a secondary respiratory acidosis or mixed acid base disorder. If the measured PCO2 is lower than the calculated value, there is also a secondary respiratory alkalosis or mixed acid base disorder. References Respiratory therapy Mathematics in medicine" }, { "id": "InternalMed_Harrison_3723", "title": "InternalMed_Harrison", "score": 0.011005710075520354, "content": "Mixed acid-base disorders—defined as independently coexisting disorders, not merely compensatory responses—are often seen in patients in critical care units and can lead to dangerous extremes of pH (Table 66-2). A patient with diabetic ketoacidosis (metabolic acidosis) may develop an independent respiratory problem (e.g., limits (range of values) of the normal respiratory and metabolic compensations for primary acid-base disturbances. (From TD DuBose Jr: Acid-base disorders, in Brenner and Rector’s The Kidney, 8th ed, BM Brenner [ed]. Philadelphia, Saunders, 2008, pp 505–546, with permission.) Key: Highor normal-AG metabolic acidosis; prevailing Paco2 below predicted value (Table 66-1) Example: Na+, 140; K+, 4.0; Cl-, 106; HCO3 -, 14; AG, 20; Paco2, 24; pH, 7.39 (lactic acidosis, sepsis in ICU) Metabolic acidosis—respiratory acidosis" }, { "id": "article-17837_19", "title": "Arterial Blood Gas -- Results, Reporting, and Critical Findings", "score": 0.010557637205201675, "content": "Example 1 [28] : ABG: pH = 7.39, PaCO 2 = 51 mm Hg, PaO 2 = 59 mm Hg, HCO 3 = 30 mEq/L and SaO 2 = 90%, on room air. pH is in the normal range, so use 7.40 as a cutoff point, in which case it is < 7.40, and acidosis is present. The elevated PaCO 2 indicates respiratory acidosis, and the elevated HCO 3 indicates a metabolic alkalosis. The value consistent with the pH is PaCO 2 . Therefore, this is a primary respiratory acidosis. The acid-base that is inconsistent with the pH is the elevated HCO3, indicating a metabolic alkalosis, so there is compensation signifying a non-acute primary disorder because it takes days for metabolic compensation to be effective. Last, the decreased PaO 2 indicates an abnormality with oxygenation. However, a history and physical will help delineate the severity and urgency of required interventions, if any. Example 2 [28] : ABG: pH = 7.45, PaCO 2 = 32 mm Hg, PaO 2 = 138 mm Hg, HCO 3 = 23 mEq/L, the base deficit = 1 mEq/L, and SaO 2 is 92%, on room air." }, { "id": "InternalMed_Harrison_3604", "title": "InternalMed_Harrison", "score": 0.010091034008931639, "content": "4. Correct the metabolic acidosis. The plasma bicarbonate concentration will usually not increase for several hours because of dilution from administered IV NaCl. The plasma [HCO−] approaches 18 meq/L once ketoacidosis disappears. Sodium bicarbonate therapy is often not recommended or necessary and is contraindicated CHAPTER 64e Fluid and Electrolyte Imbalances and Acid-Base Disturbances: Case Examples 64e-2 for children. Bicarbonate is administered to adults with DKA for extreme acidemia (pH <7.1); for elderly patients (>70 years old), a threshold pH of 7.20 is recommended. Sodium bicarbonate, if administered, should only be given in small amounts. Because ketoacids are metabolized in response to insulin therapy, bicarbonate will be added to the ECF as ketoacids are converted. Overshoot alkalosis may occur from the combination of exogenously administered sodium bicarbonate plus metabolic production of bicarbonate. 5." }, { "id": "pubmed23n0389_1235", "title": "[Severe accidental hypothermia in an elderly woman].", "score": 0.009900990099009901, "content": "Profound hypothermia (core temperature of less than 28 degrees C) is a life threatening state and a medical emergency associated with a high mortality rate. The prognosis depends on underlying diseases, advanced or very early age, the duration prior to treatment, the degree of hemodynamic deterioration, and especially, the methods of treatment, including active external or internal rewarming. This is a case study of an 80-year-old female patient with severe accidental hypothermia (core temperature 27 degrees C). She was found in her home lying immobile on the cold floor after a fall. The patient was in a profound coma with cardiocirculatory collapse, and the medical staff treating her was inclined to pronounce her deceased. On her arrival at the hospital, she was resuscitated, put on a respirator and actively warmed. Very severe metabolic disorders were found, including a marked metabolic acidosis composed of diabetic ketoacidosis (she had suffered from insulin treated type 2 diabetes mellitus) and lactic acidosis with a very high anion gap (42) and a hyperosmotic state (blood glucose 1202 mg/dl). There were pathognomonic electrocardiographic abnormalities, J-wave of Osborn and prolonged repolarization. Slow atrial fibrillation with a ventricular response of 30 bpm followed by a nodal rhythm of 12 bpm and reversible cardiac arrest were recorded. The pulse and blood pressure were unobtainable. Despite the successful resuscitation and hemodynamic and cognitive improvement, rhabdomyolysis (CKP 6580 u/L), renal failure and hepatic damage developed. She was extubated and treated with intravenous fluids containing dopamine, bicarbonate, insulin and antibiotics. Her medical condition gradually improved, and she was discharged clear minded, functioning very well and independent. Renal and liver tests returned eventually to normal limits. Progressive bradycardia, hypotension and death due to ventricular fibrillation or asystole commonly occur during severe hypothermia. Respiratory and metabolic, sometimes lactic, acidosis, lethargy and coma, hypercoagulopathy, hyperosmolar state, acute pancreatitis and renal and hepatic failure are frequent complications of hypothermia. Underlying predisposing causes of hypothermia are diabetic ketoacidosis, cerebrovascular disease, mental retardation, hypothyroidism, pituitary and adrenal insufficiency, malnutrition, acute alcoholism, liver damage, hypoglycemia, sepsis, hypothalamic dysfunction, sepsis and polypharmacy, and especially, the use of sedative and narcotic drugs. Our case demonstrates once again that CPR once begun should continue until the successful rewarming because \"no one is dead until warm and dead\"." }, { "id": "pubmed23n0014_13264", "title": "[Contribution to acid-base metabolism in hypertonic dehydration by the study of \"fraction R\" (underterminate anions) (author's transl)].", "score": 0.009900990099009901, "content": "A study on the value of \"R fraction\" of plasma electrolites (undetermined anions), in order to know better the metabolic acidosis of the hypertonic dehydration is achieved. \"R fraction\" value was obtained by the formulae: R fraction = plasma N+ --(plasma Cl- + plasma HCO3-). The mean values in patients with hypertonic dehydration was: 12.4 +/- 8.3 mEq./l., more than the normal standard data of our laboratory: 8.55 +/- 3.4 mEq./l. Authors make two groups in accordance with the \"R\" value: one with low \"R fraction\" (25 cases): 4.79 +/- 4.70 mEq./l.; and another with high \"R fraction\" (32 cases): 20.04 +/- 6.6 mEq./l., and compare the differences (ethiologic, clinic, shock and metabolic) between the two groups. It is confirmed that acidosis in hypertonic dehydration is essentially hyperchloremic. It was speculated on the \"anion gap\" and the total value of chloride in this dehydration." }, { "id": "InternalMed_Harrison_3736", "title": "InternalMed_Harrison", "score": 0.009870205751012062, "content": "Metabolic acidosis can occur because of an increase in endogenous acid production (such as lactate and ketoacids), loss of bicarbonate (as in diarrhea), or accumulation of endogenous acids (as in renal failure). Metabolic acidosis has profound effects on the respiratory, cardiac, and nervous systems. The fall in blood pH is accompanied by a char acteristic increase in ventilation, especially the tidal volume (Kussmaul respiration). Intrinsic cardiac contractility may be depressed, but ino tropic function can be normal because of catecholamine release. Both present; the decrease in central and pulmonary vascular compliance predisposes to pulmonary edema with even minimal volume overload. CNS function is depressed, with headache, lethargy, stupor, and, in some cases, even coma. Glucose intolerance may also occur. There are two major categories of clinical metabolic acidosis: high-AG and non-AG, or hyperchloremic, acidosis (Table 66-3 and Table 66-4)." }, { "id": "wiki20220301en438_3535", "title": "Delta ratio", "score": 0.00986235277423017, "content": "Result 4: if the result of the ratio is greater than 2 in a high anion gap metabolic acidosis, it is usually because there was a pre-existing higher than normal bicarbonate level. This is commonly found in people with chronic respiratory acidosis from chronic lung disease such as chronic obstructive pulmonary disease (COPD), who can't breathe off their excess carbon dioxide owing to poor lung function, and retain bicarb in order to counteract the acidosis caused by the retained CO2. Alternatively it could be caused by a concurrent metabolic alkalosis such as vomiting causing acid loss and hence alkalosis, or diuretic use with loss of Cl¯ and a compensatory bicarb retention in order to maintain plasma electrical neutrality." }, { "id": "pubmed23n0419_17156", "title": "[Acute encephalopathy due to thiamine deficiency with hyperammonemia in a chronic hemodialysis patient: a case report].", "score": 0.00980392156862745, "content": "Hemodialysis(HD) patients are at risk for thiamine deficiency because of low intake and accelerated loss of thiamine during HD. We report here an HD patient, an 82-year-old woman, who developed acute encephalopathy due to thiamine deficiency with hyperammonemia. She was admitted to Nishikawa Town Hospital due to pneumonia and was treated with ABPC/SBT for one week. While she was cured of pneumonia, she had a persistently poor appetite. On the twenty-fourth day after admission, HD with intradialytic parenteral nutrition(IDPN), which consisted of 10% glucose 500 ml, in order to correct her malnutrition, was started. She suddenly presented confusion, speech disturbance and ophthalmoplegia. HD with IDPN was stopped after two hours because of her symptoms. Laboratory studies disclosed plasma glucose of 186 mg/dl and serum ammonium of 155 micrograms/dl. Arterial blood gas analysis(inhaling 3 l/min O2) showed severe metabolic acidosis and respiratory acidosis (pH 7.138, pCO2 44.8 mmHg, pO2 108.9 mmHg, HCO3- 15.1 mmol/l). Her malnutrition, unexplained metabolic acidosis and neurological presentation raised the suspicion of acute encephalopathy due to thiamine deficiency. Fursultiamine 100 mg was administered intravenously. After two hours, metabolic acidosis disappeared (pH 7.437, pCO2 33.9 mmHg, pO2 161.0 mmHg, HCO3- 22.9 mmol/l), and she regained her clear consciousness and serum ammonium decreased at 16 micrograms/dl on the next morning. Serum lactate and thiamine level were shown later to be 57.5 mg/dl and 27 nmol/l, respectively. Her clinical course suggests that the glucose load including IDPN may have caused deterioration of the neurological disorder under the condition of thiamine deficiency. Furthermore, it is possible that a relationship exists between thiamine deficiency and hyperammonemia." }, { "id": "pubmed23n0226_7085", "title": "[Problems of acid-base equilibrium of the organism].", "score": 0.00980392156862745, "content": "The physiopathology, clinical aspects and diagnosis of changes in Acid-Base balance are reviewed. Balance depends on diet, metabolism and efficiency of the emunctory organs (intestinal, renal and respiratory). Changes in Acid-Base balance are more frequent than is commonly thought and are also seen in out-patients whose general condition is not serious. Specific diagnosis is based exclusively on blood measurement of pH, PCO2 and HCO3. It is necessary and sufficient for the physician to remember to carry out these studies more often. It is thus possible to identify and correct initial situations of altered A-B balance which, if ignored, may aggravate general condition to a sometimes fatal extent." }, { "id": "wiki20220301en040_1102", "title": "Metabolic acidosis", "score": 0.009765540040889122, "content": "Buffer The decreased bicarbonate that distinguishes metabolic acidosis is therefore due to two separate processes: the buffer (from water and carbon dioxide) and additional renal generation. The buffer reactions are: H+ + HCO3- <=> H2CO3 <=> CO2 + H2O The Henderson-Hasselbalch equation mathematically describes the relationship between blood pH and the components of the bicarbonate buffering system: Using Henry's law, we can say that [] = 0.03 × Pa (Pa is the pressure of in arterial blood) Adding the other normal values, we get Consequences Acute Metabolic Acidosis Acute Metabolic Acidosis most often occurs during hospitalizations, and acute critical illnesses. It is often associated with poor prognosis, with a mortality rate as high as 57% if the pH remains untreated at 7.20. At lower pH levels, acute metabolic acidosis can lead to impaired circulation and end organ function." }, { "id": "pubmed23n0278_1663", "title": "[Dwarfism, arterial hypertension and hyperkalemic acidosis corrected with thiazides. A case of type II pseudohypoaldosteronism].", "score": 0.009708737864077669, "content": "Type II pseudohypoaldosteronism is a rare tubulopathy defined by abnormal renal potassium excretion. A 12 1/2 year-old girl, was admitted for dwarfism. Her parents were not consanguineous and her 5 living sibs were normal. At admission, she had moderate hypertension: systolic 130-150 mmHg; diastolic 80-100 mmHg and no pubertal development. pH (arterial): 7.34; bicarbonates: 18-20 mEq/l; chloride: 112-120 mEq/l; potassium: 5.6-7 mEq/l; aldosterone: 200-700 pg/ml (N &lt; 60); plasma renin activity: 0.4 ng/ml/hr (N 2.2 +/- 0.2). The bone maturation was 8 1/2 years. All the other renal function tests were normal. The titratable acidity was 22 mEq/day (N 20-40) and the ammonia excretion 15.2 mEq/l (N 44-61). The fractional excretion of potassium was 6.5% (N 11.8 +/- 1.9). This girl was given polystyrene sulfonate resin followed by hydrochlorothiazide (1 to 3 mg/kg/day). There was a subsequent improvement in all data, a growth spurt and pubertal development. This is the fifth case of type II pseudohypoaldosteronism reported in childhood and the first one with hypertension. The beneficial effect of hydrochlorothiazide is underlined." }, { "id": "pubmed23n0083_1722", "title": "Diuretic abuse and central pontine myelinolysis.", "score": 0.009615384615384616, "content": "Patients with eating disorders often use diuretics to eliminate fluid to achieve lower body weight. Diuretic abuse can lead to severe hyponatremia. Central pontine myelinolysis, a disruption of the myelinated neurons of the pons, has been associated with rapid correction of severe hyponatremia. A case is presented of a 35-year-old woman who was brought to the emergency service by ambulance complaining of vomiting for 7 days and that she could not hear well because she was 'worn out'. Initial laboratory values included serum Na 91 mEq/l, K 1.6, Cl 46, bicarbonate 33, BUN 4 mg/dl, glucose 306 mg/dl. After 32 h of intravenous fluids, the serum Na was 126, K 4.0, Cl 89, bicarbonate 25, glucose 118 mg/dl. On the 3rd hospital day the serum Na was 139. On the 4th hospital day she was alert and appropriate. On the 5th hospital day, however, she was confabulating and chatty. The serum Na was 139. She progressed to develop a spastic quadriparesis, speech and swallowing difficulties. A magnetic resonance imaging scan showed central pontine myelinolysis. She acknowledged taking 400 mg daily of furosemide and drinking much water. She had a past history of anorexia nervosa. She had a residual weight phobia and strove to keep her weight below 106 lb. Her height was 5 feet, 6 inches. As illustrated by this case, diuretic abuse can cause severe hyponatremia and the subsequent risk of central pontine myelinolysis. In patients with severe chronic or subacute hyponatremia, a safe restoration rate for serum Na has been less than 0.55 mEq/l/h. Serum Na should be below 135 within the first 48 h and hypernatremia should be avoided." }, { "id": "pubmed23n0103_13539", "title": "[Program for interpreting acid-base disorders and assessing blood oxygenation].", "score": 0.009615384615384616, "content": "The paper describes a program for the interpretation of deviations in the acid-base state (AAS) and the estimation of the blood oxygenation levels. The program was developed for the Iskra-226 microcomputer and is intended for a direct measurement of the gas composition of the blood. The program makes it possible to calculate the AAS and the blood oxygenation levels (20 parameters), to estimate the AAS deviation type and the degree of its compensation, it accumulates and stores the patient data, keeps records of case histories." }, { "id": "pubmed23n0866_3505", "title": "Trimethoprim/Sulfamethoxazole-Induced Severe Lactic Acidosis: A Case Report and Review of the Literature.", "score": 0.009523809523809525, "content": "Propylene glycol (PG) is used as a solvent in numerous medications, including trimethoprim/sulfamethoxazole (TMP/SMX) and lorazepam, and is metabolized in the liver to lactic acid. Cases of lactic acidosis related to PG toxicity have been described and always involved large doses of benzodiazepines and PG. We present the first case of severe lactic acidosis after a 3-day course of TMP/SMX alone, involving allegedly safe amounts of PG.A 31-year-old female with neurofibromatosis and pilocytic astrocytoma, receiving temozolomide and steroids, was admitted to the intensive care unit for pneumonia and acute respiratory failure requiring intubation. Her initial hemodynamic and acid-base statuses were normal. She was treated with intravenous TMP/SMX for possible Pneumocystis jirovecii pneumonia and was successfully extubated on day 2. On day 3, she developed tachypnea and arterial blood gas analysis revealed a severe metabolic acidosis (pH 7.2, PCO2 19 mm Hg, bicarbonates 8 mEq/L) with anion gap of 25 mEq/L and lactate of 12.1 mmol/L. TMP/SMX was discontinued and the lactate decreased to 2.9 mmol/L within 24 hours while her plasma bicarbonates normalized, without additional intervention. The patient never developed hypotension or severe hypoxia, and her renal and liver functions were normal. No other cause for lactic acidosis was identified and it resolved after TMP/SMX cessation alone, suggesting PG toxicity.Although PG-related lactic acidosis is well recognized after large doses of lorazepam, clinicians should bear in mind that TMP/SMX contains PG as well and should suspect PG toxicity in patients developing unexplained metabolic acidosis while receiving TMP/SMX. " }, { "id": "pubmed23n0564_4476", "title": "[Meeting point Stewart. Buffer bases, base excess and strong ions].", "score": 0.009523809523809525, "content": "Development of a two-buffer model which simulates the acid-base properties of blood and allows comparison of the different acidbase concepts according to Stewart and to Siggaard-Andersen. The two-buffer model consisted of different aqueous solutions of bicarbonate/CO(2) (pCO(2), sCO(2), pK(1)), HEPES buffer (A(tot), pK(a)) and electrolytes. These were used to calculate the pH from the independent variables according to Stewart - strong ion difference (SID), pCO(2) and total concentration of the weak acids (A(tot)) - from which all other dependent variables (cHCO(3)(-), cA(-), BB, BE) were obtained and compared with the measured values. The normal pH (7.408) was calculated from the normal values for SID (48 mmol/l), pCO(2) (40 mmHg) and A(tot) (45.2 mmol/l) and agreed perfectly with the measured value (7.409+/-0.001). This was also valid for all calculated and measured pH values when the SID was varied: non-respiratory alkalosis ( upward arrow) or acidosis ( downward arrow), pCO(2):respiratory acidosis ( upward arrow) or alkalosis ( downward arrow) and A(tot):hyperproteinemic acidosis ( upward arrow) or hypoproteinemic alkalosis ( downward arrow) were varied and the sum of the buffer bases (BB) was always equal to the SID. All changes and hence BE were also equal, providing that A(tot) was normal. This was not the case, however, if A(tot) was outside the normal range, when BE was then the difference from the normal BB at the respective reference point. Whereas the deviation of the measured pCO(2) was acceptable (1.74+/-0.86 mmHg), this was not the case for the SID (-6.18+/-3.58 mmol/l) calculated from the measured ion concentrations (Na, K, Ca, Cl). Despite controversial discussions, both concepts are much closer than might be expected. Whereas in the Stewart approach the focus of analysis is on plasma, with the Siggaard-Andersen approach it is on blood. Hence, a combined analysis of the blood gases (pH, pCO(2), pO(2), sO(2), cHb, BE) and of the strong ion gap (SIG) may be useful." }, { "id": "pubmed23n0609_14977", "title": "Cardiotoxicity after massive amantadine overdose.", "score": 0.009433962264150943, "content": "Amantadine hydrochloride is an antiviral medication used as therapy for parkinsonism and as a cognitive enhancer. We report 2 cases of massive, acute ingestion of amantadine hydrochloride confirmed with serial serum levels. A 47-year-old woman presented to the emergency department (ED) 30 minutes after ingesting 10 g of amantadine (150 mg/kg) by her report. Initial ECG revealed a sinus rhythm with rate of 93 bpm, and a QRS of 84 msec. While in the ED, the patient sustained a pulseless cardiac arrest and the monitor revealed ventricular tachycardia. She was successfully defibrillated. Postdefibrillation ECG showed a sinus rhythm (rate = 82 bpm), QRS of 236 msec, and QTc of 567 msec. The serum potassium was 1.0 mEq/L (1.0 mmol/L). The patient was given 300 ml (300 cc) 3% sodium chloride IV over 10 minutes. Ten minutes after completion of the hypertonic saline infusion, the patient's ECG abnormalities resolved and the QRS was 88 msec. Her potassium was repleted over the next 11 hours postpresentation, and she also received an IV bolus of 4 g of magnesium sulfate immediately after the cardiac arrest. No further hypotension, dysrhythmia, conduction delay, or ectopy was noted during the patient's hospital stay. The second case involved a 33-year-old female patient who presented 1 hour after ingesting 100 tablets of amantadine hydrochloride (100 mg/tab). Initial ECG revealed sinus tachycardia with a QRS of 113 msec, an R wave in lead aVR of 4-5 mm and a QTc of 526 msec. Her serum potassium was 3.0 mEq/L (3.0 mmol/L), her serum calcium was 9.4 mg/dl (2.35 mmol/L), and serum magnesium was 2.1 mg/dl (0.86 mmol/L) on labs drawn at initial presentation. The patient was intubated for airway protection, and her potassium was repleted and corrected over the next 9 hours. Her ECG abnormalities improved 8 hours after initial presentation and normalized at approximately 14 hours postingestion. The patient was discharged home 11 days after her ingestion. Acute amantadine toxicity manifests with life-threatening cardiotoxicity. Concurrent, often profound, hypokalemia may complicate the administration of sodium bicarbonate in the management of cardiac dysrhythmias." }, { "id": "pubmed23n0513_9996", "title": "[Diagnosis and treatment of disordered acid-base balance].", "score": 0.009433962264150943, "content": "Differential diagnosis in disordered acid-base homeostasis is usually possible by measuring the pH, pCO2, pO2 and bicarbonate concentration, and enables differentiation between respiratory alkalosis and acidosis, and metabolic alkalosis and acidosis. Compensatory counter-regulation (respiratory or renal) can make correct assessment of the primary disorder problematic. Treatment of the underlying disease, in particular the provision of adequate oxygenation in respiratory disorders is of the essence. In chronic forms of metabolic acidosis, for example in chronic renal insufficiency and elderly patients, bicarbonate substitution should be initiated in order to prevent the negative effects on various organ systems. Sodium bicarbonate formulations that can be assimilated from the small bowel are especially tolerable and suitable." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 101, 391 ] ], "word_ranges": [ [ 17, 66 ] ], "text": "We are being told about erythema súdenita or fifth disease (also called megaloerythema), caused by parvovirus B19. It is typical that after an episode of high fever an erythema appears on both cheeks in the form of a \"slap\" that usually has a cranial-caudal extension in the following days." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Chickenpox.", "2": "Rubella.", "3": "Erythema infectiosum or 5th disease.", "4": "Sudden exanthema or 6th disease.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en013_144133", "title": "Fifth disease", "score": 0.01647457627118644, "content": "Signs and symptoms Fifth disease starts with a low-grade fever, headache, rash, and cold-like symptoms, such as a runny or stuffy nose. These symptoms pass, then a few days later, the rash appears. The bright red rash most commonly appears in the face, particularly the cheeks. This is a defining symptom of the infection in children (hence the name \"slapped cheek disease\"). Occasionally, the rash will extend over the bridge of the nose or around the mouth. In addition to red cheeks, children often develop a red, lacy rash on the rest of the body, with the upper arms, torso, and legs being the most common locations. The rash typically lasts a few days and may itch; some cases have been known to last for several weeks. Patients are usually no longer infectious once the rash has appeared." }, { "id": "InternalMed_Harrison_14557", "title": "InternalMed_Harrison", "score": 0.015395731436193865, "content": "CLINICAL MANIFESTATIONS Erythema Infectiosum Most B19V infections are asymptomatic or are associated with only a mild nonspecific illness. The main manifestation of symptomatic B19V infection is erythema infectiosum, also known as fifth disease or slapped-cheek disease (Fig. 221-2 and Fig. 25e-1A). Infection begins with a minor febrile prodrome ~7–10 days after exposure, and the classic facial rash develops several days later; after 2–3 days, the erythematous macular rash may spread to the extremities in a lacy reticular pattern. However, its intensity and distribution vary, and B19V-induced rash is difficult to distinguish from other viral exanthems. Adults typically do not exhibit the “slapped-cheek” phenomenon but present with arthralgia, with or without the macular rash." }, { "id": "InternalMed_Harrison_1655", "title": "InternalMed_Harrison", "score": 0.014331690636628786, "content": "(Reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005.) Figure 25e-1 A. Erythema leading to “slapped cheeks” appearance in erythema infectiosum (fifth disease) caused by parvovirus B19. B. Lacy reticular rash of erythema infectiosum. (Panel A reprinted from K Wolff, RA Johnson: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. New York, McGraw-Hill, 2009.) PART 2 Cardinal Manifestations and Presentation of Diseases Figure 25e-4 In rubella, an erythematous exanthem spreads from the hairline downward and clears as it spreads. (Courtesy of Stephen E. Gellis, MD; with permission.)" }, { "id": "InternalMed_Harrison_1621", "title": "InternalMed_Harrison", "score": 0.014331501831501833, "content": "226) may exhibit pharyngitis, lymphadenopathy, and a nonspecific maculopapular exanthem. The rash of erythema infectiosum (fifth disease), which is caused by human parvovirus B19, primarily affects children 3–12 years old; it develops after fever has resolved as a bright blanchable erythema on the cheeks (“slapped cheeks”) with perioral pallor (Chap. 221). A more diffuse rash (often pruritic) appears the next day on the trunk and extremities and then rapidly develops into a lacy reticular eruption that may wax and wane (especially with temperature change) over 3 weeks. Adults with fifth disease often have arthritis, and fetal hydrops can develop in association with this condition in pregnant women." }, { "id": "wiki20220301en009_127412", "title": "Rubella", "score": 0.01405924071756362, "content": "The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 °C (100.4 °F). The rash of rubella is typically pink or light red. The rash causes itching and often lasts for about three days. The rash disappears after a few days with no staining or peeling of the skin. When the rash clears up, the skin might shed in very small flakes where the rash covered it. Forchheimer spots occur in 20% of cases and is characterized by small, red papules on the area of the soft palate. Rubella can affect anyone of any age. Adult women are particularly prone to arthritis and joint pains. In children, rubella normally causes symptoms which last two days and include: Rash beginning on the face which spreads to the rest of the body. Low fever of less than 38.3 °C (101 °F). Posterior cervical lymphadenopathy." }, { "id": "wiki20220301en013_144132", "title": "Fifth disease", "score": 0.01368047539652003, "content": "Erythema infectiosum, fifth disease, or slapped cheek syndrome is one of several possible manifestations of infection by parvovirus B19. Fifth disease typically presents as a rash and is more common in children. While parvovirus B19 can affect humans of all ages, only two out of ten individuals will present with physical symptoms. The name \"fifth disease\" comes from its place on the standard list of rash-causing childhood diseases, which also includes measles (first), scarlet fever (second), rubella (third), Dukes' disease (fourth, but is no longer widely accepted as distinct from scarlet fever), and roseola (sixth)." }, { "id": "pubmed23n0380_15658", "title": "[Five cases of erythema infectiosum in adults].", "score": 0.013669868215322761, "content": "The similarities between clinical features of erythema infectiosum and collagen disease or other viral infections prompted us to investigate clinical manifestations and laboratory data of parvovirus B19 (B19) infection in adults. We diagnosed all five patients as acute B19 infection by antibody assays. The age of patients ranged from 18 to 39 years old (mean 29), and all patients were female. All five patients showed high fever, arthralgia and edema of the extremities. Four of the five patients showed skin rash of the extremities or cheeks. Two patients were diagnosed as erythema infectiosum by family physicians before coming to us. The three remaining patients were suspected to be systemic lupus erythematosus, adult Still disease or rubella indivisually and referred to our hospital. A-27-old female (case 5) visited our hospital because of polyarthralgia and butterfly rash on her face. A test for antinuclear antibodies (ANA) was positive at a dilution of 1:320. Rheumatoid factor (RF) was also detected by latex fixation test. Her AST was 51 IU/L, ALT 68 IU/L and LDH 568 IU/L. Her symptoms persisted for 3 weeks and hepatic dysfunction recovered within 3 weeks. Five months later. ANA was negative at the dilution of less than 1:40. We suggest that the similarities between some symptoms of B19 infection and clinical and serological manifestation of collagen diseases merit closer attention." }, { "id": "InternalMed_Harrison_4114", "title": "InternalMed_Harrison", "score": 0.012592592592592593, "content": "(Table 72-13) Exanthems are characterized by an acute generalized eruption. The most common presentation is erythematous macules and papules (morbilliform) and less often confluent blanching erythema (scarlatiniform). Morbilliform eruptions are usually due to either drugs or viral infections. For example, up to 5% of patients receiving penicillins, sulfonamides, phenytoin, or nevirapine will develop a maculopapular eruption. Accompanying signs may include pruritus, fever, eosinophilia, and transient lymphadenopathy. Similar maculopapular eruptions are seen in the classic childhood viral exanthems, including (1) rubeola (measles)—a prodrome of coryza, cough, and conjunctivitis followed by Koplik’s spots on the buccal mucosa; the eruption begins behind the ears, at the hairline, and on the forehead and then spreads down the body, often becoming confluent; (2) rubella—the eruption begins on the forehead and face PART 2 Cardinal Manifestations and Presentation of Diseases" }, { "id": "wiki20220301en004_55541", "title": "Scarlet fever", "score": 0.012285797269822828, "content": "Mouth The streptococcal pharyngitis, which is the usual presentation of scarlet fever in combination with the characteristic rash, commonly involves the tonsils. The tonsils will appear swollen and reddened. The palate and uvula are also commonly affected by the infection. The involvement of the soft palate can be seen as tiny red and round spots known as Forchheimer spots. Variable presentations The features of scarlet fever can differ depending on the age and race of the person. Children less than 5 years old can have atypical presentations. Children less than 3 years old can present with nasal congestion and a lower grade fever. Infants may present with symptoms of increased irritability and decreased appetite. Children who have darker skin can have a different presentation, as the redness of the skin involved in the rash and the ring of paleness around the mouth can be less obvious. Suspicion based on accompanying symptoms and diagnostic studies are important in these cases." }, { "id": "article-21297_10", "title": "Erythema Infectiosum -- History and Physical", "score": 0.01222692036645525, "content": "The most common and classic presentation of erythema infectiosum is a mild febrile illness with rash. Beginning symptoms of infection can include fever, malaise, myalgias, diarrhea, vomiting, and headache. After initial viremia, the classic erythematous malar rash involving the cheeks with surrounding oral pallor develops. This rash does not develop early in the disease process. The rash is classically characterized as a “slapped-cheek rash” and maybe the only clinical diagnostic finding in this disease process. This facial rash can last 4 to 5 days. At the time the facial rash develops, the patient usually feels well, and the viremia has resolved. This rash is thought to be immune-mediated. Days after the facial rash develops, a maculopapular rash usually develops on the trunk and limbs. This rash is nonpruritic and usually lasts about 1 week. The rash may also have a lacy or reticular appearance as it starts to resolve. The reticular rash is often present more on the extensor surfaces. The palms of the hands and soles of the feet are typically not affected. [6] Exposure to sun or heat may exacerbate the rash." }, { "id": "InternalMed_Harrison_15513", "title": "InternalMed_Harrison", "score": 0.012034161490683228, "content": "eXantHems Enterovirus infection is the leading cause of exanthems in children in the summer and fall. While exanthems are associated with many enteroviruses, certain types have been linked to specific syndromes. Echoviruses 9 and 16 have frequently been associated with exanthem and fever. Rashes may be discrete or confluent, beginning on the face and spreading to the trunk and extremities. Echovirus 9 is the most common cause of a rubelliform (discrete) rash. Unlike the rash of rubella, the enteroviral rash occurs in the summer and is not associated with lymphadenopathy. Roseola-like rashes develop after defervescence, with macules and papules on the face and trunk. The Boston exanthem, caused by echovirus 16, is a roseola-like rash. A variety of other rashes have been associated with enteroviruses, including erythema multiforme (see Fig. 25e-25) and vesicular, urticarial, petechial, or purpuric lesions. Enanthems also occur, including lesions that resemble the Koplik’s spots seen" }, { "id": "article-28669_10", "title": "Rubella -- History and Physical", "score": 0.01176635103280195, "content": "Postnatal infection with rubella can be asymptomatic in approximately 25% to 50% of the patients, especially in young children. The incubation period ranges from 14 to 21 days and is followed by a prodromal illness characterized by low-grade fever, malaise, anorexia, headaches, sore throat, and adenopathy. The lymphadenopathy typically involves postauricular, suboccipital, and anterior cervical lymph nodes. The exanthem could be the first manifestation in children and consists of pinpoint pink macules and papules that classically begin on the face and rapidly spreads to involve the trunk and extremities. Occasionally, the rash is scarlatiniform or purpuric. The rash typically lasts for 3 days and fades in the same directional pattern as it appears. [1] Petechiae on the soft palate (Forchheimer spots) can also be observed in approximately 20% of the patients." }, { "id": "pubmed23n0782_13219", "title": "Epidemiological and clinical features of erythema infectiosum in children in Novi Sad from 2000 to 2009.", "score": 0.011550486336266791, "content": "Erythema infectiosum (EI) is a common childhood illness, caused by human parvovirus B19. It occurs sporadically or in epidemics and is characterized by mild constitutional symptoms and a blotchy or maculopapular lacy rash on the cheeks (slapped-cheek) spreading primarily to the extremities and trunk. The aim of our study was to analyse the epidemiological and clinical characteristics of erythema infectiosum in children. This study included 88 children observed in the Department of Dermatology of the Institute for Child and Youth Health Care of Vojvodina, in Novi Sad, during the period January 2000-December 2009. We compared the data about the clinical characteristics during and after the outbreak of EI observed from December 2001 to September 2002. The data were retrieved from the hospital database. During the study period, EI was detected in 88 children (44 females and 44 males), 0.213% of the total number of 41,345 children observed in the Department of Dermatology. An outbreak of erythema infectiosum was observed from December 2001 to September 2002, with the peak frequency in April and May 2002 and 39 diagnosed cases, and stable number of cases from 2005 to 2009 (a total of 49 diagnosed cases). The average age of infected children was 7.59 +/- 3.339. Eleven (12.5%) children were referred from primary care pediatricians with the diagnosis of urticaria or rash of allergic origin. The most constant clinical sign was reticular exanthema on the limbs, present in 100% of the cases, followed by 89.77% of cheek erythema. Pruritus was present in 9.09% of the children, mild constitutional symptoms in 5.68% and palpable lymph glands in 3.41% of the children. In all the cases the course of the disease was without complications. The results of this study confirm the presence of EI (the fifth disease) in our area with a mild course in the majority of patients. Since the diagnosis of EI is usually based on clinical findings, continuing medical education of primary health care pediatricians is essential for reducing the number of misdiagnosed cases." }, { "id": "article-26717_7", "title": "Parvoviruses -- History and Physical -- Erythema Infectiosum", "score": 0.011510654490106544, "content": "The prodrome of symptoms begins during viremia, where patients experience a headache, myalgias, and fever. The exanthem develops one to one and one-half weeks later. It is important to know that the patient is not contagious once the eruption occurs. At this time, the patient will have a “slapped cheek” appearance, described as erythema of the cheeks, sparing the central face. This finding is the most recognizable for this disease. Adults may not have the facial rash with this infection. Later, a maculopapular eruption occurs that looks “lacy” and reticular and favors the extremities but occurs on the trunk to a lesser extent. The eruption can last anywhere from one to three weeks. The rash can worsen when exposed to heat or sunlight. Arthritis of the small joints may occur, namely the hands, feet, and knees; however, this is more common in adults. It is especially common in women and is rare in children, where it occurs in only 10%. [5] [6] [7] [8]" }, { "id": "wiki20220301en230_10204", "title": "Chickenpox", "score": 0.011384306592234836, "content": "Signs and symptoms The early (prodromal) symptoms in adolescents and adults are nausea, loss of appetite, aching muscles, and headache. This is followed by the characteristic rash or oral sores, malaise, and a low-grade fever that signal the presence of the disease. Oral manifestations of the disease (enanthem) not uncommonly may precede the external rash (exanthem). In children the illness is not usually preceded by prodromal symptoms, and the first sign is the rash or the spots in the oral cavity. The rash begins as small red dots on the face, scalp, torso, upper arms and legs; progressing over 10–12 hours to small bumps, blisters and pustules; followed by umbilication and the formation of scabs." }, { "id": "pubmed23n0554_19573", "title": "Erythema infectiosum in children. A Clinical study.", "score": 0.010973630831643003, "content": "Erythema infectiosum is a childhood illness characterized by mild constitutional symptoms and a blotchy or maculopopular lacy rash on the cheeks (slapped - cheek) spreading primarily to the extremities and trunk. The disease is caused by human parvovirus B19. Erythema infectiosum epidemics occur in a cyclic fashion, mostly during winter and spring months. The diagnosis of erythema infectiosum is usually based on the appearance and pattern of the rash. The aim of our study was to establish the frequency and clinical characteristics of erythema infectiosum in children, in the period between 2000 and 2004 at the Institute of Child and Youth Health Care, Department of Dermatology, Novi Sad There were 0.23% of children with a clinical picture of infectious erythema. There was an outbreak of erythema infectiosum from December 2001 to September 2002. The highest number of cases was detected in April and May of 2002 from 2003 to 2004, no cases with infekctious erythema were diagnosed. The average age of injected children was 7.38. Female children were affected slightly more often than male (56.41% : 43.58%). Pruritus was detected in 10.26% of children. The most constant clinical sign was reticular exanthema on the limbs, present in 100% of cases, jollowed by 89.74% of cheek exanthema, while limb and trunk exanthema was present in 7.68% of children. Adenopathies and mild constitutional symptoms were present in 5.12% of children. No complications were recorded in any of the cases." }, { "id": "wiki20220301en088_4975", "title": "Human herpesvirus 6", "score": 0.010941234056030636, "content": "Primary infection in adults tend to be more severe. Diagnosis for the virus, particularly HHV-6B, is vital for the patient because of the infection's adverse effects. Symptoms that point to this infection, such as rashes, go unnoticed in patients that receive antibiotics because they can be misinterpreted as a side-effect of the medicine. HHV-6B is known to be associated with the childhood disease roseola infantum, as well as other illnesses caused by the infection. These include hepatitis, febrile convulsions, and encephalitis. Children who suffer from exanthema subitum, caused by an HHV-6B infection, experience fevers lasting 3 to 5 days; rashes on the torso, neck, and face; and sometimes febrile convulsions, however, the symptoms are not always present together. Primary infections in adults are rare since most occurrences are in children. When the infection does occur for the first time in an adult the symptoms can be severe." }, { "id": "InternalMed_Harrison_1622", "title": "InternalMed_Harrison", "score": 0.010617403986387944, "content": "Exanthem subitum (roseola) is caused by human herpesvirus 6 and is most common among children <3 years of age (Chap. 219). As in erythema infectiosum, the rash usually appears after fever has subsided. It consists of 2to 3-mm rose-pink macules and papules that coalesce only rarely, occur initially on the trunk and sometimes on the extremities (sparing the face), and fade within 2 days." }, { "id": "pubmed23n1001_12342", "title": "Pain, swelling and irritability in the sun: what is the diagnosis?", "score": 0.009900990099009901, "content": "A 7-year-old boy presented with a 24-hour history of severe burning pain affecting both hands that had started within minutes of playing outdoors. His mother reported that he had been running his hands under cold water and shaking his hands and head to try and relieve the pain. On examination, there was swelling of his hands, eyelids and cheeks. His parents mentioned that his hands and face had 'swollen in the sun' every summer from the age of 2 years.A 3-year-old girl presented with a 2-day history of left upper limb swelling following a day of prolonged sun exposure. Examination revealed non-pitting oedema extending from her left shoulder to hand with no associated tenderness, erythema or rash. Her mother reported six previous episodes of irritability following sun exposure during which she would cry and flap her hands 'for hours'.Oral steroids and antihistamines were prescribed in both cases with little effect. Findings of routine baseline investigations were normal in both cases. A radiograph of the upper limb in the second patient disclosed nothing abnormal. QUESTIONS: What is the most likely diagnosis for both patients?Venomous insect bites/stingsErythropoietic protoporphyriaIgE-mediated reactionMixed connective tissue diseaseComplement deficiencyWhich investigative approach will be most helpful?Complement function evaluationPhysical urticarial evaluationPorphyria work-upAutoantibody screenImmunodeficiency work-upHow would you manage these patients? <b<iAnswers can be found on page 02.</i</b" }, { "id": "wiki20220301en013_144072", "title": "Roseola", "score": 0.009900990099009901, "content": "Rash Once the febrile phase subsides, a rash develops. In some cases, the rash can present after one or two days after the fever resolves. The rash is classically described as an erythematous morbilliform exanthem and presents as a distribution of soft pink, discrete, and slightly raised lesions each with a 2-5mm diameter. It classically begins on the trunk (torso) and spreads outward to the neck, extremities, and face. This pattern is referred to as a centrifugal spread. Usually, peeling and itching are not characteristic of this rash. This phase can last anywhere from several hours to 2 days." }, { "id": "InternalMed_Harrison_14430", "title": "InternalMed_Harrison", "score": 0.009842009842009843, "content": "Clinically, chickenpox presents as a rash, low-grade fever, and malaise, although a few patients develop a prodrome 1–2 days before onset of the exanthem. In the immunocompetent patient, chickenpox is usually a benign illness associated with lassitude and with body temperatures of 37.8°–39.4°C (100°–103°F) of 3–5 days’ duration. The skin lesions—the hallmark of the infection—include maculopapules, vesicles, and scabs in various stages of evolution (Fig. 217-1). These lesions, which evolve from maculopapules to vesicles over hours to days, appear on the trunk and face and rapidly spread to involve other areas of the body. Most are small and have an erythematous base with a diameter of 5–10 mm. Successive crops appear over a 2to 4-day period. Lesions can also be found on the mucosa of the pharynx and/or the vagina. Their severity varies from one person to another. Some individuals have very few lesions, while others have as many as 2000. Younger children tend to have fewer vesicles than" }, { "id": "pubmed23n0601_23388", "title": "Diffuse exanthema in a patient receiving varenicline.", "score": 0.00980392156862745, "content": "A diffuse exanthema in a patient receiving varenicline is reported. A 71-year-old white woman, who was initially admitted to the hospital for elective vascular bypass surgery, had a three-day history of a diffuse rash, severe itching, and moderate headache. Her symptoms started two days before her admission. She denied having a fever, chills, nausea, vomiting, diarrhea, and flulike symptoms. She also denied having had contact with anyone who was ill, tick or insect bites, exposure to cats, or any changes in her diet, habits, or personal hygiene. Her medical problems included peripheral vascular disease, chronic obstructive pulmonary disease (COPD), dyslipidemia, hypertension, and hypothyroidism. In addition to several medications she had been taking for over 2 years, she had been taking varenicline as an aid for smoking cessation for eight days. The patient had been smoking for 40 years. The bright-red rash covered 70% of her torso and four extremities. She had mild swelling in her cheeks, but not on the eyelids or lips. Both of her lungs were clear on auscultation, with distant breath sounds caused by her COPD. Varenicline was discontinued, and her symptoms had completely resolved by the eighth day following discontinuation of the medication. While it is possible that other medications caused her symptoms, she had been taking most of them for over 2 years and all of them for over 1 year. Also, continuation of these drugs did not prevent her symptoms from resolving, nor did it cause a recurrence of the skin reaction. A patient developed diffuse exanthema after being treated with varenicline." }, { "id": "pubmed23n0317_9945", "title": "Witchcraft's syndrome: Munchausen's syndrome by proxy.", "score": 0.009708737864077669, "content": "A 28-year-old man presented to the Dermatology Outpatient Department with a complaint of a burning sensation and soreness over his left cheek and left ear of 10 days duration. It had started suddenly one morning when he woke up from sleep. He noticed a large blister with intense redness over his left cheek, associated with a burning sensation. There was a history of similar episodes over the past year, and all were sudden in onset, involved the cheeks, and were noticed after waking up from sleep. The patient volunteered that the episodes were always associated with a drinking spree the previous night. The individual was a healthy man with a wife and two children. The patient had been dependent on alcohol for the past year, and had been consuming alcohol for many years. On examination, there was an eschar occupying almost the entire cheek, with a few scattered lesions over the left tragus and left external ear. Peripheral scarring was noted with hyperpigmentation. While the angle of the mouth was superficially involved on the left side, the oral mucosa was normal. The right cheek also showed a few areas of scarring with patches of alopecia. There were no similar lesions elsewhere on the body. The peculiar history and the morphology of the lesion, that defied any classical diagnosis description, prompted us to interrogate both the man and his wife with regard to any serious differences. After much persuasion and on assurance of secrecy, the wife admitted that her husband was an alcoholic and was neglecting his family. When her efforts to prevent his drinking failed, she resorted to this drastic measure. Each time he passed out after a drinking bout, she poured acid on his cheek, hoping that the sequelae would frighten him from drinking. The acid was readily available to her as she used it for domestic cleaning. The couple were sent for psychiatric evaluation as Munchausen's syndrome by proxy (MSBP) or witchcraft's syndrome (WS) was suspected. Detailed psychiatric evaluation, together with psychometric assessment, revealed that the patient had an alcohol dependence (Axis-I diagnosis) and had a cyclothymic personality. Severe marital discord due to alcohol dependence had been present for the past 2 years. Evaluation of the patient's wife revealed that she was under significant psychologic distress. She showed major depressive symptoms with a histrionic personality. She revealed that she had resorted to using the corrosive out of frustration and anger over the behavior of the patient while he was in an inebriated state. The couple are currently undergoing psychiatric treatment." }, { "id": "pubmed23n0779_2060", "title": "Multiple cystic disease: K17 dysfunction?", "score": 0.009615384615384616, "content": "Our patient is a 29-year-old woman without any previous disease who presented with different kinds of lesions on her face, neck, and chest. She first noticed the lesions 10 years ago and, since that time, they have become more numerous. She has no affected relatives. On physical examination, she had multiple cystic lesions on her neck, chest, and vulva, which were between 0.3 cm and 1 cm and skin-colored or yellowish (Figure 1). She presented with small, white papules on her face measuring approximately 0.2 cm, localized on her forehead and cheeks. Some of these papules had a blueish appearance (Figure 2). She also presented clinically typical eruptive syringomas on her upper and lower eyelids and neck and multiple facial milia. Finally, a sacrococcygeal pilonidal cyst was diagnosed and surgically removed. Her nails and teeth were clinically normal. Biopsies of each kind of lesion were performed, with the following results: (1) neck cystic lesion: steatocystoma; (2) small, white facial papule: eccrine hidrocystoma; (3) blueish facial papule: apocrine hidrocystoma; and (4) small neck papule: syringoma (Figure 3). With these findings, our diagnosis was steatocystoma multiplex with multiple eccrine and apocrine hidrocystomas, eruptive syringomas, and sacrococcygeal pilonidal cyst." }, { "id": "pubmed23n0876_17161", "title": "Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl.", "score": 0.009523809523809525, "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": "wiki20220301en033_29235", "title": "Kawasaki disease", "score": 0.009447258313146883, "content": "The most common skin manifestation is a diffuse macular-papular erythematous rash, which is quite nonspecific. The rash varies over time and is characteristically located on the trunk; it may further spread to involve the face, extremities, and perineum. Many other forms of cutaneous lesions have been reported; they may include scarlatiniform, papular, urticariform, multiform-like erythema, and purpuric lesions; even micropustules were reported. It can be polymorphic, not itchy, and normally observed up to the fifth day of fever. However, it is never bullous or vesicular." }, { "id": "pubmed23n0657_20200", "title": "A red face in a lupus patient: thinking beyond lupus rash.", "score": 0.009433962264150943, "content": "A 61-year-old woman with a history of systemic lupus erythematosus presented with a facial rash followed by fever. The diagnosis of lupus flare was made by the general practioner who prescribed corticosteroids. The evolution was unfavorable and the patient was hospitalized. On admission, she presented with high fever and a sharply demarcated papular erythema overlying her cheeks. Biology was inflammatory with elevated C-reactive protein, sedimentation rate and leucocyte count. The diagnosis of erysipelas of the face was made on the basis of the malar and non pruritic papular erythema, fever, the high C-reactive protein levels and the absence of response to corticosteroids. The evolution was favorable under intravenous antibiotics and rapid tapering of the corticosteroids. To our knowledge, this is the first report of facial erysipelas in a patient with a history of systemic lupus erythematosus. This coincidence is a rare condition which may lead to erroneous diagnosis and inappropriate therapy." }, { "id": "pubmed23n0500_12593", "title": "[Viral exanthem].", "score": 0.009433962264150943, "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": "pubmed23n1100_17412", "title": "Diagnostic Delays for Non-melanoma Skin Cancers in Renal Transplant Recipients during the COVID-19 Pandemic: What is Hiding Behind the Mask?", "score": 0.009345794392523364, "content": "Dear Editor, The ongoing pandemic of coronavirus disease 2019 (COVID-19) was declared by the World Health Organization on March 11, 2020, and remains a global challenge. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), transmitted primarily through respiratory droplets and aerosols. Even though the COVID-19 vaccine has become available since December 2020, the main preventive measures still include social distancing, hand washing, and the use of protective face masks. By May 22, 2021, 3,437,545 deaths caused by SARS-CoV-2 have been registered by WHO, confirming the burden of this disease (1). Consequently, the pandemic has become a challenge for health care systems, as they had to be focused on the care of patients with COVID-19. During the first lockdown from March to May 2020, it was advised to postpone clinical visits whenever this could be done without risk. This recommendation was mainly aimed at older patients and those with chronic diseases, as it has been shown that they are at greater risk for complications from COVID-19. Renal transplant recipients (RTRs) are at a greater risk for infections and different cancers due to their permanent immunosuppressive therapy. The most common malignancies in RTRs are skin cancers, particularly non-melanoma skin cancers. It has been estimated that RTRs have a 65-250 times higher risk for cutaneous squamous cell carcinoma (SCC), 10 times higher risk for basal cell carcinoma, and 2-5 times higher risk for melanoma when compared with the general population (2-4). RTRs are at a higher risk for complications from COVID-19, not only because of their immunosuppressive therapy but also because of different comorbidities, such as hypertension, cardiovascular disease, and diabetes mellitus (5). Therefore, RTRs tend to limit their medical visits and postpone clinical examinations for skin cancer screenings. Moreover, during clinical visits the patients are commonly asked to keep their protective masks on, increasing the risk of overlooking their facial skin changes. Herein we present two RTRs who developed skin cancers during the COVID-19 pandemic, and the tumors were diagnosed with a significant delay. Patient 1 A 67-year-old woman with unknown primary kidney disease received a renal allograft from a deceased donor in 2014. The immunosuppressive protocol included antithymocyte globulin induction with tacrolimus, mycophenolate mofetil, and steroid maintenance. In January 2020, she had noticed a reddish squamous lesion on her right cheek, which enlarged slowly. Since there were no other symptoms, she postponed the dermatologic examination. Additionally, she further postponed the visit to her physician during the pandemic as she wanted to avoid social contact as much as possible. One year later, at the nephrologist's examination, she was asked to take off her face mask for a skin check, and two skin tumors on her right cheek were noticed (Figure 1). One lesion was located at the angle of her mandible and presented as a hypertrophic, sharply marginated lesion with central crusting and a diameter of 2 cm. The other lesion was at the right zygomatic region and appeared as a scaly, erythematous lesion with a diameter of 7 mm. The patient was referred to a dermatologist, and a biopsy of both lesions was indicated. The pathohistological analysis revealed cutaneous SCC in situ for the mandibular lesion and actinic keratosis for the zygomatic lesion. SCC in situ has been excised, and actinic keratosis was treated by cryosurgery. Patient 2 A 66-year-old woman received a renal allograft from a deceased donor in 2010 due to chronic glomerulonephritis without biopsy. The immunosuppressive protocol included basiliximab induction with tacrolimus, mycophenolate mofetil, and steroid maintenance. In June 2020, an erosion occurred at her left infraocular area and did not heal but instead gradually enlarged. The patient suspected that the \"wound\" developed due to the friction from the rim of her eyeglasses. Six months later, the nephrologist noticed the erosion which was 10×5 mm in size with a slightly elevated, pearl-colored margin (Figure 2). The patient was referred to a dermatologist who indicated tumor excision due to suspected basal cell carcinoma. The pathohistological analysis confirmed the clinical diagnosis. DISCUSSION Both presented patients did not inform their family physicians about their skin changes because they avoided all non-nephrological medical visits during the pandemic. The additional reason for the diagnostic delay was the fact that they kept the masks on their faces during most examinations, with the skin lesions behind the mask consequently remaining unnoticed. The problem of diagnostic delay of skin cancers during the COVID-19 pandemic has been recognized by several studies. Canadian authors compared the number of biopsies for skin cancers during the first 15 weeks in 2020 and during the same period in 2019. They found a decrease in the number of biopsies for non-melanoma skin cancers (NMSC) and melanoma of 18% and 27%, respectively (6). A multicenter study performed in northern-central Italy showed that the number of skin cancer (NMSC and melanoma) diagnoses fell by 56.7% in weeks 11 to 20 of 2020 compared with the average number noted in the same periods of 2018 and 2019 (7). Furthermore, a single-center retrospective study in Italy demonstrated that the number of advanced skin cancers surgically treated between May 18 and November 18, 2020, was significantly higher than in the same period in 2019. These findings led the authors to conclude that the surgical excisions were postponed due to the delay in follow-ups, which resulted in increased incidence of advanced skin cancers (8). RTRs are at particular risk of severe consequences from diagnostic delay with regard to skin cancers. Namely, skin cancers in RTRs are more aggressive and are associated with a higher incidence rate of metastases and recurrences than in the general population (9). Therefore, RTRs should be advised to regularly check their skin for potential skin cancer, which includes self-examinations and dermatologic follow-ups." }, { "id": "wiki20220301en009_127411", "title": "Rubella", "score": 0.009345794392523364, "content": "Signs and symptoms Rubella has symptoms similar to those of flu. However, the primary symptom of rubella virus infection is the appearance of a rash (exanthem) on the face which spreads to the trunk and limbs and usually fades after three days, which is why it is often referred to as three-day measles. The facial rash usually clears as it spreads to other parts of the body. Other symptoms include low-grade fever, swollen glands (sub-occipital and posterior cervical lymphadenopathy), joint pains, headache, and conjunctivitis." }, { "id": "pubmed23n0956_8506", "title": "Frey syndrome following herpes zoster in an otherwise healthy girl.", "score": 0.009259259259259259, "content": "A 12-year-old girl presented with red spots appearing on the left side of her face. The girl was usually healthy and fully vaccinated, including varicella vaccination.Six years prior to her presentation, she had suffered an episode of blister rash on the left side of her face, including lesions in the ear canal and buccal mucous membrane. A diagnosis of herpes zoster was made, and she was treated with acyclovir with complete skin recovery. A hearing examination demonstrated mild-to-moderate left neurosensory hearing loss.Since then, she is having short episodes of redness on her face without pain or sweating at the exact distribution of the zoster blisters 6 years ago. The appearance of spots is related to sour foods, such as sour flavoured candies, yoghourt and green apples. The diagnosis of postherpetic Frey syndrome was made, and observational approach was adopted due to the benign character of symptoms." }, { "id": "pubmed23n0848_8151", "title": "[A Case of Dengue Fever and Subsequent Long-lasting Depression Accompanied by Alopecia in a Japanese Traveler Returning from Bali, Indonesia].", "score": 0.009174311926605505, "content": "Recovery from dengue fever is generally rapid and uneventful. However, recuperation is often prolonged and may be accompanied by noticeable depression. We present herein on a traveler to Indonesia who developed long-lasting depression after the classic symptoms of dengue fever such as fever, arthralgia, and macropapular rash had resolved. A previously healthy 42-year old japanese woman presented to the Travel Clinic of Seirei Yokohama Hospital with complaints of 4 days of fever, joint aches, bone pain, and a macropapular rash on her torso. She had returned from Bali 5 days previously. During her 1-week stay, one day was spent in rural, mountainous areas where she was exposed to several mosquito bites. The 1st serum sample collected 4 days after the disease onset gave positive result in the rapid dengue IgM antibody test and the rapid dengue NS1 antigen immunechromatographic test. The DENV-1 genome was detected with RT-PCR. Her 13-year old son, who had accompanied her, was also diagnosed as having dengue fever and he recovered without event. The Above-mentioned symptoms resolved within one week. However, the patient suffered from prolonged depression. She also noticed loss of hair 3 months after the disease onset Administration of a Serotonin-Noradrenalin Reuptake Inhibitor and a minor tranquillizer required to allow her requied to lead a normal life. Although she gradually felt better, it took approximately 2 years until she had recovered completely without taking any antidepressant and minor tranquillizer. It is a well-known fact in endemic countries that dengue fever could have an significant impact on the patients' mental well-being. However, it appears that physicians in non-endemic countries are not fully aware of the prolonged depression, which can occur subsequent to the acute illness. Follow-up consultations of returing travelers who have recoverd from dengu fever should be arranged to monitor their mental and emotional states closely." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 45, 98 ] ], "word_ranges": [ [ 7, 16 ] ], "text": "in adults without other data, Pneumococcus is the 1st." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Mycoplasma pneumoniae.", "2": "Chlamydia pneumoniae.", "3": "Streptococcus pneumoniae.", "4": "Legionella pneumophila serogroup 1.", "5": "Haemophilus influenzae." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0744_24315", "title": "The incidence and etiology of community-acquired pneumonia in fever outpatients.", "score": 0.019327731092436976, "content": "The purpose of this study was to analyze the incidence, etiology and clinical characteristics of community-acquired pneumonia (CAP) among outpatients with sore throat and/or cough, and thus to provide theoretical basis for timely and accurate diagnosis and treatment for CAP. We used chest X-rays for fever (a temperature greater than 37.5°C) patients, who were recruited since 2007, presenting with sore throat and/or cough. The patients' age, gender, days of fever, respiratory symptoms (e.g. cough and sputum), peripheral blood count and etiology (pathogens) of CAP were recorded. Of all the 6539 fever outpatients, those aged 10-39 and above 60 years old accounted for 61.0% and 15.6%, respectively. In total, 402 were diagnosed with CAP with an incidence rate of 6.1%. Among them, 38.1% were above 60 years old. The prevalence increased with age. Of the 402 CAP patients, 36.8% (148/402) presented no respiratory symptoms and 30.1% (121/402) had positive etiology. The top three pathogens were Mycoplasma pneumoniae (23.1%), Streptococcus pneumoniae (17.3%) and Haemophilus influenzae (9.1%). Among the 121 etiology-positive patients, 14 cases were mixed infections (at least one atypical pathogen). Nine cases were M. pneumoniae mixed with bacterial/virus infection, and five cases were Chlamydia pneumoniae mixed with other bacteria/mycoplasma infection. We found that fever outpatients have a higher prevalence of CAP, which increases with age, i.e. older people are more susceptible to CAP. S. pneumoniae and H. influenzae are common pathogens in CAP; however, atypical pathogens, especially M. pneumoniae, remain the most common pathogens in CAP." }, { "id": "pubmed23n0261_5835", "title": "[Treatment of community-acquired pneumonia by pristinamycin (Pyostacine 500). Results of a non comparative open study].", "score": 0.018750547621133797, "content": "Activity of natural streptogramin (NSG) appears well adapted to pathogens responsible for CAP. The goal of this multicenter pilot study was to bring first data about efficacy of NSG in treatment of CAP. PATIENTS METHOD: Ten days of a NSG (1 gr b.i.d. or t.i.d.) regimen was administered to 46 hospitalized adult patients for CAP defined with fever &gt; 38 degrees C, respiratory symptoms and X-ray opacity. Severely ill patients were excluded. A broncho-pulmonar sample (expectoration or trantracheal aspiration or protected distal sample) was performed in all patients. two patients were excluded because of pulmonary embolism (n = 1) or tuberculosis (n = 1) and 44 patients were analyzed. 50% of them had associated disease, 20% had failure of prior antibiotherapy. At inclusion, mean fever was 39.2 +/- 0.7 degrees C, respiratory rate was 22 +/- 5/mn, PaO2 was 74 +/- 10 mmHg, chest X-ray showed bilateral opacity in 16%, unilateral in 84% and pleural fluid level in 6 cases. Etiological diagnosis was determined in 70% of cases. Streptococcus pneumoniae (n = 14), Haemophilus influenzae (n = 5), Legionella pneumophila (n = 2), Mycoplasma pneumoniae (n = 2) and Chlamydia psittaci (n = 1) were the most frequent isolated pathogens. 40 patients (91%) were cured with NSG and delay to obtain apyrexia was 4.4 +/- 3.9 days. NSG was stopped in 4 patients: 1 clinical and bacteriological failure (Klebsiella pneumoniae), 2 clinical failures (1 pneumococcus with purulent pleurisy, 1 pneumococcus with worsening of respiratory status), 1 patient with resistant H. influenzae strain in spite of favourable clinical evolution. NSG was well tolerated in 86% of patients. these data invite to carry on evaluation of first line therapy of CAP with NSG." }, { "id": "pubmed23n0302_11471", "title": "[Community acquired pneumonia. Reliability of the criteria for deciding ambulatory treatment].", "score": 0.017966484047695776, "content": "To determine whether criteria for not admitting community-acquired pneumonia (CAP) patients diagnosed in the emergency room are appropriate, and to characterize the symptoms, etiology and course of CAP. This one-year prospective, protocol study of immunocompetent CAP patients diagnosed in the emergency room of our hospital enrolled patients not considered to require hospital admission according to the recommendations of the Spanish Society of Respiratory Disease (SEPAR). Medical histories, chest X-rays and blood analysis were obtained for all patients. Blood cultures were analyzed for antibodies against Legionella pneumophila, Mycoplasma pneumoniae, Coxiella burnetii, Chlamydia pneumoniae, Chlamydia psittaci and influenza virus types A and B. The patients received erythromycin for 14 days and were regularly checked by the pulmonologist in the outpatient clinic until signs and symptoms had disappeared. One hundred six patients were enrolled. Mean age was 36 +/- 13 years. Only 3 patients had to be admitted to hospital, after which outcome was good. The main symptoms were fever (106, 100%) and cough (83, 78%). In 46 (43.4%) chest sounds were normal. Microbiologic diagnoses were achieved for 28 (26.4%) and Coxiella burnetii was the agent most often found (19, 17.9%). Outcome was good in all cases, with faster disappearance of symptoms than of radiological signs. The SEPAR criteria for admitting patients with CAP are appropriate. The clinical symptoms of such patients are non specific, a noteworthy finding being that many patients had normal chest sounds. Coxiella burnetii was the most common causative agent. Both clinical and radiological outcomes were excellent." }, { "id": "pubmed23n0374_17667", "title": "Community-acquired pneumonia. A prospective outpatient study.", "score": 0.017806267806267807, "content": "We initiated a prospective study with a group of practitioners to assess the etiology, clinical presentation, and outcome of community-acquired pneumonia in patients diagnosed in the outpatient setting. All patients with signs and symptoms suggestive of pneumonia and an infiltrate on chest X-ray underwent an extensive standard workup and were followed over 4 weeks. Over a 4-year period, 184 patients were eligible, of whom 170 (age range, 15-96 yr; median, 43 yr) were included and analyzed. In 78 (46%), no etiologic agent could be demonstrated. In the remaining 92 patients, 107 etiologic agents were implicated: 43 were due to \"pyogenic\" bacteria (39 Streptococcus pneumoniae, 3 Haemophilus spp., 1 Streptococcus spp.), 39 were due to \"atypical\" bacteria (24 Mycoplasma pneumoniae, 9 Chlamydia pneumoniae, 4 Coxiella burnetii, 2 Legionella spp.), and 25 were due to viruses (20 influenza viruses and 5 other respiratory viruses). There were only a few statistically significant clinical differences between the different etiologic categories (higher age and comorbidities in viral or in episodes of undetermined etiology, higher neutrophil counts in \"pyogenic\" episodes, more frequent bilateral and interstitial infiltrates in viral episodes). There were 2 deaths, both in patients with advanced age (83 and 86 years old), and several comorbidities. Only 14 patients (8.2%) required hospitalization. In 6 patients (3.4%), the pneumonia episode uncovered a local neoplasia. This study shows that most cases of community-acquired pneumonia have a favorable outcome and can be successfully managed in an outpatient setting. Moreover, in the absence of rapid and reliable clinical or laboratory tests to establish a definite etiologic diagnosis at presentation, the spectrum of the etiologic agents suggest that initial antibiotic therapy should cover both S. pneumoniae and atypical bacteria, as well as possible influenza viruses during the epidemic season." }, { "id": "pubmed23n0423_5698", "title": "Microbiological etiology in clinically diagnosed community-acquired pneumonia in primary care in Orebro, Sweden.", "score": 0.01577384634417914, "content": "To study the etiology of clinically diagnosed community-acquired pneumonia (CAP) in antibiotically naive patients attending a primary care center and treated at their homes. A three-year prospective study was carried out, and 177 patients presenting with clinical signs of CAP were included. All patients had chest X-rays after inclusion, and 82 (46%) showed infiltrates. Nasopharyngeal swab culture was performed on all patients, and 51% produced a representative sputum sample. Paired sera were obtained from 176 patients. Among the 82 patients with radiographically proven CAP, Streptococcus pneumoniae was detected in 26 patients (32%), Haemophilus influenzae in 23 (28%), Mycoplasma pneumoniae in 15 (18%), and Chlamydia pneumoniae in four (5%). Serologic evidence of a viral infection was found in 13 patients (16%). Among the 95 patients without infiltrates, S. pneumoniae was found in 21 (22%), H. influenzae in 14 (15%), M. pneumoniae in two (2%), and C. pneumoniae in five (5%). Viral infection was detected in 19 (20%) of these 95 patients. In primary care in Sweden, the initial antibiotic treatment in any patient with pneumonia should be effective against S. pneumonia and H. influenzae. In addition, M. pneumoniae should be targeted during recurrent epidemics. C. pneumoniae, and especially Legionella, seem to be uncommon in primary care." }, { "id": "pubmed23n0693_12592", "title": "Clinical, epidemiological, and etiological profile of inpatients with community-acquired pneumonia at a general hospital in the Sumaré microregion of Brazil.", "score": 0.014610995574041486, "content": "To analyze the clinical, etiological, and epidemiological aspects of community-acquired pneumonia (CAP) in hospitalized individuals. We prospectively studied 66 patients (&gt; 14 years of age) with CAP admitted to the Hospital Estadual Sumaré, located in the Sumaré microregion of Brazil, between October of 2005 and September of 2007. We collected data related to clinical history, physical examination, pneumonia severity index (PSI) scores, and laboratory tests (blood culture; sputum smear microscopy and culture; serology for Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila; and detection of Legionella sp. and Streptococcus pneumoniae antigens in urine). The mean age of patients was 53 years. Most had a low level of education, and 55.7% presented with at least one comorbidity at the time of hospitalization. The proportion of elderly people vaccinated against influenza was significantly lower among the inpatients than in the general population of the Sumaré microregion (52.6% vs. &gt; 70%). Fever was less common among the elderly patients (p &lt; 0.05). The clinical evolution was associated with the PSI scores but not with age. The etiology was confirmed in 31 cases (50.8%) and was attributed to S. pneumoniae, principally detected by the urinary antigen test, in 21 (34.4%), followed by C. pneumoniae, in 5 (8.2%). The mortality rate was 4.9%, and 80.3% of the patients were classified as cured at discharge. The knowledge of the etiologic profile of CAP at the regional level favors the appropriate choice of empirical treatment, which is particularly relevant in elderly patients and in those with comorbidities. The lack of influenza vaccination in elderly patients is a risk factor for hospitalization due to CAP." }, { "id": "pubmed23n0638_14059", "title": "Clinico-pathological study of atypical pathogens in community-acquired pneumonia: a prospective study.", "score": 0.014595601187779958, "content": "Atypical respiratory pathogens such as Mycoplasma pneumoniae, Legionella species, and Chlamydia pneumoniae are isolated with increasing frequency from community-acquired pneumonia (CAP). This study highlights the importance of organisms responsible for CAP. One hundred consecutive patients with clinically and radiographically diagnosed CAP were evaluated from October 2005 to October 2006. Sputum, bronchoalveolar lavage, and blood samples were collected for microbiological culture. Determination was performed for specific immunoglobulin M (IgM) for Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila, Coxiella burnettii, adenovirus, and influenza virus. The most common isolated bacteria was Streptococcus pneumoniae (22%) followed by Haemophilus influenzae (18%). Mycoplasma pneumoniae was isolated from 5% and Legionella pneumophila was isolated from 5% of patients. The most common positive serological reaction was for Chlamydia pneumoniae (30%) and Adenovirus (30%). In the study of accuracy of determination of specific IgM for Mycoplasma pneumoniae and Legionella pneumophila compared to culture, the sensitivity was 60% and 80% respectively, specificity was 93.7 %, and 98.9 % respectively, and accuracy was 92 % and 97 % respectively. This study highlights the prominence of mixed bacterial/viral infections in lower respiratory tract infection diagnosis. Our data showed that at least 30% of our patients had concurrent infections. This observation raises two important questions: 1) whether sequential or concurrent viral and bacterial infections have a synergistic impact on the evolution of disease in children; and 2) should diagnostic batteries for any patient with CAP include methods for detecting both the typical and atypical bacterial or viral pathogens." }, { "id": "pubmed23n0360_4843", "title": "[Pneumonia caused by Haemophilus influenzae. Study in a series of 58 patients].", "score": 0.014509285029885476, "content": "Haemophilus influenzae tends to form part of the usual respiratory flora in adults, especially if they have a chronic underlying disease or are smokers. Pneumonia due to H. influenzae is frequently involved in respiratory infections and its level of resistance to ampicillin has remained stable over the last five years. Most of the literature on the subject was published more than 10 years ago. In this study, we describe the clinical features and evolution of 58 adult patients admitted to hospital for pneumonia due to H. influenzae over a 2-year period, with this group accounting for 6.5% of all the patients admitted with pneumonia during this time period. The etiological diagnosis was made using a good quality sputum sample. Forty patients (69%) were male. The mean age (+/- SD) of the group was 67 (+/-16.8) years and all the patients had at least one underlying disease. The mean duration of the symptoms was 6.7 days. All patients presented an increase in the quantity or purulence of the sputum. On admittance, respiratory failure was present in 52 patients (90%). Gram-negative coccus-bacilli were observed in the direct sputum test and H. influenzae grew in the culture. In two cases, H. influenzae was recovered from the blood culture and in one from bronchial aspiration obtained through bronchoscopy. Another pathogen was identified in 28 patients (48%). In 21 it was another pyogenic bacteria (15 S. pneumoniae, 4 M. catharralis, 1 K. pneumoniae, 1 E. coli), an atypical microorganism in 5 (3 C. pneumoniae, 2 C. burnetii) and a respiratory virus in 2 (syncytial and influenza A). Atypical bacteria and respiratory virus were detected using serological techniques. The radiographic infiltrate was unilobar in 54 of the 58 patients and all showed an alveolar pattern. The empirical treatment included the administration of a third generation cephalosporin (or a fluoroquinolone in patients allergic to penicillin). The evolution was favorable in all the cases in which H. influenzae was the only pathogen or was accompanied by an atypical microorganism or a respiratory virus. Four patients with mixed bacterial pneumonia died (2 S. pneumoniae, 1 E. coli and 1 M. catharralis). The study indicates that pneumoniae due to H. influenzae affects a population with an underlying disease, preferably pulmonary, that it has a longer clinical period than that for pneumococcal pneumonia, that it is slightly bacteremic and, that, usually, it evolves benignly with a low mortality." }, { "id": "pubmed23n0416_23455", "title": "Prospective epidemiologic survey of patients with community-acquired pneumonia requiring hospitalization in Switzerland.", "score": 0.014486215538847116, "content": "Community-acquired pneumonia (CAP) is a common problem and the principal infection requiring hospitalization, but its treatment is complicated by the difficulty in microbiological diagnosis and the increasing incidence of antibiotic resistance among respiratory pathogens. The purpose of this paper is to present the main epidemiologic features of patients with CAP requiring hospitalization in our country. We enrolled three hundred and eighteen adult patients with CAP requiring hospitalization in seven large medical centers in Switzerland during two winter periods. The patients' mean age was 70.4 years. This study describes the epidemiology of these patients. Clinical, radiologic and microbiological evaluations were performed at study entry during treatment, and at 4 weeks post-therapy. For microbiological diagnostic purposes, sputum culture, throat swab culture, PCR, blood cultures, Legionella urinary antigen and serologic evaluations were also performed. Despite the higher mean age, the overall mortality rate was 8%, lower than in other comparable studies. The most common underlying diseases present at study entry were cardiac failure (23%), chronic obstructive pulmonary disease (20%), renal failure (15%), and diabetes (12%); 40% of the patients were smokers. Although dyspnea, cough and positive pulmonary auscultation findings were present in about 90% of patients, fever &gt;38 degrees C was present in only 64%. The most frequently isolated respiratory pathogens were Streptococcus pneumoniae (12.6%), Haemophilus influenzae (6%), Staphylococcus aureus (1.6%), and Moraxella catarrhalis (1.6%). Atypical pathogens were frequently found, with the following distribution: Mycoplasma pneumoniae, 7.5%; Chlamydia pneumoniae, 5.3%; and Legionella pneumophila, 4.4%. The mean duration between onset of symptoms and hospital admission was 4.8 days, and the mean treatment duration was 12.1 days. Two weeks after the start of therapy, although clinical symptoms were absent, radiologic infiltrates were still present in 24% of patients. The microbiological diagnosis in CAP can be established in only about 50% of cases with the combination of several diagnostic tools. Epidemiologic surveys of CAP should be performed on a regular basis, regionally, as a way to improve the management of these infections." }, { "id": "pubmed23n0764_9859", "title": "Atypical pathogens causing community-acquired pneumonia in adults.", "score": 0.013746157224418094, "content": "To determine the frequency of community-acquired respiratory pathogens with special focus on atypical organisms in patients presenting to a tertiary care facility with community-acquired pneumonia (CAP). The descriptive study on adult patients was conducted from February 2007 to March 2008 at the Aga Khan University Hospital, Karachi. It comprised 124 consenting patients of age 16 and above who presentd with a diagnosis of community-acquired pneumonia. The diagnostic modalities used were based on significant changes in antibody titer or persisting high antibody titers in the case of Mycoplasma pneumoniae and Chalmydia pneumoniae infections, or bacterial antigen in urine, in the case of Legionella pneumophila serogroup 1 infection. Pyogenic bacteria were identified on the results of respiratory secretions or blood cultures. Continuous data and categorical variables were worked out using SPSS version 15. Among the 124 patients enrolled, an etiologic agent was identified in 44 (35.4%) patients. The most common organism was Mycoplasma pneumoniae (n = 21, 17%), followed by Chlamydia pneumoniae (n = 15, 12%), Streptococcus pneumoniae (n = 9, 7%), Haemophilus influenzae (n = 2, 1.6%), Klebsiella pneumoniae (n = 2, 1.6%) and Staphylococcus aureus (n = 1, 0.8%). Streptococcus pneumoniae was the most common organism isolated from blood cultures. No cases of Legionella pneumophila serogroup 1 were identified. Mycoplasma pneumoniae and Chalmydia pneumoniae are significant etiologic agents for community-acquired pneumonia occurring in Karachi. Local treatment guidelines for community-acquired pneumonia should include therapy directed specifically at these agents." }, { "id": "pubmed23n0271_8731", "title": "[Community-acquired pneumonia: prospective study of 101 adult, immunocompetent patients for 1 year].", "score": 0.013437950937950938, "content": "A one year prospective study was carried out to assess the etiology of community-acquired pneumonia (CAP), and also to know the incidence, characteristics and evolution of infection by Chlamydia pneumoniae; and the effectiveness of DNA probes in CAP due to Mycoplasma pneumoniae and Legionella. One hundred and ten patients with a diagnosis of CAP in the emergency department were studied. Serologic studies were performed, and also tests commonly used for the diagnosis of respiratory tract pathogens in respiratory samples, including serology and culture of Chlamydia pneumoniae and DNA probes for Mycoplasma pneumoniae and Legionella. In 72 cases (71.3%) some pathogen was found and in 5 cases more than one microorganism was involved. The etiology was bacterial in 31% of the cases, with S. pneumoniae being the most frequent (19 cases). Forty percent of the cases were \"atypical\" pneumonias with 33 cases of M. pneumoniae and 5 by Chlamydia pneumoniae. Diagnostic data of viral pneumonia were found in 2 cases. DNA probes were not useful for the diagnosis of pneumonia by Legionella pneumophila and had low effectiveness (31.8%) in Mycoplasma pneumoniae CAP. a) M. pneumoniae was the most frequent pathogen (33%). b) DNA probes for M. pneumoniae had low sensitivity in sputum (31.8%) and none in pharyngeal exudate. c) Acute infection by C. pneumoniae was diagnosed in 5 cases. Previous data of infection were recorded in 60.4% of the patients. d) Bacterial pneumonia (31%) was underestimated due to a low rate of bacteremic cases (7.9%) and the low number of positive cultures with definitive diagnostic value. e) The evolution was good except in two cases (death due to staphylococcal pneumonia with alcohol withdrawal syndrome and multiorganic failure by disseminated chicken-pox)." }, { "id": "pubmed23n0392_11445", "title": "Community-acquired pneumonia: epidemiologic and clinical considerations.", "score": 0.013379846330477788, "content": "An incidence of between 2 and 44 per 1000 population has been reported for community-acquired pneumonia. Epidemiologic studies describe a wide range of causative organisms, including Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Legionella spp., Moraxella catarrhalis, Chlamydia pneumoniae and viruses such as influenza A and B. However, the frequency with which they are reported varies widely. On analysis of these studies, the variation can be explained by a number of factors. The results depend on the definition of pneumonia and the criteria for assigning a causative role to any particular organism. Older studies have not included diagnostic methods for newly described organisms such as C. pneumoniae and Legionella spp. The improved diagnostic methods for these organisms and for Mycoplasma pneumoniae are reflected in more recent studies. Further variation depends on the population studied. As many patients with mild pneumonia are successfully treated in the community, those studies that are hospital-based include patients with more severe pneumonia often in the elderly or in patients with underlying diseases such as chronic obstructive pulmonary disease. The prior use of antibiotics not only contributes to the high percentage of cases for which no etiologic agent is found, but also ensures that treatment failures are selected for hospitalization. This further changes the result, depending on the antibiotic agents used most commonly in the community. The inclusion of nursing home patients or groups where alcoholism is more common will also favor particular organisms. Finally, the timing of the study may be such that an epidemic is included. This has relevance mostly for Mycoplasma pneumoniae, C. pneumoniae, Legionella spp. and influenza. In the assessment of the patient with community-acquired pneumonia, any one of the above organisms can be considered to be responsible. As initial treatment is empirical, other information can be used to ensure that an antibiotic with an adequate spectrum is chosen. Factors of importance are age, underlying illness, severity of disease and any locally recognized epidemics or endemic organisms. Differences in clinical presentation are not sufficiently distinct to allow for accurate prediction of the causative agent. Similarly, chest radiograph changes are not sufficiently specific to discriminate reliably between diverse organisms such as S. pneumoniae, Mycoplasma pneumoniae and Legionella spp. Current recommendations for choice of an empirical antibiotic agent are therefore based, not on the assumption of a single etiologic agent indicated by clinical presentation or radiographic appearances, but on age of the patient, severity of illness, the presence of underlying conditions and the range of possible organisms in that patient group." }, { "id": "pubmed23n0496_7620", "title": "Guidelines for community-acquired pneumonia: are they reflected in practice?", "score": 0.01195135588481968, "content": "Community-acquired pneumonia (CAP) is common, costly, and clinically serious. Several national and international practice guidelines have been developed to promote more appropriate, cost-effective care for patients with CAP. This article compares and contrasts eight international practice guidelines for the management of CAP, describes the extent to which recommendations are reflected in practice, and proposes explanations for non-adherence to guidelines. We found consistency in recommendations across all the guidelines for the management of patients with CAP requiring intensive care. In this setting, all guidelines recommend chest radiography, sputum Gram stain and culture, blood cultures, testing for Legionella pneumophila, and timely administration of antibiotics active against both typical (i.e. Streptococcus pneumoniae, Hemophilus influenzae) and atypical organisms (i.e. Legionella spp., Mycoplasma pneumoniae, and Chlamydia pneumoniae). Recommendations for the management of the average inpatient with pneumonia were more variable, with the greatest differences between the North American and European guidelines. The North American guidelines (in contrast to European ones), recommended empiric treatment of typical and atypical organisms in all inpatients. There were also differences in policies regarding the necessity of chest radiography, sputum studies, and serologic testing. Some guidelines explicitly embrace the use of prediction rules to inform the decision to hospitalize, while others do not. Some of these admission decision algorithms focus on identifying low risk patients, while others are most concerned with high risk patients. There was also considerable variation in the specificity and operationalization of clinical criteria for switching from parenteral to oral antibiotics or judging appropriateness for discharge. Many recommendations for key management decisions tended to lack explicit, objective, and actionable criteria that could be easily implemented in real world practice. Review of the pneumonia literature revealed that physician performance of guideline-recommended best practices is often suboptimal. Administration of timely antibiotics (&lt; or =8 hours of presentation) and use of first-line antibiotics occurred in 75-85% and 18-79% of cases, respectively. Collection of blood cultures within 24 hours of presentation and prior to administration of antibiotics was achieved in 69-83% and 63-82% of cases, respectively. Screening the eligibility of CAP patients for hospital-based pneumococcal and influenza vaccination occurred on average in 11 and 14% of hospitalizations, respectively, in the US. Lack of awareness of guidelines, conflicting advice among them, and lack of specific, objective, actionable recommendations most likely contribute to nonadherence to CAP guidelines. Increased attention to these factors will be needed if professional society practice guidelines are to fulfill their promise as tools for improving the quality and outcomes of care for patients with pneumonia." }, { "id": "pubmed23n0373_1293", "title": "Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines.", "score": 0.01113133151349712, "content": "Since the last British study of the microbial aetiology of community acquired pneumonia (CAP) about 20 years ago, new organisms have been identified (for example, Chlamydia pneumoniae), new antibiotics introduced, and fresh advances made in microbiological techniques. Pathogens implicated in CAP in adults admitted to hospital in the UK using modern and traditional microbiological investigations are described. Adults aged 16 years and over admitted to a teaching hospital with CAP over a 12 month period from 4 October 1998 were prospectively studied. Samples of blood, sputum, and urine were collected for microbiological testing by standard culture techniques and new serological and urine antigen detection methods. Of 309 patients admitted with CAP, 267 fulfilled the study criteria; 135 (50.6%) were men and the mean (SD) age was 65.4 (19.6) years. Aetiological agents were identified from 199 (75%) patients (one pathogen in 124 (46%), two in 53 (20%), and three or more in 22 (8%)): Streptococcus pneumoniae 129 (48%), influenza A virus 50 (19%), Chlamydia pneumoniae 35 (13%), Haemophilus influenzae 20 (7%), Mycoplasma pneumoniae 9 (3%), Legionella pneumophilia 9 (3%), other Chlamydia spp 7 (2%), Moraxella catarrhalis 5 (2%), Coxiella burnetii 2 (0.7%), others 8 (3%). Atypical pathogens were less common in patients aged 75 years and over than in younger patients (16% v 27%; OR 0.5, 95% CI 0.3 to 0.9). The 30 day mortality was 14.9%. Mortality risk could be stratified by the presence of four \"core\" adverse features. Three of 60 patients (5%) infected with an atypical pathogen died. S pneumoniae remains the most important pathogen to cover by initial antibiotic therapy in adults of all ages admitted to hospital with CAP. Atypical pathogens are more common in younger patients. They should also be covered in all patients with severe pneumonia and younger patients with non-severe infection." }, { "id": "wiki20220301en002_144441", "title": "Pneumonia", "score": 0.01092861386979034, "content": "Bacteria Bacteria are the most common cause of community-acquired pneumonia (CAP), with Streptococcus pneumoniae isolated in nearly 50% of cases. Other commonly isolated bacteria include Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, and Mycoplasma pneumoniae in 3% of cases; Staphylococcus aureus; Moraxella catarrhalis; and Legionella pneumophila. A number of drug-resistant versions of the above infections are becoming more common, including drug-resistant Streptococcus pneumoniae (DRSP) and methicillin-resistant Staphylococcus aureus (MRSA)." }, { "id": "wiki20220301en016_45446", "title": "Atypical pneumonia", "score": 0.010250195662601935, "content": "Epidemiology Mycoplasma is found more often in younger than in older people. Older people are more often infected by Legionella. Terminology \"Primary atypical pneumonia\" is called primary because it develops independently of other diseases. It is commonly known as \"walking pneumonia\" because its symptoms are often mild enough that one can still be up and about. \"Atypical pneumonia\" is atypical in that it is caused by atypical organisms (other than Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). These atypical organisms include special bacteria, viruses, fungi, and protozoa. In addition, this form of pneumonia is atypical in presentation with only moderate amounts of sputum, no consolidation, only small increases in white cell counts, and no alveolar exudate." }, { "id": "pubmed23n0360_22946", "title": "[Pneumonia due to Haemophilus influenzae.Study in a series of 58 patients]", "score": 0.00980392156862745, "content": "Haemophilus influenzae tends to form part of the usual respiratory flora in adults, especially if they have a chronic underlying disease or are smokers. Pneumonia due to H. influenzae is frequently involved in respiratory infections and its level of resistance to ampicillin has remained stable over the last five years. Most of the literature on the subject was published more than 10 years ago. In this study, we describe the clinical features and evolution of 58 adult patients admitted to hospital for pneumonia due to H. influenzae over a 2-year period, with this group accounting for 6.5&amp;#37; of all the patients admitted with pneumonia during this time period. The etiological diagnosis was made using a good quality sputum sample. Forty patients (69&amp;#37;) were male. The mean age (+/- SD) of the group was 67 (+/-16.8) years and all the patients had at least one underlying disease. The mean duration of the symptoms was 6.7 days. All patients presented an increase in the quantity or purulence of the sputum. On admittance, respiratory failure was present in 52 patients (90&amp;#37;). Gram-negative coccus-bacilli were observed in the direct sputum test and H. influenzae grew in the culture. In two cases, H. influenzae was recovered from the blood culture and in one from bronchial aspiration obtained through bronchoscopy. Another pathogen was identified in 28 patients (48&amp;#37;). In 21 it was another pyogenic bacteria (15 S. pneumoniae, 4 M. catharralis, 1 K. pneumoniae, 1 E. coli), an atypical microorganism in 5 (3 C. pneumoniae, 2 C. burnetii) and a respiratory virus in 2 (syncytial and influenza A). Atypical bacteria and respiratory virus were detected using serological techniques. The radiographic infiltrate was unilobar in 54 of the 58 patients and all showed an alveolar pattern. The empirical treatment included the administration of a third generation cephalosporin (or a fluoroquinolone in patients allergic to penicillin). The evolution was favorable in all the cases in which H. influenzae was the only pathogen or was accompanied by an atypical microorganism or a respiratory virus. Four patients with mixed bacterial pneumonia died (2 S. pneumoniae, 1 E. coli and 1 M. catharralis). The study indicates that pneumoniae due to H. influenzae affects a population with an underlying disease, preferably pulmonary, that it has a longer clinical period than that for pneumococcal pneumonia, that it is slightly bacteremic and, that, usually, it evolves benignly with a low mortality." }, { "id": "pubmed23n0083_17139", "title": "[Legionella dumoffii and Legionella pneumophila serogroup 5 isolated from 2 cases of fulminant pneumonia].", "score": 0.009708737864077669, "content": "We encountered two cases of legionella pneumonia which ran a dramatic course and isolated Legionella dumoffii from one patient and Legionella pneumophila serogroup 5 from the other patient. The patient from whom L. dumoffii was isolated was a 59-year-old male with no basic disease. He presented chill, fever, coughing and other symptoms, starting on July 3, 1986, his disease was diagnosed as pneumonia at the clinic of his company. The patient was then introduced and admitted to our hospital. On admission chest radiography disclosed zonal pneumonia with an unclear border in the right superior lobe of the lung; a beta-lactam preparation was administered, but no effect was obtained and the lung lesion showed a rapid advance. From this condition, we suspected legionella pneumonia and changed the therapy to treatment with erythromycin and rifampicillin. Despite this, no improvement occurred and the patient died on the 26th hospital day. Colonies like Legionella colonies were separated from a total of seven specimens of biopsy aspirated matter from the airway and autopsy collected lung abscess and tracheal secretions, and the bacterium was identified L. dumoffii based on the biochemical and serological properties. In addition, the patient's serum was found to have an increased antibody titer against L. dumoffii. Based on these findings, the patient's disease was diagnosed as pneumonia as caused by L. dumoffii, a relatively rare bacterium as a member of the genus Legionella. The patient from whom Legionella pneumophila serogroup 5 was isolated was an 81-year-old man with basic diseases such as heart failure, anemia and hypothyroidism. He presented fever, general fatigue, anorexia and other symptoms, starting around June 2, 1987; pneumonia was suspected and the patient was urgently admitted to our hospital. The patient died of pneumonia of unknown cause on the second hospital day. To clarify the cause, autopsy was conducted; a large number of colonies like Legionella colonies were noted in the lung tissue. Identification test was then conducted and the bacterium was identified as L. pneumophila; we concluded that the patient's pneumonia had been caused by the identified bacterium L. pneumophila. The isolate was further subjected to slide agglutination test and identified as L. pneumophila serogroup 5." }, { "id": "pubmed23n0386_6960", "title": "[Community acquired pneumonia in patients older than 60 years. Incidence of atypical agents and clinical-radiological progression].", "score": 0.009708737864077669, "content": "Seventy five patients older than 60 years with a community acquired pneumonia followed up in an outpatient clinic, were prospectively studied in order to determine the incidence of atypical agents, clinical-radiological characteristics, progression and the differences with pneumonia in younger patients. Clinical-radiological evaluation protocols were activated in the first visit and in two subsequent controls. Etiological diagnosis was made by means of serology (in the first visit and three weeks later). Initially, 85 patients older than 60 years were included of which 75 non hospitalized were fully followed up. Also, in the comparative study, 216 outpatient clinic patients 60 years old or younger were followed up during the same period. In the first group the frequency of atypical agents was 33.3%. The most frequently isolated bacteria was Coxiella burnetii (13.3%)followed by virus and Legionella pneumophila. No case of Mycoplasma pneumoniae was diagnosed. The most frequent radiological onset was alveolar infiltrate (85%). The comparative study between the two populations (older or younger than 60 years), found few clinical differences (dyspnea more frequent in older,feverish chill in younger) and auscultation (crackles more frequent in older). We did not find differences remaining clinical-radiological or laboratory data. Most patients presented a favourable clinical and radiological progression. Only 2 patients needed hospital admission (2.7%). In outpatient clinic patients older than 60 years with community acquired pneumonia a high number of atypical agents have been found. The clinical-radiological evolution was satisfactory for most of them. Age was not a decisive element in determining hospital admissions." }, { "id": "wiki20220301en073_57840", "title": "Pneumococcal pneumonia", "score": 0.009662447257383966, "content": "Pneumococcal pneumonia is a type of bacterial pneumonia that is caused by Streptococcus pneumoniae (which is also called pneumococcus). It is the most common bacterial pneumonia found in adults, the most common type of community-acquired pneumonia, and one of the common types of pneumococcal infection. The estimated number of Americans with pneumococcal pneumonia is 900,000 annually, with almost 400,000 cases hospitalized and fatalities accounting for 5-7% of these cases. The symptoms of pneumococcal pneumonia can occur suddenly, typically presenting as a severe chill, later including a severe fever, cough, shortness of breath, rapid breathing, and chest pains. Other symptoms like nausea, vomiting, headache, fatigue, and muscle aches could also accompany the original symptoms. Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur. Chest X-rays will typically show lobar consolidation or patchy infiltrates." }, { "id": "pubmed23n0354_19943", "title": "Prospective study of community-acquired pneumonia of bacterial etiology in adults.", "score": 0.009615384615384616, "content": "The aim of this study was to prospectively analyze the bacterial etiology of community-acquired pneumonia in adults in Spain. From May 1994 to February 1996, 392 episodes of CAP diagnosed in the emergency department of a 600-bed university hospital were studied. An etiological diagnosis based on noninvasive microbiological investigations was achieved in 228 cases (58%); 173 of these diagnoses were definitive and 55 probable. Streptococcus pneumoniae, which caused 23.9% of the episodes, was the predominant pathogen observed, followed by Chlamydia pneumoniae (13.5%) and Legionella pneumophila (12.5%). Other less frequent pathogens found were Haemophilus influenzae (2.3%), Pseudomonas aeruginosa (1.5%), Mycoplasma pneumoniae (1.3%), Coxiella burnetii (1%), Moraxella catarrhalis (2 cases), Nocardia spp. (2 cases), and Staphylococcus aureus (2 cases). Streptococcus pneumoniae was significantly more frequent in patients with underlying disease and/or age &gt; or =60 years (28% vs. 13%, P = 0.002), while Legionella pneumophila was more frequent in patients below 60 years of age and without underlying disease (20% vs. 9%, P = 0.006). Likewise, Streptococcus pneumoniae and Legionella pneumophila were the most frequent etiologies in patients requiring admission to the intensive care unit, occurring in 29% and 26.3% of the patients, respectively. In addition to Streptococcus pneumoniae, other microorganisms such as Chlamydia pneumoniae and Legionella spp. should be seriously considered in adults with community-acquired pneumonia when initiating empiric treatment or ordering rapid diagnostic tests." }, { "id": "pubmed23n0070_6122", "title": "[Community-acquired pneumonia: 573 cases].", "score": 0.009615384615384616, "content": "To evaluate the epidemiology and incidence of community-acquired pneumonia (CAP) a retrospective study of 573 cases which had been diagnosed during a 3 1/2 year period was carried out. There was a male predominance (2.09/1) with mean age of 53.33 years. The diagnostic delay (days) was 1.5. The mean hospital stay was 13.39 days. The most common underlying disease was COLD (27%). 34% of patients had received previous therapy. The most common clinical features were cough, fever, and mucous sputum. The most common radiological pattern was alveolar (81%). There was increased ESR and moderately high GOT and GPT. The microbiological diagnosis was achieved in 35.4%, with positive sputum culture (mostly pneumococcus) in 26.8% an positive blood culture in 5.9%. Ten patients died (1.7%). The following factors predicted a poor prognosis: age 75 years, underlying disease, bilateral radiological involvement and leukocytosis with neutrophilia." }, { "id": "InternalMed_Harrison_11627", "title": "InternalMed_Harrison", "score": 0.009596017177820848, "content": "presenting manifestations The presentation of pneumococcal pneumonia does not reliably distinguish it from pneumonia of other etiologies. In a subset of cases, pneumococcal pneumonia is recognized at the outset as associated with a viral upper respiratory infection and is characterized by the abrupt onset of cough and dyspnea accompanied by fever, shaking chills, and myalgias. The cough evolves from nonpurulent to productive of sputum that is purulent and sometimes tinged with blood. Patients may describe stabbing pleuritic chest pain and significant dyspnea indicating involvement of the parietal pleura. Among the elderly, the presenting clinical symptoms may be less specific, with confusion or malaise but without fever or cough. In such cases, a high index of suspicion is required because failure to treat pneumococcal pneumonia promptly in an elderly patient is likely to result in rapid evolution of the infection, with increased severity, morbidity, and risk of death." }, { "id": "pubmed23n0964_5085", "title": "A case report of Legionella and Mycoplasma pneumonia: Co-incidence or co-infection?", "score": 0.009523809523809525, "content": "Concurrent or sequential coinfections of Legionella pneumophila and Mycoplasma pneumoniae have been reported in the past though infrequently. Distinguishing a true co-infection from cross reactivity is often challenging as the diagnosis is mostly dependent on serological testing. A 77-year-old male presented with worsening dyspnea, cough with yellow sputum, diarrhea and fever of 2-days duration. Patient had history of chronic obstructive pulmonary disease (COPD) on home oxygen, bronchiectasis, rheumatoid arthritis (on methotrexate and leflunomide), treated pulmonary tuberculosis and 30-pack-year smoking. Chest X-ray showed bilateral interstitial changes with left lower lobe infiltrate. On day 5, his urine antigen for L pneumophila serogroup 1 was reported positive. The following day his serum M pneumoniae IgM antibody titers were reported elevated at 6647 U/mL. Patient was started on antibiotics and placed on non-invasive positive pressure ventilation. The patient was diagnosed with possible Legionella and Mycoplasma co-infection. Sputum Mycoplasma polymerase chain reaction (PCR) and serum cold agglutinins were obtained on day 6 and later reported negative. He was treated with azithromycin for 10 days with clinical improvement. Serological testing alone is an indirect measure with poor sensitivity and specificity and has its own limitations. Urine antigen detection confirms L pneumophila serogroup 1 infection in a patient with suggestive symptoms. However, diagnosis of M pneumonia should be based on combination of tests including serology and PCR to confirm true co-infection." }, { "id": "wiki20220301en252_19887", "title": "Delafloxacin", "score": 0.009433962264150943, "content": "Susceptible bacteria for CABP are: Streptococcus pneumoniae, Staphylococcus aureus (methicillin-susceptible [MSSA] isolates only), Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Haemophilus influenzae, Haemophilus parainfluenzae, Chlamydia pneumoniae, Legionella pneumophila, and Mycoplasma pneumoniae. It has not been tested in pregnant women. In the European Union it is indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI) in adults when it is considered inappropriate to use other antibacterial agents that are commonly recommended for the initial treatment of these infections." }, { "id": "pubmed23n0345_14710", "title": "[Comparative study of clinical features of typical and atypical pneumonias].", "score": 0.009433962264150943, "content": "We prospectively analyzed the clinical and laboratory features of 74 patients with community-acquired pneumonia who required hospitalization between May 1996 and October 1997. Typical pathogens were identified in 47, and atypical pathogens in 27. The average age was higher in patients affected by typical pathogens (73.9 years), than in patients affected by atypical pathogens (50.9 years). Univariable analysis found that atypical pneumonias were more frequent in healthy patients than typical pneumonias. Moreover, the presence of relatives with symptoms of airway infection, headache, and earache was more common among the patients with atypical pneumonias, while leukocytosis and elevated C-reactive protein levels were more frequent among patients with typical pneumonias. Typical pathogens accounted for up to 79.6% of the cases of pneumonia with in older patients (aged 60 years or more), whereas atypical pathogens accounted for up to 80% of the cases of pneumonia in younger patients (aged under 60 years). This difference was statistically significant. Of all 74 patients, 39 (52.7%) were afflicted by severe community-acquired pneumonia, as categorized by American Thoracic Society guidelines. The most common pathogen among these patients was Streptococcus pneumoniae. Legionella was one of the top four. Selection of the initial antimicrobial treatment is an important clinical decision that should be made on the basis of clinical features at admission, age, and severity of the patient's illness." }, { "id": "pubmed23n0307_18318", "title": "[Community-acquired pneumonia (CAP) with hospital treatment. The value of the clinical picture and complementary exams in predicting its etiology].", "score": 0.009345794392523364, "content": "We studied 162 patients with community-acquired pneumonia admitted for hospital treatment, in order to determine the utility of clinical and ancillary examinations for predicting etiology and guiding the most appropriate empirical treatment. Acute first appearance of symptoms, purulent expectoration, chest sounds indicating lung condensation, pleuritic chest pain and leukocytosis over 12,500/ml were statistically significant in differentiating typical pneumonias from those with atypical behavior patterns. The last two features were the most relevant according to multivariate analysis. We conclude that careful taking of case histories and basic blood testing continue to be relevant and must not be considered anachronistic for the differential diagnosis of community-acquired pneumonias." }, { "id": "pubmed23n0744_19024", "title": "[Diagnosis, treatment and prognosis of community acquired pneumonia - results from three primary care centers in Iceland].", "score": 0.009259259259259259, "content": "To study how general practitioners diagnose and treat adult patients with community acquired pneumonia (CAP) and evaluate outcomes. Retrospective chart review for one year on patients 18 years and older diagnosed with CAP in three different primary care centers in Iceland. A total of 215 patients were diagnosed with CAP. Of those 195 were both diagnosed and treated in the primary health care and 20 patients were referred for specialized care. Mean age was 50.3 years (SD= 21.0) and 126 (65%) of the patients were women. Most patients had been ill for less than a week and did not have a previously diagnosed lung disease. Cough was the most common symptom (71%) and 96% had abnormal chest auscultation. Vital signs were frequently not recorded. A chest radiograph was done in third of the cases and showed abnormality in over 80%. Most patients (94%) were treated with antibiotics usually extended spectrum penicillin. Phone consultations were the most common form of communication after diagnosis and about 12% of subjects had their antibiotics changed and about 10% had a chest radiograph done after diagnosis had been made. There was no mortality from CAP during the study period. CAP was diagnosed clinically and managed in primary care in most cases. CAP was more common in women and a minority of patients had underlying lung diseases. Vital sign measurements were used less than expected. Broad spectrum antibiotics were widely used for treatment. CAP had no mortality." }, { "id": "pubmed23n0541_9407", "title": "[A multicentre study on the pathogenic agents in 665 adult patients with community-acquired pneumonia in cities of China].", "score": 0.009174311926605505, "content": "To investigate the pathogenic causes of community-acquired pneumonia (CAP) in adult patients in China, the relation of previous antibiotic use and the Pneumonia Patient Outcome Research Team (PORT) classification to microbial etiology, and the prevalence of drug resistance of common CAP bacteria. A prospective study was performed on 665 consecutive adult patients with CAP at 12 centers in 7 Chinese cities during one year. The etiology of pneumonia was considered if one of the following criteria was met: (1) valid sputum sample yielding one or more predominant strains; (2) blood cultures yielding a bacterial pathogen; (3) seroconversion, a &gt; or = 4-fold increase or decrease titers of antibodies to Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila. Minimum inhibitory concentration (MIC) of respiratory tract isolates was determined using the agar dilution method. Pathogens were identified in 324/610 patients (53.1%) with valid serum samples and sputum cultures as follows: Mycoplasma pneumoniae (126, 20.7%), Streptococcus pneumoniae (63, 10.3%), Haemophilus influenzae (56, 9.2%), Chlamydia pneumoniae (40, 6.6%), Klebsiella pneumoniae (37, 6.1%), Legionella pneumophila (31, 5.1%), Staphylococcus aureus (23, 3.8%), Escherichia coli (10, 1.6%), Moraxella catarrhalis (8, 1.3%), Pseudomonas aeruginosa (6, 1.0%). Of 195 patients with a bacterial pathogen, an atypical pathogen was identified in 62 (10.2%) cases. The non-susceptibility rate of Streptococcus pneumoniae to penicillin, azithromycin, and moxifloxacin was 20.3%, 75.4% and 4.3% respectively. Atypical pathogens have important role in CAP, with Mycoplasma pneumoniae being the most common pathogen, and mixed infection of atypical pathogens with bacteria was found in 10.2% of the cases. Streptococcus pneumoniae and Haemophilus influenzae remain the most important bacteria for CAP. More than 75.0% of Streptococcus pneumoniae was resistant to macrolides and 20.3% was resistant to penicillin." }, { "id": "pubmed23n0412_8111", "title": "[Etiology of community-acquired pneumonia among adult patients in Japan].", "score": 0.009174311926605505, "content": "To clarify the etiology of community-acquired pneumonia (CAP) in Japan, the causative pathogens were prospectively investigated in adult patients admitted to Kurashiki Central Hospital. The microbiological diagnosis was based on the results of quantitative sputum culture, blood culture, and other invasive procedures, including transthoracic needle aspiration or bronchoscopic examination. Five hundred fifty-two episodes of CAP in 540 patients were admitted between July 1994 and June 1999. Causative pathogens were identified in 353 episodes (63.9%). Several characteristics about the etiology of CAP in Japan were recognized: 1) Streptococcus pneumoniae is the most common pathogen followed by Haemophilus influenzae; 2) Mycoplasma pneumonia is dominant among young patients; 3) Chlomydia pneumoniae is one of the significant pathogens in Japan as well as in western countries; 4) Streptococcus milleri group and anaerobes are important pathogens in patients with suppurative pulmonary diseases; 5) The incidence of Legionella pneumonia is far lower than in western countries; 6) The prevalence of tuberculosis in CAP is still high in Japan; etc. Recognition of these results will lead us to treat patients with prompt antimicrobial therapy." }, { "id": "pubmed23n0318_17964", "title": "Comparative study of the clinical presentation of Legionella pneumonia and other community-acquired pneumonias.", "score": 0.00909090909090909, "content": "The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases." }, { "id": "pubmed23n0559_2677", "title": "Clinical differentiation of atypical pneumonia using Japanese guidelines.", "score": 0.00909090909090909, "content": "Atypical pneumonia occupies an important position in community-acquired pneumonia. The aim of this study was to examine whether making a diagnosis of atypical pneumonia is possible based upon the Japanese Respiratory Society guidelines. The data from three prospective studies were reviewed. A total of 285 patients with mycoplasmal pneumonia or chlamydial pneumonia and 515 patients with pneumococcal pneumonia or Haemophilus influenzae pneumonia were assessed to determine whether these pneumonias met the diagnostic criteria for atypical pneumonia used in the Japanese Respiratory Society guidelines. The criteria were: (i) age less than 60 years; (ii) no or only minor underlying diseases; (iii) persistent cough; (iv) limited chest auscultatory findings; (v) no sputum, or no identified aetiological agent by rapid diagnosis; and (vi) a peripheral white blood cell count below 10,000/microL. All items of the criteria proved to be valid except for 'age' in patients with Chlamydophila pneumoniae pneumonia using multiple regression analysis. The sensitivity and specificity for atypical pneumonia were 77.0% and 93.0% based on four or more of the criteria respectively. Pure atypical pneumonia can be differentiated to some degree by clinical symptoms and laboratory findings. It is important to differentiate and treat bacterial pneumonia and atypical pneumonia in regions such as Japan, where Streptococcus pneumoniae resistance to macrolides is high. Treatment covering the two types of pneumonia should be considered in elderly patients and those with underlying respiratory disease." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "3": { "exist": true, "char_ranges": [ [ 0, 103 ] ], "word_ranges": [ [ 0, 14 ] ], "text": "Although the majority of ACTH-producing adenomas recur, surgery is always the first therapeutic option." }, "4": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Initially try medical treatment and, if not effective, resort to surgery.", "2": "Adrenalectomy.", "3": "Selective surgical resection of the adenoma.", "4": "Radiotherapy to try to reduce tumor size.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0302_5541", "title": "[Cushing's disease. A challenge of size].", "score": 0.018129614438063987, "content": "Cushing's syndrome constitutes a real challenge for the clinician who has to elucidate its etiology. ACTH determinations should allow to classify the etiology as belonging to either the ACTH-dependent or the ACTH-independent group, but variable biological characteristics of pituitary or ectopic ACTH secreting tumors may complicate the investigation. For small pituitary adenomas, magnetic resonance imaging (MRI) has increased the sensitivity of detection over CT scans; however, the small average size of 4-5 mm of corticotroph adenomas, including a significant proportion of tumors of less than 3 mm, limits MRI to a sensitivity which varies between 42-80%. In situations where a pituitary tumor is small (&lt; 6 mm or not detectable by MRI), it is recommended to perform bilateral petrosal sinus sampling including a stimulation of ACTH secretion by CRH administration, to confirm the pituitary source of ACTH prior to undertaking pituitary exploration. Transsphenoidal selective removal of the pituitary corticotroph adenoma is the treatment of choice; immediate surgical success rate is high (75-90%) when the tumor is a microadenoma visible at MRI. However success rate decreases (50-60%) when surgical exploration is performed without radiological detection. The other end of the spectrum of size of the corticotroph adenomas includes either tumors larger than 10 mm (macroadenomas) or tumors invading the cavernous sinus; in either case, immediate success rate of surgical removal is only 50-70%. Radiotherapy coupled to medical (ketoconazole, op \"DDD) or surgical (bilateral laparoscopic adrenalectomy) control of hypercorticism may be necessary. Longer follow-up series indicate a relapse rate of up to 25% after 10 years, suggesting frequent incomplete resection. It is hoped that further progress in our understanding of the molecular basis of the pathophysiology of this disease will allow the development of new therapeutic strategies which will circumvent the current limitations resulting in part, from the size of these tumors." }, { "id": "pubmed23n0276_17309", "title": "[The treatment of Cushing's disease].", "score": 0.016876750700280115, "content": "The differential diagnosis of Cushing's disease remains difficult to establish. The selective transsphenoidal adenomectomy is the initial treatment of choice. In a group of 65 patients, 50 (77%) initially responded to surgery with correction of their hypercortisolism. Forty-three out of 51 (84%) patients with small pituitary tumors responded favourably to surgery, but recurrency occurred in 10% of the cases. Medical treatment with steroids inhibitors or antagonists is only an adjuvant treatment. In case of surgery failure or recurrency, bilateral adrenalectomy is usually performed. Conventional radiotherapy may be used after surgery in presence of macroadenomas or invasive adenomas. Correction of the hypercortisolism, after a second surgery, was achieved in 50% of the cases and was always associated with a panhypopituitarism." }, { "id": "wiki20220301en015_42172", "title": "Cushing's disease", "score": 0.014617971231085373, "content": "Treatment The first-line treatment of Cushing's disease is surgical resection of ACTH-secreting pituitary adenoma; this surgery involves removal of the tumor via transsphenoidal surgery (TSS). There are two possible options for access to the sphenoidal sinus, including of endonasal approach (through the nostril) or sublabial approach (through an incision under the upper lip); many factors such as the size of nostril, the size of the lesion, and the preferences of the surgeon cause the selection of one access route over the other." }, { "id": "pubmed23n0397_20336", "title": "Radiation therapy in the multimodal treatment approach of pituitary adenoma.", "score": 0.014525835235526044, "content": "Pituitary tumors are relatively uncommon, comprising 10-12% of all intracranial tumors. The treatment consisting of surgery, radiotherapy and drug therapy or a combination of these modalities is aimed at the control of tumor cell proliferation and--in endocrine active tumors--the reduction of hormone secretion. However, the slow proliferation characteristics of pituitary tumors necessitate long-term studies for the evaluation of the treatment results. In the last decade there has been continuous improvement in surgical procedures, radiotherapy techniques and drug generation. In this paper, literature will be reviewed to assess the role of modern radiotherapy and radiosurgery in the management of pituitary adenomas. Nowadays, magnetic resonance imaging for the definition of the target volume and a real three-dimensional (3-D) treatment planning with field conformation and the possibility for non-coplanar irradiation has to be recommended. Most groups irradiate these benign tumors with single doses of 1.8-2.0 Gy up to a total dose of 45 Gy or 50.4 Gy in extensive parasellar adenomas. Adenomas are mostly small, well circumscribed lesions, and have, therefore, attracted the use of stereotactically guided high-precision irradiation techniques which allow extreme focussing and provide steep dose gradients with selective treatment of the target and optimal protection of the surrounding brain tissue. Radiation therapy controls tumor growth in 80-98% of patients with non-secreting adenomas and 67-89% for endocrine active tumors. Reviewing the recent literature including endocrine active and non-secreting adenomas, irradiated postoperatively or in case of recurrence the 5-, 10- and 15-year local control rates amount 92%, 89% and 79%. In cases of microprolactinoma primary therapy consists of dopamine agonists. Irradiation should be preferred in patients with macroprolactinomas, when drug therapy and/or surgery failed or for patients medically unsuitable for surgery. Reduction and control of prolactin secretion can be achieved in 44-70% of patients. After radiotherapy in acromegaly patients somatomedin-C and growth hormone concentrations decrease to normal levels in 70-90%, with a decrease rate of 10-30% per year. Hypercortisolism is controlled in 50-83% of adults and 80% of children with Cushing's disease, generally in less than 9 months. Hypopituitarism is the most common side effect of pituitary irradiation with an incidence of 13-56%. Long-term overall risk for brain necrosis in a total of 1,388 analyzed patients was estimated to be 0.2%. Other side effects are rare too, and do also depend on the damage produced by tumor itself or preceding surgery. They include deterioration of vision in 1.7% of all cases, vascular changes in 6.3%, neuropsychological disorders such as dementia in 0.7% and secondary malignancies in 0.8%, if single doses of 2.0 Gy and total doses of 50 Gy are not exceeded. Conventional radiation therapy of pituitary adenoma is highly effective. It is recommended after subtotal resection of primary tumors such as macroadenomas, after gross total resection from endocrine active adenomas with postsurgical hormone secretion and for recurrent tumors. Radiosurgery seems to be a possible treatment alternative in experienced centers, and only in patients with adenomas smaller than 25-30 mm with a minimum distance of 2-3 mm to the chiasm." }, { "id": "pubmed23n0328_12253", "title": "[Treatment of pituitary adenoma].", "score": 0.014052540081128067, "content": "RECOMMENDED TREATMENTS: The different therapeutic strategies proposed for pituitary adenomas are relatively well-known thanks to numerous studies evaluating their effect on outcome. Unfortunately, large comparative clinical trials are difficult to construct due to the small number of cases of this rare condition. Therapeutic recommendations are thus generally based on the opinion of recognized experts. MICROADENOMA: Small (&lt; 10 mm) prolactin-secreting adenomas should be treated surgically, generally by transsphenoidal adenomectomy, or medically by dopaminergic agonists: bromocriptin, quinagolide or cabergolin (the two latter drugs are more effective and better tolerated than their parent compound bromocriptin). MACROADENOMA: The expected success rate for surgical treatment of macroadenomas is low and dopaminergic agonists is generally recommended (including cases with visual impairment since the effect can be very rapid). Prolactin levels can be lowered and tumor volume reduced (in &gt; 70% of cases). ACROMEGALY: Surgery is the firs intention treatment for acromegaly. In case of unsuccessful surgery (the criteria for \"cure\" are much more strict in 1998 than previously), somatostatin analog and/or hypothalamo-hypophyseal radiotherapy are recommended. Slow release formulations of somatostatin analogs can now be given by monthly (octreotide LP) or biweekly (lanreotide LP) injections. CUSHING'S DISEASE: Cure can be achieved in &gt; 80% of cases with surgery, the first intention treatment of choice. If surgery is unsuccessful, radiotherapy can be proposed associated with anticortisol drugs (mitotane), if needed, while waiting for the late effect of radiotherapy. CLINICALLY SILENT ADENOMAS: Non-functional adenomas should be operated. Some propose adjuvant radiotherapy in all cases and others only if residual tissue persists post-operatively." }, { "id": "wiki20220301en015_42173", "title": "Cushing's disease", "score": 0.014021164021164021, "content": "Some tumors do not contain a discrete border between the tumor and pituitary gland; therefore, careful sectioning through the pituitary gland may be required to identify the location of the tumor. The probability of successful resection is higher in patients where the tumor was identified at initial surgery in comparison to patients where no tumor was found initially; the overall remission rates in patients with microadenomas undergoing TSS are in range of 65%–90%, and the remission rate in patients with macroadenomas are lower than 65%. Patients with persistent disease after initial surgery are treated with repeated pituitary surgery as soon as the active persistent disease is evident; however, reoperation has a lower success rate and increases the risk of pituitary insufficiency." }, { "id": "pubmed23n0514_14767", "title": "Diagnosis and treatment of pituitary adenomas.", "score": 0.013914299470389985, "content": "Pituitary tumors cause symptoms by secreting hormones (prolactin, PRL, responsible for amenorrhea-galactorrhea in women and decreased libido in men; growth hormone, GH, responsible for acromegaly; adrenocorticotropic hormone, ACTH, responsible for Cushing's syndrome; thyroid-stimulating hormone, TSH, responsible for hyperthyroidism), depressing the secretion of hormones (hypopituitarism), or by mass-related effects (headaches, visual field abnormalities...). All patients with pituitary tumors should be evaluated for gonadal, thyroid and adrenal function as well as PRL and GH secretion. Specific stimulation and suppression tests for pituitary hormones are performed in selected situations for detecting the type of hypersecretion or the response to treatment. Imaging procedures (mainly magnetic resonance imaging, MRI, nowadays) determine the presence, size and extent of the lesion. The classification of pituitary tumors is based on the staining properties of the cell cytoplasm viewed by light microscopy and immunocytochemistry revealing the secretory pattern of the adenoma. Treatment of pituitary adenomas consists of surgery (performed in more than 99% of cases via a transphenoidal route) and radiotherapy, generally fractionated or, in selected cases, using stereotactic techniques such as gamma-knife. The availability of medical treatment (dopamine, DA, agonists, somatostatin analogs, GH-receptor antagonists...) has profoundly modified the indications of radiotherapy, drugs being now generally used as a second-line treatment, after surgery (or even as first-line treatment). Based on the results of the different treatment modalities for each type of pituitary adenoma, recommendations will be proposed. They may be summarized as follows. For treatment of GH-secreting adenomas, trans-sphenoidal surgery is the first-line therapy except when the macroadenoma is giant or if surgery is contra-indicated; postoperative radiation therapy (fractionated, or by gamma-knife) is performed for partially resected tumors or when GH levels remain elevated (eventually after a trial of somatostatin analog). Somatostatin analogs, now available in slow release form, are proposed when surgery is contra-indicated, or has failed to normalize GH levels, or in waiting for the delayed effects of radiation therapy. If the probability of surgical cure is low (e.g. in patients with very large and/or invasive tumors), then somatostatin analogs may be reasonable primary therapeutic modality provided that the tumor does not threaten vision or neurological function. Pegvisomant, the new GH-receptor antagonist, is indicated in case of resistance to somatostatin analogs. Patients with PRL-secreting microadenomas may be treated either with trans-sphenoidal surgery or medically with DA agonists. In patients with macroadenomas, even in the presence of chiasmatic syndrome, DA agonists are now proposed as primary treatment. Indeed, effects on visual disturbances are often very rapid (within a few hours or days) and tumoral shrinkage is usually very significant. For patients with ACTH-secreting adenomas, primary therapy is generally trans-sphenoidal surgery by a skilled surgeon, whether or not a microadenoma is visible on MRI. Radiotherapy is reserved for patients who are subtotally resected or remain hyper-secretory after surgery. In waiting for the effects of radiotherapy, adrenal steroidogenesis inhibitors (mitotane, ketoconazole) may be indicated. If drugs are not available or not tolerated, bilateral adrenalectomy may be proposed. For patients with clinically non functioning adenomas (generally gonadotropin-secreting adenomas on immunocytochemistry), trans-sphenoidal surgery with or without postoperative radiation therapy is performed for almost all patients whether or not they have visual consequences of their tumor. Selected patients with small, incidentally discovered microadenomas may be carefully followed without immediate therapy." }, { "id": "pubmed23n0492_20465", "title": "Transsphenoidal surgery in Cushing disease: 10 years of experience in 34 consecutive cases.", "score": 0.013704318936877076, "content": "Cushing disease is a rare disorder. Because of their small size the adrenocorticotropic hormone (ACTH)-producing tumors are often not detectable on neuroimaging studies. To obtain a cure with transsphenoidal surgery (TSS) may therefore be difficult. In this report the authors present 10 years of experience in the treatment of patients with Cushing disease who were followed up with the same protocol and treated by the same surgeon. Thirty-four patients, 26 of them female and eight of them male (mean age 40 years, range 13-74 years) were studied. All had obvious clinical signs and symptoms of Cushing syndrome. Magnetic resonance (MR) imaging was performed in all patients, and inferior petrosal sinus (IPS) sampling was done in 14. In 12 patients MR imaging indicated a pituitary tumor; 10 were microadenomas and two were macroadenomas. In six patients with no visible tumor, the results of IPS sampling supported the diagnosis. All patients underwent TSS; the mean follow-up duration was 6 +/- 0.5 years. Selective adenomectomy was performed in 32 and hemihypophysectomy in the other two patients. A cure was obtained in 31 patients (91%) after one TSS and in two more patients after further TSS; one patient was not cured despite two TSSs and one underwent bilateral adrenalectomy. Disease recurrence was seen in two patients after 3 years, and they were successfully treated with stereotactic gamma knife surgery. Half of the patients had an ACTH deficiency postoperatively, whereas one third had other pituitary hormone insufficiencies. There were no serious complications attributable to the surgical intervention. Transsphenoidal surgery with selective adenomectomy is an effective and safe treatment for Cushing disease. In the patients presented in this study, the surgical outcome seemed to depend on careful preoperative evaluation and the surgeon's experience. For optimal results in this rare disease the authors therefore suggest that the endocrinological, radiological, and surgical procedures be coordinated in a specialized center." }, { "id": "pubmed23n0313_10871", "title": "Outcomes of therapy for Cushing's disease due to adrenocorticotropin-secreting pituitary macroadenomas.", "score": 0.013584708494796881, "content": "We reviewed our experience with 21 patients who had Cushing's disease due to ACTH-secreting macroadenomas to clarify the natural history of this disease. All patients had typical clinical and biochemical features of ACTH-dependent hypercortisolism. Their mean maximal tumor diameter was 1.6 +/- 0.1 cm, and the range was 1.0-2.7 cm. Six patients had cavernous sinus invasion, three had invasion of the floor of their sella, and nine had suprasellar extension. The observed remission rate was significantly lower in macroadenoma patients than in microadenoma patients (67% vs. 91%; chi 2 = 5.7; P &lt; 0.02). Cavernous sinus invasion (odds ratio, 35; 95% confidence interval, 2.6-475; P &lt; 0.008) and presence of a maximum tumor diameter 2.0 cm or more (odds ratio, 12.9; 95% confidence interval, 1.4-124; P &lt; 0.02) emerged as the only predictors of residual disease after surgery. The observed recurrence rate was significantly higher in macroadenoma patients than in microadenoma patients (36% vs. 12%; chi 2 = 4.2; P &lt; 0.05). Macroadenoma patients tended to suffer from recurrences earlier than did microadenoma patients (16 vs. 49 months). Stepwise multiple logistic regression did not identify any predictors of disease recurrence in macroadenoma patients. Eight macroadenoma patients underwent a total of nine repeat surgical procedures, but none of these resulted in clinical remissions. Only four of seven (57%) patients followed for a sufficient period of time achieved normal urinary free cortisol levels after conventional radiotherapy. Three (75%) of these four patients had re-recurrent hypercortisolism after brief periods of eucortisolism. Pharmacological agents and adrenalectomy were effective in the management of hypercortisolism in patients with residual and recurrent disease. Our results indicate that ACTH-secreting macroadenomas are more refractory to conventional treatments than are ACTH-secreting microadenomas." }, { "id": "pubmed23n0589_8642", "title": "Long-term results after microsurgery for Cushing disease: experience with 426 primary operations over 35 years.", "score": 0.01217948717948718, "content": "The aim of this paper was to demonstrate the long-term results following microsurgery in a single surgeon's continuous series of patients with Cushing disease (CD), to assess the influence of changes in surgical procedures, and to compare the results with those of other treatment modalities. In particular, preoperative diagnosis, tumor size, results of histological examination, and complications were considered. Between 1971 and 2004, 426 patients suffering from newly diagnosed CD underwent primary surgery. Pre-operative measures included clinical examination, endocrinological workup (testing of the hypothalamic-pituitary-adrenal axis, and 2- and 8-mg dexamethasone overnight suppression tests), sellar imaging (polytomography, computed tomography, and magnetic resonance [MR] imaging), and in patients with negative results on imaging studies, inferior petrosal sinus sampling. Follow-up examinations consisting of endocrinological workup, and imaging took place 1 week and 3 months after surgery and then at yearly intervals. During microsurgery as first treatment, the adenoma finding rate was 86.6%. After selective adenomectomy, the remission rate was 75.9%, and this rate showed no improvement over the years. The best results were achieved in microadenomas confirmed on MR imaging or histopathological investigation. The recurrence rate (15%) and the complication rate (5.9%) declined over the years. If no adenoma was found, exploration of the sella turcica was performed in 45.6%, hypophysectomy in 3.5%, and hemihypophysectomy in 50.9% of these patients, leading to an early remission in 37.9%. In case of persistence or recurrence, further treatment (repeated operation, adrenalectomy, radio-therapy, or medical treatment) was used to control the disease. Microsurgery remains the treatment of first choice in CD, even though no improvement in remission rates was observed over the years, because complication or remission rates for other treatment options are comparable or worse." }, { "id": "pubmed23n0672_1561", "title": "Pituitary radiotherapy for Cushing's disease.", "score": 0.012168464004663364, "content": "The treatment of choice for Cushing's disease is pituitary surgery. Second-line treatments include repeat pituitary surgery, radiation therapy, medical therapy, and bilateral adrenalectomy. The most used modalities to irradiate patients with Cushing's disease include fractionated radiotherapy and single-dose Gamma Knife. We aim to review the efficacy and safety of radiotherapy in patients with persistent or recurring Cushing's disease. Remission of Cushing's disease after radiotherapy ranges from 42 to 83%. There seems to be no clear difference according to the technique of radiation used. Most patients experience remission of disease within 3 years from treatment, with only few cases reaching normal cortisol secretion after a longer follow-up. Control of tumor growth varies from 93 to 100%. Severe side effects of radiotherapy, such as optic neuropathy and radionecrosis, are uncommon. New-onset hypopituitarism is the most frequent side effect of radiation, occurring in 30-50% of patients treated by fractionated radiotherapy while it has been reported in 11-22% of patients after Gamma Knife. Radiotherapy is an effective second-line treatment in patients with Cushing's disease not cured by surgery. Consideration of the advantages and disadvantages of radiotherapy in comparison with other therapeutic options should always be carried out in the single patient before deciding the second-line therapeutic strategy for persisting or recurring Cushing's disease." }, { "id": "wiki20220301en015_42174", "title": "Cushing's disease", "score": 0.012115877495016438, "content": "Pituitary radiation therapy is another option for treatment of postoperative persisting hypercortisolemia following unsuccessful transsphenoidal surgery. External-beam pituitary RT is more effective treatment for pediatric CD in children with cure rates of 80–88%. Hypopituitarism specifically growth hormone deficiency has been reported as the only most common late morbidity of this treatment; GHD has been reported in 36% and 68% of the patients undergoing post-pituitary RT for Cushing's disease. Bilateral adrenalectomy is another treatment that provides immediate reduction of cortisol level and control of hypercortisolism. However, it requires education of patients, because lifelong glucocorticoid and mineralocorticoid replacement therapy is needed for these patients. One of the major complications of this treatment is progression of Nelson's syndrome which is caused by enhance level of tumor growth and ACTH secretion post adrenalectomy in 8–29% of patients with CD." }, { "id": "wiki20220301en063_67746", "title": "Multiple endocrine neoplasia type 1", "score": 0.01133711971117862, "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": "wiki20220301en025_46774", "title": "Anovulation", "score": 0.010932551319648095, "content": "Treatment for hyperprolactinemia: For anovulatory women with hyperprolactinemia without symptoms, they can forgo treatment and continue with close follow up and medical observation. If symptoms of hyperprolactinemia are present, dopamine agonists, such as bromocriptine, are first line treatment which act by inhibiting production of prolactin by the pituitary and can shrink a prolactin-secretin lesion (i.e. prolactinoma) if present. In rare cases, endoscopic transnasal transsphenoidal surgery and radiotherapy, may be required to resect and shrink a prolactinoma if greater than 10 mm in size. Importantly, individuals should be able to conceive following normalization of serum prolactin levels and shrinking or removal of the tumor." }, { "id": "wiki20220301en082_43655", "title": "Nelson's syndrome", "score": 0.010821110152430256, "content": "Cause Common causes include bilateral adrenalectomy for the treatment of Cushing's disease, and hypopituitarism. The onset of the disease can occur up to 24 years after a bilateral adrenalectomy has been performed, with an average of up to 15 years after. A preventative measure that can be utilized is prophylactic radiotherapy when a bilateral adrenalectomy is being performed in order to prevent Nelson's syndrome from manifesting. Screening can also be done with the help of an MRI in order to visualize the pituitary for tumors. If tumors are not present then an MRI should be performed at intervals. Hyper-pigmentation and fasting ACTH levels within plasma above 154 pmol/l are predictive of Nelson's syndrome after an adrenalectomy. Risk factors include being younger in age and pregnancy." }, { "id": "pubmed23n0257_4929", "title": "Stereotactic radiosurgery for pituitary adenomas: imaging, visual and endocrine results.", "score": 0.010679663364227123, "content": "To determine the endocrine, ophthalmologic, and tumor growth control responses after stereotactic radiosurgery using the gamma unit, we reviewed our experience in 35 patients with pituitary adenomas. Twenty-four females and 11 males (mean age 47 years, range 9-81 years) had radiosurgery with average follow-up of 26 months (range 6-60 months). Most patients were refractory to surgical removal. Fifteen patients had Cushing's disease. Prior transsphenoidal resection was performed in 14 patients (6 had two prior operations), fractionated radiotherapy in 3, and adrenalectomy in 2. In 11 evaluable patients, the hormone response was normalized in 8, decreased in 2 and increased in 1. Five patients remained on cortisol suppression. Of 12 patients with imaging follow-up, 4 had decreased tumor size, 6 had no change, and 2 had an increase; these 2 patients underwent subsequent surgery. Ten patients had acromegaly, and 6 had undergone prior surgery. Of 8 evaluable patients, growth hormone secretion has normalized in 3, decreased in 3, and increased in 2. Six tumors decreased in size, and 2 were unchanged. One patient had repeat resection 21 months after radiosurgery and one patient underwent repeat radiosurgery. Ten patients had non-secreting adenomas; all 10 had prior operations (1-4 operations, 6 underwent frontal craniotomy) and 5 had undergone fractionated radiotherapy. Eight patients had panhypopituitarism prior to radiosurgery. Four tumors decreased in size and 6 were without change.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0355_17142", "title": "Pituitary disorders. Drug treatment options.", "score": 0.010180358759758217, "content": "Pituitary diseases are relatively common entities in the general population. They include pituitary adenomas and hypopituitarism. Pituitary tumours can cause symptoms of mass effect and hormonal hypersecretion that can be reversed with surgical resection or debulking of the adenoma, radiotherapy, or medical treatment. Transsphenoidal adenomectomy is the treatment of choice for acromegaly, Cushing's disease, gonadotropin-secreting tumours; and thyrotropin (TSH)-secreting adenomas. Pituitary irradiation and medical therapy are secondary options. Conversely, medical treatment is the primary choice for prolactinomas. Dopamine agonists are very effective in the treatment of prolactin (PRL)-secreting tumours, with rates of control as high as 80 to 90% for microprolactinomas (&lt; 10 mm) and 60 to 75% for macroprolactinomas (&gt; or = 10 mm). Somatostatin analogues have also shown efficacy in patients with acromegaly who have not responded to surgery or in patients with TSH-secreting adenomas who have not improved with surgery and radiotherapy. In patients with Cushing's disease, who are not cured surgically or who relapse after pituitary adenomectomy and irradiation, steroidogenic inhibitors can be an efficient method of controlling the hypercortisolism. Pituitary insufficiency is the partial or complete loss of the anterior hypophyseal function, which is due to hypothalamic or pituitary disease. Although the classic sequence of loss of pituitary secretion is growth hormone (GH), gonadotropins, TSH, and corticotropin (ACTH), the order to begin the replacement therapy of the deficient hormone(s) is cortisol, thyroxine, androgens/estrogens and, if necessary, GH. There are multiple preparations that can be used to achieve clinical and biochemical improvement. In general, the hormone replacement therapy is lifelong." }, { "id": "pubmed23n0279_19608", "title": "Treatment of secretory pituitary adenoma with radiation therapy.", "score": 0.009900990099009901, "content": "A retrospective review of 44 patients with secretory pituitary adenoma treated with radiation therapy (median total dose of 4,500 cGy with a median fraction size of 225 cGy) was performed to analyze response rates and possible variables associated with failure to respond and with complications. The treatment technique used for 75% of the patients was a combination field; an opposed-lateral fields technique was used for the remainder. Median follow-up was 78.5 months, with 59% followed up for more than 60 months and 34% for more than 120 months. Overall survival was 90%, and disease-free survival was 62%. Response rates were 86% for the group with prolactinoma, 67% for the group with acromegaly, and 50% for the group with Cushing disease; the overall response rate was 71%. Findings of suprasellar extension and those from treatment with opposed-lateral fields correlated significantly with failure to respond. A higher percentage of patients with invasive macroadenomas also failed to respond. More complications were found in patients treated with opposed-lateral fields, but the numbers were too small to reach significance. Radiation therapy remains an important adjunct for the treatment of many patients with secretory pituitary adenoma." }, { "id": "wiki20220301en641_10995", "title": "Low-grade myofibroblastic sarcoma", "score": 0.00980392156862745, "content": "Treatment and prognosis Past treatments for LGMS, including surgery, radiotherapy, and chemotherapy, have not been systematically investigated nor validated. Currently, the primary and most common treatment for non-metastatic LGMS is surgical resection with, where possible, removal of all tumor cells in order to reduce this tumor's recurrence rate (e.g. ~27% and ~38% in two different studies). Following this surgery, individuals should undergo long-term observation to check for post-surgical recurrences and the uncommon instances of metastases. One study suggested that tumor cells with high rates of proliferation, tumors containing areas of necrosis, tumor sizes >10 cm in largest diameters, and deep-seated tumors are at higher risks for metastasizing." }, { "id": "pubmed23n0373_7284", "title": "[Radiosurgical treatment of hypophyseal adenomas with the gamma knife: results in a group of 163 patients during a 5-year period].", "score": 0.00980392156862745, "content": "Gamma knife radiosurgery of pituitary adenomas is considered to be very perspective. It can be a very useful complement of traditional microsurgery, pharmacotherapy or fractionated radiotherapy which are seldom a sufficient treatment on their own. The modern radiosurgery does not offer the experience representative enough in this indication. We can offer results of medium long follow-up for tumor growth and hormonal hypersecretion of pituitary adenomas in a relatively large series of patients. We have analyzed a group of 163 patients with pituitary adenoma treated with gamma knife during 5 years and followed 12-60 months, median 24 months after irradiation. An antiproliferative effect has been achieved in 1-2 years using the minimal dose to the margin 16-35 Gy, median 20 Gy in all our patients who were controlled by MRI (n = 126 patients). One half of these adenomas evidently decreased their size. Our effective antiproliferative dose was safe for the surrounding structures. The hormonal normalization has been achieved at 50.4% from 133 hypersecreting adenomas (39/91 = 43% of acromegalics, 11/13 = 85% of patients with Cushing's disease, 2/9 = 22% of patients with Nelson's syndrome, 11/18 = 61% of prolactinomas). The median latency was 12 months. The minimal dose to the margin was 10-45 Gy, median 35 Gy. Rare side effects were provoked only by increasing the dose to influence the hypersecretion-the development of partial hypopituitarism in 3.1% of patients, the panhypopituitarism in 0.6% of patient and there was 1 hemianopic visual field defect (0.6%). Radiosurgery by gamma knife has a similar value for pituitary adenomas as microsurgery has with different distribution of advantages and drawbacks. This makes it suitable for the combined treatment where pharmacotherapy has its place under special conditions. Fractionated radiotherapy has now a marginal importance." }, { "id": "wiki20220301en082_43663", "title": "Nelson's syndrome", "score": 0.009708737864077669, "content": "Research Through multiple advancements within the medical field, caregivers have been able to stray away from utilizing bilateral adrenalectomy as the treatment for Cushing's disease. This has decreased the risk of patients presenting with Nelson's syndrome. Alternative treatments for Nelson's syndrome have been discovered. The most utilized technique for Nelson's syndrome has been transsphenoidal surgery. In addition, pharmacotherapy, radiotherapy, and radiosurgery have been utilized accompanying a surgical procedure. Pharmacological drugs can also be given accompanying a transsphenoidal surgery including the following: pasireotide, temozolomide and octreotide. Within rats/mice, rosiglitazone has been an effective measure, however this has not been discovered in humans yet. References External links Pituitary disorders Syndromes Rare diseases" }, { "id": "pubmed23n0351_5065", "title": "Radiotherapy in the management of giant pituitary adenomas.", "score": 0.009708737864077669, "content": "The description of giant pituitary adenoma is not clear yet. In this study we tried to identify which adenomas can be defined as giant pituitary adenomas when tumor control and progression free survival (PFS) are taken as end points and we also tried to evaluate prognostic factors other than tumor size. Between January 1981 and December 1997, 74 patients with pituitary macroadenomas more than 2 cm in size were treated. Of these 30 had tumors of more than 4 cm, while 44 patients were with tumors of 2-4 cm. Two patients received primary radiotherapy, while 72 were treated postoperatively. In the postoperative group, 52 patients underwent immediate radiotherapy after surgery and 20 were treated with irradiation after regrowth or progression of the tumor after initial surgery. The mean and median tumor doses were 5518 and 5425 cGy, respectively. Overall primary tumor control rate was 84%. The local control rates among patients with tumors more than 4 cm and among patients with tumors 2-4 cm after radiotherapy were 73 and 91%, respectively. PFS was 65% for patients who had a tumor size of more than 4 cm and 87% for the patients with tumor size of 2-4 cm (P = 0.09). Young age (&lt;20) and tumors of unclassified histology were the bad prognostic factors. Six months after radiotherapy normalisation or improvement in hormonal hypersecretion and visual field and acuity deficits were 82 and 63%, respectively. Tumors more than 4 cm in size may be more convenient for the definition of 'giant pituitary adenoma' when tumor control and PFS are taken as the end points." }, { "id": "wiki20220301en303_11413", "title": "Pleomorphic xanthoastrocytoma", "score": 0.009615384615384616, "content": "Treatment Surgery is often the treatment of choice. Total resection (removal of the tumor) is often possible. However, the best choice of treatment will depend on many individual factors, including: The patient's medical history and overall health condition The type, location, and size of the tumor The patient's age How well the patient tolerates specific medications, procedures, or therapy How slowly or quickly the tumor is expected to progress If surgery is performed and the tumor is completely resected, further treatment may not be required. The patient will, however, need repeated MRIs to monitor for tumor re-growth. For tumors that recur, another surgical resection might be attempted. For tumors that could not be completely removed, radiation therapy may also be recommended. Also called radiotherapy, this treatment uses high-energy radiation to damage or kill cancer cells and shrink tumors." }, { "id": "pubmed23n0361_7760", "title": "The efficacy of conventional radiation therapy in the management of pituitary adenoma.", "score": 0.009615384615384616, "content": "To evaluate the efficacy of conventional radiotherapy for reducing tumor size and endocrine hypersecretion of pituitary adenomas. We reviewed the records of 91 patients with pituitary adenoma, who were first treated between 1969 and 1994 and had been followed for more than 2 years (median, 8.2 years.) Of these patients, 86 had received postoperative radiotherapy, and 5 had received radiotherapy alone. The median total dose was 51 Gy. Clinical symptoms related to mass effects or endocrine hypersecretion were assessed. The efficacy of radiotherapy was evaluated before treatment and during the follow-up period (1-14 years; median, 3 years) by estimating tumor size on computed tomography or magnetic resonance imaging in 56 patients, as well as by endocrine testing in the 22 patients who had secreting adenomas. Local control rate, prognostic factors, and side effects were analyzed. Mass-effect symptoms improved in 72% and 79% of patients who had such symptoms due to nonsecreting adenomas and secreting adenomas, respectively. Symptoms of endocrine hypersecretion abated in 67% of patients who had such symptoms. Excessive hormone levels normalized in 74% of patients who showed endocrine hypersecretions. The greatest size reduction was seen 3 years after the completion of radiotherapy (24% CR, 62% PR, 12% NC, and 3% PD in nonsecreting adenomas, and 32% CR, 36% PR, 27% NC, and 5% PD in secreting adenomas). Three patients with secreting adenomas (2 with prolactinoma and 1 with Cushing's disease) showed a mismatch between reduction in tumor size and normalization of endocrine hypersecretion. The 10-year local control rates were 98%, 85%, 83%, and 67% for nonsecreting adenoma, growth-hormone-secreting adenoma, prolactinoma, and Cushing's disease, respectively. Univariate analyses showed that disease type and radiation field size were significant prognostic factors. Brain necrosis occurred in 1 patient who received a 60-Gy dose of irradiation. We conclude that conventional external radiotherapy with 50 Gy is safe and sufficient to control pituitary adenoma. Careful observation is required in the management of secreting adenomas because the effects on tumor size and endocrine hypersecretion may be mismatched in some secreting adenomas." }, { "id": "Surgery_Schwartz_11119", "title": "Surgery_Schwartz", "score": 0.009539473684210526, "content": "production, CT or MRI scans of the chest and anterior mediastinum are performed first, followed by imaging of the neck, abdomen, and pelvis if the initial studies are negative.Treatment Laparoscopic adrenalectomy is the treatment of choice for patients with adrenal adenomas. Open adrenalectomy is reserved for large tumors (≥6 cm) or those suspected to be adrenocortical cancers. Bilateral adrenalectomy is curative for primary adrenal hyperplasia.The treatment of choice in Cushing’s disease is transsphe-noidal excision of the pituitary adenoma, which is successful in 80% of patients. Pituitary irradiation has been used for patients with persistent or recurrent disease after surgery. However, it is associated with a high rate of panhypopituitarism, and some patients develop visual deficits. This has led to increased use of stereotactic radiosurgery, which uses CT guidance to deliver high doses of radiotherapy to the tumor (photon or gamma knife) and also bilateral laparoscopic" }, { "id": "pubmed23n1011_7959", "title": "Outcomes of Patients with Nelson's Syndrome after Primary Treatment: A Multicenter Study from 13 UK Pituitary Centers.", "score": 0.009523809523809525, "content": "Long-term outcomes of patients with Nelson's syndrome (NS) have been poorly explored, especially in the modern era. To elucidate tumor control rates, effectiveness of various treatments, and markers of prognostic relevance in patients with NS. Retrospective cohort study of 68 patients from 13 UK pituitary centers with median imaging follow-up of 13 years (range 1-45) since NS diagnosis. Management of Cushing's disease (CD) prior to NS diagnosis included surgery+adrenalectomy (n = 30; eight patients had 2 and one had 3 pituitary operations), surgery+radiotherapy+adrenalectomy (n = 17; two received &gt;1 courses of irradiation, two had ≥2 pituitary surgeries), radiotherapy+adrenalectomy (n = 2), and adrenalectomy (n = 19). Primary management of NS mainly included surgery, radiotherapy, surgery+radiotherapy, and observation; 10-year tumor progression-free survival was 62% (surgery 80%, radiotherapy 52%, surgery+radiotherapy 81%, observation 51%). Sex, age at CD or NS diagnosis, size of adenoma (micro-/macroadenoma) at CD diagnosis, presence of pituitary tumor on imaging prior adrenalectomy, and mode of NS primary management were not predictors of tumor progression. Mode of management of CD before NS diagnosis was a significant factor predicting progression, with the group treated by surgery+radiotherapy+adrenalectomy for their CD showing the highest risk (hazard ratio 4.6; 95% confidence interval, 1.6-13.5). During follow-up, 3% of patients had malignant transformation with spinal metastases and 4% died of aggressively enlarging tumor. At 10 years follow-up, 38% of the patients diagnosed with NS showed progression of their corticotroph tumor. Complexity of treatments for the CD prior to NS diagnosis, possibly reflecting corticotroph adenoma aggressiveness, predicts long-term tumor prognosis." }, { "id": "pubmed23n0613_14523", "title": "Long-term results of stereotactic gamma knife radiosurgery for pituitary adenomas. Specific strategies for different types of adenoma.", "score": 0.009433962264150943, "content": "Long-term results of gamma knife radiosurgery for pituitary adenomas are presented and treatment strategies for different adenoma types are discussed. Two hundred and sixty-seven patients with pituitary adenoma have been treated by gamma knife radiosurgery during the past 12 years. There were 131 cases of nonfunctioning and 136 cases of functioning adenomas, in which 71 GH-producing, 33 PRL-producing and 32 ACTH-producing adenomas were included. Retreatment with the gamma knife was done in 8 cases because of large tumors or uncontrolled hormones. Micro- and small adenomas could be cured by gamma knife radiosurgery alone. Surgical or chemical debulking was necessary before radiosurgery for a large tumor with extrasellar extension. Retreatment was effective and safe in some cases. Nonfunctioning adenomas showed higher control rates than functioning adenomas even with lower dose treatment. Cushing disease showed the best response because of the smallest tumor size with the highest dose treatment. Acromegaly and prolactinoma were difficult to control because of larger tumors with lower dose treatment. The rate of hormone normalization was also high in Cushing disease but lower in prolactinoma and lowest in acromegaly. High-dose treatment was necessary for functioning adenomas to control tumor growth and oversecretion of hormones. In conclusion, gamma knife radiosurgery was effective and safe for the treatment of pituitary adenomas. However, the treatment strategies should be specific to each adenoma type according to the radiosensitivity, chemosensitivity and biological nature of the tumor." }, { "id": "pubmed23n0107_13252", "title": "Diagnostic problems and operative treatment of pituitary microadenomas.", "score": 0.009345794392523364, "content": "Over an average observation period of 53 months 26 patients with endocrinological active microadenoma of the hypophysis (12 M. Cushing, 14 acromegaly) were retrospectively examined. Only in 11 cases did the CT-examination demonstrate intrasellar tumour expansion. Both the problems of and the criteria for CT-diagnosis of microadenoma were demonstrated. In 22 cases (84%) the microsurgical transsphenoidal exstirpation of the adenoma led to an adequate reduction in both ACTH and HGH. No postoperative deterioration of the other hypophysial functions was seen. It could be further demonstrated that where the surgical therapy failed local radiation therapy with high voltage radiation of the hypophysis region led to a reduction of the abnormal hormone secretion. The comparism of our results with those reported in the literature led us to suggest a combined therapy concept in which the indication for operative, conservative and radiation therapy is delineated." }, { "id": "pubmed23n0251_19096", "title": "[Use of the radiosurgery knife in the treatment of hypophyseal adenomas].", "score": 0.009259259259259259, "content": "BACKGROUND. Surgery of pituitary adenomas did not produce quite satisfactory results. Therefore radiosurgery using Leksell's gamma knife has become the most widely used method which-with the contribution of MRI-meets the most important demands of aimed irradiation: a sufficiently high dose of radiation of the tumour and minimal radiation load of functionally important surrounding structures. The objective of the investigation was to assemble experience with this therapeutic method. METHODS AND RESULTS. During the period between October 1992 and September 1994 a total of 41 patients were treated: 16 men, 12-66 years old, mean age 40.8 years; 25 women age 16-76 years, mean age 50.2 years. Female:male ratio 1.5 : 1. In 30 patients (73.2%) a microsurgical operation had preceded, in 5 (12.2%) conventional fractionated radiotherapy and in 11 patients (26.9%) primary radiosurgery. As far as the type of pituitary adenoma is concerned, it conditioned acromegaly in 30, Cushing's syndrome in 3 or Nelson's syndrome in 1, or a prolactinoma was involved (in 2 patients). In five instances the adenoma was hormonally inactive. Its localization was most frequently intrasellar (36), less frequently parasellar (5). The range of administered doses varied as regards the maximum between 12.5 and 80 Gy, the average being 46.8 Gy, to the periphery of the adenoma a dose of 10-49 Gy was administered, on average 24.7 Gy using a 50-80% isodose. The time interval after treatment is relatively short for detailed analysis or evaluation. During current evaluation the authors did not observe in any of the patients progression of the disease, and in several patients diminution of the tumour was found. Karnofski's score seemed to improve. CONCLUSIONS. Radiosurgery, using Leksell's gamma knife, is after failure of conservative and microsurgical therapeutic possibilities suitable further treatment of pituitary adenoma. In indicated cases it may be the first choice. Postirradiation follow up indicates promising effects, for more detailed evaluation a several years' interval is necessary." }, { "id": "pubmed23n0357_4617", "title": "Treatment of pituitary-dependent Cushing's syndrome: long-term results of unilateral adrenalectomy followed by external pituitary irradiation compared to transsphenoidal pituitary surgery.", "score": 0.009253843582887701, "content": "The preferred treatment of Cushing's disease (CD) nowadays is transsphenoidal pituitary surgery (TPS). Prior to TPS, patients at the Leiden University Medical Centre were treated by unilateral adrenalectomy followed by external pituitary irradiation (UAPI). We report on long-term results of both UAPI and TPS and compare remission, relapse rates, and complications. A retrospective study was carried out on 130 patients with CD. Patients with pituitary macroadenoma were excluded. Eighty-six and 44 patients underwent UAPI and TPS, respectively. Of these patients, 85 and 41 were evaluable for long-term results. Remission following UAPI and TPS was identical at 64% (54/85 and 27/41). Cumulative relapse was also comparable - 17% (9/54) and 22% (6/27), respectively, - for UAPI and TPS, although the mean follow-up periods were different - 21.4 years and 8.5 years, respectively. Cumulative disease-free survival curves after UAPI and TPS are identical until 5 years of follow-up, but diverge thereafter indicating more sustained remissions following UAPI (P = 0.17, Wilcoxon statistic). Pituitary dysfunction following UAPI (36%) and pituitary surgery (55%) likewise did not differ significantly. However, pituitary dysfunction was an immediate event after TPS, whereas it developed after a mean interval of 17.8 years following UAPI.Low-dose dexamethasone testing during follow-up had no value in predicting therapeutic outcome. The results of unilateral adrenalectomy followed by external pituitary irradiation do not justify that this therapy is totally abandoned in favour of transsphenoidal pituitary surgery. Unilateral adrenalectomy followed by external pituitary irradiation is a valid therapeutic modality for the treatment of Cushing's disease, and could be considered as alternative to bilateral adrenalectomy and under some circumstances to transsphenoidal pituitary surgery." }, { "id": "wiki20220301en635_29674", "title": "Myxofibrosarcoma", "score": 0.009174311926605505, "content": "The recommended treatment for individuals presenting with localized MFS tumors is radical surgical resection. The resection should include a 2 cm margin of soft tissue surrounding the tumor, with planned resection of the entire area as defined by MRI-detected increased signals on T2-weighted images. This is done to ensure that all tumor tissue is removed in order to avoid the high risks of local recurrences and worsening prognoses. Historically, about 10% of patients treated with radical surgery developed recurrences at the surgical site and a significant number of these patients developed metastatic disease. Consequently, adjuvant radiotherapy has been used to help reduce these recurrences and metastatic transformations. For patients with a limb tumor that cannot be resected (less than 5% of all cases)), limb amputation is the treatment of choice. Recurrent and metastatic MFS first-line treatment has employed two chemotherapy drugs, anthracycline and Ifosfamide, while second-line" }, { "id": "pubmed23n0329_761", "title": "[The place of radiosurgery in the treatment of hypophyseal adenoma].", "score": 0.009174311926605505, "content": "Since 1984, the neurosurgical team of Sainte-Anne Hospital in Paris has taken in charge almost 750 patients for linear accelerator radiosurgery. But only a small percentage of them were harbouring a pituitary tumor. That is why the present paper is based mostly on literature data. Pituitary adenoma radiosurgery (RS) is a second intention therapeutic method. It should be recommended only after failure of medical and/or surgical treatment. Two main methods can be used: linear accelerator-radiosurgery and Cobalt-60 gamma unit. Both procedures provide equivalent results in terms of dosimetry, accuracy and clinical data. Results of various series presented in recent and updated literature have been studied and analysed. They show and confirm the efficiency of radiosurgery on tumor and hormone secretion controls, with few cases of pituitary insufficiency. However, results were disappointing concerning visual disorders, particularly if visual dysfunction and impairment existed before radiosurgery. All authors agree nowadays on different points: a) indications: invasive adenomas, with an incomplete resection, or adenomatous recurrences, b) contraindications: tumoral size &gt; 20 mm, distance to visual pathways &lt; 5 mm, c) imperative precautionary measures: less than 8 Gray must be delivered on visual pathways, less than 40 Gray on oculomotor nerves. In some cases, stereotactic fractioned radiotherapy may be an alternative treatment for large tumors close to visual pathways." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 250, 350 ] ], "word_ranges": [ [ 40, 58 ] ], "text": "There is no point in repeating the cytology (since this is a screening test, not a diagnostic test)," }, "2": { "exist": true, "char_ranges": [ [ 0, 249 ] ], "word_ranges": [ [ 0, 40 ] ], "text": "Colposcopy is indicated for all patients with altered cytology (intraepithelial lesion or suspicion of invasive cancer or HPV infection), as a second level of screening. If lesions are observed in this test, a biopsy of the lesion will be performed." }, "3": { "exist": true, "char_ranges": [ [ 351, 469 ] ], "word_ranges": [ [ 58, 76 ] ], "text": "performing a hysterectomy for an intraepithelial lesion that has not been confirmed by biopsy is not indicated either," }, "4": { "exist": true, "char_ranges": [ [ 474, 586 ] ], "word_ranges": [ [ 77, 94 ] ], "text": "performing curettage of the endometrial cavity does not provide information since the lesion is from the cervix." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Repeat cytology in 1 month.", "2": "Colposcopy with possible biopsy.", "3": "Hysterectomy with bilateral salpinguectomy and ovarian conservation.", "4": "Fractionated uterine curettage.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "Gynecology_Novak_3040", "title": "Gynecology_Novak", "score": 0.01308227465214761, "content": "2. Treatment is recommended for a histologic diagnosis of CIN 3 or if colposcopy is unsatisfactory. Although invasive cervical cancer is very rare in this age group, prospective follow-up of a histological diagnosis of CIN 2 or 3, not otherwise specified, in young women should be limited to those women likely to be compliant with the recommendations. 3. After 2 consecutive negative for intraepithelial lesion or malignancy results, implying negative cytology and colposcopy with satisfactory colposcopic examinations, adolescents and young women can return to routine cytologic screening. An annual screening interval should be recommended. 4. Treatment is recommended if CIN 3 is diagnosed histologically or if CIN 2 or 3 persists for 24 months. 1. Hysterectomy remains the preferred management recommendation for women with a histological diagnosis of AIS on a specimen from a diagnostic excisional procedure (Fig 19.16F). 2." }, { "id": "pubmed23n0310_14604", "title": "Comparing two modalities of management of women with cytologic evidence of squamous or glandular atypia: early repeat cytology or colposcopy.", "score": 0.011768707482993197, "content": "Early repeat cytology is recommended in most screening programs for cervical cancer in subjects with squamous or glandular abnormalities not amounting to neoplasia (atypical squamous cells of undetermined significance, ASCUS), but immediate colposcopy is also recommended in some countries, especially those where there is easy access to colposcopic facilities. We evaluated the cost-effectiveness of the two procedures in a prospective study of women with cytologic ASCUS, invited to cytocolposcopic assessment after 6 months. Colposcopy-directed biopsy was assumed as the gold standard, and the accuracy of colposcopy at 6 months was assumed to be equal to that of immediate colposcopy. Out of 874 compliers, punch biopsy was performed in 303 cases (34.7%), and 19 CIN2+ lesions were detected (CIN2 = 12, CIN3 = 6, microinvasive carcinoma = 1). Detecting 13 CIN2+ lesions at colposcopy required 874 colposcopies and 303 directed biopsies: the cost per CIN2+ lesion detected with the procedure was 2,749 US$. Detecting 15 CIN2+ lesions at repeat cytology required 874 cytologic examinations, 137 colposcopies, 64 directed biopsies, and 6 diagnostic large-loop resections, the latter being performed in subjects with high-grade squamous intraepithelial lesion and less severe lesions at punch biopsy: the cost per CIN2+ lesion detected with the procedure was 1,961 US$. The policy of repeat smear was more cost-effective than immediate colposcopy. According to such results, the protocol of the Florence screening program has been modified since October 1996." }, { "id": "Gynecology_Novak_3039", "title": "Gynecology_Novak", "score": 0.011407584652625136, "content": "7. A repeat diagnostic excisional procedure is acceptable. The Guidelines allow for hysterectomy if a repeat diagnostic excisional procedure is not feasible. An undisclosed invasive cancer within the endocervical canal must be excluded prior to hysterectomy. 8. For women with histologically proven residual/recurrent CIN 2 or 3, the Guidelines permit a repeat excisional procedure or hysterectomy. 1. For adolescents with a histological diagnosis of CIN 2 or 3 not otherwise specified, the Guidelines state that either treatment or observation by cytology and colposcopy every 6 months for up to 24 months is acceptable provided colposcopy is satisfactory (Fig 19.16E). Allowing for the subjectivity in this histological distinction, observation is preferred for a diagnosis of CIN 2 alone, but treatment is acceptable. 2." }, { "id": "article-19238_16", "title": "Cervical Intraepithelial Neoplasia -- Treatment / Management", "score": 0.011248326141943163, "content": "Women treated for CIN-2, or greater should have a Pap smear and HPV testing 12 and 24 months after the procedure. Even with positive endocervical margins on an excised specimen, the procedure is deemed 70 to 80% effective. When margins are positive, repeat cytology testing in 4-6 months accompanied by an endocervical curettage is the course of action.  A repeat excisional procedure is one option for treatment of persistent or recurrent CIN-2 or 3. In some circumstances, patients will opt for a hysterectomy, which is also appropriate for recurrent CIN. [1]" }, { "id": "Surgery_Schwartz_11848", "title": "Surgery_Schwartz", "score": 0.010161603654761651, "content": "1790SPECIFIC CONSIDERATIONSPART IIHPV test performed at the same time also is negative, test-ing should be repeated every 5 years for women ages 30 to 65 years. Screening is not recommended for women age older than 65 or without a cervix (prior hysterectomy) unless they have a history of high-grade precancerous lesions. Women with a history of cervical dysplasia, HPV infection, or cervical cancer need more frequent screening based on their diagnosis. Primary high-risk HPV (hrHPV) screening is also an acceptable alterna-tive to cytologic screening for women ages 30-65 because of an increased detection of high-grade squamous intraepithelial lesion (HSIL) and increased negative predictive value.6HPV Vaccine. Three HPV vaccines have been approved by the U.S. Food and Drug Administration (FDA).7 In 2006, a quad-rivalent (4vHPV) vaccine was approved that targets HPV 16 and 18, which cause 70% of cervical cancers, and HPV geno-types 6 and 11, which cause 90% of genital warts. In Decem-ber" }, { "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": 0.009900990099009901, "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": "pubmed23n0520_3152", "title": "Recurrent smear abnormalities where repeat loop treatment is not possible: is hysterectomy the answer?", "score": 0.009900990099009901, "content": "The objective of this study was to determine the outcome of women who underwent hysterectomy for recurrent cytological abnormalities where repeat loop treatment was considered not to be technically possible because of insufficient remaining cervical tissue. Women undergoing a hysterectomy for the above indication at the Northern Gynaecological Cancer Centre over a period of 10 years (1992-2001) were identified from a prospectively collected database. Case notes were then reviewed and women undergoing hysterectomy for other indications were excluded. Relevant demographic and clinical data were then extracted. 33 patients meeting the above criteria were identified. The overall hysterectomy rate for this indication was 0.73%. 20 out of the 33 women had significant pathology on the hysterectomy specimen. 95% of these had high-grade disease with one having a Stage 1A1 squamous carcinoma. None of the patients required more radical treatment than a simple hysterectomy. There were no major complications following the hysterectomy. Positive endocervical margins on the previous loop specimen (P = 0.05) was an important correlating factor predicting the presence of CIN on the hysterectomy specimen. One out of the thirty hysterectomies (3.3%) performed using the vaginal route had incomplete excision compared to one of three (33%) using the abdominal route. Hysterectomy was successful in treating 85.2% of the women; only 4 women subsequently developed vaginal intraepithelial neoplasia. Simple hysterectomy appears to be a suitable diagnostic and treatment option for women with recurrent high-grade cytological abnormalities where further loop treatment is technically not possible. Incomplete excision at the endocervical margin on the previous loop specimen was the main factor associated with the presence of cervical intraepithelial neoplasia at hysterectomy." }, { "id": "pubmed23n0590_65", "title": "[Management of CIN1].", "score": 0.00980392156862745, "content": "A cervical intraepithelial neoplasia grade 1 (CIN1) is a lesion of basal cells consisting in an architecture disorganization and cytological atypia limited to the lower third of the cervical epithelium. It is considered as a precancerous lesion uterine cervix carcinoma while they spontaneously regress in more than 60% of cases in two years. The problems related to the management of CIN1 as defined by the recommendations established in 2002 are the over-treatment and the great variability of clinical practices. Moreover, the potential of new tests has been investigated since 2002. To establish these new recommendations, the medline database has been consulted and the references essentially published between 2001 and May 2007 have been investigated. Publications were selected and classified according to their level of evidence (LE) in order to establish the grade of recommendations. One of the problems encountered when facing a CIN1 is to misdiagnose a more severe lesion firstly because of the intra- and interobserver variability and secondly because the colposcopy-directed biopsy is not mandatorily representative of the more severe lesion. Nevertheless, because the risk of cancer is extremely low, a conization is not necessary in an asymptomatic woman with a LSIL/ASC-US pap smear in case of CIN1 even if the squamocolumnar junction is not entirely visualized (LE 2/3). The endocervical curettage cannot be recommended in this case because its efficacy is globally poor and unknown in case of CIN1. Concerning the natural history of CIN1, the recent studies, which included more than 1200 women and more than 700 for two of them, confirm that the rate of progression of a CIN1 to a CIN3 or more severe lesion is less than 9% in the two years following the initial diagnosis (LE2). A CIN1 is associated with a risk of evolution to a CIN2 or more severe lesion that is not markedly more important than the risk associated with a LSIL/ASC-US pap smear while the colposcopy is normal or the biopsy is negative (between 8 and 13% whatever the results of the initial colposcopy) (LE 2/3). The recommendation in case of CIN1 is a strict follow-up. A colposcopy and a treatment are necessary in case of persistence or progression of the abnormalities (LE2). Data from trials studying the contribution of HPV testing in case of CIN1 show that its sensitivity is similar to repeat cytology with less referral to colposcopy to detect CIN2 or more severe lesion. These data have been considered to establish follow-up recommendations to manage CIN1: if the exams (cytology and/or HPV testing) at 12 months are negative, patients can be followed by an annual cytology. In case of aggravation of the cytology, a colposcopy is necessary. In case of positive HPV testing or persisting ASC-US/LSIL at 12 months, a repeat control is necessary at 18 months and a treatment is proposed according to colposcopy findings." }, { "id": "pubmed23n0039_4419", "title": "[Review of cervical smears in a gynaecologic department after a period of ten years under the consideration of colposcopic findings(author's transl)].", "score": 0.00980392156862745, "content": "The study comprises 96042 cytologic cases within a period of 10 years. After screening women were admitted for biopsies. The histologic findings are reported. By 690 \"right positive smears\" 71 squamous cell cervical cancers stage Ib or more 87 microcarcinomata-1, 377 carcinomata-in-situ of the cervix, 100 dysplasias, 47 adenocarcinomata and 8 different malign tumors were found. 61 cases having histologic diagnosis outside are just mentioned. 629 cases which had been diagnosed in our hospital are described extensively. The first biopsy was nearly always taken by selective scraping of the ecto- and endocervix. Technical improvements of this method are explained. The efficiency of cytodiagnosis is especially pointed out by separating cases which could have been recognized or suspected by means of inspection or colposcopy only. 140 out of 282 carcinomata-in-situ and 7 invasive, mainly endocervical cancers (Ib-III), could only be diagnosed by a smear. In 17 woemn who turned out to have invasive cancer (Ib -III) a positive smear was the only reason for admission. Careful inspection of the cervix in the hospital, however, was sufficent to reveal the correct diagnosis. In our material the cervical smear could be of little help in cancer diagnosis of the upper genital tract such as adenocarcinoma of the corpus uteri, sarcoma and ovarian cancer. 39 of the 45 women with endometrial cancer cells in the specimen had bleeding anomalies, especially postmenopausal. The number of \"false negative smears\" mainly yields from histologic examination of 2415 uteri after hysterectomy and 4497 specimen after curettage of cervix and corpus uteri. In the first group 1 microcarcinoma-2 and 5 carcinomata-in-situ, in the second group which obviously is less representative 4 carcinomata-in-situ were found unexpectedly. It is also searched for cases which had a negative smear first and a positive or suspect smear later. This happened in 41 patients. The underlying lesion were 5 advanced cancers, 2 microcarcinomata-3 and 34 carcinomata-in-situ. Up to 30 months elapsed between the last negative cytologic finding and histologic diagnosis. 121 out of 811 suspect or positive smears were \"false positive\". Cytologic grouping III, IV and V inconsistently matched with the corresponding histologic results. The type and extension of squamous cell atypias are anticipated with little certainty. The great number of suspect specimen (group III) both in microcarcinoma-4 (6 in 78) and carcinoma-in-situ (33 in 344) was striking. Therefore we consider a histologic diagnosis to be necessary in this group as well as in group IV and V. The method of fractioned cervical scraping makes the decision of hospital admission easier. Low risk for the patient does not imply any loss in diagnostic security." }, { "id": "pubmed23n0926_116", "title": "Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology.", "score": 0.009708737864077669, "content": "To evaluate the performance of routine endocervical curettage (ECC) for diagnosing high-grade cervical intraepithelial neoplasia (CIN) 2 or worse and additional precancers not otherwise detected by ectocervical biopsies. In a secondary analysis of the Biopsy Study, a cross-sectional study conducted between 2009 and 2012 at the University of Oklahoma Health and Sciences Center that found an incremental increase in detection of cervical precancers by multiple biopsies at colposcopy, ECC was performed in most women aged 30 years or older. Cervical intraepithelial neoplasia 2 or worse yield by ECC alone was evaluated in analyses stratified by cervical cytology (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesions [LSIL] compared with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions [ASC-H] or high-grade squamous intraepithelial lesions [HSIL] or worse), colposcopic impression (less than high-grade compared with high-grade), human papillomavirus (HPV)-16 infection status, whether the examination was satisfactory, and by ECC indications per the current guidelines for cervical cancer screening. The diagnostic value of ECC for detecting additional disease was evaluated by the number of lesion-directed ectocervical biopsies. Of the 204 women aged 30 years or older, 181 (88.7%) underwent ECC. Overall ECC detected 14.4% CIN 2 or worse (95% CI 10.0-20.2%). Endocervical curettage was more likely to find disease in the endocervix among women with high-grade cytology, positive HPV-16 infection, or high-grade colposcopic impressions (respective P values &lt;.05). Among women with ASC-US or LSIL cytology, those with an unsatisfactory examination had a 13.0% CIN 2 or worse yield on ECC (95% CI 6.1-25.7); when colposcopic examination was normal or satisfactory with visible abnormal lesions, ECC detected less than 5% CIN 2 or worse in the endocervix. An ASC-H or HSIL or worse cytology was associated with a CIN 2 or worse yield of 25.8% by ECC (95% CI 16.6-37.9%). However, ECC found only 3.9% (95% CI 1.9-7.8%) additional CIN 2 or worse beyond the cumulative disease detected by up to four biopsies of visible acetowhite ectocervical lesions. Additional CIN 2 or worse yield by ECC increased when fewer lesion-directed biopsies were taken (P&lt;.05). The additional yield of CIN 2 or worse by ECC in a colposcopy with up to four ectocervical biopsies was low. Based on our findings, we recommend routine ECC be performed in women aged 45 years old or older with HPV-16 infection and in any woman aged 30 years or older with HSIL or worse or ASC-H cytology, high-grade colposcopic impression, or ASC-US or LSIL cytology and an unsatisfactory examination. ClinicalTrials.gov, NCT00339989." }, { "id": "pubmed23n0476_21145", "title": "[Is it necessary to make screening pap smears after hysterectomy?].", "score": 0.009708737864077669, "content": "To precise the risk of cancer of the vagina after hysterectomy. In our file of cervicovaginal and vulvar pathology, we looked for all VAIN and invasive cancers of the vagina on a 10-year period. Out of 2152 patients, we found but 45 cases, 13 of which only after total or radical hysterectomy: 4 cases of invasive cancer of the vagina (1 after radical hysterectomy for invasive cancer of the cervix, and 3 after total hysterectomy for CIN); 9 cases of VAIN (5 after total hysterectomy for CIN; and 4 VAIN (3 after radical hysterectomy for cervical invasion). In our series, we did not observe precancerous or invasive lesion of the vagina after hysterectomy for benign lesion. Indeed, the 13 cases of invasive or in situ cancers of the vagina we found had undergone simple or radical hysterectomy for cervical lesion. We think that the cytological follow-up of the vaginal vault after hysterectomy for benign lesion can be, if not stopped, at least quite spaced out. On the other hand, the follow-up must be imperatively maintained in the event of hysterectomy for precancerous lesion or cancer of cervix." }, { "id": "pubmed23n0311_7629", "title": "Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness.", "score": 0.009615384615384616, "content": "Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration-approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up. Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration-approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparison of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared. As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus-negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p &lt; 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case). The Food and Drug Administration-approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions." }, { "id": "pubmed23n0916_11936", "title": "See and treat strategy by LEEP conization in patients with abnormal cervical cytology.", "score": 0.009615384615384616, "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." }, { "id": "pubmed23n0517_23238", "title": "Pitfalls in the diagnosis of cervical intraepithelial neoplasia 1.", "score": 0.009523809523809525, "content": "This review article outlines the issues involved in (1) the cytologic diagnosis of low-grade squamous intra-epithelial lesion (cervical intraepithelial neoplasia [CIN] 1), (2) histologic diagnosis of CIN 1, (3) the advantages and disadvantages of various management strategies for CIN 1 confirmed by biopsy, and (4) the evolving technology that may be useful for predicting the course of the disease. A MEDLINE search was conducted using the search terms cervical intraepithelial neoplasia, low-grade dysplasia, mild dysplasia, low-risk squamous intraepithelial lesion, mild dyskaryosis, HPV, colposcopy, histology, and cytology. RESULTS.: Using a loop electrosurgical excision procedure or cone biopsy assessment of the cervix as the gold standard, a cytologic assessment of CIN 1 alone results in a high false-positive rate (51.5%) and a false-negative rate (24%) for CIN 3. The appropriate second test after low-grade squamous intraepithelial lesion (CIN 1) cytologic results includes repeat cervical cytologic analysis. Subsequent human papillomavirus testing provides no advantage and increases the cost of care. Immediate referral to colposcopy is costly but minimizes the percent of women lost to follow-up. Using a loop electrosurgical excision procedure or cone biopsy assessment of the cervix as the gold standard, the colposcopically directed biopsy may give a false-positive result (11.7%) or false-negative result (up to 31%) for CIN 3. One contributing issue is the moderate interobserver reliability of histologic analysis (kappa= 0.46). There are advantages and disadvantages to both the immediate and expectant management strategies. The most crucial concern for immediate treatment is overtreatment, and that for expectant management the high rate of patients lost to follow-up. Novel technologies, including MIB-1, p16(INK)4a, and genetic assessments, may be helpful in predicting those CIN 1 lesions destined to progress or to persist. The cytologic and histologic diagnosis of CIN 1 is fraught with problems related to the subjectivity of the diagnosis. Both management options are also fraught with concerns. Any technique that can better predict disease course would be an advantage to the care of women with this abnormality." }, { "id": "pubmed23n0031_3103", "title": "[The value of vaginal cytology after total hysterectomy for benign or malignant lesions (author's transl)].", "score": 0.009523809523809525, "content": "The necessity of vaginal stump smears is demonstrated by way of 1773 smears taken from 846 hysterectomized patients. In 1,18 per cent of cases operated for benign indications there are found pathological changes on the vaginal end; 7,5 percent pathological neoplastic deformations are found following hysterectomy for carcinoma in situ; recurrences of cervical, corpus- and ovarial carcinomata are detected by vaginal stump smears at an early data. The leaving of a vaginal cuff is discussed as being responsible for the increased occurrence of new malignant growth following carcinoma in stu-operations. The other results are compared with those stated in literature." }, { "id": "pubmed23n0876_985", "title": "Follow-up of women with cervical cytological abnormalities showing atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion: a nationwide cohort study.", "score": 0.009433962264150943, "content": "Atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion in abnormal cervical cytology among young women in cervical cancer screening is an increasing health burden, and comparative effectiveness studies of different management options for such diagnoses are needed. The objective of the study was to compare the incidence of invasive cervical cancer, following different management options pursued after an atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion index smear. In this nationwide cohort study, we included all women aged 22-50 years and resident in Sweden 1989-2011 and with at least 1 cervical smear registered during the study period (n = 2,466,671). Follow-up of a first atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion cytological diagnosis within 25 months was classified as repeat cytology, colposcopy/biopsy, or without further assessment. Incidence rate ratios and 95% confidence intervals of subsequent cervical cancer within 6.5 years following atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion were estimated using Poisson regression by age group and management strategy. Women managed with repeat cytology within 6 months after atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cytology had a similar risk of cervical cancer compared with colposcopy/biopsy (incidence rate ratio, 1.1, 95% confidence interval, 0.5-2.5, and incidence rate ratio, 2.0, 95% confidence interval, 0.6-6.5, respectively) among women aged 22-27 years. For women aged 28 years and older, women managed with repeat cytology had a higher risk for cervical cancer than women managed with colposcopy/biopsy. Our findings suggest that women with a first cytological diagnosis of atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion up to age 27 years may indeed be safely followed up with repeat cytology within 6 months. A large amount of colposcopies that are currently performed in this group, therefore, could safely be discontinued." }, { "id": "pubmed23n0071_20981", "title": "[Advantages and disadvantages of celioscopic surgery in gynecology].", "score": 0.009433962264150943, "content": "In the last decade, operative laparoscopy has been a break through in the practice of gynecology. Recent progress has been made with the development of cold light, appropriate atraumatic instrumentation, video-camera and CO2 laser. Laparoscopy provides access to the pelvis, allowing for diagnosis and treatment of a variety of pathologies. The most frequent indication is the treatment of ectopic pregnancy. Salpingotomy with tubal preservation, the procedure of choice for young women wanting to become pregnant, has been used in 88 cases. However, tubal preservation is not always possible (rupture of the ovarian tube, hemosalpinx), and sometimes not even advisable (inflammatory lesions, homolateral recurrence) and salpingectomy was necessary in 294 cases. Another indication for salpingectomy is painful chronic salpingitis, resulting from an undetected or ill-treated Chlamydia trachomatis infection: 84 cases. Infertility surgery is the second most important indication for laparoscopic procedure. The authors have performed salpingoovariolysis in 49 cases, neosalpingostomy in 34 cases and fimbrioplasty in 31 cases. Reproductive outcome at 18 months post-operatively was comparable to results following microsurgical techniques, with a rate of ongoing pregnancies of 53% for adhesiolysis and 27.7% for distal tuboplasties. Immediate opening of hydrosalpinges at the time of diagnostic laparoscopy allows for precise evaluation of the tubal mucosa, thereby establishing prognosis. Laparoscopy also allows for management or ovarian cyst, first explored to determine the absence of any sign of malignancy. In most cases, the cyst's contents and wall may be entirely removed by laparoscopy: 115 cases.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0420_6501", "title": "A randomized trial on the management of low-grade squamous intraepithelial lesion cytology interpretations.", "score": 0.009345794392523364, "content": "This study was undertaken to compare alternative strategies for the initial management of low-grade squamous intraepithelial lesion (LSIL) cytology. A total of 1572 women with a community-based LSIL interpretation were randomly assigned to immediate colposcopy, triage based on enrollment HPV DNA testing and liquid-based cytology at a colposcopy referral threshold of high-grade squamous intraepithelial lesion (HSIL), or conservative management based on repeat cytology at a referral threshold of HSIL. All arms included 2 years of semiannual follow-up and colposcopy at exit. Loop electrosurgical excision procedure was offered to women with histologic diagnoses of cervical intraepithelial neoplasia (CIN) grade 2 or 3 at any visit or persistent CIN grade 1 at exit. The main study end point was 2-year cumulative diagnosis of CIN grade 3. The 2-year cumulative diagnosis of CIN grade 3 was approximately 15% in all study arms. The HPV triage arm was closed early because more than 80% of women were HPV positive, precluding efficient triage. The immediate colposcopy strategy yielded 55.9% sensitivity for cumulative cases of CIN grade 3 diagnosed over 2 years. A conservative management strategy of repeat cytology at the HSIL threshold referred 18.8% of women while detecting 48.4% of cumulative CIN grade 3. At lower cytology thresholds, sensitivity would improve but would ultimately yield unacceptably high referral rates. LSIL cytology is best managed by colposcopy initially, because there was no useful triage strategy identified. Management of these patients, after colposcopy to rule out immediately overt CIN grade 2 or 3, needs to be determined." }, { "id": "pubmed23n0533_15131", "title": "Abnormal Pap smears: a comparison of total abdominal hysterectomy and cone biopsy in management.", "score": 0.009345794392523364, "content": "A recent study found that colposcopy is still not available to over 50% of gynaecologists practicing in Nigeria and that 91% of them will do either cone biopsy or hysterectomy for moderately or severely abnormal Pap smears. Currently, there are no local data to guide such patient care. In order to compare cone biopsy and hysterectomy in terms of their pick-up rates of cervical intraepithelial neoplasia and invasive cancer in women with abnormal pap smears, a retrospective review of entries in the histology reports of all cases of cone biopsy and hysterectomy done for abnormal Pap smears from 1975-2004 at the histopathology department of the University of Nigeria Teaching Hospital, Enugu, Nigeria, was carried out. The study revealed that 203 women with moderately to severely abnormal Pap smears were treated with either cone biopsy or hysterectomy. A total of 88 (43.3%) women had cone biopsy, while the remaining 115 (56.7%) had total abdominal hysterectomy. Those who had cone biopsy were significantly younger than those who had hysterectomy (mean ages: 44.6+/-8.8 vs 52.3+/-9.8 years; p=0.008). There was no significant difference in parity between those who had cone biopsy and those who had hysterectomy (mean parity: 5.7+/-2.3 vs 6.5+/-2.2; p=0.102). For all the 203 women, the histology was reported as normal in 97 (47.8%) women and inflammatory in six (3.0%). The three cases of invasive cervical carcinoma were found in women with moderately abnormal Pap smears. One had a cone biopsy, while the other two had a simple total abdominal hysterectomy. Cone biopsy and hysterectomy did not differ significantly in their pick-up rates of the various categories of cervical lesions including invasive carcinoma (p&gt;0.05 for all categories). It was concluded that cone biopsy and hysterectomy have similar pick up rates for the various types of cervical lesions. For this reason, in the absence of colposcopy as occurs in many parts of the developing world, cone biopsy may be adequate treatment and should be offered first to women with moderately to severely abnormal Pap smears." }, { "id": "pubmed23n0298_12148", "title": "Adenoid basal carcinoma of the cervix: a potential pitfall in cervicovaginal cytology.", "score": 0.009259259259259259, "content": "Adenoid basal carcinoma (ABC) of the cervix is a quite uncommon, indolent, yet invasive neoplasm rarely identified on cervicovaginal smears. This may be due in part to sampling. Unless ABCs become ulcerated, even vigorous brushing of the endocervical canal may not be adequate to dislodge the small, cohesive cells of this neoplasm. Fortunately, the association of ABC with squamous intraepithelial lesions (SIL) often results in its incidental diagnosis on follow-up cervical biopsy or endocervical curettage. We report two cases of ABC. In case 1, a 79-yr-old white woman was diagnosed with squamous-cell carcinoma on cervicovaginal (CV) smear. High-grade SIL, carcinoma in situ, and ABC were identified on subsequent cervical cone biopsy and hysterectomy. Retrospective evaluation of the CV smear revealed a few aggregates of small, uniform cells, with hyperchromatic nuclei representing fragments of ABC. In case 2, atypical basaloid cells suspicious for ABC were recognized on the CV smear of a 67-yr-old black woman, and ABC was subsequently confirmed on cervical cone biopsy. In neither case did the intervening cervical biopsy reveal ABC. In addition to a review of the clinical information useful in the diagnosis of ABC, the cytologic features of these two cases are compared with their subsequent histopathology and contrasted with other similar lesions comprising the differential diagnosis of small neoplastic cells found in cervicovaginal smears." }, { "id": "pubmed23n0517_21824", "title": "A prospective evaluation of \"see and treat\" in women with HSIL Pap smear results: is this an appropriate strategy?", "score": 0.009259259259259259, "content": "The evaluation of abnormal cervical cytologic results is time consuming and costly. Most patients with high-grade squamous intraepithelial lesion (HSIL)-cervical intraepithelial neoplasia 3 (CIN 3) Pap smear results require an excisional procedure for diagnostic or therapeutic reasons. \"See and treat\" is a surgical procedure that involves a loop electrosurgical excisional procedure (LEEP) simultaneously to diagnose and to treat premalignant cervical disease in one visit. This procedure eliminates a second visit that typically is required for treatment. Data is lacking on the incidence of CIN 2 and CIN 3 in patients with an HSIL (CIN 2) Pap smear result. The objective of this study was to determine the incidence of CIN 2 and CIN 3 in patients with an HSIL (CIN 2) Pap smear using a see-and-treat protocol. Women referred from local health departments to our university-based colposcopy clinic for evaluation of an HSIL (CIN 2) Pap smear result were evaluated for inclusion in a see and treat protocol. All eligible patients underwent colposcopy to rule out an obvious cervical carcinoma followed by an immediate LEEP to remove the transformation zone. A colposcopic impression was made using the Reid colposcopic index. Pathologic specimens were analyzed for the presence of CIN and the incidence of CIN 2 and CIN 3 was determined. To date, 51 patients have been enrolled in the study. Exclusion criteria included age less than 19 years, pregnancy, or medical contraindications. The mean age of the patients was 26 years (range, 19-45 years). Forty-seven percent were white, 47% were black, and 6% were Hispanic. Of the 51 patients who underwent LEEP, 43 of 51 (85%) had satisfactory colposcopy and no patient had a lesion suspicious for cervical carcinoma. The average Reid colposcopic index was 3.5. Of the 51 LEEP specimens, 4 of 51 had no evidence of CIN (8%), 4 of 51 (8%) had CIN 1, 18 of 51 (35%) had CIN 2, and 25 of 51 (49%) had CIN 3. Eighty-four percent of patients had either CIN 2 or CIN 3, resulting in an overtreatment rate (CIN 1 or less) of 16%. The use of a see and treat protocol for patients with HSIL (CIN 2) Pap smear results may be an acceptable treatment option because of a high incidence of CIN 2 and CIN 3." }, { "id": "wiki20220301en274_24975", "title": "Squamous intraepithelial lesion", "score": 0.009174311926605505, "content": "A squamous intraepithelial lesion (SIL) is an abnormal growth of epithelial cells on the surface of the cervix, commonly called squamous cells. This condition can lead to cervical cancer, but can be diagnosed using a Pap smear or a colposcopy. It can be treated by using methods that remove the abnormal cells, allowing normal cells to grow in their place. In the Bethesda system, the cytology can be graded as LSIL (low-grade squamous intraepithelial lesion) or HSIL (high-grade squamous intraepithelial lesion). References Papillomavirus-associated diseases" }, { "id": "pubmed23n0746_12707", "title": "Role of vault cytology in follow-up of hysterectomized women: results and inferences from a low resource setting.", "score": 0.009174311926605505, "content": "The study was undertaken to assess the utility of cervico-vaginal/vault cytology in the follow-up of women treated for cervical cancer and benign gynecological conditions. Records of 3,523 cervico-vaginal smears from 2,658 women who underwent hysterectomy and/or radiotherapy or chemotherapy, over a 10-year period were retrieved. Data was collected on type of treatment received, indication for hysterectomy, age of patient, presenting symptoms, stage of tumor, interval since treatment, cytology and biopsy results. The results of cytology versus other parameters were analyzed separately for women treated for cervical cancer and those hysterectomized for benign indications. Malignant cells were detected in 141/1949 (7.2%) follow-up smears from treated cervical cancer cases (140 recurrences and 1 VAIN). Around 92% of recurrences of cervical cancer were detected with in 2 years of follow-up and 75% of these women were symptomatic. Cytology first alerted the clinicians to a recurrence in a quarter of cases. On the other hand, VAIN was detected in 5/1079 (0.46%) vault smears from 997 women hysterectomized for benign gynecologic disease. All these women were asymptomatic and majority (80%) were detected in follow-up smears performed between 3 and 10 years. Vault cytology is an accurate tool to detect local recurrences/VAIN in women treated for cervical cancer or benign gynecological conditions. It may even first alert the clinicians to a possibility of recurrence. However, due to extremely low prevalence of VAIN/vaginal cancer, it seems unwarranted in women hysterectomized for benign indications, especially in resource constrained settings." }, { "id": "pubmed23n0420_6500", "title": "Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance.", "score": 0.00909090909090909, "content": "This study was undertaken to compare alternative strategies for the initial management of a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). A total of 3488 women with a community-based ASCUS interpretation were randomly assigned to immediate colposcopy, triage that was based on enrollment HPV DNA testing and liquid-based cytology at a colposcopy referral threshold of high-grade squamous intraepithelial lesion (HSIL), or conservative management based on repeat cytology at a referral threshold of HSIL. All arms included 2 years of semiannual follow-up and colposcopy at exit. Loop electrosurgical excision procedure was offered to women with histologic diagnoses of cervical intraepithelial neoplasia (CIN) grade 2 or 3 at any visit or persistent CIN grade 1 at exit. The study end point was 2-year cumulative diagnosis of CIN grade 3. The 2-year cumulative diagnosis of CIN grade 3 was 8% to 9% in all study arms. The immediate colposcopy strategy yielded 53.6% sensitivity for cumulative cases of CIN grade 3 diagnosed over 2 years. The human papillomavirus (HPV) triage strategy referred 55.6% of women and detected 72.3% of cumulative cases of CIN grade 3. A conservative management strategy of repeat cytology at the HSIL threshold referred 12.3% of women while detecting 54.6% of cumulative CIN grade 3. To compare triage tests, we re-estimated the performance of HPV and cytology in successfully referring women with underlying CIN grade 3 (ie, ignoring the insensitivity we discovered in colposcopically directed biopsies). A single enrollment HPV test identified 92.4% of the women diagnosed with CIN grade 3. Serial cytology, even at an ASCUS threshold, would have required two visits to achieve similar sensitivity (95.4%) and would have referred 67.1% to colposcopy. HPV triage is at least as sensitive as immediate colposcopy for detecting CIN grade 3 and refers about half as many women to colposcopy. Follow-up that used repeat cytology is sensitive at an ASCUS referral threshold but requires two follow-up visits and ultimately more colposcopic examinations than HPV triage." }, { "id": "wiki20220301en096_22714", "title": "Cartwright Inquiry", "score": 0.00909090909090909, "content": "of microinvasion. This was at a time when there was ample scientific reason for concern about the damage caused by hysterectomy or cone biopsy and uncertainty about whether immediate use of these procedures was automatically the best thing to do for symptomless lesions, particularly in young women who might want children. Green's practice, although motivated by a desire to avoid unnecessary and damaging interventions in symptomless women, was easy for others to condemn due to the lack of any relevant policy, research, or ethical framework for cervical screening at that time.' The Case study authors note that the number of women managed by limited biopsy alone is shown in Appendix 3 of the Inquiry Report. There were 5 patients managed by limited biopsy only, with no evidence given as to whether any of these 5 patients suffered harm as a result." }, { "id": "Gynecology_Novak_3037", "title": "Gynecology_Novak", "score": 0.00907258064516129, "content": "2. At 24-months, those with ASC-US or greater should be referred. 3. Prospective follow-up by HPV DNA testing in this age group is not useful because of the high rate of positive results. 1. Both excisional and ablative procedures are acceptable treatment modalities for women with histologically proven CIN 2 or 3 with satisfactory colposcopy (Fig. 19.16D). An excisional procedure is recommended for residual/recurrent CIN 2 or 3. 2. Ablation is unacceptable for women with a histologic diagnosis of CIN 2 or 3 and unsatisfactory colposcopy. 3. Cytologic and colposcopic follow-up of CIN 2 or 3 is necessary only in specific circumstances. Acceptable posttreatment follow-up options include cytology alone, every 6 months, combined cytology and colposcopy every 6 months, and HPV DNA testing at 6 to 12 months. 4. If HPV DNA testing is positive or if the repeat cytology is ASC-US or greater, referral for colposcopy and endocervical sampling is recommended. 5." }, { "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": 0.009009009009009009, "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": "pubmed23n0299_15617", "title": "[Outpatient diagnostic hysteroscopy: 14,000 cases].", "score": 0.009009009009009009, "content": "Hysteroscopy is a technique which plays a fundamental diagnostic role in gynecological practice. The possibility of obtaining a direct intracavitary view and performing specific biopsies give it a greater level of diagnostic accuracy than intrauterine curettage. The authors' personal experience of 13,923 case enables the correct method of performing this procedure to be codified in order to avoid the inherent risks and complications. The main indication is abnormal uterine bleeding which is the most frequently observed pathology in gynecological practice. In cases of metrorrhagia in women of child-bearing age benign organic pathology accounts for 45% of patients and malignant pathology 0.3%. Post-menopausal patients reveal an increase in the incidence of organic pathology in general and neoplastic pathologies in particular (8.1%). Complications linked to this type of technique are extremely rare and in overall terms affect 1% of cases. The analysis of results shows that hysteroscopy today represents an extremely reliable and repeatable outpatient procedure. However, in spite of these advantages, including savings in health costs, it is not widely used at a capillary level given that if performed by persons who are not expert it may become traumatic and unreliable. The correct execution of hysteroscopy in fact calls for dexterity acquired over time which is not conditioned by the learning of previous techniques and requires an adequate period of training." }, { "id": "pubmed23n0304_15763", "title": "Neoplasia associated with atypical glandular cells of undetermined significance on cervical cytology.", "score": 0.008928571428571428, "content": "The clinical importance of atypical glandular cells of undetermined significance (AGUS) on cervicovaginal smear has not been well defined. Between January 1990 and April 1996, 127 smears were reported as showing AGUS changes by the cytopathology division at the University of Massachusetts Medical Center. The medical records of these women were reviewed: 17 women were excluded because of previous hysterectomy or gynecologic cancer, 85 were biopsied, 16 were followed by repeat smears, and 9 were lost to follow-up. Forty-four women had negative biopsies or cervicitis. There were 15 endometrial lesions: 10 hyperplasias (2 with atypia) and 5 adenocarcinomas. Twenty-five women had cervix lesions including 3 endocervical atypias, 12 low-grade cervical intraepithelial neoplasia (CIN), 6 high-grade CIN, one adenocarcinoma in situ, and 3 invasive adenocarcinomas. One patient had ovarian cancer. Two of the 16 women followed by repeat pap smear eventually had a cancer diagnosis: one with cervix cancer and one with colon cancer. We were unable to identify a subgroup of women with AGUS who were at increased risk for serious pathology when we compared multiple demographic variables, symptoms, or the presence of coexistent squamous abnormalities on cervical cytology. The mean age of the 15 women with endometrial lesions was 59.9 years, which was significantly older than those patients with cervix lesions who had a mean age of 38.9 years. The presence of AGUS on cervical cytology is a marker for significant gynecologic neoplasia and should be investigated with colposcopically directed biopsies, endocervical curettage, and, in older women, endometrial biopsy." }, { "id": "pubmed23n1098_2733", "title": "Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?", "score": 0.008928571428571428, "content": "To compare and evaluate the results and suitability of two different approaches to the treatment of post-conization International Federation of Gynaecology and Obstetrics (FIGO) stage IA1 cervical carcinoma: a more radical approach, directly scheduling a second surgery versus a more conservative one, which consists of performing a cotest (PAP plus HPV-test) in a follow-up visit and deciding whether to apply a second surgery on the basis of the results. Retrospective descriptive study including 144 cases of stage IA1 cervical carcinoma diagnosed after a loop electrosurgical excisional procedure (conization), between 1987 and 2019 in the Mother-and-Child University Hospital of Gran Canaria (Spain). Selected patients were split into two groups for analysis: patients directly undergoing a second surgical intervention (hysterectomy or re-conization) after diagnosis and patients who were followed-up before making a decision whether to schedule a second surgery or continue to follow-up. 75% of women directly receiving a second surgical intervention (no post-conization follow-up) underwent hysterectomy, while 25% underwent re-conization. Histological outcomes from hysterectomized patients showed 65% negative results for intraepithelial lesions, 9% low-grade squamous intraepithelial lesions (LSIL), 16% high-grade squamous intraepithelial lesions (HSIL) and only 10.5% confirmed invasive lesions: hysterectomy complication rate was 7%. Histological studies from women subjected to re-conization showed 32% negative results, 37% LSIL, 5% HSIL and 26% malignancy. In the group of patients who were followed-up after diagnosis, 8.8% needed a second intervention; none of them showed negative histological results, while 100% hysterectomized and 25% patients with re-conization showed HSIL. No unnecessary hysterectomy procedures were conducted in this group. HPV-16 was the most common genotype in both groups. Conization proved to be a suitable alternative to hysterectomy as a treatment for post-conization stage IA1 cervical cancer. Our results showed that 65% hysterectomy procedures conducted without previously monitoring for residual disease corresponded to negative results and were therefore, unnecessary. We conclude that confirmation of the presence of residual disease by using cotest is essential to make a decision on further treatment and that a conservative management is often possible and, in our opinion, preferable." }, { "id": "pubmed23n0300_12494", "title": "Clinical Significance of a cervical cytologic diagnosis of atypical squamous cells of undetermined significance. Favoring a reactive process or low grade squamous intraepithelial lesion.", "score": 0.008849557522123894, "content": "To define the clinical significance of qualifying the cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS) as favoring either a reactive process or a low grade squamous intraepithelial lesion (LSIL) in an effort to provide management guidelines. A total of 118 consecutive nonpregnant women with a cytological diagnosis of ASCUS favoring either a reactive process or LSIL were evaluated in our colposcopy clinic by repeat cervical cytologic smear, colposcopy and colposcopically directed biopsies and/or endocervical curettage, as indicated. Of the 58 patients evaluated for a smear of ASCUS, favoring a reactive process, 5 (8.6%) had cervical intraepithelial neoplasia (CIN) CIN 1 documented by biopsy. None had a high grade lesion. Twenty-six (45%) of the 58 patients who had a cytologic diagnosis of ASCUS favoring a reactive process had a repeat smear that was normal. None was found to have CIN. Of the 60 patients who had a cervical diagnosis of ASCUS favoring LSIL, 9 (15%) had CIN 1 or CIN 2. Nineteen (32%) of the 60 patients who had a cytologic diagnosis of ASCUS favoring LSIL had a repeat smear that was normal. One of these patients had CIN 1 on biopsy. The sensitivity of a repeat smear, in this limited series, after an initial smear of ASCUS favoring a reactive process is 100%, while it was 66% after an initial smear of ASCUS favoring LSIL. This study showed that in our laboratory a cytologic diagnosis of ASCUS favoring either a reactive process or LSIL is associated with a very low risk that the patient is haboring CIN. In the patient whose initial smear shows ASCUS favoring a reactive process, a repeat smear that is normal is reassuring. The patient whose smear shows ASCUS favoring LSIL probably requires further evaluation even in the presence of a normal repeat smear." }, { "id": "pubmed23n0079_10832", "title": "Colposcopy as a method of management strategy in CIN and microinvasive cancer.", "score": 0.008849557522123894, "content": "During nearly 40 years of using colposcopy, an original management strategy in CIN and early cervical cancer was developed and confirmed in 2 study groups of cervical lesions containing respectively 1228 and 6001 cases. This approach is based on colposcopy as the main method in early detection of CIN and cancer, with supplementary cytology in necessary cases, and on a coloposcopic-histological staging of these lesions for treatment qualification. Colposcopy alone is a fairly adequate method for diagnosis of 60% of examined cases, and coloscopy with directed biopsy in the next 20% of colposcopically highly suspect findings. Only in the remaining 20% of colposcopically less suspect findings and in the cases of \"unsatisfactory colposcopy\", supplementary was cytology required. In this study colposcopy findings connected with histological evaluation of the specimens provided a basic way for determining the advancement of processes and the selection method for the appropriate type and extent of treatment. CIN 1 and 2 and small focuses of CIN 3 including CIS entirely visible on the ectocervix, in childless young women were treated by cryosurgery. In all remaining cases of CIN 3, the basic therapeutic method was cold-knife conization. In exceptional cases simple hysterectomy can be a more adequate treatment. Depending on our colposcopic-histological staging, in Stage IA1--conization, whereas in Stage IA2--a moderately extended hysterectomy should be optionally performed. The management strategy introduced is an economical, fully effective and quick way of detection and selection of the method for the treatment of CIN and early cervical cancer." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 0, 253 ] ], "word_ranges": [ [ 0, 44 ] ], "text": "Both parents are carriers of a mutation (because they are not sick and have already had a homozygous child), and the next offspring has a 50% chance of receiving the mutation from each parent, so the probability of receiving it from both is 50%x50%=25%." }, "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 probability that the next offspring will be affected is 25%.", "2": "The probability that the next offspring will be affected is 50%.", "3": "Having had an affected child, the next offspring will also be affected.", "4": "Having had a homozygous F5O8del child, the next offspring will be heterozygous carriers (67%) or homozygous genotype without the mutation (33%).", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "wiki20220301en002_113148", "title": "Bayes' theorem", "score": 0.018329427519250083, "content": "Using genetic test results Parental genetic testing can detect around 90% of known disease alleles in parents that can lead to carrier or affected status in their child. Cystic fibrosis is a heritable disease caused by an autosomal recessive mutation on the CFTR gene, located on the q arm of chromosome 7. Bayesian analysis of a female patient with a family history of cystic fibrosis (CF), who has tested negative for CF, demonstrating how this method was used to determine her risk of having a child born with CF: Because the patient is unaffected, she is either homozygous for the wild-type allele, or heterozygous. To establish prior probabilities, a Punnett square is used, based on the knowledge that neither parent was affected by the disease but both could have been carriers: Given that the patient is unaffected, there are only three possibilities. Within these three, there are two scenarios in which the patient carries the mutant allele. Thus the prior probabilities are ⅔ and ⅓." }, { "id": "InternalMed_Harrison_4866", "title": "InternalMed_Harrison", "score": 0.014446302489780752, "content": "In most instances, an affected individual is the offspring of heterozygous parents. In this situation, there is a 25% chance that the offspring will have a normal genotype, a 50% probability of a heterozygous state, and a 25% risk of homozygosity for the recessive alleles (Figs. 82-10, 82-13B). In the case of one unaffected heterozygous and one affected homozygous parent, the probability of disease increases to 50% for each child. In this instance, the pedigree analysis mimics an autosomal dominant mode of inheritance (pseudodominance). In contrast to autosomal dominant disorders, new mutations in recessive alleles are rarely manifest because they usually result in an asymptomatic carrier state." }, { "id": "wiki20220301en002_113149", "title": "Bayes' theorem", "score": 0.013863377941047843, "content": "Next, the patient undergoes genetic testing and tests negative for cystic fibrosis. This test has a 90% detection rate, so the conditional probabilities of a negative test are 1/10 and 1. Finally, the joint and posterior probabilities are calculated as before. After carrying out the same analysis on the patient’s male partner (with a negative test result), the chances of their child being affected is equal to the product of the parents' respective posterior probabilities for being carriers times the chances that two carriers will produce an affected offspring (¼)." }, { "id": "wiki20220301en230_28433", "title": "Obligate carrier", "score": 0.013853559268970375, "content": "Autosomal Recessive In an autosomal recessive disease, if an individual is heterozygous for the mutant allele, they are a carrier because the disease is recessive. If homozygous, they have the disease. All offspring of an affected individual are either heterozygous or homozygous for the mutated allele. Consequently, all unaffected (heterozygous) offspring of an affected individual are obligate carriers of the disease because they will necessarily carry the mutated allele. Detection" }, { "id": "wiki20220301en157_7443", "title": "Lethal allele", "score": 0.01281763826606876, "content": "Types of lethal allele Recessive lethals A pair of identical alleles that are both present in an organism that ultimately results in death of that organism are referred to as recessive lethal alleles. Though recessive lethals may code for dominant or recessive traits, they are only fatal in the homozygous condition. Heterozygotes will sometimes display a form of diseased phenotype, as in the case of achondroplasia. One mutant lethal allele can be tolerated, but having two results in death. In the case of homozygous achondroplasia, death almost invariably occurs before birth or in the perinatal period. Not all heterozygotes for recessive lethal alleles will show a mutant phenotype, as is the case for cystic fibrosis carriers. If two cystic fibrosis carriers have children, they have a 25 percent chance of producing offspring having two copies of the lethal allele, eventually resulting in the death of the child." }, { "id": "wiki20220301en078_39518", "title": "Transmission disequilibrium test", "score": 0.012453258547008548, "content": "We first describe the TDT in the case where families consist of trios (two parents and one affected child). Our description follows the notations used in Spielman, McGinnis & Ewens (1993). The TDT measures the over-transmission of an allele from heterozygous parents to affected offsprings. The n affected offsprings have 2n parents. These can be represented by the transmitted and the non-transmitted alleles and at some genetic locus. Summarizing the data in a 2 by 2 table gives: The derivation of the TDT shows that one should only use the heterozygous parents (total number b+c). The TDT tests whether the proportions b/(b+c) and c/(b+c) are compatible with probabilities (0.5, 0.5). This hypothesis can be tested using a binomial (asymptotically chi-square) test with one degree of freedom: Outline of the test derivation" }, { "id": "pubmed23n1008_19791", "title": "Impact of genetic testing and family health history of cystic fibrosis in the early prenatal diagnosis and prevention of a new case of genetic disorder.", "score": 0.011262441068622314, "content": "Cystic fibrosis (CF) is a multi-system autosomal recessive disorder, results of mutations in the CF transmembrane conductance regulator (CFTR) gene, located on the long arm of chromosome 7. We present a special family couple with particular medical history of CF, who comes to our Clinic for genetic tests and a prenatal genetic counseling, to prevent the birth of a new affected CF child. Genetic analysis showed that the first affected child, a daughter, is compound heterozygous for two clinically significant recessive mutations: c.1521_1523delCTT; p.Phe508del, inherited from her mother, who carries the same CFTR mutation, and c.1853_1863delTTTTGCATGAA; p.IIe618Argfs 2, inherited from her father, who is heterozygous, healthy carrier, for the same CFTR mutation. In our case report, early prenatal genetic testing, pre- and post-test genetic counseling was crucial in the management of the present pregnancy, to prevent the birth of a new affected CF child." }, { "id": "pubmed23n0367_6050", "title": "[Genetic counseling in cystic fibrosis].", "score": 0.010407905803195963, "content": "Genetic counseling is an important part of health care in patients with cystic fibrosis or respiratory diseases associated with the CFTR (cystic fibrosis transmembrane conductance regulator) gene, including certain types of allergic bronchopulmonary aspergilloses or bronchial diseases (diffuse bronchiectasia). The basic goal is to provide patients with information on the transmission of cystic fibrosis and to asses the risk of recurrence. This risk is determined from molecular biology analyses examining the CFTR gene. Genotyping is the only means of screening for the heterozygous state, frequent in the French population (about 1/30). Because of the large number of mutated alleles not covered entirely by the genetic tests, there remains a question of probability expressed as a residual risk of a heterozygous state. A prenatal genotype diagnosis should be proposed to heterozygous couples who have a 25% risk of having a diseased child. Technically, this is almost always possible and the results are highly reliable. Nevertheless, there remains the risks related to sample taking and the ethical issue about which the patients must be informed. Management of these at risk couples who desire a child must be based on a multidisciplinary approach, particularly important when one of the parents has overt cystic fibrosis." }, { "id": "article-550_4", "title": "Genetics, Autosomal Recessive -- Mechanism", "score": 0.010184036393713814, "content": "The most common situation of an autosomal recessive disease occurs when the parents are each carrier or heterozygous (Dd). Children of carrier parents have a 25% chance of inheriting the disorder. This value is obtained by using the Punnet square model used in genetics. Each parent has a 50% chance of passing on the disease allele. Using the multiplication rule of probability, there is a 50% chance that the father passes on his disease allele and a 50% chance that the mother passes on her disease allele; 50% x 50% = 25%. So with the mating of carrier parents, there is a 25% chance that the child will be affected, a 50% chance that the child would be a carrier, and 25% chance that they would be homozygous dominant and unaffected." }, { "id": "pubmed23n0666_15054", "title": "Identification of the second CFTR mutation in patients with congenital bilateral absence of vas deferens undergoing ART protocols.", "score": 0.009945355191256831, "content": "Congenital bilateral absence of vas deferens (CBAVD) is a manifestation of the mildest form of cystic fibrosis (CF) and is characterized by obstructive azoospermia in otherwise healthy patients. Owing to the availability of assisted reproductive technology, CBAVD patients can father children. These fathers are at risk of transmitting a mutated allele of the CF transmembrane conductance regulator (CFTR) gene, responsible for CF, to their offspring. The identification of mutations in both CFTR alleles in CBAVD patients is a crucial requirement for calculating the risk of producing a child with full-blown CF if the female partner is a healthy CF carrier. However, in the majority of CBAVD patients, conventional mutation screening is not able to detect mutations in both CFTR alleles, and this difficulty hampers the execution of correct genetic counselling. To obtain information about the most represented CFTR mutations in CBAVD patients, we analysed 23 CBAVD patients, 15 of whom had a single CFTR mutation after screening for 36 mutations and the 5T allele. The search for the second CFTR mutation in these cases was performed by using a triplex approach: (i) first, a reverse dot-blot analysis was performed to detect mutations with regional impact; (ii) next, multiple ligation-dependent probe amplification assays were conducted to search for large rearrangements; and (iii) finally, denaturing high-performance liquid chromatography was used to search for point mutations in the entire coding region. Using these approaches, the second CFTR mutation was detected in six patients, which increased the final detection rate to 60.8%." }, { "id": "pubmed23n0265_20005", "title": "Carrier risk calculations for recessive diseases when not all the mutant alleles are detectable.", "score": 0.009900990099009901, "content": "The number of recessive diseases, such as cystic fibrosis, in which some but not all of the mutations causing the disease can be detected using genetic probes, is certain to increase. For counselling purposes, the probability that a consultand known not to have a detectable mutation is nevertheless a carrier, needs to be calculated with as much accuracy as possible. This paper describes a program, available from the author, written specifically to make these calculations. As an example, results are presented for cystic fibrosis, assuming an incidence of 1 in 2,400 and that 80% of the mutations, being delta F508 mutations, are detectable. Numerical results are given when information may be available on the parents, one or two sibs and one or two children of the consultand. When test results are available on the children, the test status of the spouse of the consultand is relevant and may also be available. Risk calculations are also presented when an aunt (uncle) of the consultand has cystic fibrosis. Finally, disease and carrier risks are given for the child of first cousins, neither of whom has a detectable mutation." }, { "id": "wiki20220301en044_34838", "title": "Fibrodysplasia ossificans progressiva", "score": 0.00980392156862745, "content": "A mutation in the gene ACVR1 (also known as activin-like kinase 2 (ALK2)) is responsible for the disease. ACVR1 encodes activin receptor type-1, a BMP type-1 receptor. The mutation causes substitution of codon 206 from arginine to histidine in the ACVR1 protein. This substitution causes abnormal activation of ACVR1, leading to the transformation of connective tissue and muscle tissue into a secondary skeleton. This causes endothelial cells to transform to mesenchymal stem cells and then to bone. Genetics FOP is an autosomal dominant disorder. Thus, a child of an affected heterozygous parent and an unaffected parent has a 50% probability of being affected. Two affected individuals can produce unaffected children. Two unaffected individuals can produce an affected offspring as a result of the mutation of the gene. The homozygous dominant form is more severe than the heterozygous form." }, { "id": "pubmed23n0578_2789", "title": "Novel CFTR missense mutations in Brazilian patients with congenital absence of vas deferens: counseling issues.", "score": 0.00980392156862745, "content": "Screening for mutations in the entire Cystic Fibrosis gene (CFTR) of Brazilian infertile men with congenital absence of vas deferens, in order to prevent transmission of CFTR mutations to offspring with the use of assisted reproductive technologies. Specific polymerase chain reaction (PCR) primers were designed to each of the 27 exons and splicing sites of interest followed by single strand conformational polymorphism and Heteroduplex Analysis (SSCP-HA) in precast 12.5% polyacrylamide gels at 7 masculineC and 20 masculineC. Fragments with abnormal SSCP migration pattern were sequenced. Two novel missense mutations (S753R and G149W) were found in three patients (two brothers) together with the IVS8-5T allele in hetrozygosis. The available screenings for CF mutations do not include the atypical mutations associated to absence of vas deferens and thus, when these tests fail to find mutations, there is still a genetic risk of affected children with the help of assisted reproduction. We recommend the screening of the whole CFTR gene for these infertile couples, as part of the work-up before assisted reproduction." }, { "id": "pubmed23n0211_12761", "title": "Mutations at more than one locus may be involved in cystic fibrosis--evidence based on first-cousin data and direct counting of cases.", "score": 0.009708737864077669, "content": "Cystic fibrosis was present in 35 of 5,265 first cousins of index cases with the disease. The gene frequency was estimated to be .0281 +/- .00544, using an improved method that allows for the influence of cousin sibship size upon the estimate. This figure is higher than that obtained by direct counting of cases in Victoria, Australia, from 1955-1979 (.0198 +/- .000127), raising the possibility that multiple gene loci may be involved in this disease. Further analysis showed that the number of affected first cousins fitted very well with an expected number based on a model involving two gene loci, each responsible for half the cases of cystic fibrosis. Agreement with expectations based on a single locus was not good. An alternate explanation of gross underascertainment of cases is dismissed because the index sibships were shown to fit very closely a truncate binomial distribution. The gene frequencies at the putative two loci would then each be .0140 and heterozygote frequencies one in 36. One in 18 people would be heterozygous at either one or the other of the loci." }, { "id": "pubmed23n0374_11071", "title": "Genetic, andrological and clinical characteristics of patients with congenital bilateral absence of the vas deferens.", "score": 0.009615384615384616, "content": "The possibility of retrieving spermatozoa from the epididymis allows patients with congenital bilateral absence of the vas deferens (CBAVD) to father a child by means of assisted reproduction techniques. This has, however, increased the chance of transmitting a mutated allele of the cystic fibrosis transmembrane conductance regulator (CFTR) gene which increases the risk of generating offspring with cystic fibrosis (CF). Because of the increased heterogeneity of the CFTR locus, the study of a discrete number of mutations, as usually carried out in a diagnostic work-up, is unable to ascertain the presence of a mutation in a relatively high proportion of the patients screened. In an attempt to increase the chance of detecting the presence of CFTR gene abnormalities, 37 patients with CBAVD and one patient with congenital unilateral agenesis of the vas deferens (CUAVD) underwent an enlarged diagnostic protocol, which included screening for the most expected mutations of the CFTR gene in our population, evaluation of the five thymidine (5T) allelic variant, sweat test, respiratory function tests, evaluation of steatocrit, and an accurate evaluation of the history of the patient to search for symptoms commonly found in patients with CF. A single CFTR gene mutation was found in 18 patients (48.6%) with CBAVD and in the patient with CUAVD. The most frequent mutation observed was the Delta F508. Eleven patients (45.8%) had the 5T variant and in five of them it was not associated with any detectable mutation of the CFTR gene. Two female partners were found to be carriers of a mutation, whereas 5 (18.5%) had the 5T variant. As many as 71% of CBVAD patients had the simultaneous presence of at least two signs and/or symptoms suggestive of CF, albeit they were of mild intensity and the patients felt fit and healthy. In conclusion, these results suggested that some patients with CBAVD without CFTR gene mutation or 5T variant, even when their sweat test is negative, may show clinical suspicion of carrying a CFTR gene mutation and therefore are at risk of generating children affected by CF if the partner carries a mutation as well. The screening for mutations and a careful clinical examination may contribute to better identification of patients with CFTR-related CBAVD." }, { "id": "article-17325_64", "title": "Albinism -- Treatment / Management -- Management of the Inheritable Nature of the Condition", "score": 0.009594882729211086, "content": "Genetics consultation before childbearing years is beneficial to parents of albino children considering future offspring, the patient with albinism and their siblings. Albinism is an obligate homozygote condition with a 100% chance of passing on their defective gene. Coordinated genetic testing of the nonaffected partner is possible if the pathogenic variant is known. This will confirm the offspring have the potential to inherit the condition, if the partner is a carrier of the same pathogenic variant, or just be obligate carriers if the partner has only wild-type genes. A couple who has already had an albino child has a 25% chance of having another child with albinism, a 50% chance of producing carrier offspring, and 25% of producing non-carrier offspring. This is assuming that one of the parents is not albino, in which case the chance of producing a second albino offspring is 50% after a confirmed albino offspring. The fact than non-albino siblings have a 67% chance of being carriers is important to convey before they consider childbearing. Of note, if two parents carry genes for different types of albinism (for example, a patient with OCA2 and a carrier for OCA1), no children will be born with albinism, but the children are at risk for being heterozygous for both mutant alleles." }, { "id": "wiki20220301en013_41679", "title": "Multiple endocrine neoplasia", "score": 0.009523809523809525, "content": "MEN1 mutations in multiple endocrine neoplasia patients and clinical genetics MEN1 gene mutations can be identified in 70-95% of MEN1 patients and in about 20% of familial isolated hyperparathyroidism cases. Almost all patients are heterozygous for mutations. One affected family has been identified with individuals both homozygous and heterozygous for MEN1 mutations. In this family, there was no difference in disease history between the homozygous and heterozygous mutation carriers. 50% of patients develop signs and symptoms by 20 years of age and more than 95% have symptoms by 40 years of age. There is significant intra- and inter-familial variability in the age of onset, the severity of disease, and tumor types. Despite numerous studies, no genotype-phenotype correlations have been established, suggesting that unknown genetic and environmental modifiers are involved in the expression of the MEN1 phenotype." }, { "id": "pubmed23n0501_15715", "title": "Cystic fibrosis screening: lessons learned from the first 320,000 patients.", "score": 0.009523809523809525, "content": "To examine the data from &gt; 335,000 Cystic fibrosis (CF) tests to detect unsuspected findings and obtain clinical data when indicated to optimize genetic counseling. A proprietary database containing 335,204 consecutive CF DNA tests and 445 CF prenatal diagnostic tests was queried. Clinical information was obtained for prenatal and selected nonprenatal cases by telephone contact with physician offices. The mutation 1078delT was found in much lower frequency than expected with rates of only 1:55,867 tests and 0.06% of CF mutations. This level is below the threshold set by the American College of Medical Genetics. Homozygosity was observed for 2789+5G&gt;A in a 29-year-old women and compound heterozygosity with delta F408 in a 40-year-old woman with isolated chronic sinusitis. Many patients elected prenatal diagnosis when not at a 1:4 risk due to echogenic bowel or IVS-8 5T issues. With the exception of 1078delT, all CF mutations in the ACMG panel were detected with a frequency of &gt; 0.1% of CF chromosomes. When ACMG guidelines are strictly adhered to, population-based CF carrier screening will accurately identify couples at risk for having children with CF." }, { "id": "wiki20220301en075_47960", "title": "Chondrodystrophy", "score": 0.009433962264150943, "content": "Percentage risk of inheritance Both average parents''' A couple already has a child with chondrodystrophy; the risk of inheritance for the next child to have the disorder is 0.1% (less than 1 in 1,000) The risk that the normal-statured child will have at least one offspring with this disorder is 0.01% (less than 1 in 10,000) One parent with chondrodystrophy and one parent without One child with normal height; the probability of that child having offspring with chondrodystrophy is 0.01% (less than 1 in 10,000) One child with normal stature; the probability of the next having chondrodystrophy is 50% (1 in 2) One child with normal stature; the probability of the next not having chondrodystrophy is 50% (1 in 2) Both parents with chondrodystrophy The probability of offspring affected by chondrodystrophy is 100% (4 in 4) The probability of offspring to be of normal size is 0% (0 in 4)" }, { "id": "pubmed23n0383_4635", "title": "Cystic fibrosis phenotype evaluation and paternity outcome in 50 males with congenital bilateral absence of vas deferens.", "score": 0.009433962264150943, "content": "Most infertile males with congenital bilateral absence of vas deferens (CBAVD) carry mutations on the cystic fibrosis transmembrane conductance regulator gene and may express mild cystic fibrosis (CF) symptoms. Barriers to paternity for these men can now be overcome by assisted reproduction. Our aims were to investigate the CF-related phenotype and clinical outcome for 50 patients with CBAVD seen at a CF adult centre between 1992 and 1999. The investigation of the patients included screening for 22 CF mutations and identification of the poly-T variant of intron 8, sweat testing, clinical investigation for CF-related extra-genital manifestations, and genetic counselling. CFTR mutations were detected on 56 alleles of the 50 patients. A total of 15 (30%) was compound heterozygote and 26 (52%) heterozygote. In all, 38% of the patients had a positive sweat test. Four patients were diagnosed with typical CF not detected previously. Twenty-one patients became fathers following ICSI (eight cases), artificial insemination by donor or IVF with sperm donor (seven cases) or through adoption (six cases). A mail survey allowed the identification of CF-related clinical symptoms. Information on the occurrence of CF-related symptoms was obtained for 58.5% of patients: in the absence of initial symptoms, no new clinical signs were reported. Patients diagnosed with CBAVD need genetic counselling before assisted reproduction. Even when no wish for paternity is expressed, CF gene screening should be associated with at least a sweat test and clinical evaluation because of possible mild forms of CF disease. Medical follow-up did not reveal any new symptoms." }, { "id": "wiki20220301en053_22197", "title": "Gitelman syndrome", "score": 0.009345794392523364, "content": "Epidemiology Gitelman syndrome is estimated to have a prevalence of 1 in 40,000 homozygous people . The ratio of men to women affected is 1:1. This disease is encountered typically past the 1st decade of life, during adolescence or adulthood but can occur in the neonatal period. Heterozygous carriers of the SLC12A3 gene mutations are 1% of the population. Parents with Gitelman syndrome have a low probability of passing the disorder to their offspring roughly 1 in 400 unless they are both carriers of the disease. History The condition is named for Hillel Jonathan Gitelman (1932– January 12, 2015), an American nephrologist working at University of North Carolina School of Medicine. He first described the condition in 1966, after observing a pair of sisters with the disorder. Gitelman and his colleagues later identified and isolated the gene responsible (SLC12A3) by molecular cloning. References External links \"Gitelman syndrome\". MedlinePlus. U.S. National Library of Medicine." }, { "id": "pubmed23n0050_18894", "title": "Reproductive decision making of aunts and uncles of a child with cystic fibrosis: genetic risk perception and attitudes toward carrier identification and prenatal diagnosis.", "score": 0.009345794392523364, "content": "This paper evaluates the perceived genetic risk, the perceived burden, the impact on reproductive decision making, and the attitudes of aunts and uncles of a child with cystic fibrosis toward carrier identification, prenatal diagnosis, and pregnancy termination. A mailed questionnaire was sent to the aunts and uncles of 32 CF children (1) who attended the Paediatric Department of the University Hospital and (2) whose parents agreed to give the names and addresses of their sibs. The results for the 109 respondents aged less than 40 years are discussed. About one-fourth of them was aware of the \"approximate\" level of the risk to be a carrier of the CF gene and/or of the risk of having a CF child themselves. Nevertheless the subjective evaluation of the genetic risk has played a part in the reproductive decision-making process of at least 39% of the respondents. About three-fourths would (probably) make use of heterozygote detection and would (probably) ask for prenatal diagnosis should they become pregnant. It is striking that less than half of the group would interrupt the pregnancy should the fetus be affected. The intention to use prenatal diagnosis was significantly correlated with age and educational level while the acceptance of pregnancy interruption was significantly correlated with perceived burden, respondents' age, and health situation of the proband." }, { "id": "wiki20220301en036_364", "title": "Germline mutation", "score": 0.009266409266409266, "content": "Cystic fibrosis is an autosomal recessive disorder that causes a variety of symptoms and complications, the most common of which is a thick mucus lining in lung epithelial tissue due to improper salt exchange, but can also affect the pancreas, intestines, liver, and kidneys. Many bodily processes can be affected due to the hereditary nature of this disease; if the disease is present in the DNA of both the sperm and the egg, then it will be present in essentially every cell and organ in the body; these mutations can occur initially in the germline cells, or be present in all parental cells. The most common mutation seen in this disease is ΔF508, which means a deletion of the amino acid at the 508 position. If both parents have a mutated CFTR (cystic fibrosis transmembrane conductance regulator) protein, then their children have a 25% of inheriting the disease. If a child has 1 mutated copy of CFTR, they will not develop the disease, but will become a carrier of the disease. The" }, { "id": "wiki20220301en577_6234", "title": "Dopamine transporter deficiency syndrome", "score": 0.009259259259259259, "content": "DTDS is inherited in an autosomal recessive pattern, which means, for affected individuals, both copies of the gene in each cell have SLC6A3 mutations. As such, each sibling of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and 25% chance of being unaffected and not a carrier. Once a SLC6A3 pathogenic variant is identified within an affected family member, carrier testing for at-risk relatives and prenatal testing or preimplantation genetic diagnosis for pregnancies can be options considered for genetic counseling. Diagnosis Diagnosis of SLC6A3-negative DTDS is established in a proband via molecular genetic testing, looking for biallelic (i.e. homozygous or compound heterozygous) pathogenic SLC6A3 variants. DTDS-positive patients are further identified by matching their genetic testing results with known characteristic clinical, laboratory, and imaging findings." }, { "id": "pubmed23n0311_2825", "title": "Relevance of genetic counselling in couples prior to intracytoplasmic sperm injection.", "score": 0.009259259259259259, "content": "Since the first reports of successful pregnancies after treatment with intracytoplasmic sperm injection (ICSI) in humans numerous attempts have been made to assess the genetic risks of this highly invasive technique. During the study period (February 1995-November 96), 142 couples were referred to our genetic counselling unit prior to ICSI. In three couples, genetic counselling revealed a high recurrence risk for a monogenic disease (myotonic dystrophy, hereditary ataxia and polycystic kidney disease). In nine out of 128 men (7%) an abnormal karyotype was identified, including three Robertsonian translocations, two reciprocal translocations, three sex chromosome aberrations and one case with centric fission of chromosome no. 7. A total of 14 men refused chromosomal analysis. Only one of the 122 women examined had an abnormal karyotype (47, XXX). Five out of six men with congenital bilateral absence of the vas deferens (CBAVD) had at least one mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Three had mutations in both CFTR alleles, including one case in which the second mutation was the 5T allele. One patient with CBAVD and a single Delta F508 CFTR mutation also had left renal agenesis. In conclusion, we strongly recommend that genetic counselling, chromosomal analysis and, in the case of CBAVD, screening for CFTR mutations should be offered to all couples with a diagnosis of male or idiopathic infertility." }, { "id": "wiki20220301en479_31596", "title": "PGM3 deficiency", "score": 0.009174311926605505, "content": "Typically, both parents of an affected child carry one abnormal gene and are unaffected by the disease. When both parents have one abnormal copy of the PGM3 gene, each child has a 25 percent chance of being affected by the disease. Sometimes the two copies of the PGM3 gene that a child inherits have identical, or homozygous, mutations. This is common if the child’s parents are related to each other, explaining why many reported cases of PGM3 deficiency have involved consanguinity families. Many patients have different mutations on the two copies of PGM3, and their mutations are called compound heterozygous mutations. In either case, the patient is not able to produce functional PGM3 protein Diagnosis" }, { "id": "pubmed23n0291_3674", "title": "Proband and parent assistance in identifying relatives for cystic fibrosis carrier testing.", "score": 0.009174311926605505, "content": "To identify, contact, and offer free cystic fibrosis (CF) carrier education, testing, and genetic counseling to the first, second, and third degree relatives of individuals with CF, study personnel contacted probands or the parents of minor probands requesting assistance in identifying relatives. We requested family pedigrees, including names, addresses, and phone numbers and if necessary a saliva sample for determination of the specific CF mutations in the family. Two hundred three families of 220 probands being followed at a large CF clinic in the Southeastern United States were eligible for inclusion in the study. Of the 203 families 109 (53.7%) assisted by providing contact information on relatives and, when necessary, a saliva sample for mutation analysis. An additional 33 (16.4%) agreed to assist but did not provide either or both contact information or saliva samples. Sixty-one (30.1%) declined to provide assistance. Thirteen percent of the probands/parents wanted to talk with relatives before providing contact information. A logistic regression model predicting proband/parent assistance is provided. This study suggests that the active outreach method used here to identify at risk relatives to offer them CF carrier testing resulted in somewhat lower proband or parent assistance than reported by other similar approaches. The strengths and weaknesses of this approach, including comments by probands and parents on the method, are discussed." }, { "id": "wiki20220301en230_28429", "title": "Obligate carrier", "score": 0.00909090909090909, "content": "In X-linked recessive disorders, only females can be the carriers of the recessive mutation, making them obligate carriers of this type of disease. Females acquire one X-chromosome from their father and one from their mother, and this means they can either be heterozygous for the mutated allele or homozygous. If heterozygous, she is a carrier of the mutated allele because the disease is recessive. If homozygous, she has the disease. An affected father with an X-linked recessive trait will always pass the trait on to the daughter. Therefore, all daughters of an affected male are obligate carriers. On the other hand, a carrier mother has a 50% chance of passing her mutated X-chromosome to the daughter. This makes all daughters of carrier mothers possible carriers but not necessarily obligate carriers. Males cannot be obligate or possible carriers of X-linked recessive traits because they only have one X-chromosome, and so are always phenotypically affected when receiving the mutated" }, { "id": "pubmed23n0408_3431", "title": "Survey of CF mutations in the clinical laboratory.", "score": 0.00909090909090909, "content": "BACKGROUND: Since it is impossible to sequence the complete CFTR gene routinely, clinical laboratories must rely on test systems that screen for a panel of the most frequent mutations causing disease in a high percentage of patients. Thus, in a cohort of 257 persons that were referred to our laboratory for analysis of CF gene mutations, reverse line probe assays for the most common CF mutations were performed. These techniques were evaluated as routine first-line analyses of the CFTR gene status. METHODS: DNA from whole blood specimens was extracted and subjected to PCR amplification of 9 exons and 6 introns of the CFTR gene. The resulting amplicons were hybridised to probes for CF mutations and polymorphisms, immobilised on membranes supplied by Roche Molecular Systems, Inc. and Innogenetics, Inc. Denaturing gradient gel electrophoresis and sequencing of suspicious fragments indicating mutations were done with CF exon and intron specific primers. RESULTS: Of the 257 persons tested over the last three years (referrals based on 1) clinical symptoms typical for/indicative of CF, 2) indication for in vitro fertilisation, and 3) gene status determination because of anticipated parenthood and partners or relatives affected by CF), the reverse line blots detected heterozygote or homozygote mutations in the CFTR gene in 68 persons (26%). Eighty-three percent of those affected were heterozygous (47 persons) or homozygous (10 persons) for the DeltaF508 allele. The only other CF-alleles that we found with these tests were the G542X allele (3 persons), the G551D allele (3 persons), the 3849+10kb C-T allele (2 persons) the R117H allele (2 persons) and the 621+1G-T allele (1 person).Of the fifteen IVS8-5T-polymorphisms detected in intron 8, seven (47%) were found in males referred to us from IVF clinics. These seven 5T-alleles were all coupled with a heterozygous DeltaF508 allele, they make up 35% of the males with fertility problems (20 men) referred to us. CONCLUSIONS: In summary, the frequency of CF chromosomes in the cohort examined with these tests was 26%, with the DeltaF508 allele affecting 83% of the CF chromosomes. It is a substantial improvement for routine CF diagnostics to have available a test system for 30 mutations plus the polypyrimidine length variants in intron 8. Our results show that this test system allows a routine first-line analyses of the CFTR gene status." }, { "id": "pubmed23n0512_17600", "title": "A novel missense mutation P1290S at exon-20 of the CFTR gene in a Portuguese patient with congenital bilateral absence of the vas deferens.", "score": 0.009009009009009009, "content": "To report a novel cystic fibrosis transmembrane conductance regulator (CFTR) gene missense mutation in a compound heterozygote with congenital bilateral absence of the vas deferens (CBAVD). Descriptive, controlled study. Tertiary academic hospital genetics laboratory and private in vitro fertilization (IVF) clinic. One 46-year-old man with CBAVD and no clinical cystic fibrosis (CF) phenotype as indicated by the advanced age at diagnosis, absence of chronic airways and gastrointestinal disease, and normal pancreatic function and sweat chloride concentration. Genomic blood DNA from the patient's parents was analyzed to perform family studies, and 109 fertile men, 32 patients with CBAVD, 15 children carriers of one CFTR mutation, and 5 patients with CF were used to rule out polymorphism. Clinical evaluation and treatment, genetical screenings. Clinical data, biochemical assays, spermiogram analysis, testicle biopsy, intracytoplasmic sperm injection (ICSI) outcome, and CFTR whole gene mutation screening and IVS8T polymorphism. The DNA analysis revealed a 7T/7T homozygote at IVS8-T, with a 4000C--&gt;T change (P1290S) in exon 20 of the CFTR gene, which was inherited from the patient's father. It was associated with a 3272-26A--&gt;G mutation in the other allele that was inherited from his mother. The novel P1290S missense CFTR mutation causes an amino acid change in a highly conserved region of the CFTR protein that controls channel opening. Pathogenicity is suggested by development of CBAVD in association with a mild CFTR mutation." }, { "id": "pubmed23n1020_8250", "title": "Pre-implantation genetic diagnosis in an Iranian family with a novel mutation in MUT gene.", "score": 0.008928571428571428, "content": "Methylmalonic acidemia (MMA), which is an autosomal recessive metabolic disorder, is caused by mutations in methylmalonyl-CoA mutase (MUT) gene. As a result, the conversion of methylmalonyl-CoA to succinyl-CoA is impaired in this disorder, leading to a wide range of clinical manifestations varying from no signs or symptoms to severe lethargy and metabolic crisis in newborn infants. Since identification of novel mutations in MUT gene can help discover the exact pathogenesis of MMA and also use these disease-causing mutations in prenatal diagnosis, this study was conducted to uncover the possible mutations in an Iranian couple with a deceased offspring clinically diagnosed as having organic acidemia. Moreover, to prevent the occurrence of the mutation in the next pregnancy, we took the advantage of pre-implantation genetic diagnosis (PGD), which resulted in a successful pregnancy. The affected individual was a 15-month-old boy who passed away due to aspiration pneumonia. The child presented at the age of 3 months with lethargy, protracted vomiting, hypotonia, and decreased level of consciousness. To find the mutated gene, Next Generation Sequencing (NGS) was performed as carrier testing for the parents and the results revealed a novel (private) heterozygous missense mutation in MUT gene (c.1055A &gt; G, p.Q352R). After performing PGD on three blastomeres, one was identified as being homozygous wild-type that was followed by successful pregnancy. Our study identified a novel, deleterious, heterozygous missense mutation in MUT gene in a couple and helps to consider the genetic counselling and prenatal diagnosis more seriously for this family with clinical phenotypes of organic acidemia." }, { "id": "pubmed23n0498_2485", "title": "Mutations in CFTR gene and clinical correlation in Argentine patients with congenital bilateral absence of the vas deferens.", "score": 0.008928571428571428, "content": "Congenital bilateral absence of the vas deferens (CBAVD) is a form of male infertility in which mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene have been identified. Here we identify different mutations of CFTR and the poly-T variant of intron 8 (IVS8) in Argentine patients and analyze sweat test values and clinical characteristic related to Cystic Fibrosis (CF). For counseling purposes the two most frequent mutations in Argentine CF population: deltaF508 and G542X were screened in wives. In all cases, it was possible to reduce the risk of CF/CBAVD descendants in these couples because none of the mutation were found in the 36 samples. Eight patients (23%) showed abnormal chloride values (&gt; 60 mmol/l). A second group of 6 patients (18%) had borderline values of sweat chloride (40-59 mmol/l). We defined another group with 6 patients (18%), with normal sweat chloride levels (30-39 mmo/l) and a fourth group of 14 (41%) patients with sweat chloride below 30 mmol/l. deltaF508, the most frequent CF mutation in the Argentine population, was found on 15 of the 72 chromosomes (21%), R117H mutation was detected on 2 of 62 chromosomes (3%). Only one R347P allele was found on 28 chromosomes analyzed (2%). On a sample of 27 patients, IVS8 analysis showed a frequency of 6/56 chromosomes (11%) of 5T allele. Even though these findings present an improvement in the detection of mutations related to clinical correlations in Argentine CBAVD population, the search for other common and uncommon mutations should be continued." } ] } } }

{ "1": { "exist": true, "char_ranges": [ [ 741, 1168 ] ], "word_ranges": [ [ 121, 189 ] ], "text": "That is, when you are in the penumbra, the pupil dilates and the iris thickens in the peripheral part, where it is already very close to the corneal endothelium in the case of a narrow chamber. Mydriasis then triggers angular closure, which is accompanied by ocular pain that may radiate backwards (headache). And increased intraocular pressure produces corneal edema that causes blurred vision. Therefore, option 1 is correct." }, "2": { "exist": true, "char_ranges": [ [ 1169, 1282 ] ], "word_ranges": [ [ 189, 208 ] ], "text": "Migraine does not have to be related to penumbra, and ocular pain and blurred vision is not particularly typical." }, "3": { "exist": true, "char_ranges": [ [ 1283, 1431 ] ], "word_ranges": [ [ 208, 232 ] ], "text": "Actinic keratitis is caused by exposure to ultraviolet radiation (such as solar radiation), and is not related to hyperopia or to being in penumbra." }, "4": { "exist": true, "char_ranges": [ [ 1487, 1695 ] ], "word_ranges": [ [ 241, 275 ] ], "text": "And finally, dry eye does not produce these symptoms either: it is more a question of burning, foreign body sensation, heaviness, etc. And it is also unrelated to the other elements: penumbra, hyperopia, etc." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Primary angular closure glaucoma.", "2": "Migraine.", "3": "Actinic keratitis.", "4": "Dry eye syndrome.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "First_Aid_Step2_690", "title": "First_Aid_Step2", "score": 0.012217839140916063, "content": "Dx: Diagnosis is based on clinical history and examination. Those that resolve may mimic a migraine headache with blurred vision; the distinction is that the headaches and blurred vision are more likely to be triggered by darkness (due to pupillary dilation) rather than by bright lights (migraine). Tx: This is a medical emergency that can cause blindness. Treatment to ↓ IOP may include eyedrops (timolol, pilocarpine, apraclonidine) or systemic medications (oral or IV acetazolamide, IV mannitol). Laser peripheral iridotomy, which creates a hole in the peripheral iris, is curative and may be performed prophylactically. generally occurs bilaterally, ■Flow of aqueous humor through the trabecular meshwork is limited, in- creasing IOP. A diseased trabecular meshwork obstructs proper drainage of the eye, leading to a gradual ↑ in pressure and progressive vision loss. occurs unilaterally." }, { "id": "wiki20220301en001_9479", "title": "Migraine", "score": 0.011166390270867882, "content": "Differential diagnosis Other conditions that can cause similar symptoms to a migraine headache include temporal arteritis, cluster headaches, acute glaucoma, meningitis and subarachnoid hemorrhage. Temporal arteritis typically occurs in people over 50 years old and presents with tenderness over the temple, cluster headache presents with one-sided nose stuffiness, tears and severe pain around the orbits, acute glaucoma is associated with vision problems, meningitis with fevers, and subarachnoid hemorrhage with a very fast onset. Tension headaches typically occur on both sides, are not pounding, and are less disabling. Those with stable headaches that meet criteria for migraines should not receive neuroimaging to look for other intracranial disease. This requires that other concerning findings such as papilledema (swelling of the optic disc) are not present. People with migraines are not at an increased risk of having another cause for severe headaches. Prevention" }, { "id": "pubmed23n1090_18188", "title": "Spontaneous filtering bleb with subsequent secondary glaucoma June consultation #1.", "score": 0.010309509401824336, "content": "A 32-year-old previously healthy woman was referred for evaluation and management of newly diagnosed hypotony in the right eye. Her ocular history was significant only for moderate myopia and an idiopathic Horner syndrome in the left eye diagnosed at age 13. The patient endorsed a history of fluctuating and decreasing vision in the right eye over the past 6 months. She denied any ocular pain, previous ocular surgery, or recent trauma. The patient was otherwise healthy and denied any previous autoimmune disease or systemic infection. She wore soft, daily disposable contact lenses and reported no abnormalities on previous routine eye examinations. At presentation, the patient's uncorrected distance visual acuity was 20/25 in the right eye and 20/200 in the left. Lensometry revealed a previous refraction of -3.00 + 0.50× 150 in the right eye and -4.00 + 1.75× 174 in the left. Intraocular pressures (IOPs) were 4 mm Hg and 15 mm Hg by applanation, and central corneal thicknesses were 573 μm and 564 μm in the right and left eyes, respectively. Slitlamp examination revealed an area of scleral thinning near the limbus in the right eye from 5 to 7 o'clock with mild overlying chemosis (Figure 1JOURNAL/jcrs/04.03/02158034-202107000-00023/figure1/v/2021-06-26T110826Z/r/image-tiff). Gonioscopy showed an open angle with mild trabecular meshwork pigmentation in both eyes without any cyclodialysis clefts, peripheral anterior synechiae (PAS), or other abnormalities. Dilated fundus examination was significant for mild optic nerve edema and chorioretinal folds in the right eye. Optical coherence tomography (OCT) of the optic nerve confirmed mild disc edema (Figure 2JOURNAL/jcrs/04.03/02158034-202107000-00023/figure2/v/2021-06-26T110826Z/r/image-tiff) and OCT of the macula confirmed mild chorioretinal folds. Anterior segment OCT (AS-OCT) and ultrasound biomicroscopy failed to show any other abnormalities. The patient was initially observed without treatment and presented urgently approximately 1 month later with decreased vision and ocular discomfort. Repeat examination revealed an IOP of 31 mm Hg and a focal area of PAS to the previous area of scleral thinning (Figure 3JOURNAL/jcrs/04.03/02158034-202107000-00023/figure3/v/2021-06-26T110826Z/r/image-tiff). In one respect, the newly elevated IOP was considered transiently therapeutic to help reverse the hyperopic shift, disc edema, and hypotony-related maculopathy. However, the situation quickly became more worrisome when shortly thereafter the IOP elevated to 55 mm Hg at subsequent follow-up, and multiple IOP-lowering medications were initiated. Over numerous additional visits, the patient's IOPs ranged from 30 to 39 mm Hg in the right eye despite rapidly advancing to maximally tolerated medical therapy including acetazolamide. She was noted to have a new relative afferent pupillary defect of the right eye, and Humphrey visual fields showed early arcuate defects (Figure 4JOURNAL/jcrs/04.03/02158034-202107000-00023/figure4/v/2021-06-26T110826Z/r/image-tiff). What would be your approach to managing this healthy, young, myopic woman who presented with hypotony due to a spontaneous, perilimbal filtration bleb that later occluded with PAS, resulting in intractably elevated IOP and field loss? What is the differential diagnosis? Would you perform a systemic workup for her initial scleral thinning, and if so, what would you check? Would you intervene for her elevated IOP in the right eye? If so, what would be your surgical approach?" }, { "id": "pubmed23n0725_17913", "title": "Macular folds: an unusual association in topiramate toxicity.", "score": 0.009900990099009901, "content": "We report two uncommon cases of acute onset myopia with macular folds following use of topiramate. A 25-year-old woman, with no prior history of glasses, taking topiramate for recurrent headaches, presented with decreased vision. On examination, she was found to have a refractive error of -5.00 DS in both eyes and intraocular pressure of 10 mmHg and 6 mmHg in the right and left eyes, respectively. She had closed angles on gonioscopy, ciliary effusion on ultrasonic biomicroscopy with inner limiting membrane folds in the macula in both eyes. She was on anti-glaucoma medication when she presented to us. A 20-year-old woman presented with acute headache and decreased vision following use of topiramate for treatment of migraine. On examination, her intraocular pressure was 25 mmHg in both eyes with closed angles on gonioscopy, a refractive error of -4.50 DS and prominent macular folds with no fluid in both eyes. There was complete resolution of macular folds and angle-closure attack after discontinuation of topiramate and conservative treatment with topical steroids and cycloplegics in both eyes. Topiramate toxicity may present with macular folds associated with angle-closure glaucoma. Folds in the inner limiting membrane might give a clue to choroidal effusion as the cause for this presentation. The symptoms resolved on the discontinuation of topiramate." }, { "id": "wiki20220301en127_44710", "title": "Dry Your Eyes (TV series)", "score": 0.009900990099009901, "content": "Stage show In the spring of 2007 Dry Your Eyes it's Give My Head Peace played sell-out shows at two venues in Northern Ireland; the Millennium Forum in Derry from 19 to 24 March and at Belfast's Grand Opera House from 26 March – 7 April. The show featured new material from Dry Your Eyes and Give My Head Peace and Tim McGarry also performed stand-up comedy. It was very well received. The next show in 2008, Give My Head Peace: Back from the Grave, also featured stand-up comedy and appearances by Dry Your Eyes characters Derek and the McDowell Brothers alongside the regular Give My Head Peace cast." }, { "id": "pubmed23n1121_2537", "title": "Aripiprazole-Induced Acute Transient Bilateral Myopia: A Case Report.", "score": 0.00980392156862745, "content": "Aripiprazole is an atypical, antipsychotic drug used for the treatment of schizophrenia, depression, bipolar disorder, and obsessive-compulsive disorder in adults. There are a few reports in the literature of ocular side effects of aripiprazole, such as transient myopia, diplopia, and acute angle closure. This report describes the case of a 34-year-old female patient who was referred to the clinic with painless blurred vision in both eyes. She had been diagnosed with major depression and had been using aripiprazole for a month. She experienced blurred vision after the first week of drug therapy. The uncorrected visual acuity (UCVA) was 4/10 in both eyes using a standard Snellen chart. She had a refractive error of -2.00 diopters and the best corrected visual acuity was 10/10 in both eyes. The ocular examination results were normal other than the refractive error. The patient was diagnosed with aripiprazole-induced, acute transient myopia. The UCVA was 10/10 in both eyes at the 2-week follow-up following termination of the aripiprazole therapy. It is important to be prepared to recognize aripiprazole-induced, acute transient myopia in patients complaining about blurred vision." }, { "id": "pubmed23n0869_14175", "title": "Importance of eye disease in headache.", "score": 0.00980392156862745, "content": "Patients who consult primary health care providers with headache accompanied by ocular symptoms should be referred to an ophthalmic casualty department. " }, { "id": "pubmed23n0830_24397", "title": "Bilateral acute angle-closure glaucoma following treatment with topiramate for headache.", "score": 0.009708737864077669, "content": "This case report adds supportive evidence to the development of acute angle-closure glaucoma (AACG), a rare but serious adverse effect following the use of topiramate (TPM) for a severe headache. A 25-year-old female reported with severe headache, suspected to be migraine, and was started on TPM 25 mg/day on the first day. However, she presented at the emergency clinic of a hospital with sudden blurring of vision and colored halos 5 days after stopping the drug, i.e., day 8. She was subjected to ophthalmic examination and was diagnosed with AACG. The intraocular pressure (IOP) was found to be elevated and she was hence started on acetazolamide 500 mg instantly, maintained on tablet acetazolamide 250 mg four times a day (QID), pilocarpine 2% eye drops QID, travoprost 0.004% once a day (OD), and dorzolamide 2% eye drops three times a day (TID). After a week's treatment, there was rapid improvement with return of IOP to normal. TPM-induced AACG is a rare serious adverse event leading to blindness but is preventable, when diagnosed early and by instituting appropriate treatment." }, { "id": "wiki20220301en466_18429", "title": "Ophthalmodynia periodica", "score": 0.009708737864077669, "content": "Ophthalmodynia periodica is also known as \"ice-pick headache\", is a primary headache disorder, so it is not caused by any other conditions. Signs and symptoms Stabbing sensations, usually in one area of the head Pain may move to different areas of the head Pain lasts for a few seconds (\"usually 5–30\") Pain appears out of nowhere Pain is completely gone after each occurrence Each occurrence happens at varied frequencies Cause Ophthalmodynia periodica does not have a confirmed cause, being a primary headache, but can be identified with other primary conditions. \"As many as 40% of all individuals with ice pick headaches have also been diagnosed as suffering with some form of migraine headache.\" Diagnosis The following diagnostic criteria are given for ophthalmodynia periodica:" }, { "id": "pubmed23n0762_17989", "title": "Topiramate-associated acute, bilateral, angle-closure glaucoma: case report.", "score": 0.009615384615384616, "content": "This paper describes a topiramate induced acute bilateral angle-closure glaucoma. This rare adverse effect is an idiosyncratic reaction characterized by uveal effusion and lens forward displacement, leading to increased intraocular pressure and vision loss. We describe a 55 year-old white woman with migraine, spasmodic torticollis and essential tremor, who developed bilateral acute angle-closure glaucoma, one week after starting topiramate 25 mg/day. She was seen at the Ophthalmology Emergency Department of the Fundação João Penido Burnier (Campinas, SP, Brazil) with a 4 hours history of blurry vision, ocular pain and bright flashes vision. Slit lamp examination revealed moderate conjunctival injection and corneal edema, and shallow anterior chambers. Intraocular pressure was 48 mmHg in both eyes. Fundoscopic examination findings were normal. She was treated with timolol, brimonidine, dorzolamide, pilocarpine, prednisone acetate eye drops and acetazolamide. One hour after those measures, as the intraocular pressure was 30 mmHg, she received a manitol intravenous injection and the intraocular pressure normalized. After 24 hours an iridotomy with Yag laser was performed. Topiramate was discontinued and she was totally recovered after one week. " }, { "id": "pubmed23n0558_12090", "title": "[Ocular findings in patients older than 99 years].", "score": 0.009615384615384616, "content": "To determine vision conditions and ocular findings in patients older than 99 years. Patients were recruited by media advertisement and examined at the Vision Institute of UNIFESP. The following examinations were performed: visual acuity, ectoscopy, refraction, biomicroscopy, tear film break-up time, Schirmer basal test, tonometry, direct and indirect ophthalmoscopy. Complementary examinations such as optical coherence tomography were performed when indicated. Thirty patients older than 99 years were identified. Mean age of 101.5+/-1.8, 25 females and 5 males. Most common systemic disease, according to history, was arterial hypertension. In 11 patients (55%), the best corrected far visual acuity was 20/100 or better. The best corrected near visual acuity was J4 or better also in 55% (11 patients) and 63.0% (7 patients) of these were the ones that had not been submitted to cataract surgery. The most frequent visual complaint was low vision for reading (55%) and other 8 patients (40%) reported no disturbance (satisfied with their vision). Lens opacity was present in 9 patients (60%) and 8 patients (40%) had previous cataract surgery (5 aphakic eyes, 9 pseudophakic eyes). Cataract was identified as important for impairment of vision in 5 patients but only 2 of them wanted to be submitted to surgery. The main cause of visual impairment was age-related macular degeneration, present in all patients, 95% with no exudative form. Vision improved with new refractive prescription in 4 patients. Once we understand the needs we can plan specific diagnostic and treatment strategies. This sample showed that most were female (83.3%), with good general health (35%), most with systemic arterial hypertension (40%), complaining of low vision for reading (55%) because of age-related macular degeneration (100%, 95% dry form). Only 40% had been previously submitted to cataract surgery. Most of the patients with cataract said to be satisfied with their vision; of the 5 patients that could be operated only 2 decided to do it. Low vision for reading, AMD and cataract were the main findings." }, { "id": "pubmed23n0477_8608", "title": "[Angle-closure glaucoma: important points in the diagnosis and follow-up].", "score": 0.009523809523809525, "content": "A 74-year-old woman visited her local physician complaining of fever, cough, headache, hyperemic left conjunctiva, and blurred vision. She was diagnosed as having common cold and medicated for it, and later, she visited our department. She had a shallow left anterior chamber with moderately dilated pupil. Gonioscopic examination of the left eye revealed a narrow angle corresponding to grade 1 by Shaffer grading system. Left intraocular pressure was 16 mmHg. She was diagnosed to have had a spontaneous recovery from a subacute attack of angle-closure glaucoma. Laser iridectomy was performed and she was put on a regular ophthalmological follow-up. Three years later, she experienced an attack of left angle-closure glaucoma secondary to lens intumescence. She was treated by phacoemulsification and aspitaion which resulted in the eventual cure." }, { "id": "wiki20220301en127_44706", "title": "Dry Your Eyes (TV series)", "score": 0.009523809523809525, "content": "Nameless characters While each of these characters had names in the script, none of them are mentioned in the show itself." }, { "id": "pubmed23n0925_371", "title": "Bilateral posterior crystalline lens dislocations in an otherwise healthy child.", "score": 0.009433962264150943, "content": "<bIntroduction:</b Ectopia lentis is defined as a crystalline lens displacement, either partially or completely, due to zonular abnormalities. It can be a result of trauma, hereditary ocular disease, or part of systemic diseases, like Marfan syndrome and homocystinuria. <bCase description:</b We report a case of a medically free 16-year-old girl, who was referred to our hospital complaining of poor vision and a squint in both eyes since childhood. Her history included a traffic accident when she was one-year-old. She was previously diagnosed with alternating esotropia, which was treated with glasses, alternating patching, and bilateral Botox injections. On examination, she had a visual acuity of 6/7.5 with correction in the right eye and 6/6 with correction in the left eye. She had an esotropia of 60 prism diopters, which was partially corrected to 40 prism diopters for near and distance vision. Fundus examination showed myopic changes in each eye and dislocated lenses in the posterior pole at 6 o'clock. Our case was stable, so we used conservative management with contact lenses. <bConclusion:</b Bilateral posterior lens dislocation is very rare. A proper examination is important and early diagnosis can prevent serious complications, such as retinal detachment or pupillary block glaucoma." }, { "id": "wiki20220301en127_48268", "title": "Daylight in Your Eyes", "score": 0.009433962264150943, "content": "in the United Kingdom and the United States, respectively, \"Daylight in Your Eyes\" also saw minor commercial success in both countries with peak positions of number 88 on the UK Singles Chart and a single entry at number 36 on the Billboard Hot Singles Sales chart." }, { "id": "pubmed23n1065_23969", "title": "Neurotrophic keratitis in autoimmune polyglandular syndrome type 1: a case report.", "score": 0.009345794392523364, "content": "Autoimmune polyglandular syndrome type 1 (APS-1) is a rare autosomal recessive disease. In patients with APS-1, the most frequently reported ocular manifestations are keratoconjunctivitis with dry eye and retinal degeneration. However, to our knowledge, no research studies have reported the relationship between APS-1 and neurotrophic keratitis (NK). Possible explanations such as limbus cell deficiency being the primary cause of APS-1 keratopathy are not applicable to our unusual case of the patient with APS-1 presenting as ocular surface disease with NK. Our case findings suggest a new explanation for the observed corneal pathology and a potential treatment for these patients. A 27-year-old woman was referred to our hospital because of intermittent blurred vision and recalcitrant ocular surface problems in both eyes for many years. She has a history of autoimmune polyglandular syndrome type 1 (APS-1), which includes hypothyroidism, hypoparathyroidism, hypoadrenalism, and hypogonadotropic hypogonadism. In vivo confocal microscopy clearly demonstrated significant degeneration of the sub-basal nerve plexus and stromal nerve bundles in her corneas bilaterally. She was diagnosed with severe NK and ocular surface disease caused by dry eye. Treatment included the application of therapeutic soft contact lenses and punctual occlusion; however, both treatments had a limited effect. Patients with APS-1 may have ocular surface disease and severe damage to corneal nerves. Regular follow-up and treatment focusing on the regeneration of corneal nerves is particularly important in these patients." }, { "id": "pubmed23n1004_9883", "title": "Ocular ischemic syndrome; A case report.", "score": 0.009345794392523364, "content": "Ocular ischemic syndrome is not a common condition so most of these cases are often misdiagnosed or treated as a different entity. Therefore, it is very important for the ophthalmologists to have this condition in mind as a differential so that the patients can be diagnosed and treated as early as possible. A 42 years female presented with painless, progressive diminution of vision in right eye over the period of 1 month. She doesn't give any history of redness of eyes, fever or trauma. There is no history of diabetes mellitus or hypertension as well. On examination, vision in right and left eyes was 1.78 and 0.30 Log Mar Units respectively. On anterior segment examination, revascularization of iris (1o 4 'o'clock hrs) in right eye was noted. On dilated fund us copy, revascularization of disc (1/3rd) was present in right eye. Cotton wool spots blot hemorrhages and micro aneurysms were also noted in right eye. Likewise, attenuation of arteries were noted on both sides. Fund us fluorescent angiography revealed delayed artery covetous and venous phase. Carotid Doppler was done which showed complete occlusion of right common carotid and bilateral internal carotid artery. These findings lead to the diagnosis as ocular ischemic syndrome so she was then referred to the cardiologist who further confirmed that no active intervention was required at present. The patient was planned for right eye pan retinal photocoagulation (PRP) and was completed in 2 sittings and was asked to follow up regularly. Early diagnosis and management is very important for uncommon conditions such as ocular ischemic syndrome to prevent further complications." }, { "id": "pubmed23n0995_23517", "title": "The Use of Topiramate for Weight Loss Causing Acute Glaucoma: A Case Report and Literature Review.", "score": 0.009259259259259259, "content": "Topiramate is a sulfa-containing drug which is able to disrupt the ocular blood barrier. Recently it has gained more popularity, being used in many clinical conditions. Nowadays, the cases of glaucoma induced by topiramate have increased due to the use of this drug to induce weight loss. We here described a 29-year-old female presented with a one-day history of blurred vision in both eyes and headache. She was using a weight loss formula containing topiramate 100 milligrams. Ophthalmologic exam revealed an important myopic shift of -7.00 spherical diopters at presentation with intraocular pressure (IOP) of 32 mmHg and a shallow anterior chamber in both eyes. After discontinuous of topiramate and use of cycloplegic eyedrops, myopic shift improved and IOP controlled after two days. The anterior chamber was significantly deeper in both eyes after two weeks. It is theorized that topiramate can provoke a ciliochoroidal effusion and, therefore, can cause an anterior displacement of lens-iris diaphragm with a secondary angular closure. The treatment must include cycloplegic and discontinuation of the drug. Sulfa-containing drugs lead to an indirect mechanism of angle closure, frequently bilateral and, as mentioned above, with a different treatment approach. If unrecognized and untreated, it can provoke high morbidity with possibility of bilateral permanent visual loss." }, { "id": "pubmed23n0680_21006", "title": "Acanthamoeba keratitis due to genotype T11 in a rigid gas permeable contact lens wearer in Spain.", "score": 0.009174311926605505, "content": "A case of a 59-year-old Spanish patient who presented with severe ocular pain, blurred vision, eyelid swelling and foreign body sensation in the right eye is reported. She was a regular gas permeable contact lens [corrected] wearer who initially claimed to maintain standard lens care. After exploration, conjunctival injection, dendritiform corneal ulcers and stromal edema were observed. She was initially treated for a possible viral keratitis due to herpes simplex virus using 3% topical acyclovir and 0.1% dexamethasone eye drops 5 times a day. The patient did not respond to this treatment and six weeks later, corneal scrapings were positive for Acanthamoeba genotype T11. She was then treated with chlorhexidine 0.02%, propamidine 0.1% and 1% cycloplegic eye drops hourly which resulted in a significant improvement. After a month, ocular pain decreased and the clinical signs of keratitis ameliorated observed as a diminution of the size of the ulcer and also in the extension and opacity of the corneal infiltrates. The patient has been following this treatment for 3 months and it is possible that she will have to carry on with it for a whole year. To the best of our knowledge, this is the first case of severe keratitis due to Acanthamoeba genotype T11 in Spain ." }, { "id": "wiki20220301en553_8137", "title": "The Gentlemen (2019 film)", "score": 0.009174311926605505, "content": "Unknown to Pearson, Dry Eye is in league with Berger, who had wanted Pearson's business disrupted to reduce the price. Dry Eye has taken Lord George's place and still hopes to take Pearson's empire for himself. Dry Eye tries to kidnap Rosalind, who kills Dry Eye's men before she runs out of bullets in her two-shot derringer. Raymond kills an assassin sent to kill Pearson; the two rush to Rosalind and Pearson fatally shoots Dry Eye as he is about to rape her. Fletcher ends his story and Raymond orders him to leave his house." }, { "id": "pubmed23n0752_4889", "title": "Fish allergy causing angioedema and secondary angle-closure glaucoma.", "score": 0.00909090909090909, "content": "A 56-year-old woman with a history of primary angle-closure glaucoma presented with acute generalised swelling, and facial angioedema following a fish meal. She complained of nausea, vomiting, headache, pain in both eyes and acute loss of vision. Her visual acuity was reduced and intraocular pressures (IOP) were elevated. Gonioscopy revealed complete angle closure in the left eye and complete to partial closure in the right eye. Through existing peripheral iridotomies the anterior capsules were seen pressed up against the iris of both eyes. A diagnosis of angle-closure glaucoma was made, medications were started to reduce the elevated intraocular pressure and systemic antihistamine to counter the allergic reaction. She was hospitalised for further management. A follow-up at 2 years revealed her visual acuities and IOP had remained normal." }, { "id": "InternalMed_Harrison_2324", "title": "InternalMed_Harrison", "score": 0.00909090909090909, "content": "Vitreous Degeneration This occurs in all individuals with advancing age, leading to visual symptoms. Opacities develop in the vitreous, casting annoying shadows on the retina. As the eye moves, these distracting “floaters” move synchronously, with a slight lag caused by inertia of the vitreous gel. Vitreous traction on the retina causes mechanical stimulation, resulting in perception of flashing lights. This photopsia is brief and is confined to one eye, in contrast to the bilateral, prolonged scintillations of cortical migraine. Contraction of the vitreous can result in sudden separation from the retina, heralded by an alarming shower of floaters and photopsia. This process, known as vitreous detachment, is a common involutional event in the elderly. It is not harmful unless it damages the retina. A careful examination of the dilated fundus is important in any patient complaining of floaters or photopsia to search for peripheral tears or holes. If such a lesion is found, laser" }, { "id": "pubmed23n0393_13274", "title": "Adie's tonic pupil-induced angle-closure glaucoma.", "score": 0.009009009009009009, "content": "A 52-year-old woman was diagnosed as having Adie's tonic pupil in her right eye. She reported few episodes of blurring of vision in her right eye in the recent few months. On one of the routine follow-up visits, right intraocular pressure (IOP) was 70 mm Hg and on gonioscopy the angle was closed 360 degrees. Medical treatment resulted in IOP reduction and laser iridotomy was then performed. This is, to our knowledge, the first description of intermittent angle-closure glaucoma attacks induced by a tonic pupil. The possibility of angle-closure glaucoma should be considered in patients with a tonic pupil, especially with symptoms of blurred vision or ocular pain." }, { "id": "pubmed23n0417_11180", "title": "Dry eyes. Eye series. 3.", "score": 0.009009009009009009, "content": "During her regular check-up a 68 year old woman patient mentions, as an aside, that the recent hot weather has left her eyes with a 'dry, gritty feeling'. The feeling is more noticeable toward the end of the day and on further questioning has gradually become more prominent over the past few years." }, { "id": "pubmed23n0823_10973", "title": "Unusual case of angle closure glaucoma in a patient with neurofibromatosis type 1.", "score": 0.008928571428571428, "content": "We report the case of a 29-year-old female patient who presented with an acute onset of anisocoria, blurred vision, nausea and severe left-sided headache. There was no history of trauma, drug abuse, or instillation of topical mydriatic compounds. The ocular history was negative for similar events. On presentation, her visual acuity was 0.2 in the left and 1.0 in the right eye with a +2.5 dpt sph. correction. Slit-lamp examination demonstrated a shallow anterior chamber as well as the presence of iris nodules in both eyes. These nodules were identified as Lisch nodules as the patient referred to the previous diagnosis as being neurofibromatosis type 1. A third nerve palsy was considered, but a brain MRI showed normal results. Her ocular motility was normal, but the left pupil was mydriatic and poorly reacting to light, with an associated raised intraocular pressure (IOP) of 38 mm Hg. An examination of the fellow eye was normal, with the IOP measuring 18 mm Hg. Gonioscopy of the right eye showed a narrow angle. On further anamnestic investigation, the patient revealed that the pain and the blurred vision begun in the morning while she was helping her mother in the garden. Finally, after showing the patient a picture of Datura flowers, which she recognized immediately, we made the unusual diagnosis of angle closure glaucoma by Datura, a well-known toxic plant with mydriatic properties. The patient was successfully treated with systemic acetazolamide and topical pilocarpine. " }, { "id": "wiki20220301en131_9404", "title": "Third Eye Blind discography", "score": 0.008928571428571428, "content": "After signing with Elektra Records, Third Eye Blind released their self-titled debut album in 1997. Helped by the singles \"Semi-Charmed Life\", \"Graduate\", \"How's It Going to Be\", \"Losing a Whole Year\", and \"Jumper\", the album peaked at number 25 on the Billboard 200 chart, sold six million copies, and went six times platinum in the United States. \"Semi-Charmed Life\" peaked at number four on the Billboard Hot 100. Their second album, 1999's Blue, included \"Anything\", \"Never Let You Go\", \"10 Days Late\", and \"Deep Inside of You\". Blue peaked at number 40 and went platinum in the US." }, { "id": "pubmed23n1147_25187", "title": "Anterior segment reconstruction due to cosmetic iris implants placed in the anterior chamber.", "score": 0.008849557522123894, "content": "A 27-year-old woman had BrightOcular iris implants placed for cosmetic purposes that changed eye color from brown to blue bilaterally. Of note, BrightOcular implants are not approved by the U.S. Food and Drug Administration (FDA) for use in the United States and have been associated with severe ocular complications. In keeping with their design, they were placed in the anterior chamber (AC) in both eyes of this patient; surgery was performed outside the United States. As has been described previously and tragically in other cases, she developed chronic inflammation, intolerable glare, angle-closure glaucoma, corneal edema, and cataracts in both eyes. For medically unmanageable elevated intraocular pressure (IOP), she underwent diode laser cyclophotocoagulation (CPC) in both eyes, and eventually, an Ahmed tube shunt (New World Medical, Inc.) was placed in the right eye. Although she was advised and urged to have the iris implants removed, despite her ocular issues, she refused removal until intolerable glare and reduced vision ensued. Ultimately, both iris implants were extracted 5 years after implantation by a U.S. surgeon; the procedures resulted in corneal decompensation and progressive cataract development. Subsequent penetrating keratoplasty (PKP) was performed for the right eye, but it failed because of contact with the glaucoma tube shunt. She sought additional consultation and presented with the following findings: corrected distance visual acuity was 20/400 in the right eye and 20/40 in the left eye, IOP of 18 mm Hg in the right eye and 16 mm Hg in the left eye, pupils were nonreactive and fixed, and extraocular muscles and central visual field were normal. Pachymetry was 868 μm in the right eye and 653 μm in the left eye. Anterior segment examination in the right eye revealed a failed corneal graft with 3+ edema, peripheral anterior synechiae (PAS) for 360 degrees, shallow AC, Ahmed tube shunt at the 11 o'clock position and remnant iris adherent to the graft-host junction for 270 degrees, 3+ posterior subcapsular cataract, and 2+ cortical cataract (Figure 1JOURNAL/jcrs/04.03/02158034-202208000-00024/figure1/v/2022-08-01T210317Z/r/image-tiff). The sclera revealed multiple circular and circumferential atrophic blue spots consistent with high-energy transscleral CPC (Figure 2JOURNAL/jcrs/04.03/02158034-202208000-00024/figure2/v/2022-08-01T210317Z/r/image-tiff). In the left eye, she had remnant fixed dilated iris for 270 degrees, missing iris superiorly for 3 clock hours, an adequate AC, and 2+ cortical cataract (Figure 3JOURNAL/jcrs/04.03/02158034-202208000-00024/figure3/v/2022-08-01T210317Z/r/image-tiff). Posterior segment examination revealed a 0.5 cup-to-disc ratio in both eyes with normal vessels, macula, vitreous, and retinal periphery, bilaterally. Given this constellation of findings, how would you proceed?" }, { "id": "wiki20220301en129_16070", "title": "List of Through the Dragon's Eye episodes", "score": 0.008849557522123894, "content": "light shoots out of his hand and melts the object he is pointing at. He threatens to melt Morris as well, but Jenny decides it would be safer to help him after all. Doris tries to contact Boris as discreetly as possible, but Charn sees her at the last minute, and melts her.Clues in the Snow was aired on 24 October 1989" }, { "id": "pubmed23n0724_10853", "title": "[A 56-year-old woman with adult-onset ophthalmoplegic migraine presenting with recurrent bilateral abducens nerve palsy].", "score": 0.008771929824561403, "content": "A 56-year-old woman had been experiencing episodic left eye pain followed within 3 days by double vision and adduction of the left eye since the age of 30. The episodes occurred once per month, and her symptoms spontaneously resolved within 3 days. The patient was diagnosed with ophthalmoplegic migraine (OM) with left abducens nerve palsy at the age of 53 years. In May 2011, she developed bilateral retro-orbital pain followed by double vision and limitation of abduction of the right eye. She recalled having a cold and high fever 10 days before the onset of the headache. MRI showed no thickening or enhancement of the right abducens nerve. Constructive interference in steady-state (CISS) MRI showed neurovascular contact between the right abducens nerve and anterior inferior cerebellar artery. Right abducens nerve palsy accompanied by OM was diagnosed after other diseases that can cause ophthalmoplegia were excluded. The patient's eye symptoms gradually improved following steroid treatment. There have been a few similar case reports of adult patients with OM showing left and right abducens nerve palsy at different time points. In this case report, we discuss the possible mechanisms related to OM." }, { "id": "wiki20220301en104_52424", "title": "One-Eye, Two-Eyes, and Three-Eyes", "score": 0.008771929824561403, "content": "Little table, away and the table would vanish. The wise woman then left and Little Two Eyes spoke the words the woman had told her would summon the table, and to her surprise there it stood. Little Two Eyes ate until she was full and said the words the woman told her would make the table disappear, and immediately it was all gone. Little Two Eyes returned home in the evening and found the plate of leftovers her sisters had left for her, but she did not touch it." }, { "id": "pubmed23n0795_22892", "title": "Anterior segment optical coherence tomography documentation of a case of topiramate induced acute angle closure.", "score": 0.008695652173913044, "content": "We present a case report of a 31-year-old female patient who presented to us with a 1 day history of acute bilateral eye pain, blurred vision and headache. She was found to have a myopic shift, raised intraocular pressure (IOP) and shallow anterior chambers in both eyes. She had been commenced on oral topiramate 1 week previously. A number of investigations, including anterior segment optical coherence tomography (AS-OCT) were done and a diagnosis of topiramate induced bilateral acute angle closure (TiAAC) was made. Topiramate was discontinued and she was managed with topical and oral antiglaucoma medications, topical steroids and cyclopegics. Her symptoms subsided dramatically at the next follow-up. The AS-OCT documentation revealed lucidly the improvement in her anterior chamber depth and anterior chamber angle parameters. Her IOP decreased, her myopic shift showed reversal and her AS-OCT findings revealed gross improvement in all the parameters angle opening distance, trabecular iris space area and scleral spur angle. This case report clearly shows with AS OCT documentation the changes which occur in the anterior segment in a case of TiAAC. " }, { "id": "pubmed23n0779_17405", "title": "\"My eyes are turned outside\".", "score": 0.008695652173913044, "content": "A 78-year-old white woman noted progressively worsening headache, fluctuating decreased vision, dizziness, and binocular horizontal and vertical diplopia of two months duration. She had a 40 prism diopter exotropia and bilateral ophthalmoplegia. An initial temporal artery biopsy (TAB) was negative for findings of giant cell arteritis (GCA). Empiric prednisone was continued, and a second TAB was positive for GCA. In time there was complete resolution of the ophthalmoplegia. " } ] } } }

{ "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, 237 ] ], "word_ranges": [ [ 0, 36 ] ], "text": "A young male patient with an aortic systolic murmur that increases with the Valsalva maneuver and signs of left ventricular enlargement is practically a \"portrait\" of the typical findings that can be found in hypertrophic cardiomyopathy." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Functional murmur.", "2": "Aortic stenosis.", "3": "Aortic insufficiency.", "4": "Hypertrophic cardiomyopathy.", "5": "Ventricular septal defect." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0135_1663", "title": "[Deep Q waves in the ECG of children--an electro-, vector- and echocardiographic study].", "score": 0.017698425074068297, "content": "Out of 9557 children we found 120 children (1,26%), who showed deep Q-waves of greater than or equal to 0.4 mV in 3 consecutive ECG's at least in one of the leads I, aVL, V4, V5 and V6. 70 children were investigated additionally by echocardiography, 45 by vectorcardiography according to Frank. Echocardiography revealed an increased septal thickness in 5 patients, a borderline thickness in 8, an increased septal/posterior wall ratio in 4. In the vectorcardiogram 51,1% of the patients had no Q-waves in lead y, mostly in combination with deep Q-waves in a VL or left axis deviation. Q-waves in lead y were combined with Q-waves in V 5/6. The determination of the main axis coincided in 80% of ECG and VCG. Looking for the various heart diseases, 30% of the children with Q-waves had a ventricular septal defect, 23,3% an endocardial cushion defect, 10,8% a patent ductus arteriosus, 3,3% a bradycardia, 2,5% a Bland-White-Garland syndrome and 1,6% a hypertrophic cardiomyopathy. 17,5% of the children had an innocent heart murmur, 5,8% no cardiac symptoms. Other diseases were found in 5%. The most frequent cause of Q-waves in children were volume-overload of the left ventricle (35%) and left axis deviation (33,3%), whereas myocardial infarction and septal hypertrophy (3,3 and 4,1%) were of minor importance. In healthy children (23,3%) we could not find any pathomechanism." }, { "id": "pubmed23n0834_15407", "title": "Electrocardiographic evolution in patients with hypertrophic cardiomyopathy who develop a left ventricular apical aneurysm.", "score": 0.015522691352449762, "content": "Hypertrophic cardiomyopathy (HCM) patients with apical aneurysm have a largely unfavourable clinical course, and are often unrecognised because echocardiography is limited in the assessment of the left ventricular (LV) apex. The aim of this study is the identification of electrocardiographic (ECG) abnormalities associated with the development of apical aneurysm in HCM patients. Electrocardiographic features were assessed in 14 HCM patients who had a good-quality baseline ECG recorded before and after the diagnosis of apical aneurysm. During follow-up (8.8±7.5years), the following ECG changes were observed: increase in QRS-complex duration (87±12ms to 118±34ms, p=0.006), QRS-complex fragmentation, decrease in QRS-complex amplitude (SV1+RV5-6, from 41±18mm to 26±11mm, p=0.015), ST-segment elevation in V4-V6 (J-point in V5, from -0.9±1.3mm to +0.7±1.3, p=0.003), positivisation of negative T waves in V3-V6 (T-wave depth in V5, from -3.4±6.6 to +3.1±4.1, p=0.005). HCM patients who develop LV apical aneurysm exhibit distinctive ECG changes along with apical remodelling. Suggestive ECGs should lead the physician to study LV apex by nonstandard echocardiographic views, and perform MRI." }, { "id": "pubmed23n0569_7300", "title": "Electrocardiographical case. Asymptomatic patient with deep T-wave inversions.", "score": 0.014772727272727272, "content": "A 45-year-old man was found to have an abnormal myocardial perfusion scan. He was asymptomatic, with no chest pain, breathlessness or palpitations. Clinical examination was unremarkable. The 12-lead electrocardiography (ECG) showed increased QRS voltage in leads V3-V6, and deep T-wave inversions noted in leads V3-V6, with an absence of septal Q waves. These ECG features were characteristic of apical variant hypertrophic cardiomyopathy (HCM). He underwent a coronary angiogram that revealed normal coronary arteries, and a left ventriculogram which showed apical HCM. Transthoracic echocardiography further confirmed the diagnosis. No drug therapy was instituted as he was asymptomatic. Apical HCM is discussed." }, { "id": "pubmed23n0215_3561", "title": "[Use of systolic times and electrocardiography for the evaluation of left ventricle involvement in aortic valve diseases].", "score": 0.014535947712418302, "content": "75 patients suffering from aortic valvulopathy without signs of left ventricular insufficiency have been examined. Left ventricular function is studied by determining systolic times with polygraphic examination (Q-S2, LVET and PEP). The ECG findings were assessed with a myocardial hypertrophy criterion based on a point-score system. Finally, the time of total carotidogram ascent, the 1/2 T and the distance between Q wave and acme of the systolic murmur (Q-acme) were measured. It is concluded that: 1) The most meaningful increases in LVET are associated with the most evident shortenings in PEP only in the phase of the disease in which left ventricular hypertrophy is at its height. 2) The delay in systolic wave ascent should be considered indicative of the functional haemodynamic importance of aortic stenosis, whereas the earliness or otherwise of systolic murmur acme is an expression of the anatomic extent of the stenosis in question." }, { "id": "pubmed23n0135_14277", "title": "[Hypertrophic cardiomyopathy with progressive left ventricular hypertrophy: a case report].", "score": 0.014393052302888367, "content": "A 64-year-old man was hospitalized in March 1983 for recurrent episodes of dyspnea and palpitation despite medical treatment. At 48 years of age (1967), hypertension was diagnosed, but well controlled by propranolol. At the age of 59 years (1979), his first episode of dyspnea and palpitation was noted, with electrocardiographic (ECG) evidence of left ventricular hypertrophy (LVH), and abnormal Q waves in leads III and a VF. The echocardiogram, however, showed mild LVH with neither asymmetric septal hypertrophy (ASH) nor systolic anterior movement (SAM). On admission (1983), his blood pressure was 130/70 mmHg, and a grade III systolic murmur was heard along the left sternal border and over the apex. On ECG, the left precordial voltage (Sv1 + Rv5) was diminished and the depth of the Q wave in lead III increased compared with that of 1978. On echocardiography, we observed prominent septal hypertrophy (IVST: 20 mm) with ASH (IVST/PWT = 2.0), SAM, an enlarged left atrium, and a diminished left ventricular (LV) cavity. Left ventricular catheterization showed a pressure gradient of 90 mmHg between the LV apex and outflow tract and histological examination of the bi-ventricular endomyocardial biopsy material showed markedly hypertrophied and mildly disarranged myocardial fibers with bizarre nuclei. We considered that this was an interesting case in which ASH and SAM developed in the progression of LVH during the follow-up period." }, { "id": "wiki20220301en011_153783", "title": "Heart murmur", "score": 0.014213242368582173, "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": "wiki20220301en042_29388", "title": "T wave", "score": 0.013782940360610263, "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." }, { "id": "pubmed23n0513_13860", "title": "[Repeated changes of electrocardiogram caused by Takotsubo-type cardiomyopathy: a case with hypertrophic nonobstructive cardiomyopathy].", "score": 0.012401015986851935, "content": "A 67-year-old woman had been examined due to abnormalities on electrocardiography (ECG) at a medical checkup three years previously. When a negative T-wave was seen in leads I, aVL, and V1 to V4, but the abnormal findings were improved at consultation. Echocardiography revealed apical hypertrophy and hypertrophic nonobstructive cardiomyopathy was diagnosed. She felt chest discomfort in September, 2003 and an ECG showed a negative T-wave in leads I, II, III aVL, aVF and V2 to V6 and an elongation of QT interval Left ventriculography revealed myocardial hypertrophy at the left ventricular apex and left ventriclar wall motion was normal. Coronary angiography did not show any significant luminal narrowing. I-123 metaiodobenzyl-guanitidine scintigraphy showed marked perfusion defects at the left ventricular apex. After five months, ECG showed an improvement of the QT interval and a decrease in the negative T-wave. We considered that the repeated changes of ECG were caused by Takotsubo-type cardiomyopathy." }, { "id": "pubmed23n0108_6825", "title": "[Regression of giant negative T waves in hypertrophic cardiomyopathy: cases simulating either dilated cardiomyopathy or severe coronary artery stenosis].", "score": 0.012320593452668924, "content": "Two cases of hypertrophic cardiomyopathy (HCM), in whom giant negative T waves resolved during 10 years, are reported. Case 1: A 33-year-old man was admitted in 1975 for careful evaluation because of an ECG abnormality. The ECG revealed a giant negative T wave (GNT) in V5 (-15 mm) and high voltage (SV1 + RV5 = 81 mm). The thickness of the apical wall was 18 mm; the anterior wall, 12 mm; the posterior wall, 16 mm; and the interventricular septum, 17 mm on the left ventriculogram and biventriculogram. The coronary angiogram was normal. From these data, this patient was diagnosed as having HCM. However, follow-up studies disclosed resolution of the GNT with decreased high voltage (SV1 + RV5 = 26 mm). The catheterization performed in 1985 showed a decrease of wall thickness: the apical wall to 10 mm; the anterior wall, 9 mm; the posterior wall, 14 mm; and the interventricular septum, 14 mm. Ejection fraction was markedly decreased from 79.8% to 27.1%, and the wall motion was generally reduced. The coronary angiogram was normal. These findings resemble the clinical pictures of dilated cardiomyopathy (DCM). Case 2: A 58-year-old man was admitted in 1974 because of easy fatiguability. His ECG revealed a GNT in V4 (-10 mm) and high voltage (SV1 + RV5 = 75 mm). The patient was diagnosed as having HCM by cardiac catheterization, right ventricular biopsy and other procedures. In 1985, the depth of the GNT and the voltage of SV1 + RV5 regressed significantly (SV1 + RV5 = 26 mm). The thickness of the apical wall was, 12 mm; the anterior wall, 19 mm; the posterior wall, 13 mm; and the interventricular septum 14 mm during recatheterization. Coronary angiography disclosed stenoses of the left main trunk (75%), the left anterior descending artery (99%) and the left circumflex artery (50%). The right coronary artery was totally occluded. In conclusion, these two cases of HCM had similar changes in their ECG during long-term follow-up studies, but the process was different. One case finally showed clinical pictures of DCM; the other, severe coronary stenoses. These suggested that blood flow to the myocardium is an important determinant for the development of clinical features simulating DCM in cases with HCM." }, { "id": "pubmed23n0477_12564", "title": "[Electrocardiography in cardiomyopathies].", "score": 0.012270324691668763, "content": "ECG plays a predominantly screening role in cardiomyopathies. It is particularly important in hypertrophic cardiomyopathies, where atrial abnormities may be present (25%), positive voltage criteria in hypertrophy of the left ventricle (63%), pathological Q or QS wave (24%), missing septal q in V5 and V6 (49%), missing increase in the R wave in V1-V3 (29%) and high R waves in V2-V3 (15%), changes in repolarization phase of the ST-T segment (87%). The left Tawar arm blockade is particularly typical for dilatation cardiomyopathies. In arrhythmogenic cardiomyopathies of the right ventricle the epsilon ware can be found as well as negative T waves in the leads from the right precordium and ventricular arrhythmias in the shape of the left Tawar arm blockade." }, { "id": "wiki20220301en011_153784", "title": "Heart murmur", "score": 0.01219047619047619, "content": "Ventricular septal defect (VSD) will present as a holosystolic (pansystolic) murmur at the left lower sternal border, associated with a palpable thrill, and increases with isometric handgrip. A right to left shunt (Eisenmenger syndrome) may develop with uncorrected VSDs due to worsening pulmonary hypertension, which will increase the murmur intensity and be associated with cyanosis. Flow murmur may be heard at the right upper sternal border in certain conditions, such as anemia, hyperthyroidism, fever, and pregnancy. Diastolic Aortic valve regurgitation will present as a diastolic decrescendo murmur heard at the left lower sternal border or right lower sternal border (when associated with a dilated aorta). This may be associated with bounding carotid and peripheral pulses (Corrigan's pulse, Watson's water hammer pulse), and a widened pulse pressure." }, { "id": "wiki20220301en563_1338", "title": "List of cardiology mnemonics", "score": 0.012029342361752333, "content": "Renal failure Embolism: pulmonary Complications of Myocardial Infarction Darth Vader Death Arrythmia Rupture(free ventricular wall/ ventricular septum/ papillary muscles) Tamponade Heart failure (acute or chronic) Valve disease Aneurysm of Ventricles Dressler's Syndrome thromboEmbolism (mural thrombus) Recurrence/ mitral Regurgitation Coronary artery bypass graft: indications DUST:p. 31 Depressed ventricular function Unstable angina Stenosis of the left main stem Triple vessel disease ECG: left vs. right bundle block WiLLiaM MaRRoW:p. 31 W pattern in V1-V2 and M pattern in V3-V6 is Left bundle block. M pattern in V1-V2 and W in V3-V6 is Right bundle block. Exercise ramp ECG: contraindications RAMP:p. 31 Recent MI Aortic stenosis MI in the last 7 days Pulmonary hypertension Endocarditis FROM JANE: Fever Roth's spots Osler's nodes Murmur of heart Janeway lesions Anemia Nail hemorrhage Emboli Heart valve sequence Try Puling My Aorta:p. 3 Tricuspid" }, { "id": "wiki20220301en014_34391", "title": "Valsalva maneuver", "score": 0.011992105376067276, "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": "wiki20220301en010_85070", "title": "Aortic stenosis", "score": 0.011530054644808744, "content": "Other peripheral signs include: sustained, heaving apex beat, which is not displaced unless systolic dysfunction of the left ventricle has developed A precordial thrill narrowed pulse pressure Electrocardiogram Although aortic stenosis does not lead to any specific findings on the electrocardiogram (ECG), it still often leads to a number of electrocardiographic abnormalities. ECG manifestations of left ventricular hypertrophy (LVH) are common in aortic stenosis and arise as a result of the stenosis having placed a chronically high-pressure load on the left ventricle (with LVH being the expected response to chronic pressure loads on the left ventricle no matter what the cause)." }, { "id": "article-23680_11", "title": "Intracardiac Shunts -- Evaluation", "score": 0.011180559853126226, "content": "After the initial history and physical examination, further workup should be done as warranted. The extent of evaluation for intracardiac shunts depends on a case-by-case basis and could include blood testing, EKG, echocardiogram, chest x-ray, CT scan, and cardiac catheterization. EKG could indicate signs of pulmonary hypertension from right ventricular hypertrophy (RVH), right axis deviation, and right atrial enlargement. RVH shows tall R wave in V1, dominant S wave in leads V5 and V6 and can also produce p pulmonale and right ventricular strain pattern on EKG that could be evidenced by ST depressions and T wave inversions in the right precordial (V1-V4) and inferior (II, III, aVF) leads. [10]" }, { "id": "article-26551_14", "title": "Palpitation -- History and Physical", "score": 0.010797897754419493, "content": "Positive orthostatic vital signs may indicate dehydration or an electrolyte abnormality. A midsystolic click and murmur may indicate mitral valve prolapse.  A harsh holosystolic murmur best heard at the left sternal border which increases with Valsalva may indicate hypertrophic obstructive cardiomyopathy. Fixed splitting of the S2 throughout the cardiac cycle and a right ventricular heave are characteristic clinical features of the atrial septal defect. An irregular rhythm indicates atrial fibrillation or atrial flutter. Evidence of cardiomegaly and peripheral edema may indicate heart failure and ischemia or a valvular abnormality. [1] [2] [6]" }, { "id": "wiki20220301en011_153734", "title": "Heart sounds", "score": 0.010064935064935065, "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": "pubmed23n0326_5127", "title": "Systolic ejection murmurs in the era of modern cardiology: what do we really know?", "score": 0.010042756289151834, "content": "The basics of pulsatile ejection dynamics are reviewed in order to clarify the relationships among left ventricular and aortic pressures, intra-left ventricular and aortic flow velocities, and cardiovascular sound. The principles of turbulent flow are examined using the Reynolds number concept, and the evidence for cause-and-effect relationships between turbulent flow and murmur generation is presented. Examples of hemodynamics and phonocardiography are given for normal subjects and are compared to patients with aortic stenosis and hypertrophic cardiomyopathy. The concepts presented are used to analyze the results of a new study suggesting increased intraventricular velocities as a new cause for systolic murmurs in adults." }, { "id": "wiki20220301en345_35422", "title": "Handgrip maneuver", "score": 0.009900990099009901, "content": "The handgrip maneuver is performed by clenching one's fist forcefully for a sustained time until fatigued. Variations include squeezing an item such as a rolled up washcloth. Physiological response The handgrip maneuver increases afterload by squeezing the arterioles and increasing total peripheral resistance. Cardiology Since increasing afterload will prevent blood from flowing in a normal forward path, it will increase any murmurs that are due to backwards flowing blood. This includes aortic regurgitation (AR), mitral regurgitation (MR), and a ventricular septal defect (VSD). Mitral valve prolapse: The click and the murmur of mitral valve prolapse are delayed because left atrial volume also increases due to mitral regurgitation along with increased left ventricular volume. Murmurs that are due to forward flowing of blood such as aortic stenosis, and hypertrophic cardiomyopathy decrease in intensity." }, { "id": "pubmed23n0099_4792", "title": "[Extreme cardiac hypertrophy in athletes. Morphological and functional echographic study].", "score": 0.009900990099009901, "content": "Cardiac hypertrophy is an adaptation phenomenon of the heart as a result of increased hemodynamic load due to intense and prolonged training in athletes. This is mainly seen in endurance athletes. In some cases cardiac hypertrophy can mimic hypertrophic cardiomyopathy, specially if hypertrophy is mainly localized at the interventricular septum as compared to the left ventricular free wall. In our study we tried to evaluate the different diagnostic features obtained by echocardiography and clinical examination in a group of 23 athletes with marked hypertrophy (all were participants to the 1984 Olympic Games held in Los Angeles) as compared to a group of 11 sportsmen with non-obstructive hypertrophic cardiomyopathy (HC). Cardiomyopathy was diagnosed on the basis of clinical, echocardiographic and angio-scintigraphic findings. The 23 athletes were selected on the basis of M-Mode and 2D echocardiographic thickness of the interventricular septum (IVS) which was in diastole greater than or equal to 15 mm. They were all asymptomatic, only 4 of the 23 athletes had ECG anomalies due to left axis deviation (LAS) and T wave inversion. Only 4 of the subjects with HC had a family history of HC. ECG changes were the following: T wave inversion (9 subjects), left axis deviation (LAD) (4 subjects), deep Q wave in D2-3, aVF, V5-6 (2 subjects) and low voltage R wave in V5-6 (1 subject). All the athletes had marked hypertrophy of the IVS. Interventricular septum thickness (IVST) was 15.7 +/- 0.6 mm, with a range from 15 to 17.5 mm. Posterior wall thickness (PWT) was 13.7 +/- 1.1 with a range from 12 to 16 mm. The sportsmen with HC had an IVST of 16.2 +/- 3.5 mm and a PWT of 11.3 +/- 1.5 mm. The IVST/PWT ratio was significantly lower (p less than 0.01) in the athletes (1.14 +/- 0.02) when compared to the group with HC (1.4 +/- 0.3). In 7 of the subjects with HC the hypertrophy was mainly localized at the anterolateral segment of the interventricular septum (in 4 of these subjects the hypertrophy involved also the antero-lateral part of the left ventricular free wall).(ABSTRACT TRUNCATED AT 400 WORDS)" }, { "id": "wiki20220301en024_55490", "title": "Aortic regurgitation", "score": 0.009828714913460677, "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": "pubmed23n0974_20919", "title": "A pediatric case of hypertrophic cardiomyopathy with mid-ventricular obstruction incidentally detected by electrocardiography.", "score": 0.00980392156862745, "content": "A 13-year-old girl was admitted to our hospital because mitral P wave and ST depression in leads II, III, aVF, and V3-6 were incidentally detected on electrocardiography at a school health examination. Although she had noted no cardiac symptoms during club volley ball games, the treadmill exercise test induced chest discomfort in the absence of obvious electrocardiographic changes. B-type natriuretic peptide was elevated at 685 pg/ml. Echocardiography revealed left mid-ventricular hypertrophy and obstruction, sparing of the apical ventricle at end-systole, and severe left atrial dilatation. Continuous-wave Doppler echocardiography clarified a peak pressure gradient of about 40 mmHg between the apical and basal sites of the left ventricle. Swan-Ganz catheterization suggested elevated atrial pressure and left ventricular end-diastolic pressure. Left ventriculography showed an \"hourglass\" appearance. Endomyocardial biopsy revealed cardiac muscle cell disarray. We diagnosed a rare pediatric case of hypertrophic cardiomyopathy with mid-ventricular obstruction. This case reconfirms that electrocardiography during school health examinations is a very important screening tool for the detection of asymptomatic or mild symptomatic cardiac diseases." }, { "id": "wiki20220301en063_19531", "title": "Valvular heart disease", "score": 0.009801118312364977, "content": "Diagnosis Aortic stenosis Patients with aortic stenosis can have chest X-ray findings showing dilation of the ascending aorta, but they may also have a completely normal chest X-ray. Direct visualization of calcifications on chest X-ray is uncommon. Other findings include dilation of the left ventricle. ECG typically shows left ventricular hypertrophy in patients with severe stenosis, but it may also show signs of left heart strain. Echocardiography is the diagnostic gold standard, which shows left ventricular hypertrophy, leaflet calcification, and abnormal leaflet closure." }, { "id": "wiki20220301en011_153779", "title": "Heart murmur", "score": 0.009788760200052645, "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": "article-36084_13", "title": "Aortic Valvular Atresia -- Evaluation", "score": 0.009672208651800488, "content": "The initial electrocardiogram classically shows right axis deviation, right ventricular hypertrophy, and right atrial enlargement, though it can also show a pattern considered normal for patient age. This is generally attributed to the hypoplastic left side of the heart, but there are a few reported cases of left axis deviation and rarely, left ventricular hypertrophy. There are occasionally problems with bundle branch conduction, and Wolff-Parkinson-White pattern, as well as right bundle branch block, have been reported. There is a reported lack of a Q wave in lead V6, and this has been reported as a possible exclusion marker for aortic valvular atresia. It should be noted, though, that the lack of this finding is not specific for aortic valvular atresia, as other congenital heart conditions or even normal infants may lack the Q wave in this lead. T wave depressions in leads I and II, as well as ST-segment depressions in the left precordial leads, have also frequently been reported. [5] [8]" }, { "id": "wiki20220301en100_5617", "title": "List of MeSH codes (C14)", "score": 0.009615384615384616, "content": "– heart failure, congestive – cardiomyopathy, dilated – dyspnea, paroxysmal – edema, cardiac – heart neoplasms – heart rupture – heart rupture, post-infarction – ventricular septal rupture – heart valve diseases – aortic valve insufficiency – aortic valve stenosis – aortic stenosis, supravalvular – williams syndrome – aortic stenosis, subvalvular – cardiomyopathy, hypertrophic – discrete subaortic stenosis – heart murmurs – heart valve prolapse – aortic valve prolapse – mitral valve prolapse – tricuspid valve prolapse – mitral valve insufficiency – mitral valve stenosis – pulmonary atresia – pulmonary valve insufficiency – pulmonary valve stenosis – leopard syndrome – pulmonary subvalvular stenosis – tricuspid atresia – tricuspid valve insufficiency – tricuspid valve stenosis" }, { "id": "pubmed23n0378_17950", "title": "Apical hypertrophic cardiomyopathy (apical hypertrophy): an overview.", "score": 0.009615384615384616, "content": "Clinical and laboratory data of apical hypertrophy were reviewed based on our experience of over 200 consecutive patients, of whom 126 patients were followed up by myself for more than 1 year (1 to 29 years). Emphasis was placed on various aspects of electrocardiography including the natural course and \"wax and wane\" phenomenon of giant negative T waves (GNT). Recent diagnostic modality, i.e., cardiac magnetic resonance imaging was also stressed. Apical hypertrophic cardiomyopathy (apical hypertrophy) was mainly discovered by annual health check including electrocardiography and characterized by giant negative T waves (GNT; -1.0-(-)4.2 mV) in the left precordial leads (V4 or V5) in middle-aged men. Transition from normal T wave to negative T wave required several years and remained usually unchanged thereafter. This change may occur rather abruptly on rare occasions. Disappearance of GNT may also occur slowly and progressively in patients, in whom apical aneurysm had developed. The diagnosis may be obtained with echocardiography, left ventriculography or ultrafast computed tomography, but was most accurate with cardiac magnetic resonance imaging, by which identification of the diversity of hypertrophy was achieved, because the multiple short-axis views were accurately obtained in addition to the exact long-axis view. Hypertrophy was not simple but quite complex in both morphology and grade. Gene abnormality may be present even in cases of apical hypertrophy. The prognosis of apical hypertrophy in Japan has been benign, and heart failure due to atrial fibrillation and left ventricular aneurysm due to the destruction of hypertrophied muscle are thought to have prognostic importance, but these were rare in our series." }, { "id": "pubmed23n0972_3826", "title": "A natural history of apical hypertrophic cardiomyopathy with development of an apical aneurysm formation: A case report following a quarter century.", "score": 0.009523809523809525, "content": "We report the definite long-term natural history of a man with apical hypertrophic cardiomyopathy (ApHCM), who developed an apical aneurysm by the age of 60 years. At 33 years, his electrocardiogram (ECG) was nearly normal. T-wave inversions were first identified in leads V5-6 of an ECG at 36 years of age. Echocardiography first demonstrated a left ventricular (LV) lateral wall hypertrophy at 37 years of age. At 42 years, echocardiography showed the pattern of diastolic spade-like appearance of the LV cavity, confirming the ApHCM diagnosis. At 54 years, a late-peaking apical systolic gradient of 10 mmHg (velocity: 1.6 m/s) emerged. At 60 years, he had developed an apical aneurysm. Cardiac computed tomography revealed no significant major coronary artery stenosis. Thus, in our case, LV hypertrophy and apical high pressure in ApHCM advanced the formation of an apical aneurysm in the absence of coronary artery disease. &lt;<bLearning objective:</b High apical systolic flow velocity of ≥1.5 m/s in apical hypertrophic cardiomyopathy (ApHCM) using echocardiography may be predictive of the development of apical aneurysm, and make us consider medical intervention by beta-blockers or verapamil to delay or prevent aneurysm formation. Because recent studies have demonstrated that ApHCM may be less benign than previously suspected, observation without medical attention for ApHCM might be hazardous.&gt;." }, { "id": "wiki20220301en345_35423", "title": "Handgrip maneuver", "score": 0.009433962264150943, "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": "article-17742_11", "title": "Aortic Regurgitation -- History and Physical -- Physical Examination", "score": 0.009419856459330144, "content": "AR is associated with widened pulse pressure as a result of systolic hypertension and decreased diastolic pressure. The apical LV impulse is hyperdynamic and displaced laterally and inferiorly. A prominent systolic thrill may be palpable at the base of the heart or suprasternal notch and over the carotid arteries. It is caused by the large forward stroke volumes and low aortic diastolic pressure. S1 is normal, but S2 is increased (with a dilated aortic root) or decreased (when the aortic leaflets are thickened). A high frequency, blowing, decrescendo, diastolic murmur is heard best third intercostal space along the left sternal border. It is easier to appreciate the murmur of AR at the end of expiration while the patient is leaning forward.  The murmur increases with squatting or isometric exercise and decreases with maneuvers that decrease blood pressure. This murmur is early diastolic with mild AR and becomes holodiastolic with severe AR." }, { "id": "pubmed23n0039_2748", "title": "Idiopathic hypertrophic subaortic stenosis.", "score": 0.009345794392523364, "content": "The clinical and laboratory findings in 29 patients with idiopathic hypertrophic subaortic stenosis are presented. Dyspnoea during exercise, angina pectoris, syncope combined with left ventricular hyperthrophy on ECG and chest X-ray and a systolic ejection murmur at the apex and the left sternal border are the most important findings. The findings were different in patients below and above 30 years of age. Most of the patients below 30 were in function group I, had a normal heart volume on chest X-+ray, and syncope was related to exercise. All patients above 30 had symptoms, nearly all were in function groups II-IV and often complained of palpitations, had increased heart volume on chest X-ray, sign of enlarged left atrium or atrial fibrillation of ECG. Syncope was not related to exercise, but always associated with palpitation in patients above 35 years of age. Pathologic Q waves were found more often in the younger age group. The differential diagnosis is discussed in relation to fixed aortic stenosis, mitral valve disease, ventricular septal defect, coronary artery disease, and hypertrophic cardiomyopathy without outflow tract obstruction." }, { "id": "pubmed23n0109_2018", "title": "[Clinical significance of electrocardiographic P-terminal force in V1 in patients with hypertrophic cardiomyopathy].", "score": 0.009345794392523364, "content": "The clinical usefulness of P-terminal force in lead V1 (P-TF) was evaluated in 49 patients with hypertrophic cardiomyopathy. These 49 patients were categorized as 17 with an abnormal P-wave (P-TF greater than or equal to 3.0 msec.mV: group A) and 32 with a normal P-wave (P-TF less than 3.0 msec.mV: group B). Systolic blood pressure response (delta SBP) during the treadmill exercise test was significantly less in the group A than in the group B (delta SBP: 36 +/- 22 mmHg, 58 +/- 26 mmHg, respectively). Left atrial dimension measured from the M-mode echocardiogram was 37.8 +/- 5.0 mm in the group A and 31.0 +/- 5.2 mm in the group B. These differences were statistically significant (p less than 0.05). Left ventricular end-diastolic pressure averaged 19.5 +/- 7.9 mmHg in the group A and 13.5 +/- 4.0 mmHg in the group B (p less than 0.05). When comparing the group A and B, negative dp/dt / positive dp/dt of the group A was significantly less (0.69 +/- 0.14, 0.90 +/- 0.18, respectively) and the time constant T of the group A was significantly prolonged (86 +/- 30 msec, 56 +/- 10 msec, respectively). According to classifications of hypertrophic cardiomyopathy, all patients with the obstructive type had an abnormal P-wave. On the contrary, the majority of patients with apical hypertrophy had a normal P-wave.(ABSTRACT TRUNCATED AT 250 WORDS)" } ] } } }

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{ "1": "Transhiatal esophagectomy.", "2": "Esophagectomy according to the Ivor-Lewis technique.", "3": "Chemotherapy plus preoperative radiotherapy.", "4": "Neoadjuvant chemotherapy.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0982_16653", "title": "The controversy of esophageal carcinosarcoma: A case report and brief review of literature.", "score": 0.01752123786407767, "content": "Esophageal carcinosarcoma (ECS) is defined as a relatively rare malignant neoplasm with both epithelial carcinomatous and sarcomatous components. Besides, there were so many various controversies in ECS. This article describes a case of ECS that was effectively treated with radical esophagectomy and adjuvant chemotherapy. Also, we discuss the presentation, differential diagnosis, treatment, and prognosis of ECS. A 58-year-old man presented with a history of progressive dysphagia and precordial pain after swallowing for 1 month. Esophagogastroduodenoscopy (EGD) revealed a large polypoid neoplasm that occupied the esophageal lumen 30 to 34 cm from the incisors. On the characteristic morphology, clinical symptom and biopsy findings, the ECS was the primary considerated. Computed tomography (CT) examination demonstrated no radiological evidence of metastatic disease. The patient underwent an Ivor Lewis esophagectomy, coupled with adequate lymph node dissection (2-field lymphadenectomy). ECS was confirmed by pathology report of postoperative. Then, the patient underwent adjuvant chemotherapy with docetaxel, oxaliplatin, and capecitabine. The patient remained alive without tumor recurrence at 24 months after multidisciplinary therapy. It is generally treated by surgery, radiotherapy, and chemotherapy according to the protocols used for other esophageal cancers (EC). However, there is no recommended clinical treatment for ECS because of the rarity of the disease. Esophagectomy with extended lymphadenectomy followed by adjuvant chemotherapy with docetaxel, oxaliplatin, and capecitabine may be recommended treatment for ECS. Chemotherapy regimen with docetaxel, oxaliplatin, and capecitabine may be a suitable adjuvant therapy for ECS." }, { "id": "pubmed23n0787_8559", "title": "The current evidence in support of multimodal treatment of locally advanced, potentially resectable esophageal cancer.", "score": 0.01738934056007227, "content": "Treatment of locally advanced resectable esophageal cancer is challenging. In the past three decades surgical treatment has become safer, chemotherapy more powerful and radiation techniques more precise. Today's stage-dependent treatment relies on modern diagnostic tools such as multidetector helical CT, high-frequency endoscopic ultrasound, PET, image fusion techniques and MRI. Specialists cooperate on multidisciplinary tumor boards that follow transparent decision trees based on the newest evidence. Results of recent randomized controlled trials are examined with emphasis on their reliability and comparability. Patients with esophagogastric cancer undergoing neoadjuvant chemotherapy, perioperative chemotherapy and neoadjuvant radiochemotherapy plus esophagectomy had a higher R-0 resection rate, fewer involved lymph nodes and better overall survival than with esophagectomy alone. While perioperative morbidity and mortality were not remarkably enhanced by neoadjuvant chemotherapy, several trials showed an increase of mortality after neoadjuvant radiochemotherapy. Adenocarcinoma seems to respond better to chemotherapy than squamous cell cancer, and squamous cell cancer seems to respond better to radiochemotherapy than adenocarcinoma. On the basis of the results of randomized trials, preoperative treatment of esophageal cancer shows a survival benefit and should be recommended as the standard treatment strategy in advanced esophageal cancer. While preoperative radiochemotherapy is the standard for advanced squamous cell cancer, both chemotherapy and radiochemotherapy may be adopted for neoadjuvant/perioperative treatment of adenocarcinoma depending on the patient's general condition. Markers to predict response are urgently needed since only responders benefit from multimodal treatment and nonresponders suffer potential harm when surgery is delayed." }, { "id": "pubmed23n0636_20833", "title": "Effects of neoadjuvant radiochemotherapy on pathological staging and prognosis for locally advanced esophageal squamous cell carcinoma.", "score": 0.015109890109890112, "content": "The role of neoadjuvant therapy in the treatment of locally advanced esophageal carcinoma still remains controversial. The aim of this study was to evaluate the effects of neoadjuvant radiochemotherapy on pathological staging and prognosis in the patients with locally advanced esophageal squamous cell carcinoma. Between January 1991 and December 2000, 473 patients with advanced esophageal carcinoma diagnosed by endoscopic biopsy underwent surgical resection in our center. With informed consent, they were randomized into four groups: neoadjuvant chemotherapy, neoadjuvant radiotherapy, neoadjuvant radiochemotherapy, and surgery alone (control group). The preoperative computed tomography staging criteria were the following: Stage I, the tumor limited to the esophageal lumen or the thickness of the esophageal wall varied between 3-5 mm; Stage II, the thickness exceeds 5 mm but no invasion to the mediastinum or distant metastasis; Stage III, the tumor invades adjacent mediastinal structure; and Stage IV, there is distant metastasis. The tumor resection rate, pathological stage, treatment-related complication, and survival among groups were compared. The radical resection rate for the patients in radiotherapy and radiochemotherapy groups was increased in comparison with the control group (P &lt; 0.05). Their pathological stage after esophagectomy was regressed significantly than that of the control group (50.85%, 55.08% vs. 0%, P &lt; 0.05). The adjuvant chemotherapy group did show significant improvement on resection rate and pathological staging compared with the control group. The treatment-related complication in the three neoadjuvant groups had no significant difference from that of the control group (P &gt; 0.05). The 3-year survival rate of radiotherapy and radiochemotherapy groups were significantly higher than that of the control group (69.49%, 73.73% vs. 53.38%, P &lt; 0.05). The 5-year survival rate of radiochemotherapy group was higher than that of the radiotherapy group although did not show a statistical difference (P &gt; 0.05). Rational application of neoadjuvant radiochemotherapy seems to provide a modest benefit in radical resection and survival in patients with locally advanced esophageal carcinoma." }, { "id": "pubmed23n0845_18804", "title": "[A Case of Early Recurrence after Esophagectomy for Cancer Following Neoadjuvant Chemotherapy Resulting in a Complete Response of the Primary Lesion].", "score": 0.01365079365079365, "content": "A 78-year-old man presented with a chief complaint of dysphagia. He was diagnosed with an esophageal squamous cell carcinoma and referred to our hospital. A type 3 tumor was identified in the lower thoracic esophagus on endoscopy. A CT scan revealed lymph node metastases at the No. 3 station. The clinical stage of the tumor was T3N1M0, Stage III. The patient was treated with neoadjuvant chemotherapy consisting of2 courses of5 -FU and nedaplatin. He had a partial response and underwent a radical esophagectomy. Histopathological examination revealed a complete response of the primary lesion and viable cancer cells in only one lymph node at the No. 3 station. No adjuvant chemotherapy was administered. Three months after the operation, recurrences in the upper abdominal multiple para-aortic lymph nodes were detected. Although he was treated with chemotherapy, he died 7 months after the operation. Even after a complete response of the primary lesion was achieved using neoadjuvant chemotherapy, esophageal cancer with lymph node metastasis has the potential for an early recurrence. Therefore, we should consider adjuvant therapy in such cases." }, { "id": "pubmed23n0989_2819", "title": "Successful multidisciplinary treatment including repeated metastasectomy for recurrent squamous cell esophageal carcinoma: a case report.", "score": 0.01317214784002773, "content": "Recurrences after radical esophagectomy are common. The prognosis for recurrent esophageal cancer is generally poor. Recurrences usually occur between 1 and 3 years of surgery, with the duration of median survival after recurrence ranging from 5 to 10 months. The number of sites and involved organs vary among patients. Consequently, a standard therapeutic strategy has not been established, and the role of surgery in the management of recurrence is unclear. A 67-year-old man presented with dysphagia 6 months previously and was diagnosed with esophageal squamous cell carcinoma (ESCC) in the upper thoracic region (T2M0M0, stage IB), for which he underwent thoracoscopy-assisted esophagectomy and lymphadenectomy. Adjuvant chemotherapy was not prescribed. Three years after the operation, he developed a solitary metastasis in the left lung, requiring segmentectomy followed by chemotherapy with combined cisplatin (CDDP) and 5-fluorouracil (5-FU). The following year, a metastatic lesion was recognized in the right lung, invading the chest wall, for which he underwent partial lobectomy with local chest wall resection. Multiple mediastinal and abdominal lymph node (LN) metastases were detected in the right lung a year later, which necessitated chemoradiation to a dose of 50.4 Gy with concomitant CDDP and 5-FU. Post-treatment computed tomography (CT) showed a good response. Positron emission tomography (PET)-CT revealed a reduction in the metastatic LNs with no fluoro-deoxy-glucose (FDG) uptake. The following year, metastases were detected in the left cervical LNs. Owing to the limited extent of metastases, resection was followed by chemoradiation to a dose of 50 Gy with CDDP and 5-FU. The following year, metastases were detected in the mediastinal LNs; chemotherapy was administered with nedaplatin and docetaxel. The follow-up CT and PET-CT demonstrated complete disappearance of the tumor, and the patient is currently surviving without recurrence for 11 years from the first curative operation. This case demonstrates that aggressive multidisciplinary treatment including surgery and radiation to achieve local control could be a meaningful treatment strategy in cases with limited and slowly occurring recurrences." }, { "id": "pubmed23n0314_21509", "title": "[Esophageal cancer].", "score": 0.012699433348068962, "content": "Esophageal cancer is a pathology with a remarkable geographical variety, considered to be a disease of the poor. The common incidence reported in western countries of 3 per 100,000 per year, contrasts with 140 per 100,000 reported in Central Asia in an area that is known as the \"esophageal cancer belt\". Among a wide spectrum of potential etiologic agents, the use of alcohol and tobacco remain the most frequently reported. The most common pathologic type is squamous cell carcinoma, although is important to consider that in the past decades, a shift to adenocarcinoma has been consistently observed. This phenomenon might have an explanation in the inclusion of tumors of the cardia and the importance of metaplasic Barret's epithelium and gastroesophageal reflux. As it happens in the majority of gastrointestinal tumors, diagnosis is often done late in esophageal cancer. The most common presenting symptoms of esophageal cancer are dysphagia and weight loss. Others are, odynophagia, upper GI bleeding, hoarseness and respiratory symptoms. In patients with advanced disease, diagnostic studies are confirmatory in nature. The combined use of contrast esophagogram and endoscopy yield to a diagnostic accuracy above 95%. These studies have to be complimentary. Computed tomography is the best modality for staging tumors of the esophagus. Although its accuracy varies from one study to another, demonstration of disease beyond the esophagus precludes surgical treatment. Endoluminal ultrasound has assumed an important role as part of the staging studies, considered by some authors superior to CT scanning. Its use is not considered rutinary because of the difficulty on passing the instrument through an obstructive lesion, and to the fact that this technology is not widely available. In the majority of patients, surgical treatment is considered to be palliative, due to the presence of advanced disease at the time of diagnosis. From the multiple surgical options available, transhiatal esophagectomy without thoracotomy is one of the more widely accepted techniques. Controversy persists regarding the optimal surgical approach to the disease. It is well accepted that prognosis depends more in the biology of the tumor and the stage of the disease rather than the surgical procedure. Overall five year survival after esophageal resection is 20%, regardless of the surgical option. Other alternatives are standard transthoracic esophagectomy, the thoraco-abdominal approach and the triple approach with extensive lymphadenectomy of cervical, mediastinal and abdominal areas. These latter procedures carry more morbidity and mortality rates. It is probably the multimodality approach with pre or postoperative chemotherapy and radiotherapy what can impact in further improvement of the poor survival rates for this disease. This combined approach is currently being investigated under control prospective randomized trials." }, { "id": "pubmed23n0695_24969", "title": "Curative treatment of oesophageal carcinoma: current options and future developments.", "score": 0.011174579392577332, "content": "Since the 1980s major advances in surgery, radiotherapy and chemotherapy have established multimodal approaches as curative treatment options for oesophageal cancer. In addition the introduction of functional imaging modalities such as PET-CT created new opportunities for a more adequate patient selection and therapy response assessment.The majority of oesophageal carcinomas are represented by two histologies: squamous cell carcinoma and adenocarcinoma. In recent years an epidemiological shift towards the latter was observed. From a surgical point of view, adenocarcinomas, which are usually located in the distal third of the oesophagus, may be treated with a transhiatal resection, whereas squamous cell carcinomas, which are typically found in the middle and the upper third, require a transthoracic approach. Since overall survival after surgery alone is poor, multimodality approaches have been developed. At least for patients with locally advanced tumors, surgery alone can no longer be advocated as routine treatment. Nowadays, scientific interest is focused on tumor response to induction radiochemotherapy. A neoadjuvant approach includes the early and accurate assessment of clinical response, optimally performed by repeated PET-CT imaging and endoscopic ultrasound, which may permit early adaption of the therapeutic concept. Patients with SCC that show clinical response by PET CT are considered to have a better prognosis, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved." }, { "id": "pubmed23n1139_84", "title": "Predictive Value of Endoscopic Observations and Biopsy After Neoadjuvant Chemoradiotherapy in Assessing the Pathologic Complete Response of Patients With Esophageal Squamous Cell Carcinoma.", "score": 0.01039136302294197, "content": "No standard method has been defined to evaluate the therapeutic response of esophageal cancer to neoadjuvant chemoradiotherapy (CRT). This study aimed to determine the predictive value of endoscopic evaluation and biopsy after CRT in predicting the complete pathological response to neoadjuvant CRT in patients with esophageal squamous cell carcinoma (SCC). This prospective, descriptive study was conducted on patients with stage II and III esophageal SCC who could undergo esophagectomy. Patients underwent neoadjuvant CRT. Four to six weeks after the end of treatment, re-endoscopy was performed and a biopsy was taken in the presence of a tumor lesion. In the absence of a tumor lesion, the marked site of the esophagus was removed as a blind biopsy. Gastrologist observations during endoscopy and the result of the pathological examination of an endoscopic biopsy were recorded. The patient underwent esophagectomy. The pathology obtained from endoscopic biopsy was compared with the pathology response obtained from esophagectomy. Sixty-nine patients were included in the study, of which 32 underwent esophagectomy. In an endoscopic examination after CRT, 28 patients had macroscopic tumor remnants and 4 patients did not. Pathological examination of the samples obtained from endoscopy showed no tumor remnants in 10 patients (31.3%), and in 22 patients (68.7%), living tumor remnants were seen in the biopsy specimen. Pathologic evaluation of the samples obtained by surgical resection showed that in 13 patients, there were no viable carcinomas in the esophagus or lymph nodes removed, and the rate of pathologic complete response was 40.6. Sensitivity, specificity, positive predictive, and negative predictive values of endoscopic observations were 94.7, 23, 64.2, and 75%, respectively. Preoperative biopsy sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 68.4, 30.7, 59, and 40%, respectively. Considering the negative and positive predictive values of endoscopic observations and biopsy after neoadjuvant CRT, it seems that these two methods alone are not suitable for assessing the pathologic complete response after neoadjuvant treatment." }, { "id": "pubmed23n0943_22557", "title": "Symptom Management for Patients With Esophageal Cancer After Esophagectomy.", "score": 0.009900990099009901, "content": "<bCASE STUDY</b KD is a 67-year-old man with a medical history of hypertension, asthma, and a 20-pack/year smoking history who developed progressive dysphagia 8 months ago. Upon consultation with his primary care provider, he underwent an esophagogastroduodenoscopy (EGD) for evaluation. A friable mass was visualized at the gastroesophageal junction, and biopsies confirmed adenocarcinoma of the esophagus. KD completed a staging evaluation with positron-emission tomography/computed tomography (PET/CT), which did not reveal distant metastatic disease. He also had an endoscopic ultrasound (EUS), which showed the tumor invading the muscularis propria and did not identify any enlarged regional lymph nodes (stage T3N0 disease). KD was referred to a medical oncologist and a radiation oncologist; he underwent concurrent chemoradiation therapy with docetaxel and fluorouracil and radiation therapy (50.4 Gy). KD was referred to thoracic surgery following restaging with PET/CT and EGD; there was no evidence of distant metastatic disease, and pathology findings revealed residual adenocarcinoma in one of the four esophageal biopsies. KD underwent Ivor Lewis esophagectomy and had a jejunostomy tube placed for nutritional requirements for 10 weeks as he adjusted to oral nutrition. Surgical pathology findings revealed residual adenocarcinoma with treatment effect; no malignancy was detected in the sampled regional lymph nodes. Four months later, KD presents with complaints of frequent postprandial diarrhea and reflux. He says he has been trying to lie down after meals due to palpitations and flushing. He is anxious about these symptoms and fearful about his long-term prognosis adjusting to the side effects of esophagectomy and would like to discuss lifestyle modifications." }, { "id": "pubmed23n0594_2846", "title": "[Current status of initial staging and posttreatment response evaluation in esophageal carcinoma].", "score": 0.009900990099009901, "content": "There has been remarkable progress in diagnostic modalities in recent years. The development of endoscopic instruments and introduction of fluoro deoxy glucose-positron emission tomography (FDG-PET) and sentinel node (SN) diagnosis markedly improved diagnostic quality. The requirement for individualized treatment is increasing with the progress in less-invasive treatment, and therefore it is necessary to select the optimal treatment individually on the basis of accurate tumor staging. In diagnosis of the T category, zoom endoscopy and autofluorescence imaging/narrow band imaging technology improved the diagnostic accuracy of T1 stage. T2 or higher tumors are diagnosed with endoscopic ultrasonography (EUS) and multidetector computed tomography (CT). In diagnosis of the N category, FDG-PET was expected to be useful. However, it often gave false-negative lymph node (LN) results, and was revealed to have low sensitivity in contrast to high specificity. It is important to detect swollen LNs using CT and then to assess qualitatively the presence or absence of metastasis with EUS and FDG-PET. SN diagnosis using radioisotopes as tracers was introduced as preliminary research for subsequent less-invasive surgery. In diagnosis of the M category, FDG-PET is currently the most important to obtain additional information missed on CT, because FDG-PET can assess the whole body. For response evaluation to neoadjuvant treatment, FDG-PET is extremely useful. It can predict histologic response and postoperative survival accurately and allow diagnosis of distant metastases in the entire body simultaneously. All information needed for a decision on surgical indications can be acquired noninvasively, and therefore FDG-PET may be the key modality in multimodality treatment." }, { "id": "pubmed23n1025_11346", "title": "Radiation-induced hepatitis masquerading as metastatic disease: the importance of correlating diagnostic imaging with treatment planning.", "score": 0.00980392156862745, "content": "We are presenting a 63-year-old Caucasian male who complained of 2 months of progressive dysphagia. Upper endoscopy discovered a mass in the distal esophagus near the gastroesophageal junction. Biopsy was consistent with adenocarcinoma. Endoscopic ultrasound (EUS) showed extension beyond the muscularis propria, with an enlarged paraesophageal lymph node (T3N1). Initial positron emission tomography (PET)/computed tomography (CT) showed hypermetabolic portocaval lymphadenopathy presumed to be metastatic, but otherwise without distant disease extension. Neoadjuvant treatment included induction FOLFOX followed by 5,600 cGy over 28 fractions in combination with 5-FU and oxaliplatin. Approximately 3.5 weeks after completion, a repeat PET/CT revealed reduced uptake in both the primary esophageal mass and regional lymph nodes. Of note there were several new mass-like foci of hypermetabolism in the liver, specifically the left lobe, concerning for metastatic disease. Image-guided biopsy did not show any identifiable lesions, but sampling was performed based on anatomical landmarks. Pathology revealed benign parenchyma with minimal inflammation and mild reactive regeneration. In light of this, the patient proceeded to undergo definitive resection via robotic Ivor-Lewis esophagectomy with only 1 positive lymph node. Given pleural involvement by the tumor, staging was revised to pT4aN1 with final histology characterized as adenosquamous carcinoma. Postoperative course was fairly uneventful, with a mild exacerbation of his chronic heart failure. The patient was discharged on post-operative day 7, with his feeding tube removed at his 2-week post-operative clinic visit. This scenario is of particular educational value from the standpoint that when the post-treatment PET/CT images are registered to the radiotherapy treatment planning CT and dose, the areas of abnormal uptake in the liver fall within the higher dose regions. Given this and the liver biopsy findings, caution should be exercised before declaring progressive disease following radiotherapy without first reviewing the treatment plan." }, { "id": "pubmed23n0237_575", "title": "[Current status of esophageal neoplasms. I].", "score": 0.00980392156862745, "content": "In Europe, carcinoma of the esophagus is a relatively rare disease with an annual mortality rate of 4-7 deaths per 105 inhabitants. Institution of appropriate therapy for esophageal carcinoma depends mainly on accurate diagnosis and staging. Computed tomography displays the anatomy of the esophagus and mediastinum with a high degree of accuracy and is a good method of assessing extra-esophageal spread of carcinoma. Preoperative nutritional support may reduce operative mortality and morbidity in high-risk patients. Today there is still no alternative to resection of the carcinoma. Esophagogastrectomy with (cervical) esophagogastrostomy with or without thoracotomy is the treatment of choice for patients with squamous cell carcinoma of the esophagus. Prognosis is still poor, with a 5-year survival rate of less than 20%. If resection is technically impossible, an endoesophageal tube can be inserted or a bypass procedure carried out to increase the quality of life with near normal ability to swallow. Radiotherapy can be used when surgery primarily is not applicable for medical reasons or is refused. Preoperative radiotherapy does not produce statistically significant short- or long-term benefit in the management of esophageal squamous cell carcinoma. Chemotherapy or combination chemotherapy have so far been insufficiently tested and cannot be recommended today for routine use. A combined modality approach is promising but needs further evaluation." }, { "id": "pubmed23n0109_8245", "title": "[Multidisciplinary treatment of thoracic esophagus carcinoma based on preoperative staging].", "score": 0.009708737864077669, "content": "Recently, with developments in CT scanning and endoscopic ultrasound (EUS), in addition to conventional ultrasound (US), significant advances have been made in the evaluation of preoperative staging. Evaluation of the presence of A3 invasion is made on the basis of X-ray, CT and EUS findings. In superficial cases of ep, mm or sm, EUS with particular reference to the X-ray and endoscopic appearance is very effective, and in our department the diagnostic accuracy in cases of mucosal lesions is 88%, while it is 84% in sm cases. Diagnosis of metastasis to cervical and abdominal lymph nodes is performed by US, while diagnosis of mediastinal lymph node metastasis is performed by EUS. The accuracy of US for detecting cervical and abdominal lymph node metastases, including those approximately 0.5 cm in size, is 95%, while that of EUS in the diagnosis of metastasis to mediastinal nodes is 89%. The 5-year survival of patients with lymph node metastasis significantly affects prognosis. Based on this, since 1985, extended dissection in the cervical, thoracic and abdominal regions has been carried out. Since 1985, some resected cases have been treated with pre- or postoperative adjuvant chemotherapy regimens, centered primarily on CDDP (majority of cases with CDDP + VDS). A significant improvement has been obtained in the 1-2-year survival of C greater than O resected cases treated since 1985, compared with cases in 1980-1984. This improvement is thought to be due to dissection of lymph nodes in the three major regions, based on more accurate preoperative evaluation and the introduction of postoperative adjuvant chemotherapy." }, { "id": "pubmed23n0727_9568", "title": "Can common hepatic artery lymph node dissection be safely omitted in surgery for clinical T1N0 thoracic esophageal squamous cell carcinoma?", "score": 0.009615384615384616, "content": "Common hepatic artery lymph node dissection is regarded as a standard procedure in esophageal cancer surgery because of aggressive lymphatic dissemination of esophageal cancer. However, lymph node dissection can prolong operation time and may be associated with complications such as chylous ascites. Here, we aimed to evaluate the effectiveness of common hepatic artery lymph node dissection in clinical T1N0 thoracic esophageal squamous cell carcinoma. Between 1996 and 2009, 1390 patients underwent surgery for esophageal cancer in our institution, and 209 were found to have clinical T1N0 disease. Exclusion criteria were nonsquamous carcinoma, double primary cancer, definite distant metastasis, administration of neoadjuvant treatment, and incomplete abdominal lymph node dissection. We retrospectively analyzed medical records, operative and pathologic data, and follow-up information. Forty-two patients were excluded from the study. Among the 167 enrolled patients, preoperative endoscopic ultrasound evaluation was performed in 160 patients. Fifty-two patients had distal esophageal or esophagogastric junction tumor. Surgery included 2 cases of tri-incisional esophagectomy, 17 cases of transhiatal esophagectomy, and 148 cases of two-field esophagectomy (Ivor Lewis operation). Common hepatic artery lymph node dissection was performed in all cases, and none of the patients had metastasis. Mean follow-up period was 35.4 ± 28.7 months. In-hospital mortality was one, and 5-year survival rate was 80.6%. Among the 15 patients with recurrence, there were two distant metastases and five distant and local recurrences but no intra-abdominal recurrence with common hepatic artery lymph node. Common hepatic artery lymph node dissection may be safely omitted in surgery for clinical T1N0 esophageal squamous cell carcinoma when preoperative evaluations including chest computed tomography, positron emission tomography and computed tomography, and esophagogastroduodenoscopy or endoscopic ultrasound are performed." }, { "id": "pubmed23n0285_5611", "title": "Concurrent radiation therapy and chemotherapy followed by esophagectomy for localized esophageal carcinoma.", "score": 0.009523809523809525, "content": "A prospective study was performed to determine the outcome of patients with esophageal cancer who received preoperative radiation therapy and chemotherapy followed by esophagectomy, and to determine the role of preresection esophagogastroduodenoscopy (EGD) in predicting the patients in whom surgery could possibly be omitted, and the impact of surgery on survival. Thirty-five patients with localized carcinoma of the esophagus received concurrent external-beam radiotherapy and chemotherapy followed by esophagectomy. Patients received 45 Gy in 25 fractions. Chemotherapy consisted of continuous infusion fluorouracil (5-FU; 1,000 mg/m2/d) on days 1 through 4 and 29 through 32 and cisplatin (100 mg/m2) on day 1. Patients underwent an Ivor-Lewis esophagectomy 18 to 33 days after completion of radiotherapy. Eighty percent of the patients had squamous cell carcinoma and 20% had adenocarcinoma. In addition, 51% had a pathologic complete response (CR). Twenty-two of the 35 underwent a preresection EGD before resection. Seventeen of the 22 (77%) had negative pathology from the preresection EGD, but seven of the 17 (41%) had residual tumor at surgery. The median survival and disease-free survival rates for all patients were 25.8 months and 32.8 months, respectively. Eighteen patients (51%) had no tumor at resection. The median survival for these patients was 36.8 months; the median disease-free survival time has not been reached. The median survival and disease-free survival rate for the patients with residual tumor in the surgical specimen were 12.9 months and 10.8 months, respectively. Preresection EGD is not reliable for determining the presence of residual disease or the patients in whom surgery could be omitted. Twenty-five percent of the patients with residual tumor in the resected surgical specimen were long-term survivors; this suggests a benefit from esophagectomy after concurrent radiotherapy and chemotherapy." }, { "id": "pubmed23n0528_7604", "title": "[Neoadjuvant therapy for resectable esophageal cancer].", "score": 0.009523809523809525, "content": "Surgical excision remains the only therapeutic approach with curative potential in patients with localized esophageal cancer. Due to the presence of lymph node metastases upon diagnosis in a large percentage of patients with locally advanced tumors and/or the presence of considerable co-morbidity, only a limited number of patients are amenable to surgery. These facts have prompted us to evaluate approaches including perioperative therapy modalities. By means of a computer-supported search (MEDLINE, ASCO Proceedings) as well as a manual literature search, randomized clinical trials and meta-analyses evaluating preoperative therapy plus surgery in patients with resectable esophageal cancer were identified. Twenty-three randomized clinical studies and five meta-analyses were identified. Interpretation--especially of the older studies--however, is hampered by the lack of a stringent application of modern examination techniques allowing for exact specification of tumor stage (resectable/locally advanced) as well as the inclusion of patients with different histological entities (squamous cell/adenocarcinoma), different surgical techniques and the low number of patients. There were no significant differences for the following perioperative therapy modalities regarding tumor-related mortality: preoperative radiotherapy versus postoperative radiotherapy, preoperative and postoperative radiotherapy versus postoperative radiotherapy (higher mortality in preoperative and postoperative radiotherapy arm), preoperative radiotherapy versus surgery, preoperative chemotherapy versus surgery, preoperative and postoperative chemotherapy versus surgery. In terms of 3-year mortality, statistically significant differences could be found for the following therapy modalities: preoperative radiochemotherapy versus surgery (preoperative therapy superior), preoperative chemotherapy versus preoperative radiotherapy (preoperative radiotherapy superior). Judging from these data, no clear recommendation for a standard multimodality approach outside clinical studies can be given for patients with resectable esophageal cancer. Neoadjuvant therapy, therefore, can only be recommended in centers with a maximum surgical expertise and in the context of multidisciplinary study protocols." }, { "id": "pubmed23n0603_14361", "title": "Comparison of oncological outcomes after laparoscopic transhiatal and open esophagectomy for T1 esophageal adenocarcinoma.", "score": 0.009433962264150943, "content": "This study compared pathological characteristics and patterns of disease recurrence for patients with pT1 esophageal adenocarcinoma treated with either laparoscopic transhiatal esophagectomy or open esophagectomy. From January 2000-December 2006, 44 patients had pT1 esophageal adenocarcinoma after esophagectomy. No patients had neoadjuvant treatment. Twenty-four patients had an Ivor Lewis operation, 4 had an open transhiatal and 16 had a laparoscopic transhiatal operation. There were 37 men. The median age was 64 years (range 35-80 years). Median lymph node yield was 19 (10-51) after an Ivor Lewis operation, 16 (3-28) after an open transhiatal operation and 15 (4-41) after a laparoscopic transhiatal operation. There were two in-hospital deaths (5%), both following open Ivor Lewis operation. All patients in the laparoscopic group had N0 disease; none received adjuvant treatment. Two patients (7%) in the open group had N1 disease, of whom one patient received adjuvant chemotherapy. Eleven patients had submucosal invasion. Alive patients had median follow-up of 36 months (range 5-87 months). One patient in the laparoscopic group had recurrence at 22 months. This patient had poorly differentiated N0 disease which was limited to the mucosa and died at 24 months. Two patients in the open group developed recurrence, at 6 months (N0 disease with submucosal invasion) and 8 months (N1 disease with submucosal invasion) and died at 7 and 14 months, respectively. Both patients had poorly differentiated tumours. The second patient with N1 disease is alive and well at 14 months. Estimated survival (Kaplan-Meier) at 3 years was 93%. As compared with open transthoracic esophagectomy, there is no oncological detriment in the treatment of pT1 esophageal adenocarcinoma by laparoscopic transhiatal esophagectomy. The incidence of recurrence is small (7%) but can occur even in patients with tumour limited to the mucosa or N0 disease." }, { "id": "pubmed23n0841_11604", "title": "Accuracy of preoperative diagnosis of lymph node metastasis for thoracic esophageal cancer patients from JCOG9907 trial.", "score": 0.009433962264150943, "content": "Accurate clinical evaluation of lymph nodes is crucial for selection of the optimum treatment strategy for individual esophageal cancer patients. This study investigated the accuracy of preoperative clinical diagnosis of lymph node metastasis for patients with clinical stage II/III esophageal squamous cell carcinoma. Patients assigned to receive surgery and postoperative chemotherapy in JCOG9907 trial were studied to evaluate the concordance between clinical and pathological nodes. Preoperative diagnosis was based on computed tomography or magnetic resonance imaging. Among 166 patients in the postoperative group, 160 with sufficient pathological data were studied. The patient background characteristics were: male/female, 147/13; median age, 61 years (range 39-75 years); primary tumor site (upper/middle/lower), 15/76/69; cN0/cN1, 53/107. The sensitivity and specificity of clinical nodes for diagnosis of pathological nodes were 72.7 and 51.3 %, respectively; the positive and negative predictive values were 82.2 and 37.7 %, respectively. The lymph nodes overestimated in the preoperative diagnosis included thoracic paratracheal lymph nodes (#106) (n = 8), middle thoracic paraesophageal lymph nodes (#108) (n = 4), lymph nodes along the lesser curvature (#3) (n = 4), right cardiac lymph nodes (#1) (n = 3), and left cardiac lymph nodes (#2) (n = 2). Diagnosis of clinical nodes has low specificity and low negative predictive value for prediction of pathological node category in the preoperative diagnosis of lymph node metastasis for patients with locally advanced resectable esophageal cancer. Clinical staging techniques must therefore be improved for accurate preoperative diagnosis." }, { "id": "pubmed23n0325_16186", "title": "High dose chemoradiotherapy followed by esophagectomy for adenocarcinoma of the esophagus and gastroesophageal junction: results of a phase II study of the Eastern Cooperative Oncology Group.", "score": 0.009345794392523364, "content": "To assess the toxicity, local response, and survival associated with multimodality therapy in a cooperative group setting, patients with biopsy-proven clinical Stage I or II adenocarcinoma of the esophagus (staged according to 1983 American Joint Committee on Cancer criteria) or gastroesophageal junction were treated with concomitant radiation and chemotherapy followed by esophagectomy. Radiotherapy was administered in daily 2-gray (Gy) fractions 5 days a week until a total of 60 Gy was reached. 5-fluorouracil (5-FU) was infused continuously at a dose of 1000 mg/m2/day for 96 hours on Days 2-5 and 28-31. On Day 2, a 10 mg/m2 bolus of mitomycin was injected intravenously. Esophagectomy was performed 4-8 weeks following completion of the radiotherapy. During the 18-month study period (August 1991 through January 1993), 46 eligible patients were accrued from 21 institutions. Eight patients were Stage I and 38 Stage II. Eighty-seven percent of patients (40 of 46) received 6000 centigray (cGy), and all received &gt;5000 cGy. Seventy-eight percent of patients (36 of 46) received &gt;90% of the planned 5-FU dose. Follow-up ranged from 11 to 36 months (median, 22 months). There were eight treatment-related deaths; two were preoperative (from adult respiratory distress syndrome) and six were postoperative. Complete or partial response prior to esophagectomy was observed in 63% of cases, stable disease in 15%, and progression in 20%. Thirty-three patients underwent esophagectomy (transhiatal, n=14; Ivor Lewis, n=16; other, n=3). No tumor was found in the specimens resected from 8 of these 33 patients; this represented a pathologic complete response rate of 17% overall and 24% for those who underwent esophagectomy. Overall median survival was 16.6 months, 1-year survival 57%, and 2-year survival 27%. Survival was significantly worse for patients with circumferential cancers (median, 18.1 months vs. 8.3 months; P &lt;0.05). High dose radiation therapy with concurrent 5-FU and mitomycin may be administered to patients with esophageal adenocarcinoma with acceptable morbidity. However, in a cooperative group setting, esophagogastrectomy following intensive chemoradiotherapy is associated with excessive morbidity and mortality. Circumferential tumor growth is a significant adverse prognostic factor." }, { "id": "pubmed23n0478_2726", "title": "[Positron emission tomography for preoperative lymph node diagnosis in esophageal carcinoma].", "score": 0.009345794392523364, "content": "Exact preoperative staging is a prerequisite for the indication and the choice of appropriate operative technique for patients with esophageal carcinoma. The objective of this prospective study was to assess whether positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) increases the accuracy of preoperative lymph node staging with standard computed tomography (CT) and thus leads to a different surgical approach. Fifty-eight patients with carcinoma of the esophagus (46 men and 12 women) with a median age of 61 years underwent FDG-PET imaging of the neck, chest, and abdomen as well as CT of the chest and abdomen. Sensitivity, specificity, and accuracy were calculated for both imaging techniques to evaluate the detection of histologically verified lymph node metastases. The FDG-PET showed higher specificity, whereas CT proved to be more accurate for detecting lymph node metastases not only of the abdomen (73% vs 59%) but also of the thorax (73% vs 63%). Resections were transhiatal in 23 patients and transthoracal in 16. As a supplement to conventional CT diagnostic procedure, FDG-PET was not decisive for the surgical approach. Altogether, pretherapeutical PET imaging did not increase the accuracy of lymph node staging for our patients with esophageal carcinoma, which had already been defined through CT. Therefore, no new consequences resulted for the surgical procedure. Due to the high costs involved with PET investigation, lymph node staging with it is momentarily indicated mainly for clinical studies and when CT does not offer unequivocal results. Increased sensitivity of the already advantageous whole-body FDG-PET imaging by means of tumor-affinitive radiopharmaceuticals and optimized apparatus resolution could lead to new indications for this staging procedure." }, { "id": "pubmed23n0618_4890", "title": "[The local control of radiotherapy following Ivor-Lewis esophagectomy in the patients with stage II A middle-third thoracic esophageal cancer].", "score": 0.009259259259259259, "content": "To investigate the local control of radiotherapy following Ivor-Lewis esophagectomy in the patients with stage IIA middle-third thoracic esophageal cancer. From June 1999 to June 2002, 125 patients with stage IIA squamous cell carcinoma of the middle-third thoracic esophagus were treated with Ivor-Lewis esophagectomy with two-fields lymphadenectomy. The survival rate was calculated by Kaplan-meier method and the difference of recurrence rate compared by chi(2) test. The 3-year and 5-year survival rates were 58.4% and 43.2% in this group, respectively. Tumor recurrence occurred in 61 of the 125 patients (48.8%) within 3 years after operation. Of all cases of recurrence, 38 patients (30.4%) developed locoregional recurrence (including 5 patients with locoregional and hematogenous recurrence simultaneously). The locoregional recurrence rate of patients who received postoperative radiotherapy (20.3%) was significantly lower than that of both the group who received adjunctive chemotherapy (40.6%) and the group without adjunctive therapy (41.4%) (P &lt; 0.05). About half of the patients would develop recurrence disease within 3 years after Ivor-Lewis esophagectomy with two-fields lymph-adenectomy. Radiotherapy following Ivor-Lewis esophagectomy is an effective strategy to control local recurrence of the stage II A middle-third thoracic esophageal cancer." }, { "id": "article-21327_17", "title": "Esophageal Cancer -- Treatment / Management -- Surgical Resection", "score": 0.009175084175084175, "content": "Localized resectable esophageal cancers comprise approximately 22% of all cases, and those presenting with regional lymph node spread comprise another 30%. The goal of surgical resection is curative. The first-line esophagectomy is offered to T1N0M0 (not endoscopic resection candidate) and selected T2N0M0. Neoadjuvant chemoradiation therapy (CRT) followed by esophagectomy is offered to T2 with positive disease node, T3, and selected T4a disease without metastasis. Relative exclusion criteria for esophagectomy include elderly patients (offered to selected patients) and high-risk patients with comorbid medical conditions. The presence of metastatic disease to other organs or extra-regional lymph nodes is an absolute contraindication to esophagectomy. Surgical procedures are divided accordingly to the anatomical position of esophageal cancer. Cervical esophageal cancer usually requires resection of portions of the larynx, pharynx, thyroid, and proximal esophagus with lower esophagus preservation. Thoracic esophageal cancer will include a total esophagectomy (cervical esophagogastrostomy) with radical two-field lymph node dissection and jejunostomy feeding tube placement. EGJ cancer will involve total esophagectomy and partial or extended gastrectomy. Thoracic cancer resection for the middle to lower esophagus can be divided into three major techniques in the United States: transhiatal, transthoracic (Ivor-Lewis), and tri-incisional esophagectomy. Esophagectomy guidelines recommend at least 15 lymph node resection for adequate staging, and this leads to s significant reduction in mortality (5-year disease-specific survival; 55% less than 11 nodes were resected, 66% for 11 to 17 nodes resected, and 75% more than 18 nodes resected). A positive circumferential resection margin has higher overall mortality compared to the negative (OR 4.02, 2.25 to 7.20, p < 0.001). Reported surgery mortality rates should be less than 5%, and a 5-year survival rate ranges from 5% to 34%. Thoracic, minimally invasive esophagectomy with abdominal laparoscopic intervention offers a surgical recovery advantage with promising better oncologic outcomes over an open thoracotomy and abdominal laparotomy procedure with an experienced surgeon at a center of excellence. Patients’ nutritional status on esophageal cancer complicated by dysphagia before and after surgery should be monitored and should be palliated with esophageal stents, lasers therapy, endoscopic dilation, and gastric/jejunal feeding tube when necessary and feasible." }, { "id": "pubmed23n0413_15844", "title": "Subtotal esophagectomy with extended 2-field lymph node dissection for thoracic esophageal cancer.", "score": 0.009174311926605505, "content": "To examine the efficacy of the Ivor Lewis esophagectomy with extended 2-field lymph node dissection for thoracic esophageal carcinoma we reviewed our experience. We analyzed the cases of 147 consecutive patients who underwent subtotal esophagectomy with extended 2-field lymph node dissection through Ivor Lewis approach for esophageal cancer from January 1996 through December 2000. Eighty-six patients were operated on for cancer of the midthoracic esophagus, 48 for cancer of the lower thoracic esophagus, and 13 for cancer of the aortal segment of the esophagus. No patient had received chemotherapy or radiotherapy before operation. There were 113 men (76.9%) and 34 women. Median age was 57 years (range 51-65 years). Postsurgical pathological studies revealed squamous cell carcinoma in 139 patients (94.6%), adenocarcinoma in five (3.4%), and adenosquamous carcinoma in three (2%). Positive abdominal and/or mediastinal lymph nodes were found in 122 patients (82.9%). At mean 43 nodes (range from 32 up to 75) were studied for each patient. Even in T(1)-T(2) tumors mediastinal or abdominal lymph nodes are involved in up to 80% of cases. However, in T(3)-T(4) stages the frequency of lymph node involvement is significantly higher (P&lt;0.05). Postsurgical staging was as follows: stage I in three patients (2%), stage IIa in 20 (13.6%), stage IIb in 29 (19.7%), stage III in 54 (36.8%), and stage IV in 41 (27.9%). All distant metastases were lymphogenous. The operative mortality rate was 6.1%, and complications occurred in 62 patients (42.1%). The overall 5-year survive rate was 28.8% (median survival 36.1 months). The 5-year survival rate for patients in stage IIa was 59%; for those in stage IIb, 39.5%; for patients in stage III, 26.7%; and 0% for patients in stage IV. Subtotal esophagectomy with extended 2-field lymph node dissection through Ivor Lewis approach for esophageal cancer is a safe operation. Long-term survival is stage dependent. Effective multimodality treatment may be helpful for patients with advanced disease." }, { "id": "pubmed23n0360_14765", "title": "[Endosonography in the preoperative evaluation of cancers of the esophagus].", "score": 0.009174311926605505, "content": "To assess the diagnostic accuracy of endoscopic ultrasonography (EUS) for the local and regional staging of esophageal cancer, and its possible alteration resulting from the performance of preoperative chemoradiation. Prospective study of 85 consecutive patients with esophageal cancer evaluated by EUS and operated on between January 1992 and December 1995. 28 of these patients had received previous induction therapy. In all cases, EUS examination was performed by the same physician not informed about the results of previous morphological explorations. Histopathological analysis of all operative specimens was performed by the same pathologist, not informed about the results of EUS. Data were collected by another independent observer. EUS examination resulted in incomplete staging in 8 patients (9.5%) with severe stenosis precluding endoscope passage. The accuracy, specificity and sensitivity of EUS in detecting the depth of esophageal involvement (T0-2 vs. T3-4) were 82.3%, 78%, and 86% respectively, and 72%, 70%, and 73% respectively for lymph node metastasis. The overall accuracy of EUS in identifying the preoperative stage was 67%, with a clear-cut alteration when patients had received induction therapy (61% vs 72%). On the other hand, 7 (64%) of the 11 patients thought to have a complete response at endosonography had no residual tumor. EUS provides precise information for the preoperative identification of locally advanced esophageal tumor, even after induction therapy. The latter alters the diagnostic accuracy of EUS, although complete responders could be identified in two-thirds of cases." }, { "id": "pubmed23n0662_19573", "title": "Phase 2 trial of preoperative irinotecan plus cisplatin and conformal radiotherapy, followed by surgery for esophageal cancer.", "score": 0.00909090909090909, "content": "Esophagectomy for locally advanced esophageal cancer (LAEC) is associated with limited survival. Trimodality therapy yields a small survival advantage, with cisplatin and 5-fluorouracil regimens most frequently studied. Newer regimens may impact these poor outcomes. This phase 2 trial assessed the feasibility and efficacy of induction chemoradiotherapy with cisplatin and irinotecan followed by esophagectomy. Patients with LAEC of the thoracic esophagus or gastroesophageal junction underwent chemotherapy with preoperative irinotecan (65 mg/m(2)) plus cisplatin (30 mg/m(2)) on Weeks 1, 2, 4, 5, 7, and 8 with concurrent conformal radiotherapy (40 grays [Gy]/20 fractions during Weeks 4-7) and external beam boost (10 Gy/5 fractions at Week 8). Esophagectomy was performed between Weeks 12 and 16. Pathologic response was the primary endpoint with follow-up data on progression, survival, and toxicity as secondary endpoints. Fifty-two patients were enrolled from November 2002 to October 2005. Nineteen patients had American Joint Committee on Cancer stage II, 22 had stage III, and 11 had stage IVA disease. Grade 3 to 4 toxicity (graded according to the National Cancer Institute Common Toxicity Criteria 2.0) during induction included neutropenia (36%), febrile neutropenia (8%), diarrhea (10%), and esophagitis (4%). Three patients withdrew from treatment due to toxicity. There was 1 treatment-related death. Clinical responses included complete response in 2%, partial response in 30%, stable disease in 62%, and progressive disease in 6% of patients. Dysphagia improved/resolved in 72% of patients during induction. Forty-three patients underwent esophagectomy and 7 (16%) achieved pathologic complete responses. Median and 3-year overall survival for patients receiving trimodality therapy was 36 months and 51%, respectively. In LAEC, concurrent irinotecan/cisplatin and radiotherapy followed by esophagectomy is reported to be associated with dysphagia improvement in 72% of patients, a significant but manageable toxicity profile, and encouraging survival compared with historic controls." }, { "id": "pubmed23n0763_2119", "title": "Curative treatment of esophageal cancer; an evidenced based review.", "score": 0.00909090909090909, "content": "In 2013, roughly 18,000 cases of esophageal cancer will be diagnosed in the United States with more than 15,000 people dying from the disease. Worldwide, an estimated 482,300 new esophageal cancer cases were diagnosed with 406,800 deaths in 2008. Squamous cell carcinoma (SCC) and adenocarcinoma (AC) account for &gt;90% of all esophageal cancer cases. The authors will examine the role of radiation therapy, chemotherapy, and surgery in the curative management of esophageal cancer by examining randomized control data, single arm phase II trials, several recently published meta-analyses, as well as retrospective data where there is no clinical trial data available. The role of positron emission tomography (PET) will be reviewed as well. Current data support the role of neoadjuvant chemoradiotherapy followed by surgical resection for locally advanced esophageal cancer with 3-year overall survival ranging from 30% to 60%. The benefit of adjuvant chemoradiation therapy is limited to margin positive and/or node positive patients. There is emerging data questioning the survival benefit of surgical resection after chemoradiotherapy. External beam radiation therapy alone results in very few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. PET scanning is vital in staging and has become a strong predictor of response and survival. Preoperative or definitive concurrent chemoradiotherapy is the established standard of care for locally advanced cancers of the esophagus. While preoperative chemotherapy is supported by level 1 evidence, the true benefit of induction chemotherapy before chemoradiotherapy has not been established in a prospective randomized control trial. The role of surgery in the management of SCC is still a hotly debated subject, however, it is still recommended for AC. There is no data to support adjuvant chemotherapy after preoperative chemoradiotherapy. The benefit of neoadjuvant chemotherapy seems to be limited AC. Radiation without chemotherapy is palliative and never curative. PET continues to be integrated into treatment decisions and predicts for response and survival after therapy." }, { "id": "pubmed23n0755_4718", "title": "Treatments for esophageal cancer: a review.", "score": 0.009009009009009009, "content": "Esophageal cancer is the eighth most common form of cancer worldwide. The treatments for esophageal cancer depend on its etiology. For mucosal cancer, endoscopic mucosal resection and endoscopic submucosal dissection are standard, while for locally advanced cancer, esophagectomy remains the mainstay. The three most common techniques for thoracic esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis). Surgery for carcinoma of the cervical esophagus requires an extensive procedure with laryngectomy in many cases. When the tumor is more advanced, neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is added. The theoretical advantages of adding chemotherapy to the treatment of esophageal cancer are potential tumor down-staging prior to surgery, as well as targeting micrometastases and, thus, decreasing the risk of distant metastasis. Cisplatin- and 5-fluorouracil-based regimes are used worldwide. Chemoradiotherapy is the standard for unresectable esophageal cancer and could also be considered as an option for resectable tumors. For patients who are medically or technically inoperable, concurrent chemoradiotherapy should be the standard of care. Although neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment; judicious patient selection is crucial. It is important to have a thorough understanding of these therapeutic modalities to assist in this endeavor." }, { "id": "pubmed23n0604_445", "title": "Lymph node analysis in esophageal resection: American College of Surgeons Oncology Group Z0060 trial.", "score": 0.009009009009009009, "content": "The American Joint Committee on Cancer staging of esophageal cancer has been criticized for not establishing a minimum standard for lymphadenectomy, and for relying on location of nodes involved rather than their number. The objective of this study was to review the current practice of American surgeons with regard to lymph node assessment during esophageal resection. The operative and pathology reports of patients who underwent staging by computed tomography and fluorodeoxyglucose-positron emission tomography and subsequent resection for esophageal cancer (multiinstitutional American College of Surgeons Oncology Group Z0060 trial) were analyzed. One hundred forty-five patients underwent resection. Operative and pathology reports were unavailable in 11 patients. The results of the remaining 134 resections (Ivor-Lewis, n = 64; transhiatal, n = 59; other, n = 11) were reviewed. Overall, 13 +/- 9 (mean +/- standard deviation) lymph nodes were evaluated per patient. More lymph nodes were evaluated in patients undergoing Ivor-Lewis (15 +/- 9) than transhiatal esophagectomy (9 +/- 7; p &lt; 0.001). The mean number of distinct lymph node stations analyzed per patient was 3 +/- 2. In 38% (51 of 134) of patients the nodes attached to the specimen were evaluated without any distinction among nodal stations. The practice of submitting named packets of nodal material resulted in 16 +/- 9 nodes per case, as opposed to the practice of submitting an entire specimen for the pathologists to dissect, which yielded 10 +/- 8 nodes (p &lt; 0.001). There is considerable variability and room to improve in the extent of resection and pathologic evaluation of esophagectomy specimens. A uniform standard for esophageal cancer resection is warranted to improve the precision and value of pathologic staging." }, { "id": "pubmed23n0567_13413", "title": "Minimally invasive transhiatal esophagectomy: lessons learned.", "score": 0.008928571428571428, "content": "Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned. A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival. Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36-79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1-3), and 1 for high-grade dysplasia in Barrett's. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180-450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10-39). The median number of nodes harvested was 10 (range = 2-26). At a median follow-up of 13 months (range = 4-42), 13 patients were alive. Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove." }, { "id": "pubmed23n0107_322", "title": "[Clinicopathological studies of the recurrence of esophageal squamous cell cancer--with special reference to the mode of recurrence and operative procedure].", "score": 0.008928571428571428, "content": "In 93 out of 201 patients (46%) with squamous cell carcinoma of the esophagus who underwent radical resection (excluding death within 30 days after operation), the site of recurrence could be identified by means of X-ray, CT, ultrasonography, and biopsy. Recurrence was found in 55% of 93 cases within 12 months after surgery and in 86% of 93 cases within 24 months. Of 93 patients with recurrences, lymph node recurrences were present in 44 cases, visceral recurrences in 32 cases, both lymph node and visceral recurrences in 11 cases and others in 6 cases. Neck and/or upper mediastinal lymph node recurrences were found in 10 out of 15 patients who had recurrences within 3 months after surgery. Careful examination should be made in the left recurrent nerve chain and extended lymph node resection of upper mediastinal region should be performed under the adequate indication. Esophageal squamous cell cancer has a tendency to recur in the lymph nodes initially, and visceral metastases may occur thereafter. The incidence of visceral recurrence increased remarkably, when neck and/or upper mediastinal lymph nodes were involved at the time of operation. Accordingly, both irradiation and chemotherapy should also be applied for improving the prognosis of esophageal carcinoma." }, { "id": "pubmed23n0919_2110", "title": "[Associated factors of postoperative relapse and metastasis in pT1bN0M0-pT4aN0M0 thoracic esophageal squamous cell carcinoma].", "score": 0.008849557522123894, "content": "To investigate the associated high risk factors of postoperative relapse and metastasis for patients with confined tumors (grade pT1b-4a) without lymph-node metastases (pN0) in thoracic esophageal squamous cell carcinoma (ESCC). Clinicopathological and follow up data of ESCC patients undergoing radical surgical resection as primary treatment in the Department of Thoracic Surgery, Shanghai Chest Hospital between January 2004 and December 2012 from Hospital Database were retrospectively collected. The inclusion criteria were as follows: (1) the first development of ESCC confirmed by histopathology without lymphatic and distant metastasis; (2) pathological stage of pT1bN0M0 to pT4aN0M0 according to the Union for International Cancer Control (UICC) in 2009; (3) curative trans-thoracic esophagectomy with R0 (tumor-free surgical margin) resection, using the Ivor-Lewis or McKeown procedure; two-field lymphadenectomy or three-field lymph node dissection based on the positive results of preoperative cervical ultrasonography examination or CT scan; (4) without adjuvant chemotherapy and/or radiotherapy before and after operation; (5) complete follow-up data. Logistic regression analysis was employed to identify the clinicopathological factors affecting the postoperative relapse and metastasis. A total of 112 patients were eligible, including 94 male cases and 18 female cases; age of (58.6±7.7) years; squamous carcinoma of upper thorax in 25 cases, of middle thorax in 67 cases and of lower thorax segment in 20 cases; 12 cases of high-differentiated ESCC, 49 cases of moderate-differentiated ESCC, poorly-differentiated ESCC in 48 cases; 4 cases of I(a stage, 9 cases of I(b, 24 cases of II(a, 62 cases of II(b, 13 cases of III(a; the tumor length &gt;4 cm in 43 cases, ≤4 cm in 69 cases. Forty-three (38.4%) patients presented relapse or metastasis during the follow-up, including 24 (21.4%) of loco-regional relapse, 13 (11.6%) of distant metastasis, and 6(5.4%) of both above. Multivariate regression analysis revealed that poorly-differentiated tumor (OR=1.899, 95%CI:1.233-2.925, P=0.004), upper-middle location (OR=2.351, 95%CI:1.188-4.653, P=0.014), and tumor length &gt;4 cm (OR=2.381, 95%CI:1.009-5.618, P=0.048) were independent risk factors of overall postoperative relapse and metastasis for thoracic ESCC with stage pT1b N0M0-T4aN0M0. Further stratified analysis identified that only poorly-differentiated tumor (OR=1.730, 95%CI:1.121-2.671, P=0.013) was an independent risk factor of loco-regional relapse, whereas pathological stage II(b-III(a (OR=3.372, 95%CI:1.206-9.428, P=0.021) was an independent risk factor of distant metastasis. Poorly-differentiated tumor, tumor length &gt;4 cm, and upper-middle location may be regarded as high risk factors for predicting overall relapse and metastasis of pN0 thoracic ESCC patients after esophagectomy. Moreover, poorly-differentiated tumor is the only independent risk factor of postoperative loco-regional relapse, meanwhile it should be noted that pathological stage II(b-III(a is closely related to postoperative distant metastasis." }, { "id": "pubmed23n0478_5253", "title": "[Endoscopy in the diagnosis and therapy of inoperable esophageal carcinoma after radiotherapy and combined radiochemotherapy].", "score": 0.008849557522123894, "content": "Treatment of inoperable (locally advanced) esophagus cancer, even today, has been a subject of numerous clinical researches. Combination of several clinical modalities is needed, of radiotherapy and chemotherapy the most frequently. This combination applied as neoadjuvant or concomitant brought to improvement of treatment results of these patients. Local control is still a big problem, since majority of these patients die of local treatment \"failure\". Because of that, estimation of the local control is very important, i.e. assessment of the tumor response the treatment. For those reasons, a study has been conducted on 52 patients with locally advanced esophagus tumor, who in the first group of 25 patients, were treated only by radiotherapy, and in the second group of 27 patients, by combined radio-chemotherapy. Pretherapy evaluation, evaluation of esophagus stenosis, as well as the tumor regression to conducted treatment, were done in all patients by radiography and endoscopy and the findings were compared: there was no statistically significant difference between investigated methods (p &gt; 0.05). Although bigger number of the tumor complete regressions was verified by radiography (6 in the first group and 5 in the second group of patients) in relation to endoscopic finding (3 in the first group and 2 in the second group of patients), which had no microscopical evidence of remaining disease. Partial tumor regression made greater differences between investigated methods (10:4 in the first group and 6:3 in the second group 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": true, "char_ranges": [ [ 0, 108 ] ], "word_ranges": [ [ 0, 16 ] ], "text": "Asthma treatment algorithm. We rule out continuing with the same treatment since the patient is symptomatic." }, "5": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" } }

{ "1": "Increase the dose of inhaled corticosteroids to 800 micrograms/day.", "2": "Add tiotropium.", "3": "Maintain the same pharmacological regimen.", "4": "Switch to ocmbined therapy with low-dose inhaled corticosteroids and long-acting beta2-adrenergics.", "5": "Add leukotrienes." }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "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": 0.017273471818926363, "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": "pubmed23n0253_4572", "title": "Periodic treatment regimens with inhaled steroids in asthma or chronic obstructive pulmonary disease. Is it possible?", "score": 0.016523506655301293, "content": "To determine whether inhaled corticosteroids can be discontinued in the stable phase of asthma or chronic obstructive pulmonary disease (COPD) or if this therapy should be continued. Nonrandomized open uncontrolled 5-year trial. Prospective study in general practice. Forty-eight patients with steroid-dependent asthma or COPD who had shown a decline in forced expiratory volume in 1 second (FEV1) of at least 80 mL per year and at least one exacerbation per year during the first 2 years of bronchodilator treatment. Subjects were treated additionally with inhaled steroids for another 2 years and were finally given the option to stop using steroids. Sixteen patients were willing to stop using beclomethasone and were studied for another year. No recruitment bias took place in this consecutive sample in the fifth year of follow-up. Two of 16 patients developed carcinomas and dropped out. Two years of bronchodilator treatment alone (400 micrograms of salbutamol or 40 micrograms of ipratropium bromide four times daily), followed by 2 years of additional inhaled corticosteroid treatment (400 micrograms of beclomethasone two times daily), and finally 1 year of bronchodilator treatment alone. Decline in lung function (FEV1), change in bronchial hyperresponsiveness, indicated by a provocative concentration of histamine causing a 20% fall in FEV1 (PC20), morning peak expiratory flow rate (PEFR), diurnal PEFR, week-to-week variation of PEFR, bronchial symptoms, and exacerbations. The course of FEV1 during the year in which beclomethasone was discontinued was not significantly different when compared with the 2-year period of beclomethasone treatment. Neither did the course of PC20, morning PEFR, diurnal PEFR, symptom score, and exacerbation rate change. Only the week-to-week variation of the PEFR increased after discontinuing steroids. Discontinuing inhaled steroids is possible in some patients with asthma or COPD after 2 years of regular treatment. This might indicate that for certain groups of patients with mild asthma or COPD, periodic treatment schedules with inhaled steroids is the treatment policy for the future." }, { "id": "pubmed23n0658_10806", "title": "Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma.", "score": 0.015424311926605505, "content": "In asthmatic patients inadequately controlled on inhaled corticosteroids and/or those with moderate persistent asthma, two main options are recommended: the combination of a long-acting inhaled ss2 agonist (LABA) with inhaled corticosteroids (ICS) or use of a higher dose of inhaled corticosteroids. To determine the effect of the combination of long-acting ss(2) agonists and inhaled corticosteroids compared to a higher dose of inhaled corticosteroids on the risk of asthma exacerbations, pulmonary function and on other measures of asthma control, and to look for characteristics associated with greater benefit for either treatment option. We identified randomised controlled trials (RCTs) through electronic database searches (MEDLINE, EMBASE and CINAHL), bibliographies of RCTs, clinical trial registries and correspondence with manufacturers until May 2008. RCTs that compared the combination of inhaled LABA and ICS to a higher dose of inhaled corticosteroids, in children and adults with asthma. Two authors independently assessed methodological quality and extracted data. We obtained confirmation from the trialists when possible. The primary endpoint was the number of patients experiencing one or more asthma exacerbations requiring oral corticosteroids. This review included 48 studies (15,155 participants including 1155 children and 14,000 adults). Participants were inadequately controlled on their current ICS regimen, experiencing ongoing symptoms and with generally moderate (FEV1 60% to 79% of predicted) airway obstruction. The studies tested the combination of salmeterol or formoterol with a median dose of 400 mcg/day of beclomethasone or equivalent (BDP-eq) compared to a median of 1000 mcg/day of BDP-eq, usually for 24 weeks or less. There was a statistically significantly lower risk of exacerbations requiring systemic corticosteroids in patients treated with LABA and ICS (RR 0.88, 95% CI 0.78 to 0.98, 27 studies, N = 10,578) from 11.45% to 10%, with a number needed to treat of 73 (median study duration: 12 weeks). The study results were dominated by adult studies; trial data from three paediatric studies showed a trend towards increased risk of rescue oral steroids (RR 1.24, 95% CI 0.58 to 2.66) and hospital admission (RR 2.21, 95% CI 0.74 to 6.64) associated with combination therapy. Overall, there was no statistically significant difference in the risk ratios for either hospital admission (RR 1.02, 95% CI 0.67 to 1.56) or serious adverse events (RR 1.12, 95% CI 0.91 to 1.37). The combination of LABA and ICS resulted in significantly greater but modest improvement from baseline in lung function, symptoms and rescue medication use than with higher ICS dose. Despite no significant group difference in the risk of overall adverse events (RR 0.99, 95% CI 0.95 to 1.03), there was an increase in the risk of tremor (RR 1.84, 95% CI 1.20 to 2.82) and a lower risk of oral thrush (RR 0.58, 95% CI 0.40 to 0.86)) in the LABA and ICS compared to the higher ICS group. There was no significant difference in hoarseness or headache between the treatment groups. The rate of withdrawals due to poor asthma control favoured the combination of LABA and ICS (RR 0.65, 95% CI 0.51 to 0.83). In adolescents and adults with sub-optimal control on low dose ICS monotherapy, the combination of LABA and ICS is modestly more effective in reducing the risk of exacerbations requiring oral corticosteroids than a higher dose of ICS. Combination therapy also led to modestly greater improvement in lung function, symptoms and use of rescue ss(2) agonists and to fewer withdrawals due to poor asthma control than with a higher dose of inhaled corticosteroids. Apart from an increased rate of tremor and less oral candidiasis with combination therapy, the two options appear relatively safe in adults although adverse effects associated with long-term ICS treatment were seldom monitored. In children, combination therapy did not lead to a significant reduction, but rather a trend towards an increased risk, of oral steroid-treated exacerbations and hospital admissions. These trends raised concern about the safety of combination therapy in view of modest improvement in children under the age of 12 years." }, { "id": "pubmed23n0554_8143", "title": "Long-acting beta2-agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma.", "score": 0.015006385696040868, "content": "Patients who continue to experience asthma symptoms despite taking regular inhaled corticosteroids (ICS) represent a management challenge. Leukotriene receptor antagonists (LTRA) and long-acting beta(2)-agonists (LABA) agents may both be considered as add-on therapy to inhaled corticosteroids (ICS). We compared the efficacy and safety profile of adding either daily LABA or LTRA in asthmatic patients who remained symptomatic on ICS. The Cochrane Airways Group Specialised Register was searched for randomised controlled trials up to and including March 2006. Reference lists of all included studies and reviews were screened to identify potentially relevant citations. Inquiries regarding other published or unpublished studies supported by the authors of the included studies or pharmaceutical companies who manufacture these agents were made. Conference proceedings of major respiratory meetings were also searched. Only randomised controlled trials conducted in adults or children with recurrent asthma where a LABA (for example, salmeterol or formoterol) or LTRA (for example, montelukast, pranlukast, zafirlukast) was added to ICS for a minimum of 28 days were considered for inclusion. Inhaled short-acting beta(2)-agonists and short courses of oral steroids were permitted as rescue medications. Other daily asthma treatments were permitted, providing the dose remained constant during the intervention period. Two reviewers independently reviewed the literature searches. Data extraction and trial quality assessment were conducted independently by two reviewers. Whenever possible, primary study authors were requested to confirm methodology and data extraction and to provide additional information and clarification when needed. Where necessary, expansion of graphic reproductions and estimation from other data presented in the paper was performed. Fifteen randomised controlled trials met the inclusion criteria; eleven trials including 6,030 participants provided data in sufficient detail to permit aggregation. All eleven trials pertained to adults with moderate airway obstruction (% predicted FEV(1) 66-76%) at baseline. Montelukast (n=9) or Zafirlukast (n=2) was compared to Salmeterol (n=9) or Formoterol (n=2) as add-on therapy to 400-565 mcg of beclomethasone or equivalent. Risk of exacerbations requiring systemic corticosteroids was significantly lower with LABA+ICS when compared to LTRA+ICS (RR= 0.83, 95% Confidence Interval (95%CI): 0.71, 0.97): the number needed to treat with LABA compared to LTRA, to prevent one exacerbation over 48 weeks, was 38 (95% CI: 23 to 247). The following outcomes also improved significantly with the addition of LABA compared to LTRA to inhaled steroids (Weighted Mean Difference; 95%CI): morning PEFR (16 L/min; 13 to 18), evening PEFR (12 L/min; 9 to 15), FEV(1) (80 mL; 60 to 100), rescue-free days (9%; 5% to 13%), symptom-free days (6%; 2 to 11), rescue beta(2)-agonists (-0.5 puffs/day; -0.2 to -1), quality of life (0.1; 0.05 to 0.2), symptom score (Standard Mean Difference -0.2; -0.1 to -0.3), night awakenings (-0.1/week; -0.06 to -0.2) and patient satisfaction (RR 1.12; 1.07 to 1.16). Risk of withdrawals due to any reason was significantly lower with LABA+ICS compared to LTRA+ICS (Risk Ratio 0.83, 95% CI 0.73 to 0.95). Withdrawals due to adverse events or due to poor asthma control, hospitalisation, osteopenia, serious adverse events, overall adverse events, headache or cardiovascular events were not significantly different between the two study groups. In asthmatic adults inadequately controlled on low doses of inhaled steroids, the addition of LABA is superior to LTRA for preventing exacerbations requiring systemic steroids, and for improving lung function, symptoms, and the use of rescue beta(2)-agonists." }, { "id": "pubmed23n0511_18535", "title": "Long-acting beta2-agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma.", "score": 0.014697120158887786, "content": "Patients who continue to experience asthma symptoms despite taking regular inhaled corticosteroids (ICS) represent a management challenge. Leukotriene receptor antagonists (LTRA) and long-acting beta2-agonists (LABA) agents may both be considered as add-on therapy to inhaled corticosteroids (ICS). We compare the efficacy and safety profile of adding either daily LABA or LTRA in asthmatic patients with asthma who remained symptomatic on ICS. MEDLINE, EMBASE, CINAHL databases were searched for randomised controlled trials up to and including January 2004. Reference lists of all included studies and reviews were screened to identify potentially relevant citations. Inquiries regarding other published or unpublished studies supported by the authors of the included studies or pharmaceutical companies who manufacture these agents were made. Conference proceedings of major respiratory meetings were also searched. Only randomised controlled trials conducted in adults or children with recurrent asthma where a LABA (for example, salmeterol or formoterol) or LTRA (for example, montelukast, pranlukast, zafirlukast) was added to ICS for a minimum of 28 days were considered for inclusion. Inhaled short-acting beta2-agonists and short courses of oral steroids were permitted as rescue medications. Other daily asthma treatments were permitted, providing the dose remained constant during the intervention period. Two reviewers independently reviewed the literature searches. Data extraction and trial quality assessment were conducted independently by two reviewers. Whenever possible, primary study authors were requested to confirm methodology and data extraction and to provide additional information and clarification when needed. Where necessary, expansion of graphic reproductions and estimation from other data presented in the paper was performed. Twelve randomised controlled trials met the inclusion criteria; only eight trials including 5,895 patients, provided data in sufficient details to allow aggregation. All eight trials pertained to adults with moderate airway obstruction (% predicted FEV1 66-76%) at baseline. Montelukast (n=6) or Zafirlukast (n=2) was compared to Salmeterol (n=7) or Formoterol (n=1) as add-on therapy to 400-565 mcg of beclomethasone or equivalent. Risk of exacerbations requiring systemic corticosteroids was significantly lower with LABA+ICS when compared to LTRA+ICS (RR= 0.83, 95% Confidence Interval (95%CI): 0.71, 0.97): the number needed to treat with LABA compared to LTRA, to prevent one exacerbation over 48 weeks, was 38 (95% CI: 23 to 247). The following outcomes also improved significantly with the addition of LABA compared to LTRA to inhaled steroids (Weighted Mean Difference; 95%CI): morning PEFR (16 L/min; 13 to 18), evening PEFR (12 L/min; 9 to 15), FEV(1) (80 mL; 60 to 100), rescue-free days (9%; 4 to 14), symptom-free days (6%; 2 to 11), rescue beta2-agonists (-0.4 puffs/day; -0.2 to -0.5), quality of life (0.1; 0.05 to 0.2), symptom score (Standard Mean Difference -0.2; -0.1 to -0.3), night awakenings (-0.1/week; -0.06 to -0.2) and patient satisfaction (RR 1.12; 1.07 to 1.16). Risk of withdrawals due to any reason was significantly lower with LABA+ICS compared to LTRA+ICS (Relative Risk 0.84, 95% CI 0.74 to 0.96). Withdrawals due to adverse events or due to poor asthma control, hospitalisation, osteopenia, serious adverse events, overall adverse events, headache or cardiovascular events were not significantly different between the two study groups. In asthmatic adults inadequately controlled on low doses of inhaled steroids, the addition of LABA is superior to LTRA for preventing exacerbations requiring systemic steroids, and for improving lung function, symptoms, and use of rescue beta2-agonists." }, { "id": "pubmed23n0827_16371", "title": "Tiotropium Respimat®: A Review of Its Use in Asthma Poorly Controlled with Inhaled Corticosteroids and Long-Acting β2-Adrenergic Agonists.", "score": 0.014211180124223602, "content": "Tiotropium bromide (Spiriva®) solution for inhalation via the Respimat® Soft Mist™ inhaler is a long-acting anticholinergic agent approved in the EU for the add-on maintenance treatment of asthma in adults currently receiving maintenance therapy with an inhaled corticosteroid (ICS) (≥800 µg budesonide per day or equivalent) and a long-acting β2-adrenergic agonist (LABA) and who have experienced at least one severe exacerbation in the previous year. Tiotropium Respimat® added to maintenance ICS/LABA treatment significantly improved lung function after 6 months' treatment and extended the time to the first asthma exacerbation in two well-designed, replicate, phase III trials in patients with poorly controlled asthma despite treatment with an ICS (≥800 µg budesonide/day or equivalent) and a LABA. Tiotropium Respimat® was also associated with a reduced incidence of severe asthma exacerbations and an increase in the median time to asthma worsening. The drug was well tolerated in asthma patients throughout 48 weeks' treatment, with a generally similar incidence of serious adverse events in tiotropium Respimat® and placebo treatment groups. Thus, in patients with poorly controlled asthma despite receiving high-dose ICS and a LABA, tiotropium Respimat® provides a valuable treatment option." }, { "id": "pubmed23n0626_19177", "title": "Combination formoterol and budesonide as maintenance and reliever therapy versus inhaled steroid maintenance for chronic asthma in adults and children.", "score": 0.012983312983312983, "content": "Traditionally inhaled treatment for asthma has been considered as preventer and reliever therapy. The combination of formoterol and budesonide in a single inhaler introduces the possibility of using a single inhaler for both prevention and relief of symptoms (single inhaler therapy). The aim of this review is to compare formoterol and corticosteroid in single inhaler for maintenance and relief of symptoms with inhaled corticosteroids for maintenance and a separate reliever inhaler. We last searched the Cochrane Airways Group trials register in September 2008. Randomised controlled trials in adults and children with chronic asthma. Two review authors independently assessed studies for inclusion and extracted the characteristics and results of each study. Authors or manufacturers were asked to supply unpublished data in relation to primary outcomes. Five studies on 5,378 adults compared single inhaler therapy with current best practice, and did not show a significant reduction in participants with exacerbations causing hospitalisation (Peto OR 0.59; 95% CI 0.24 to 1.45) or treated with oral steroids (OR 0.83; 95% CI 0.66 to 1.03). Three of these studies on 4281 adults did not show a significant reduction in time to first severe exacerbation needing medical intervention (HR 0.96; 95% CI 0.85 to 1.07). These trials demonstrated a reduction in the mean total daily dose of inhaled corticosteroids with single inhaler therapy (mean reduction ranged from 107 to 267 micrograms/day, but the trial results were not combined due to heterogeneity). The full results from four further studies on 4,600 adults comparing single inhaler therapy with current best practice are awaited.Three studies including 4,209 adults compared single inhaler therapy with higher dose budesonide maintenance and terbutaline for symptom relief. No significant reduction was found with single inhaler therapy in the risk of patients suffering an asthma exacerbation leading to hospitalisation (Peto OR 0.56; 95% CI 0.28 to 1.09), but fewer patients on single inhaler therapy needed a course of oral corticosteroids (OR 0.54; 95% CI 0.45 to 0.64). These results translate into an eleven month number needed to treat of 14 (95% CI 12 to 18), to prevent one patient being treated with oral corticosteroids for an exacerbation. The run-in for these studies involved withdrawal of long-acting beta(2)-agonists, and patients were recruited who were symptomatic during run-in.One study included children (N = 224), in which single inhaler therapy was compared to higher dose budesonide. There was a significant reduction in participants who needed an increase in their inhaled steroids with single inhaler therapy, but there were only two hospitalisations for asthma and no separate data on courses of oral corticosteroids. Less inhaled and oral corticosteroids were used in the single inhaler therapy group and the annual height gain was also 1 cm greater in the single inhaler therapy group, [95% CI 0.3 to 1.7 cm].There was no significant difference found in fatal or non-fatal serious adverse events for any of the comparisons. Single inhaler therapy can reduce the risk of asthma exacerbations needing oral corticosteroids in comparison with fixed dose maintenance inhaled corticosteroids. Guidelines and common best practice suggest the addition of regular long-acting beta(2)-agonist to inhaled corticosteroids for uncontrolled asthma, and single inhaler therapy has not been demonstrated to significantly reduce exacerbations in comparison with current best practice, although results of five large trials are awaiting full publication. Single inhaler therapy is not currently licensed for children under 18 years of age in the United Kingdom." }, { "id": "pubmed23n0289_9527", "title": "The use of beta 2-adrenoceptor agonists in the treatment of bronchial asthma.", "score": 0.012910166756320602, "content": "All guidelines recommend short-acting inhaled beta 2-adrenoceptor agonists as the first-line drugs in acute asthma attacks and inhaled corticosteroids as the drugs of choice when regular daily treatment is needed. Short-acting inhaled beta 2-adrenoceptor agonists are not effective in reducing nocturnal awakenings because of their short duration of action. In addition there has been an intense debate about the regular use of these drugs. This debate is reviewed. They should only be used on \"as needed basis\". The Swedish guidelines for the treatment of asthma were the first to recommend the new long-acting inhaled beta 2-adrenoceptor agonists at relatively early stage of the illness (800 micrograms daily of inhaled corticosteroids). Two recently completed large multicentre studies with salmeterol in asthmatics support this opinion. Both studies showed a better asthma control with a combination of a low inhaled steroid dose and salmeterol compared to a doubling of the steroid dose. In most asthmatic patients, still symptomatic on inhaled steroids doses 400 to 800 micrograms daily, a test of the addition of inhaled salmeterol is recommended. The steroid dose can be kept low and safe. However, asthmatic patients with either frequent or severe exacerbations should primarily have their steroid dose increased." }, { "id": "wiki20220301en038_67960", "title": "Budesonide/formoterol", "score": 0.012407255763170302, "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": "wiki20220301en607_12089", "title": "Indacaterol/glycopyrronium bromide/mometasone", "score": 0.012304374274180168, "content": "It is the first asthma triple-combination therapy; it consists of a fixed-dose combination of three active substances (indacaterol, glycopyrronium bromide and mometasone furoate) in capsules, to be administered using an inhaler. An optional electronic sensor may also be co-packed with the product. The sensor will be attached to the base of the inhaler to collect data on the use of the inhaler by the patient. The sensor will send the data to an app on a smart phone or other suitable device. It was approved for medical use in the European Union in July 2020. Medical uses Indacaterol/glycopyrronium bromide/mometasone is indicated as a maintenance treatment of asthma in adults not adequately controlled with a maintenance combination of a long acting beta2 agonist and a high dose of an inhaled corticosteroid who experienced one or more asthma exacerbations in the previous year." }, { "id": "pubmed23n0371_11224", "title": "Comparison between formoterol 12 microg b.i.d. and on-demand salbutamol in moderate persistent asthma.", "score": 0.012280701754385965, "content": "Inhalation of on-demand salbutamol (ODS) several times daily is sometimes the only beta2-agonist prescribed in moderate persistent asthma, whereas a long-acting beta2-agonist should be added. This trial aimed to compare the efficacy of formoterol dry-powder capsule 12 microg b.i.d. (Foradil) and ODS in patients with moderate persistent asthma treated with inhaled corticosteroids, in the conditions of real practice. Two hundred and fifty-nine patients were randomized (formoterol; 130; ODS: 129) in this open, parallel-group trial. The mean increases in morning peak expiratory flow (PEF primary variable) and evening PEF over the 3-month treatment period were statistically significantly higher with formoterol: +25.7 and +24.1 l min(-1), respectively vs. +4.5 and +0.5 l min(-1) respectively with ODS. The increase in FEV1 was statistically significantly higher with formoterol at months 1 and 3. Formoterol reduced the use of salbutamol as rescue medication by two-thirds. The percentages of symptom-free days and nights statistically significantly increased with formoterol (+20% and +33% respectively), but did not significantly change with ODS. Clinically relevant and statistically significant improvement in the mean total score of the St George's Hospital Respiratory Questionnaire was observed in the formoterol group. Adverse events were similar in the two groups. The results show that treatment with formoterol has significant advantages over ODS in patients with moderate persistent asthma." }, { "id": "wiki20220301en285_17318", "title": "Tiotropium bromide", "score": 0.012266196801301164, "content": "Tiotropium was patented in 1989, and approved for medical use in 2002. It is on the World Health Organization's List of Essential Medicines. In 2019, it was the 132nd most commonly prescribed medication in the United States, with more than 5million prescriptions. Medical uses Tiotropium is used as maintenance treatment of chronic obstructive pulmonary disease (COPD). It may also be used as an add-on therapy in people with moderate-to-severe asthma on medium to high dose inhaled corticosteroids (ICS). It is not however approved for acute exacerbations of COPD or acute worsening of asthma. Tiotropium is also used in a combination inhaler with olodaterol, a long-acting beta-agonist, for the treatment of COPD, under the brand names Stiolto and Spiolto among others. Adverse effects" }, { "id": "pubmed23n0817_7505", "title": "The use of β2-agonist therapy before hospital attendance for severe asthma exacerbations: a post-hoc analysis.", "score": 0.012124542124542125, "content": "Patterns of inhaled β2-agonist therapy use during severe asthma exacerbations before hospital attendance are poorly understood. To assess β2-agonist use prior to hospital attendance. We undertook an exploratory post hoc analysis of data from a 6-month clinical trial of 303 patients randomised to combination budesonide/formoterol inhaler according to a Single combination inhaler as Maintenance And Reliever Therapy regimen ('SMART') or fixed-dose budesonide/formoterol with salbutamol as reliever ('Standard'). Patterns of β2-agonist use for 14 days before hospital attendance with a severe asthma exacerbation were determined by electronic monitoring of inhaler use. There were 22 hospital attendances in 16 patients during the study. Seven and nine hospital attendances were eligible for analysis in the SMART and Standard groups, respectively. In both regimens, β2-agonist use increased before hospital attendance, with a median (range) maximum daily number of actuations of 14 (9 to 63) budesonide/formoterol in SMART and 46 (6 to 95) salbutamol in Standard with 4 (0 to 10) budesonide/formoterol actuations on the day of maximal salbutamol use. There was delay in obtaining medical review despite high β2-agonist use, in 9/16 patients. Different patterns of use were observed, including repeated days of no inhaled corticosteroid despite marked salbutamol use, which occurred in 3/9 patients in the Standard group. Delay in obtaining medical review in association with high β2-agonist use is common in patients before hospital presentation with severe exacerbations of asthma. The SMART regimen reduced nonadherence with inhaled corticosteroid therapy during severe exacerbations." }, { "id": "wiki20220301en071_9479", "title": "Long-acting beta-adrenoceptor agonist", "score": 0.01211719315167591, "content": "Long-acting β adrenoceptor agonists (LABAs, more specifically, long-acting β2 adrenergic receptor agonists) are usually prescribed for moderate-to-severe persistent asthma patients or patients with chronic obstructive pulmonary disease (COPD). They are designed to reduce the need for shorter-acting β2 agonists such as salbutamol (albuterol), as they have a duration of action of approximately 12 hours in comparison with the 4-to-6-hour duration of salbutamol, making them candidates for sparing high doses of corticosteroids or treating nocturnal asthma and providing symptomatic improvement in patients with COPD. With the exception of formoterol, long-acting β2 agonists are not recommended for the treatment of acute asthma exacerbations because of their slower onset of action compared to salbutamol. Their long duration of action is due to the addition of a long, lipophilic side-chain that binds to an exosite on adrenergic receptors. This allows the active portion of the molecule to" }, { "id": "pubmed23n0664_7844", "title": "Single maintenance and reliever therapy (SMART) of asthma: a critical appraisal.", "score": 0.012038606565883696, "content": "The use of a combination inhaler containing budesonide and formoterol as both maintenance and quick relief therapy (SMART) has been recommended as an improved method of using inhaled corticosteroid/long-acting beta agonist (ICS/LABA) therapy. Published double-blind trials show that budesonide/formoterol therapy delivered in SMART fashion achieves better asthma outcomes than budesonide monotherapy or lower doses of budesonide/formoterol therapy delivered in constant dosage. Attempts to compare budesonide/formoterol SMART therapy with regular combination ICS/LABA dosing using other compounds have been confounded by a lack of blinding and unspecified dose adjustment strategies. The asthma control outcomes in SMART-treated patients are poor; it has been reported that only 17.1% of SMART-treated patients are controlled. In seven trials of 6-12 months duration, patients using SMART have used quick reliever daily (weighted average 0.92 inhalations/day), have awakened with asthma symptoms once every 7-10 days (weighted average 11.5% of nights), have suffered asthma symptoms more than half of days (weighted average 54.0% of days) and have had a severe exacerbation rate of one in five patients per year (weighted average 0.22 severe exacerbations/patient/year). These poor outcomes may reflect the recruitment of a skewed patient population. Although improvement from baseline has been attributed to these patients receiving additional ICS therapy at pivotal times, electronic monitoring has not been used to test this hypothesis nor the equally plausible hypothesis that patients who are non-compliant with maintenance medication have used budesonide/formoterol as needed for self-treatment of exacerbations. Although the long-term consequences of SMART therapy have not been studied, its use over 1 year has been associated with significant increases in sputum and biopsy eosinophilia. At present, there is no evidence that better asthma treatment outcomes can be obtained by moment-to-moment symptom-driven use of ICS/LABA therapy than conventional physician-monitored and adjusted ICS/LABA therapy." }, { "id": "pubmed23n0261_8244", "title": "Efficacy of Uniphyl, salbutamol, and their combination in asthmatic patients on high-dose inhaled steroids.", "score": 0.011992358850997595, "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": "pubmed23n0855_21102", "title": "Long-acting muscarinic antagonists (LAMA) added to combination long-acting beta2-agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma.", "score": 0.011930926216640502, "content": "Maintenance treatment with long-acting beta2-agonists and inhaled corticosteroids (LABA/ICS) can relieve asthma symptoms and reduce the frequency of exacerbations, but there are limited treatment options for people who do not gain control on combination LABA/ICS. Long-acting muscarinic antagonists (LAMA) are a class of inhaled drug which have been effective for people with chronic obstructive pulmonary disease and are now becoming available for people with asthma to take alongside their LABA/ICS inhaler. To assess the effects of adding a long-acting muscarinic antagonist (LAMA) to combination long-acting beta2-agonists (LABA) and inhaled corticosteroids (ICS) in adults whose asthma is not well controlled by LABA/ICS. We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to January 2016. We also searched ClinicalTrials.gov, the WHO trials portal, and reference lists of other reviews, and we contacted trial authors for additional information. We included parallel randomised controlled trials (RCTs) of at least 12 weeks' duration. Studies met the inclusion criteria if they compared LAMA as an add-on to LABA/ICS versus LABA/ICS alone for adults with asthma. We included studies reported as full text, those published as abstract only, and unpublished data. Primary outcomes were exacerbations requiring oral corticosteroids (OCS), validated measures of asthma control, and serious adverse events (including mortality). Two review authors screened searches and independently extracted details on risk of bias and numerical data. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MD) using a random-effects model. We rated all outcomes using GRADE. We found four double-blind, double-dummy trials comparing LAMA to placebo, including 1197 people with asthma taking combination LABA/ICS. One of the trials was designed to study glycopyrronium bromide but was withdrawn prior to enrolment, and the other three all studied tiotropium bromide (mostly 5 µg once daily via Respimat) over 48 to 52 weeks. People in the trials had a mean forced expiratory volume in one second (FEV1) of 55% of their predicted value, indicating severe asthma.People randomised to take tiotropium add-on had fewer exacerbations requiring oral corticosteroids than those continuing to take LABA/ICS alone, but the confidence intervals did not rule out no difference (OR 0.76, 95% CI 0.57 to 1.02; moderate quality evidence). Over 48 weeks, 328 out of 1000 people taking their usual LABA/ICS would have to take oral corticosteroids for an exacerbation compared with 271 if they took tiotropium as well (95% CI 218 to 333 per 1000). Analyses comparing the number of exacerbations per patient in each group (rate ratio) and the time until first exacerbation (hazard ratio) were in keeping with the main result. Quality of life, as measured by the Asthma Quality of Life Questionnaire (AQLQ) was no better for those taking tiotropium add-on than for those taking LABA/ICS alone when considered in light of the 0.5 minimal clinically important difference on the scale (MD 0.09, 95% CI - 0.03 to 0.20), and evidence for whether tiotropium increased or decreased serious adverse events in this population was inconsistent (OR 0.60, 95% CI 0.24 to 1.47; I(2) = 76%).Within the secondary outcomes, exacerbations requiring hospital admission were too rare to tell whether tiotropium was beneficial over LABA/ICS alone. There was high quality evidence showing benefits to lung function (trough FEV1 and forced vital capacity (FVC)) and potentially small benefits to asthma control. People taking tiotropium add-on were less likely to experience non-serious adverse events. Tiotropium add-on may have additional benefits over LABA/ICS alone in reducing the need for rescue oral steroids in people with severe asthma. The effect was imprecise, and there was no evidence for other LAMA preparations. Possible benefits on quality of life were negligible, and evidence for the effect on serious adverse events was inconsistent. There are likely to be small added benefits for tiotropium Respimat 5 µg daily on lung function and asthma control over LABA/ICS alone and fewer non-serious adverse events. The benefit of tiotropium add-on on the frequency of hospital admission is still unknown, despite year-long trials.Ongoing and future trials should clearly describe participants' background medications to help clinicians judge how the findings relate to stepwise care. If studies test LAMAs other than tiotropium Respimat for asthma, they should be at least six months long and use accepted and validated outcomes to allow comparisons of the safety and effectiveness between different preparations." }, { "id": "pubmed23n0521_11765", "title": "As-needed inhaled beta2-adrenoceptor agonists in moderate-to-severe asthma: current recommendations.", "score": 0.011117955035417309, "content": "Intermediate-acting inhaled beta2-agonists (e.g. albuterol [salbutamol]), once recommended for round-the-clock bronchodilation, are now recommended to be used exclusively as-needed. Guidelines advise that asthma should be controlled with anti-inflammatory therapeutic strategies so that the as-needed requirement for inhaled beta2-agonists should be infrequent; ideally less than several times per week, up to once a day for exercise, and none at night. These recommendations are based upon the recognition that asthma is primarily an inflammatory condition and that the major thrust of therapy should be anti-inflammatory, including environmental control and administration of inhaled corticosteroids (ICS), leukotriene-receptor antagonists, and possibly oral theophylline and inhaled cromones; the cromones include cromolyn sodium (sodium cromogylcate) and nedocromil. While this is the primary rationale behind the as-needed infrequent prescription of the inhaled beta2-agonist paradigm, there are a number of detrimental effects that can be seen with regularly scheduled (or frequent as-needed) use of inhaled beta2-agonists. These include tolerance to the bronchodilator and particularly the bronchoprotective effects, increased airway responsiveness to allergen, worsened asthma control, and, probably most importantly, over-reliance on an excellent symptom reliever leading to undertreatment. Any or all of these could be responsible for the demonstrated dose-response relationship between inhaled beta2-agonist overuse and death from asthma. Several controlled clinical trials, which have included many patients with at least moderately severe asthma, have failed to demonstrate any obvious advantage to the regular scheduled use of inhaled beta2-agonists compared with as-needed inhaled beta2-agonists. On the other hand, despite no obvious advantage, regular use of albuterol 1000-1200 microg/day appears to be well tolerated and reasonably safe. When asthma is treated using an as-needed, infrequent inhaled beta2-agonist, the requirements for beta2-agonists become a useful marker of whether or not the asthma is adequately controlled. When inhaled beta2-agonists are required inordinately frequently (i.e. when asthma is not adequately controlled), after ensuring compliance with ICS, the most common strategy is to add one of the long-acting inhaled beta2-agonists twice daily. On the basis of the available evidence, the as-needed intermediate-acting inhaled beta2-agonist therapeutic strategy appears appropriate for patients with moderate-to-severe asthma." }, { "id": "pubmed23n0381_22605", "title": "Clinical outcome of adding long-acting beta-agonists to inhaled corticosteroids.", "score": 0.010968592663629824, "content": "Current asthma management guidelines state that where a patient is receiving a low to moderate dose of inhaled corticosteroids and is still experiencing symptoms the dose of corticosteroid should be increased and, if necessary, a long-acting bronchodilator should be added. Many studies have now shown that the addition of a beta2-agonist with long-acting properties is more effective at controlling asthma symptoms than increasing the dose of corticosteroid alone. The Formoterol and Corticosteroid Establishing Therapy (FACET) study was a 12-month study comparing exacerbation rates in patients treated with budesonide (100 microg or 400 microg) twice daily alone vs, treatment with budesonide (100 microg or 400 microg) twice daily plus formoterol 9 microg twice daily (delivered dose). The addition of formoterol reduced the rates of mild and severe exacerbations compared with budesonide alone, with the lowest rates seen in patients receiving high-dose budesonide and formoterol. There was no difference in the profile of exacerbations in any groups, indicating formoterol does not mask any signs of inflammation. The addition of formoterol to budesonide was also shown to result in improved lung function (as measured by peak expiratory flow rate and forced expiratory volume in 1 second), night-time awakenings and the use of as-needed medication when compared with an increase in the dose of budesonide. In all cases, increasing the dose of budesonide and addition of formoterol resulted in the most improvement and a significant increase in quality of life, measured by Asthma Quality of Life Questionnaire (AQLQ), was noted. In conclusion, the addition of formoterol to established treatment with inhaled corticosteroids provides superior asthma control compared with an increase in the dose of corticosteroid alone." }, { "id": "wiki20220301en565_18787", "title": "Chronic cough", "score": 0.010851156012446336, "content": "Treating children who have a non-specific chronic cough with asthma medications such as inhaled beta2-agonists (e.g., salbutamol) or inhaled corticosteroids does not improve the clinical symptoms. Codeine-based cough medications are contraindicated for children under 12 years old due to the risk of respiratory suppression and the potential for opioid toxicity. Leukotriene receptor antagonist-based medications and methylxanthines are not recommended for treating children with persistent non-specific cough." }, { "id": "InternalMed_Harrison_20163", "title": "InternalMed_Harrison", "score": 0.01070658442405095, "content": "Stepwise Therapy For patients with mild, intermittent asthma, a short-acting β2-agonist is all that is required (Fig. 309-8). However, use of a reliever medication more than twice a week indicates the need for regular controller therapy. The treatment of choice for all patients is an ICS given twice daily. It is usual to start with an intermediate dose (e.g., 200 μg bid of beclomethasone dipropionate [BDP]) or equivalent and to decrease the dose if symptoms are controlled after 3 months. If symptoms are not controlled, a LABA should be added, which is most conveniently given by switching to a combination inhaler. The dose of controller should be adjusted accordingly, as judged by the need for a rescue inhaler. Low doses of theophylline or an antileukotriene may also be considered as an add-on therapy, but these are less effective than LABA. In patients with severe asthma, low-dose oral theophylline is also helpful, and when there is irreversible airway narrowing, the long-acting" }, { "id": "pubmed23n0045_4554", "title": "[Salmeterol and prolonged treatment of asthma: international clinical data].", "score": 0.01056652169064347, "content": "Salmeterol is an original molecule with a selective-beta-2-sympathomimetic effect which is intended to a prolonged treatment of asthma. This inhaled preparation has a long duration of action which points to its use on a BID regimen. Results of the phase III development has been assessed in 2,277 subjects. Salmeterol administered at a dose of 50 micrograms morning and evening results in a marked increase in FEV1, which remains superior to 15% by comparison with baseline 12 hours after the last dose in the majority of subjects. In the specific case of more severe asthma (FEV1 less than 50% of predicted), the use of 100 micrograms morning and evening allows for an extra-improvement in FEV1. In the majority of studies, salmeterol has resulted in an almost complete remission of the clinical symptomatology: disappearance or major diminution in the use of inhaled salbutamol administered as a rescue medication on a PRN basis (during the day and at night) and of nocturnal awakenings, global improvement of clinical scores. Daily peak expiratory flow rates (morning and night values) are considerably improved (greater than or equal to 50 l/min) with a significant reduction of daily swings. Lung function tests are also very significantly improved. Salmeterol has proved to be largely superior to the comparison medications, salbutamol taken at a dose of 200 micrograms four times a day, and optimal therapy with theophylline. Clinical acceptability of salmeterol is good and is not different from salbutamol." }, { "id": "wiki20220301en002_60432", "title": "Asthma", "score": 0.009879277401424353, "content": "Humidified Oxygen to alleviate hypoxia if saturations fall below 92%. Corticosteroid by mouth are recommended with five days of prednisone being the same 2 days of dexamethasone. One review recommended a seven-day course of steroids. Magnesium sulfate intravenous treatment increases bronchodilation when used in addition to other treatment in moderate severe acute asthma attacks. In adults intravenous treatment results in a reduction of hospital admissions. Low levels of evidence suggest that inhaled (nebulised) magnesium sulfate may have a small benefit for treating acute asthma in adults. Overall, high quality evidence do not indicate a large benefit for combining magnesium sulfate with standard inhaled treatments for adults with asthma. Heliox, a mixture of helium and oxygen, may also be considered in severe unresponsive cases. Intravenous salbutamol is not supported by available evidence and is thus used only in extreme cases." }, { "id": "pubmed23n0315_18454", "title": "Formoterol. An update of its pharmacological properties and therapeutic efficacy in the management of asthma.", "score": 0.00980392156862745, "content": "Formoterol, a selective beta 2-adrenoceptor agonist, produces effective dose-proportional bronchodilation, which persists for up to 12 hours, in patients with reversible obstructive respiratory disease. Bronchodilation is significant within minutes of inhalation, maximal within 2 hours, and at therapeutic doses is equivalent to that produced by standard doses of traditional beta 2-agonists. In single-dose studies comparing the two long-acting beta 2-agonists formoterol and salmeterol, significant bronchodilation is achieved more rapidly with formoterol than salmeterol. Duration of bronchodilation is similar with both drugs. The therapeutic efficacy of inhaled formoterol has been equal to or greater than that of salbutamol (albuterol), fenoterol and terbutaline in both short and long term clinical trials. Formoterol reduces symptoms of nocturnal asthma and reduces the need for rescue medication compared with salbutamol. Recent studies have shown that the addition of inhaled formoterol 12 or 24 micrograms twice daily to existing inhaled corticosteroid regimens improves lung function and reduces asthma symptoms compared with placebo. In one well designed study, the frequency of severe exacerbations of asthma over 12 months was decreased by adding formoterol to existing regimens of inhaled corticosteroids. Tolerance to the bronchodilator response of formoterol has not been observed in long term clinical trials. Because of its long duration of action, formoterol offers significant therapeutic advantages over shorter-acting beta 2-agonists in the treatment of nocturnal and exercise-induced asthma. Formoterol is effective in preventing exercise-induced asthma in adults and children and confers significantly more protection than salbutamol when administered 3 and 12 hours before exercise. In general, inhaled formoterol is well tolerated. The most commonly reported adverse effects, tremor and palpitations, are those traditionally associated with the use of beta 2-agonists. Oral formoterol and high doses of inhaled formoterol are associated with more adverse events than are the recommended doses of 6 to 24 micrograms. Formoterol is currently recommended for use as an alternative to increasing inhaled steroid dosage in patients whose symptoms are inadequately controlled despite therapy with low to moderate doses of inhaled steroids and intermittent short-acting beta 2-agonists, and results of recent studies support therapeutic guidelines. Long term clinical studies comparing formoterol and salmeterol have not yet been published. Further studies to evaluate the earlier use of formoterol in patients with mild to moderate asthma are needed to determine the role and long term safety of formoterol in the management of asthma." }, { "id": "pubmed23n0253_22285", "title": "Continuous and on demand use of bronchodilators in patients with non-steroid dependent asthma and chronic bronchitis: four-year follow-up randomized controlled study.", "score": 0.00980392156862745, "content": "A previous two-year study of continuous and on demand bronchodilator therapy in patients with moderate asthma and chronic bronchitis showed a deterioration in lung function in those on continuous therapy. A two-year follow-up study was undertaken of patients who had been shown in the previous study to have non-steroid dependent (mild) asthma and chronic bronchitis, in order to investigate the effect of continuous and on-demand treatment with bronchodilator therapy. Patients for the study were drawn from 29 general practices in the catchment area of the University of Nijmegen, the Netherlands. A total of 83 patients (27 with asthma and 56 with chronic bronchitis) were selected from a group of 160 patients who had completed the previous two-year bronchodilator trial. During these first two years the selected subjects had been shown to be non-steroid dependent (no rapid decline in lung function and a low number of exacerbations of their condition per year), and they were followed up for another two years of treatment with bronchodilator therapy. At the start of the four-year study, patients were randomly assigned to one of two parallel treatment groups: continuous treatment (dry powder inhalations of either salbutamol 1600 micrograms or ipratropium bromide 160 micrograms daily) or treatment on demand (only during exacerbations or periods of dyspnoea). Outcome parameters were the annual decline in lung function, changes in peak flow rate, bronchial hyper-responsiveness, exacerbation rate, respiratory symptoms and reported health. After correction for possibly confounding variables and for regression to the mean, the decline in lung function was 49 ml year in patients taking bronchodilators continuously and 51 ml year in patients using bronchodilators on demand, irrespective of the drug use. Continuously treated patients, whether suffering from asthma or chronic bronchitis, did not differ from patients treated on demand with respect to mean morning peak flow rate, diurnal (and week to week) variation of the peak flow rate, bronchial hyper-responsiveness, exacerbation rate and reported health. There was no difference between the long-term effects of salbutamol and ipratropium. Continuous use of bronchodilators over four years in patients with non-steroid dependent asthma or chronic bronchitis does not increase the decline in lung function which had been observed previously in patients with moderate asthma or chronic bronchitis during two years of continuous treatment with bronchodilators." }, { "id": "pubmed23n0274_13859", "title": "Cessation of long-term treatment with inhaled corticosteroid (budesonide) in children with asthma results in deterioration. The Dutch CNSLD Study Group.", "score": 0.009708737864077669, "content": "Inhaled corticosteroid has been shown to be effective in the management of asthma. However, there is a lack of studies that assess the effect of cessation after long-term treatment with inhaled corticosteroid. This question was addressed in 28 children with stable asthma, aged 11 to 18 yr of age, who had completed 28 to 36 months of treatment with inhaled corticosteroid (budesonide 200 micrograms 3 times/day) and inhaled beta-2-agonist (salbutamol 200 micrograms 3 times/day). The children were randomized in a 1:2 ratio in a double-blind study either to continue budesonide (n = 8) during a period of 6 months or to decrease the dose of budesonide (n = 20) within 2 months, followed by placebo for 4 months. Treatment with salbutamol 600 micrograms daily was continued in both groups. Eight children from the tapering-off group withdrew, mainly due to symptoms of asthma, compared with none in the continuous treatment group. Five patients in the tapering-off group experienced exacerbations for which prednisolone was given, compared with none in the continuous treatment group. After tapering-off, symptoms of asthma and additional bronchodilator use increased, and both FEV1% predicted and PD20 histamine (provocation dose of histamine causing a 20% fall in FEV1) decreased, whereas these all remained unchanged in the group that continued treatment with inhaled corticosteroid. We conclude that in this study long-term treatment with 600 micrograms budesonide daily suppressed underlying mechanisms of asthma, but did not cure the disease." }, { "id": "pubmed23n1033_5973", "title": "Add-on tiotropium versus step-up inhaled corticosteroid plus long-acting beta-2-agonist in real-world patients with asthma.", "score": 0.009708737864077669, "content": "<bBackground:</b A step-up approach (increasing inhaled corticosteroid [ICS] dose and/or add-on treatment) is recommended for asthma that is uncontrolled despite ICS plus long-acting beta-2-agonist (LABA) combination treatment. Understanding the impact of different treatment options on health outcomes can help guide treatment decision-making. <bObjective:</b To compare the effectiveness of add-on tiotropium 1.25 µg (two puffs once daily) versus an increased ICS plus LABA dose in a real-world cohort of patients with asthma initiated on ICS plus LABA. <bMethods:</b De-identified data from patients ages ≥12 years and with asthma who were initiated on ICS plus LABA, and then had tiotropium added (Tio group; index date) or an ICS plus LABA dose increased (inc-ICS group; index date) were collected from two medical and pharmacy claims data bases (2014-2018). To account for population/group differences, propensity score matching was performed. The primary end point was the exacerbation risk after the index date. Secondary end points included exacerbation rates 6 and 12 months postindex, health-care resource utilization, costs, and short-acting beta-2-agonist (SABA) refills 12 months postindex. <bResults:</b Overall, 7857 patients (Tio group, 2619; inc-ICS group, 5238) were included. The exacerbation risk was 35% lower in the Tio group than in the inc-ICS group (hazard ratio 0.65 [95% confidence interval, 0.43-0.99]; p = 0.044). Exacerbation rates in the Tio group also were significantly lower within 6 and 12 months postindex (64% and 73%, respectively). All-cause and asthma-related emergency department (ED) visits were 47% and 74% lower, respectively (p &lt; 0.0001 for both), and all-cause and asthma-related hospitalizations were 48% (p &lt; 0.01) and 76% (p &lt; 0.001) lower, respectively, in the Tio group. Also, significantly fewer patients in the Tio group versus the inc-ICS group required SABA refills (56% versus 67%, p &lt; 0.0001). <bConclusion:</b Add-on tiotropium significantly decreased the risk and rate of exacerbations, decreased all-cause and asthma-related ED visits and hospitalizations, and reduced SABA refills compared with increasing the ICS plus LABA dose. The findings supported the use of add-on tiotropium for patients with uncontrolled asthma taking ICS plus LABA." }, { "id": "pubmed23n0528_19512", "title": "Long-acting beta2-agonists versus placebo in addition to inhaled corticosteroids in children and adults with chronic asthma.", "score": 0.009615384615384616, "content": "Long-acting inhaled beta2-adrenergic agonists are recommended as 'add-on' medication to inhaled corticosteroids in the maintenance therapy of asthmatic adults and children aged two years and above. To quantify in asthmatic patients the safety and efficacy of the addition of long-acting beta2-agonists to inhaled corticosteroids on the incidence of asthma exacerbations, pulmonary function and other measures of asthma control. We identified randomised controlled trials (RCTs) through electronic database searches (the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE and CINAHL), bibliographies of RCTs and correspondence with manufacturers, until April 2004. RCTs were included that compared the addition of inhaled long-acting beta2-agonists to corticosteroids with inhaled corticosteroids alone for asthma therapy in children aged two years and above and in adults. Studies were assessed independently by two review authors for methodological quality and data extraction. Confirmation was obtained from the trialists when possible. The primary endpoint was rate of asthma exacerbations requiring systemic corticosteroids. Secondary endpoints included pulmonary function tests (PFTs), symptom scores, adverse events and withdrawal rates. Of 594 identified citations, 49 trials met the inclusion criteria: 27 full-text publications, one unpublished full-text report and 21 abstracts. Twenty-three citations (21 abstracts and two full-text publications) provided data in insufficient detail, 26 trials contributed to this systematic review. All but three trials were of high methodological quality. Most interventions (N = 26) were of four-month duration or less. Eight trials focused on children and 18 on adults, with participants generally symptomatic with moderate airway obstruction despite their current inhaled steroid regimen. If a trial had more than one intervention or control group, additional control to intervention comparisons were considered separately. Formoterol (N = 17) or salmeterol (N = 14) were most frequently added to low-dose inhaled corticosteroids (200 to 400 microg/day of beclomethasone (BDP) or equivalent). The addition of a daily long-acting beta2-agonist (LABA) reduced the risk of exacerbations requiring systemic steroids by 19% (relative risk (RR) 0.81, 95% CI 0.73 to 0.90). The number needed to treat for one extra patient to be free from exacerbation for one year was 18 (95% CI 13 to 33). The addition of LABA significantly improved FEV1 (weighted mean difference (WMD) 170 mL, 95% CI 110 to 240) using a random-effects model, increased the proportion of symptom-free days (WMD 17%, 95% CI 12 to 22, N = 6 trials) and rescue-free days (WMD 19%, 95% CI 12 to 26, N = 2 trials). The group treated with LABA plus inhaled corticosteroid showed a reduction in the use of rescue short-acting beta2-agonists (WMD -0.7 puffs/day, 95% CI -1.2 to -0.2), experienced less withdrawals due to poor asthma control (RR 0.5, 95% CI 0.4 to 0.7) and less withdrawals due to any reason (RR 0.9, 95% CI 0.8 to 0.98), using a random-effects model. There was no group difference in risk of overall adverse effects (RR 0.98, 95% CI 0.92 to 1.05), withdrawals due to adverse health events (RR 1.29, 95% CI 0.96 to 1.75) or specific adverse health events. In patients who are symptomatic on low to high doses of inhaled corticosteroids, the addition of a long-acting beta2-agonist reduces the rate of exacerbations requiring systemic steroids, improves lung function, symptoms and use of rescue short-acting beta2-agonists. The similar number of serious adverse events and withdrawal rates in both groups provides some indirect evidence of the safety of long-acting beta2-agonists as add-on therapy to inhaled corticosteroids." }, { "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": 0.009615384615384616, "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": "pubmed23n0284_4019", "title": "[Comparative study] of beclomethasone and budesonide, with same posology (400 micrograms every 12 hours), in the control of cortico-dependent intrinsic asthma].", "score": 0.009523809523809525, "content": "Inhaled steroids have rendered an undoubtful benefit in the control of airway inflammation of the asthmatic patients. Our objective was to compare clinical efficacy between budesonide (BUD) and beclomethasona depropionate (BDP), when administered at equal doses (800 micrograms/24 hours). A two ways crossed open clinical trial was designed. Thirty-three steroid dependent chronic asthmatic patients (18 females, 15 males) were included. Ages ranged from 29 to 73 years (mean = 52.5 +/- 11.7). All subjects suffered a severe asthma, with several years of activity (mean = 11.7 +/- 7.8), insufficiently controlled by inhaled steroids and bronchodilators, who required regular systemic steroids supply. The parameters compared were: the patients subjective symptoms punctuation (cough, expectoration, thoracic noises, exercise induce dyspnea and dyspnea at rest), salbutamol needs (number of inhalations/day), additional prednisone needs, sputum eosinophil counts, FEV1 measurement and inespecific bronchial reactivity control (PD20 methacoline). After a baseline week patients received one of the drugs for 6 weeks and, after a lavage week, the other drug was administered for another 6 weeks. All patients improved with both therapies. We got the following conclusions: 1) a significative decrease in salbutamol (p &lt; 0.05-0.001) and prednisone needs (p &lt; 0.05-0.001); 2) this decrease has been more important during BUD therapy, although without significative differences; 3) no significant variations in sputum eosinophils, FEV1 or bronchial reactivity were observed; 4) both drugs, when administered at equal doses, have probed to be equally effective in severe steroid dependent asthma control." }, { "id": "pubmed23n0768_8024", "title": "The effects of long-acting β2-agonists plus inhaled corticosteroids for early reversibility in patients with airway obstruction.", "score": 0.009523809523809525, "content": "Salbutamol, as a short-acting β2-agonist, was popularly used in the past for detection of reversibility in patients with airway obstruction when it was the only drug available in the treatment of airway obstruction. Today, the combination of long-acting β2-agonists (LABA) and inhaled glucocorticoids are the first choice of therapy, with or without the presence of reversibility, in patients with airway obstruction. We aimed to compare the efficacy of salbutamol and long acting β2-agonists plus inhaled glucocorticoids for early reversibility test in patients with airway obstruction. Symptomatic patients (cough, dyspnea, and/or wheezing) with airway obstruction according to pulmonary function testing (FEV1/FVC value less than 70% of expected) who had never used bronchodilators before or had not received short- or long-acting inhaled bronchodilator therapy within the most recent 12 hours were evaluated. Reversibility measurements were made by administering the combination of long-acting β2-agonists (LABA) and inhaled glucocorticoids after 15 minutes. A total of 90 patients were evaluated. The mean age of patients was 57.3±17.7 (range, 8-88) years and the male-to-female ratio was 69/21. The baseline pulmonary function test results were mean FVC; 2,747±1,181 mL and 74.7%±21.4%, mean FEV1; 1,716±825 mL and 57.5%±19.0%, mean FEV1/FVC; 61.4%±7.4%. The bronchodilator drugs given before reversibility testing were as salmeterol/fluticasone (FTC/SAL), formoterol/budesonide (BUD/FOR), beclomethasone dipropionate/formoterol (BDP/FOR) and salbutamol (SLB) in 24, 22, 24 and 20 patients, respectively. The reversibility was positive in 33 (36.7%) patients. The absolute change and percentage of change in mean FEV1 were 206±252 mL, 13.2%±16.6% for FTC/SAL group, 273±201 mL, 14%±8% for BUD/FOR group, 240±151 mL, 18.7%±15.9% for BUD/FOR groupand 171±116 mL, 13.3%±11.8% for SLB group. There was no statistically significant for reversibilty results between LABAs/inhaledsteroids and SLB group. And the patients with positivere versibility test were significantly higher in both of BUD/FOR and BDP/FOR groups than SLB group. We think that performance of an early reversibility test using the combination of a LABA and an inhaled corticosteroid for treatment would enhance both the education of the patient in using the device and the reliability of the drug. And, we suggest that: \"you should make the reversibility test with Long-Acting β2-Agonists plus Inhaled Corticosteroids which used in treatment of obstructive lung diseases\"." }, { "id": "pubmed23n0077_18624", "title": "Assessment of reversibility of airway obstruction in patients with chronic obstructive airways disease.", "score": 0.009433962264150943, "content": "Spirometry before and after an inhaled beta agonist or a course of oral prednisolone is widely used to detect reversible airflow limitation in patients with chronic obstructive lung disease. How many of these patients have a response and how the response to beta agonists relates to the response to corticosteroids is not clear. In 127 outpatients (mean (SD) FEV1 0.92 (0.38) 1) who had a clinical diagnosis of chronic obstructive lung disease (continuous breathlessness for more than six months and an FEV1/forced vital capacity (FVC) ratio less than 60%) and who appeared to be stable, the change in FEV1 was measured after salbutamol 200 micrograms from a metered dose inhaler and 5 mg from a nebuliser. Symptoms and spirometric values were recorded before and after two weeks of oral prednisolone 30 mg. Reversibility was defined as a response in FEV1 of 15% or more from baseline alone and as a 15% change and a minimum increase of at least 200 ml. The latter gave results that showed greater internal consistency between the drug regimens. On the basis of this criterion 56 patients (44%) had no response to salbutamol or prednisolone, 71 responded to salbutamol (including all 27 steroid responders), and 25 patients had a response to salbutamol 5 mg but not to 200 micrograms. In general, the largest increase in FEV1 after salbutamol occurred in the subjects with greatest improvement after prednisolone. Subjects showing a response in FEV1 after two weeks' prednisolone had a fall in total symptom score, unlike those who had no response to any treatment or a response to salbutamol only. These data show that reversibility in response to beta agonists is common in patients diagnosed on clinical grounds as having stable chronic obstructive lung disease, that it can be substantial, and that it is best detected by using a larger dose of salbutamol. Salbutamol responders were those most likely to improve after a trial of oral prednisolone. Allowance should be made for the variability of FEV1 in the calculation of the percentage response at low baseline values (less than 1 litre)." } ] } } }

{ "1": { "exist": false, "char_ranges": [], "word_ranges": [], "text": "" }, "2": { "exist": true, "char_ranges": [ [ 0, 179 ] ], "word_ranges": [ [ 0, 33 ] ], "text": "Treatment with a brace in Risser from 0 to 2 can be considered since there is still growth to occur and correction can take place. Its use is considered for curves between 30-40º." }, "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": "Recommend swimming and review in three months.", "2": "Prescribe a brace-type orthosis.", "3": "Refer to physiotherapy for spine elastification.", "4": "Check in 6 months with a new X-ray.", "5": null }

{ "clinical_case_options": { "MedCorp": { "RRF-2": [ { "id": "pubmed23n0825_810", "title": "Effectiveness of brace treatment for adolescent idiopathic scoliosis.", "score": 0.019704911667637354, "content": "Effectiveness of brace treatment for adolescent idiopathic scoliosis (AIS) was demonstrated by the BrAIST study in 2013. Objectives of this study were to confirm its effectiveness by analyzing our results and to clarify the factors affecting the results of the treatment. According to the Scoliosis Research Society AIS brace studies standardization criteria, patients with age 10 years or older, Risser 0 to II, less than 1 year post-menarche, curve magnitude 25 to 40 degrees before brace treatment and who received no prior treatment were included in the study. At skeletal maturity, the rate of the patients whose curve was stabilized, exceeded 45 degrees, and who were recommended or underwent surgery were investigated. Additionally, initial correction rate by the brace and factors affecting the results were investigated. A total of 33 patients (27 females and 6 males) could be followed-up until their skeletal maturity and included in the analysis. An average age was 11.9 years, average Cobb angle was 30.8°, and Risser sign was 0 in 13 patients, I in 5, and II in 15 patients before treatment. There were 13 thoracic curves, 14 thoracolumbar or lumbar curves, and 6 double curves. Initial correction rate by the brace was 53.8% for the total curves. In terms of curve pattern, 34.4% for thoracic curve, 73.9% for thoracolumbar or lumbar curve, and 48.8% for double curve. After an average follow-up period of 33 months, 8 patients improved in more than 6 degrees, change of 17 patients were within 6 degrees, and 8 progressed in more than 6 degrees. Therefore, totally, 76% (25/33) of the curves were stabilized by the treatment. Four curves (12%) exceeded 45 degrees and one patient (3%) underwent surgery. Our results were better than the reported natural history. Factors that affected the results were hump degree before treatment and initial correction rate by the brace. 76% of the curve with AIS could be stabilized by brace treatment. Brace treatment was effective for treatment of AIS. Factors affecting the results were hump degrees and initial correction rate." }, { "id": "pubmed23n0573_15298", "title": "The natural history of idiopathic scoliosis.", "score": 0.018031189083820662, "content": "Background. The natural history of idiopathic scoliosis is a crucial issue in the planning and assessment of different treatment methods. This article presents the evaluation of scoliotic deformity in immature patients who have been in observation without any treatment. Material and methods. 159 patients (128 girls, 31 boys) were examined between 1971 and 2002. Skoliosis was diagnosed at a mean age of 6 years 4 months (range 2.1-8.10), and observation was concluded at a mean age of 16 years 11 months (range 14.6-20.3). The mean follow-up was 10 years 5 months. The prognostic factors analyzed were: age, sex, Cobb angle, Mehta angle, apical vertebral rotation, specific rotation, Risser test. The progression and regression of curvature was analyzed in different biological age periods, and was measured by calculating the difference in the Cobb angle on successive x-rays divided by the interval between x-rays. Results. The mean progression of curvature before age 5 was 5.7 degrees per year; in the 6-10 age bracket, 2.3 degrees per year; in the 11-15 age bracket, 7.4 degrees per year; in the &gt;15 age bracket, 0.3 degrees per year. The mean progression for patients with Risser 1 was 8.8 degrees per year; Risser 2, 7.3 degrees per year; Risser 3, 5.1 per year; Risser 4, 2.1 degrees per year; Risser 5, 0.3 degrees per year. Conclusions. The progression of curvature in idiopathic scoliosis is variable, and is influenced by age. Knowledge of the natural history of idiopathic scoliosis is a crucial tool in predicting the development of spinal curvature. The Risser test and biological age are the only effective predictors of progression." }, { "id": "pubmed23n0726_2853", "title": "Effectiveness of the Charleston night-time bending brace in the treatment of adolescent idiopathic scoliosis.", "score": 0.01779500158177792, "content": "Part-time or night-time bracing has been introduced to address the poor compliance and psychological burden of full-time bracing. The results of various bracing methods vary, however, due to a lack of consistent inclusion criteria and definitions of brace effectiveness. We have evaluated the effectiveness of the Charleston night-time bending brace in the treatment of adolescent idiopathic scoliosis based on the new standardized criteria proposed by the Scoliosis Research Society. To be included in this study, patients met the following criteria proposed by the Scoliosis Research Society: diagnosis of adolescent idiopathic scoliosis, age 10 years and older when the orthosis was prescribed, Risser 0-2, a primary curve magnitude of 25 to 40 degrees, and no prior treatment. A total of 95 patients (87 girls, 8 boys) were included. At skeletal maturity, 80 patients (84.2%) had 5 degrees or less curve progression and 15 (15.8%) had 6 degrees or more progression. Seven patients (7.8%) were recommended to undergo or underwent surgery before skeletal maturity. Eleven patients (12.6%) progressed beyond 45 degrees. According to these 3 criteria, the Charleston night-time brace was successful in 74 patients (77.9%). Depending on curve type, we observed success rates of 78.3% (47/60) for double, 71.4% (15/21) for thoracic, 83.3% (5/6) for thoracolumbar, and 87.5% (7/8) for lumbar curves. Success rates of 80.0% (36/45) and 76.0% (38/50) were observed in patients with curve magnitudes at bracing of 25 to 30 degrees and 31 to 40 degrees, respectively. Patients with high apex curves had a 67.6% (23/34) success rate, and those with low apex curves had 83.0% (39/47) success rate. Brace success rates among patients with initial Risser signs of 0, 1, and 2 were 68.8% (22/32), 80.6% (25/31), and 84.4% (27/32), respectively. Compared with the results of previous natural history and conventional brace study, the Charleston night-time bending brace is effective for the treatment of adolescent idiopathic scoliosis. Level VI." }, { "id": "pubmed23n0573_23658", "title": "[A clinical follow-up study on treatment of adolescent idiopathic scoliosis with brace].", "score": 0.016893997092016895, "content": "To evaluate clinical outcomes of bracing and analyze related factors that influence curative effects in adolescents with idiopathic scoliosis, and to investigate indications of bracing. Seventy-nine patients with AIS who had no history of prior therapy were treated with a brace. Several parameters were consecutive measured and documented during the period of follow-up including Cobb's angles, curve patterns, menarche status, sitting heights, standing heights, Risser sign, apical vertebral rotation, and so on. The average period of followed-up was 30 months (12 months to 60 months). Twenty-one patients (26.6%) presented curve deterioration, 40 patients have no obvious curve change, 18 patients (22.8%) got a curve improvement. There was significantly lower percentage of curve progression and higher percentage of curve improvement in cases with Cobb's angle less than 35 degrees at the first visit (P &lt; 0.05). The percentage of curve progression was significantly greater in the cases with apical vertebral rotation beyond grade III while the percentage of curve improvement was lower (P &lt; 0.05). Curve patterns, Risser sign and other parameters were found to make their effects on the percentage of curve progression and improvement, which, however, was not statistically significant (P &gt; 0.05). Bracing can limit or improve mild and moderate curve of idiopathic scoliosis effectively, especially in cases with initial curve magnitude ranging from 20 degrees to 35 degrees . Risser sign is not a reliable parameter for measuring the outcome of bracing treatment for idiopathic scoliosis. Surgery is advised as soon as possible for the cases with initial Cobb's angles greater than 45 degrees and initial apical vertebral rotation beyond grade III early while bracing did not work." }, { "id": "pubmed23n0830_21807", "title": "Mild angle early onset idiopathic scoliosis children avoid progression under FITS method (Functional Individual Therapy of Scoliosis).", "score": 0.016666666666666666, "content": "Physiotherapy for stabilization of idiopathic scoliosis angle in growing children remains controversial. Notably, little data on effectiveness of physiotherapy in children with Early Onset Idiopathic Scoliosis (EOIS) has been published.The aim of this study was to check results of FITS physiotherapy in a group of children with EOIS.The charts of the patients archived in a prospectively collected database were retrospectively reviewed. The inclusion criteria were:diagnosis of EOIS based on spine radiography, age below 10 years, both girls and boys, Cobb angle between 118 and 308, Risser zero, FITS therapy, no other treatment (bracing), and a follow-up at least 2 years from the initiation of the treatment. The criterion for curve progression were as follows: the Cobb angle increase of 68 or more, for curve stabilization; the Cobb angle was 58 comparing to the initial radiograph,for curve correction; and the Cobb angle decrease of 68 or more at the final follow-up radiograph.There were 41 children with EOIS, 36 girls and 5 boys, mean age 7.71.3 years (range 4 to 9 years) who started FITS therapy. The curve pattern was single thoracic (5 children), single thoracolumbar (22 children) or double thoracic/thoracolumbar (14 children), totally 55 structural curvatures. The minimum follow-up was 2 years after initiation of the FITS treatment, maximum was 16 years, mean 4.8 years). At follow-up the mean age was 12.53.4 years. Out of 41 children, 10 passed pubertal growth spurt at the final follow-up and 31 were still immature and continued FITS therapy. Out of 41 children, 27 improved, 13 were stable, and one progressed. Out of 55 structural curves, 32 improved, 22 were stable and one progressed. For the 55 structural curves, the Cobb angle significantly decreased from 18.085.48 at first assessment to 12.586.38 at last evaluation,p&lt;0.0001, paired t-test. The angle of trunk rotation decreased significantly from 4.782.98 to 3.282.58 at last evaluation, p&lt;0.0001,paired t-test.FITS physiotherapy was effective in preventing curve progression in children with EOIS. Final postpubertal follow-up data is needed." }, { "id": "pubmed23n0637_18882", "title": "Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner.", "score": 0.01624468557649597, "content": "The SRS criteria give the methodological reference framework for the presentation of bracing results, while the SOSORT criteria give the clinical reference framework for an appropriate bracing treatment. The two have not been combined in a study until now. Our aim was to verify the efficacy of a complete, conservative treatment of Adolescent Idiopathic Scoliosis (AIS)according to the best methodological and management criteria defined in the literature. Study Design. Retrospective study. Population. We included all AIS patients respecting the SRS inclusion criteria (age 10 years or older; Risser test 0-2; Cobb degrees 25-40 degrees ; no prior treatment; less than one year post-menarchal) who had reached the end of treatment since our institute database start in 2003. Thus we had 44 females and four males, with an age of 12.8 +/- 1.6 at the commencement of the study. Methods. According to individual needs, two patients have been treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 h/d, and seven for 18 h/d at start), and two with exercises only (1 male, 1 female): these were excluded from further analysis. Outcome criteria. SRS (unchanged; worsened 6 degrees or more; over 45 degrees at the end of treatment; surgically treated; two years' follow-up); clinical (ATR, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimal; minimal). Statistics. Paired ANOVA and t-test, Tukey-Kramer and chi-square test. Median reported compliance during the 4.2 +/- 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45 degrees , nor was any patient fused, and this remained true at the two-year follow-up for the 85% that reached it. Only two patients (4%) worsened, both with single thoracic curve, 25-30 degrees Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1 degrees ): thoracic (-7.3 degrees ), thoracolumbar (-8.4 degrees ) and lumbar (-7.8 degrees ), but not double major. Statistically significant improvements have also been found for aesthetics and ATR. Respecting also SOSORT management criteria and thus increasing compliance, the results of conservative treatment were much better than what had previously been reported in the literature using SRS criteria only." }, { "id": "pubmed23n0638_18760", "title": "Treatment of thoraco-lumbar curves in adolescent females affected by idiopathic scoliosis with a progressive action short brace (PASB): assessment of results according to the SRS committee on bracing and nonoperative management standardization criteria.", "score": 0.015178671446174526, "content": "The effectiveness of conservative treatment of scoliosis is controversial. Some studies suggest that brace is effective in stopping curve progression, whilst others did not report such an effect.The purpose of the present study was to effectiveness of Progressive Action Short Brace (PASB) in the correction of thoraco-lumbar curves, in agreement with the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardisation Criteria. Fifty adolescent females (mean age 11.8 +/- 0.5 years) with thoraco-lumbar curve and a pre-treatment Risser score ranging from 0 to 2 have been enrolled. The minimum duration of follow-up was 24 months (mean: 55.4 +/- 44.5 months). Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three situations were distinguished: curve correction, curve stabilisation and curve progression.The Kruskal Wallis and Spearman Rank Correlation tests have been used as statistical tests. CM mean value was 29,30 +/- 5,16 SD at t1 and 14,67 +/- 7,65 SD at t5. TA was 12.70 +/- 6,14 SD at t1 and 8,95 +/- 5,82 at t5. The variation between measures of Cobb and Perdriolle degrees at t1,2,3,4,5 and between CM t5-t1 and TA t5-t1 were significantly different.Curve correction was accomplished in 94% of patients, whereas a curve stabilisation was obtained in 6% of patients. The PASB, due to its peculiar biomechanical action on vertebral modelling, is highly effective in correcting thoraco-lumbar curves." }, { "id": "pubmed23n0740_12959", "title": "Scoliosis detection, patient characteristics, referral patterns and treatment in the absence of a screening program in Norway.", "score": 0.0150997150997151, "content": "Early diagnosis of idiopathic scoliosis allows for observation and timely initiation of brace treatment in order to halt progression. School scoliosis screening programs were abolished in Norway in 1994 for lack of evidence that the programs improved outcome and for the costs involved. The consequences of this decision are discussed. To describe the detection, patient characteristics, referral patterns and treatment of idiopathic scoliosis at a scoliosis clinic during the period 2003-2011, when there was no screening and to compare treatment modalities to the period 1976-1988 when screening was performed. Patient demographics, age at detection, family history, clinical and radiological charts of consecutive patients referred for scoliosis evaluation during the period 2003-2011, were prospectively registered. Patients were recruited from a catchment area of about 500000 teenagers. Maturity was estimated according to Risser sign and menarcheal status. Severity of pain was recorded by a verbal 5-point scale from no pain to pain at all times. Physical and neurological examinations were conducted. The detector and patient characteristics were recorded. Referral patterns of orthopedic surgeons at local hospitals and other health care providers were recorded. Patient data was obtained by spine surgeons. Treatment modalities in the current period were compared to the period 1976-1988. We registered 752 patients with late onset juvenile and adolescent idiopathic scoliosis from 2003-2011. There were 644 (86%) girls and 108 (14%) boys. Mean age at detection was 14.6 (7-19) years. Sixty percent had Risser sign ≥ 3, whilst 74% were post menarche with a mean age at menarche of 13.2 years. Thirty-one percent had a family history of scoliosis. The mean major curve at first consultation at our clinic was 38° (10°-95°). About 40% had a major curve &gt;40°. Seventy-one percent were detected by patients, close relatives, and friends. Orthopaedic surgeons referred 61% of the patients. The mean duration from detection to the first consultation was 20(0-27) months. The proportion of the average number of patients braced each year was 68% during the period with screening compared to 38% in the period without screening, while the proportion for those operated was 32% and 62%, respectively ( p=0.002, OR 3.5, (95%CI 1.6 to 7.5). In the absence of scoliosis screening, lay persons most often detect scoliosis. Many patients presented with a mean Cobb angle approaching the upper limit for brace treatment indications. The frequency of brace treatment has been reduced and surgery is increased during the recent period without screening compared with the period in the past when screening was still conducted." }, { "id": "pubmed23n0730_6128", "title": "Bracing can reduce high degree curves and improve aesthetics immediately after the end of growth. Final results of a retrospective case series.", "score": 0.014896867838044309, "content": "Recently it has been shown that idiopathic scoliosis (IS) curves can be reduced with bracing, and it has been proposed that this could be useful in non-surgically treated high degree curves even after Risser 3. Moreover, bracing has been shown to be able to improve aesthetics, and this could be another reason to treat some patients with cosmetic needs. Our aim is to preliminary check if results can be obtained in IS patients after Risser 3. Design. Retrospective uncontrolled cohort study. Inclusion criteria. All IS patients treated on a voluntary basis for aesthetic reasons and/or for curve reduction; Risser 4-5 at start; end of treatment reached. Population. 34 females and 2 males, age 16.2±1.6 years, Cobb angle 27.6°±8.9°. Treatment. Lyon or SPoRT braces 18 to 24 hours/day, specific SEAS exercises, rapid weaning (2-3 hours every 6 months). Outcome criteria: SRS (unchanged; worsened over 6°; over 45° at the end of treatment; surgically treated), radiographic and clinical. Statistics. ANOVA and chi-test. The reported compliance during the 2.8 ± 1.1 treatment years was 95.1%, while residual growth was 0.9 ± 1.1 cm. Improvements were found in 39% of this cohort, (46% in curves over 30°). Only 1 patient progressed 6°. We found highly statistically significant reductions of maximal (-4.4°), thoracic (-6.0°) and thoracolumbar (-6.6°) curves. Statistically significant improvements were found for Aesthetic Index. Before 20 years of age, even in skeletally mature patients, it is possible to reach radiographic and aesthetic improvements, although not as good as during growth. Correction is based on bone growth, but ligaments and neuromuscular control of posture can also be involved." }, { "id": "pubmed23n1161_2657", "title": "Brace and Physiotherapeutic Scoliosis Specific Exercises (PSSE) for Adolescent Idiopathic Scoliosis (AIS) treatment: a prospective study following Scoliosis Research Society (SRS) criteria.", "score": 0.014678448699067256, "content": "A growing scientific evidence for conservative treatment of AIS has recently proved that bracing is superior to natural history. Our aim was to investigate the effectiveness of a combined treatment with brace and PSSE for AIS. Prospective study, following SRS research inclusion criteria (&gt; 10 years, 25<supο</sup - 40<supο</sup, Risser 0-2, &lt; 1-year post-menarche, no prior treatment). 102 consecutive patients (87 females-15 males, mean age 12.8 years, Risser 0.48, Cobb Thoracic 29.2<supο</sup, Lumbar 27.8<supο</sup) received treatment with Cheneau brace and PSSE. Average follow-up time was 26.4 months. A scale from A to C was used to evaluate compliance with brace and PSSE (A: full-compliant, B: partially compliant, C: non-compliant). 7 subjects dropped-out (6.8%), so finally 95 patients included for statistical analysis, using paired t-test. Sixty-two patients (65.3%) remained stable, 22 improved &gt; 5<supο</sup (23.2%) and 11 progressed (11.5%). In-brace correction (IBC) was 49.7% for thoracic and 61.7% for lumbar curves. Analysis of progressed cases revealed that IBC (31.7% for thoracic and 34.4% for lumbar curves) and compliance (81.8% C for brace, 63.6% C for PSSE) was lower than average. Group A for treatment compliance (65.3%), showed significantly better results (70.9% stable, 29.1% improved, 0% progressed). A combination of bracing and PSSE can effectively treat AIS, according to SRS inclusion criteria. 88.5% of patients avoided progression &gt; 5<supο</sup and only 6.4% overpassed 40<supο</sup. IBC and compliance are the most important prognostic factors for successful treatment result. Early detection of AIS is also necessary for increased possibilities of effective conservative treatment." }, { "id": "pubmed23n0721_6639", "title": "Evolution of the curve patterns during brace treatment for adolescent idiopathic scoliosis.", "score": 0.014292277065999694, "content": "The curve pattern of idiopathic scoliosis is important for making decisions concerning bracing. However, whether the curve pattern changes during brace treatment have not been fully documented. The aim of this study was to investigate the changes of curve pattern during brace treatment in skeletally immature patients with adolescent idiopathic scoliosis (AIS). From January 2002 to January 2011, AIS patients treated with a Boston or Milwaukee brace were recruited after meeting the following inclusion criteria: older than 10 years of age at initiation of bracing; having a Cobb angle of 25°-40°; with a Risser sign 0-2; being regularly followed until the weaning of brace or the necessity of surgical treatment; and without history of previous treatment. A total of 130 female and 11 male AIS patients were included. The mean age was 12.9 years at initiation of bracing, and the female patients were, on average, 2.7 months past menarche. The mean follow-up period was 2.6 years (range 1.0-5.5 years). The definitions of changes in curve patterns were divided into four categories as follows: (1) shift of the apex of the main curve; (2) change in the curve span of more than two vertebrae; (3) change in the main curve type with regard to the apex location; and (4) change of curve direction. The patients were divided into two groups. Group A was comprised of patients who had experienced one or more categories of curve pattern changes, and Group B was comprised of those who had not. Of these 39 patients, 14 had apex shifting, 2 underwent curve span changes, 22 experienced changes in the main curve type, and one female had both changes in the apex and curve span. At the initiation of bracing, patients in Group A demonstrated significantly lower menarchal status (P = 0.018) and lower Risser grade (P = 0.025) than those in Group B. The difference in the percentage of patients who underwent Boston bracing between the two groups was statistically significant (41.5 % for Group A vs. 24.0 % for Group B, P = 0.023). Changes in curve pattern can occur during brace treatment. Patients with less skeletal maturity and those treated with a Boston brace are more susceptible to this phenomenon." }, { "id": "pubmed23n0805_1755", "title": "Low rate of surgery in juvenile idiopathic scoliosis treated with a complete and tailored conservative approach: end-growth results from a retrospective cohort.", "score": 0.013931254268153882, "content": "The main distinctive aspect of Juvenile Idiopathic Scoliosis (JIS) with respect to Adolescent Idiopathic Scoliosis (AIS) is the high risk of severe deformity and surgery. Approximately 70% of curves in patients with JIS progress and ultimately require surgery. There are presently very few studies with long-term follow-up of JIS and even fewer looking specifically at bracing Purpose To verify the effectiveness of a complete conservative treatment, including bracing and exercises, for JIS. Retrospective cohort observational study nested in a clinical prospective database of consecutive outpatients. Patient Sample Inclusion criteria: JIS, no previous treatment, all consecutive radiographies available from treatment start to end of growth (Risser sign 3). We found 30 patients, 27 females, 10 JIS type 1; mean age at first diagnosis was 7.8 +/-1.5 and mean treatment lasted 5.8 years. Cobb degrees 24.4+/-10 degrees, with 7 cases &gt;30 degrees, and 2 &gt; 45degrees. Outcome Measures Physiological measures. Radiographic and clinical data. Treatment (exercises alone, or elastic-rigid-highly rigid braces plus exercises) was tailored and continuously changed according to Cobb degrees, individual preferences, anthropometric characteristics, pubertal spurt, remaining growth, rotation, hump, lumbar curve take-off, and imbalance. The SOSORT Guidelines for patients' management have been followed. Funding and Conflict of Interest: no. 33.3% (95% Confidence Interval 16.4-50.2%) of patients worsened over the years. At the end of growth, 6.6% (0-15.5%) had surgical deformities (&gt;45degrees). We observed a good correction in the first years of treatment until pubertal growth spurt, when progression was usually noted and treatment changed increasing corrective forces (hours or rigidity of bracing). 23 cases were followed up until they had two consecutive radiographies showing Risser sign 5 and showed stability. Conservative treatment initiated already in childhood may favorably change the natural history of JIS with the aim of reaching a curve as far as possible from surgical thresholds. Observation, physical exercises, braces can be useful tools in the hand of physicians, but they must be carefully utilized by a deep knowledge of JIS." }, { "id": "pubmed23n0239_2151", "title": "[Results of brace treatment in idiopathic scoliosis--evaluation of the patients treated for over 2 years or those who completed the treatment].", "score": 0.01384895533831704, "content": "The results of the brace treatment (Milwaukee brace, Thoraco-Lumbo-Sacral-Orthosis, Boston-Milwaukee brace) were studied in 509 patients with idiopathic scoliosis, who were braces for an average of 3 years and 3 months ranging from 2 to 10 years. Of these patients, 60 were followed up for about 24 months after the brace was discontinued. The distribution of these patients according to curve pattern was as follows: 319 had thoracic curve; 78 had lumbar curve (combining lumbar and thoracolumbar curves together as one group); and 112 had double major curve. The findings are summarized and conclusions were drawn as follows. 1. The best correction was obtained within a year after the initiation of bracing, followed by a gradual loss of correction. 2. There was a significant difference between the final correction rate and the best correction rate in the brace. 3. In the patients with ages ranging from 11 to 14 years and with curves of 30 degrees or less at the beginning of brace treatment, the curves were maintained within 30 degrees at the final stage. 4. Those patients who cooperated well in wearing their braces had a smaller loss of correction at the final stage. 5. In 63 per cent of the cases who showed progression in the brace, iliac apophysis did not appear at the beginning of brace treatment. 6. Moiré topography was used for the analysis of cosmesis and it was shown to be a valuable method of three dimensional evaluation. 7. In 60 patients who were followed up for 24 months on average after the brace was discontinued, the curves had improved an average of 1.6 degrees at the time of their last check up." }, { "id": "wiki20220301en506_25267", "title": "Management of scoliosis", "score": 0.013214957859422307, "content": "Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45 degrees to 50 degrees and by the Scoliosis Research Society (SRS) at a Cobb angle of 45 degrees. SOSORT uses the 45-degree to 50-degree threshold as a result of the well-documented, plus or minus five degrees measurement error that can occur while measuring Cobb angles. Scoliosis braces are usually comfortable for the patient, especially when it is well designed and fit; also after the 7- to 10-day break-in period. A well fit and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls." }, { "id": "pubmed23n0258_3346", "title": "Effectiveness of TLSO bracing in the conservative treatment of idiopathic scoliosis.", "score": 0.013002658690594882, "content": "A clear understanding of the effectiveness of the thoracolumbosacral orthosis (TLSO) as a conservative treatment for idiopathic scoliosis is still necessary. In the past few years, the review of pertinent literature has emphasized the lack of properly matched control studies and erroneous interpretations of results due to the use of univariate analysis. Also, in a previous controlled study evaluating the bracing of idiopathic scoliosis, the researchers mixed different types of braces and patients. Therefore, their findings were not specific to any kind of orthosis. In our study, we responded to these criticisms by providing a homogeneous group of patients with a control group and by conducting a multivariate analysis to assess the effectiveness of the TLSO. All the patients at the University Pediatric Hospital Scoliosis Clinic aged 8 through 15 with initial Cobb's angle between 20 and 40 degrees and evidence of progression were assessed. All the patients who used the TLSO and showed full compliance with treatment (n = 54) were compared with a control group. The control group consisted of the patients who needed the treatment with the brace but did not use it for several reasons (n = 47). Neither group showed significant differences in sex, initial age, initial Cobb's angle, menarche, Risser sign, or curve pattern. The mean follow-up period was 3.3 years after skeletal maturity. The results were analyzed using a multivariate analysis because the natural history of scoliosis is determined by multiple factors.(ABSTRACT TRUNCATED AT 250 WORDS)" }, { "id": "pubmed23n0716_15021", "title": "Treatment of lumbar curves in scoliotic adolescent females with progressive action short brace: a case series based on the Scoliosis Research Society Committee Criteria.", "score": 0.012991943307883749, "content": "A prospective interventional study. To determine the outcomes of adolescents affected by idiopathic lumbar scoliosis treated with a progressive action short brace (PASB). The efficacy of conservative treatment of scoliosis is still debated. In a recent study, we showed that the PASB was effective in correcting deformities in adolescents with idiopathic thoracolumbar scoliosis. The purpose of the present study was to extend our preliminary findings by determining the results of PASB treatment in scoliotic adolescents with lumbar curves. Patients were 40 adolescent girls (age [mean ± SD] = 11.6 ± 0.7 yr]) with lumbar curves and a pretreatment Risser score between 0 and 2. All patients were prescribed with a full-time PASB. The minimum duration of follow-up was 24 months (mean ± SD = 41.6 ± 34.5 mo). Anteroposterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), 1 year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), and 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization, and curve progression. RESULTS.: A significant reduction in CM was achieved from t1 (Cobb angle [mean ± SD] = 26.4° ± 2.8) to t5 (Cobb angle [mean ± SD] = 13.8° ± 7.9; P &lt; 0.001). Likewise, the PASB reduced TA from Perdriolle rotation angles of 10.8° (SD = 3.7) at t1 to 7.9° (SD = 4.2) at t5 (P &lt; 0.05). Curve correction was accomplished in 82.5% of patients, whereas curve stabilization was obtained in 17.5% of patients. None of the patients experienced curve progression. The PASB allows a complete curve correction in most cases. No patients exhibited curve progression." }, { "id": "pubmed23n1022_12424", "title": "Is brace treatment unnecessary for cases of adolescent idiopathic scoliosis above Risser sign 3?", "score": 0.012710505212510024, "content": "Skeletally mature cases of adolescent idiopathic scoliosis with mild curves are generally considered to have a low risk of deterioration. Previous reports have indicated that brace treatment in these cases has a high success rate; however, it is unclear whether brace treatment is necessary. The purpose of this study was to determine the incidence of adolescent idiopathic scoliosis progression during one year of follow-up in cases with a Risser sign ≥3, which were not treated with a brace, and to identify risk factors for progression. This retrospective, single center study included 54 cases of adolescent idiopathic scoliosis presenting to a university hospital in Japan between 2008 and 2017, with a Risser sign ≥3, which were not treated with brace treatment and had at least 2 years of follow-up data. The primary outcome was adolescent idiopathic scoliosis progression, defined as a deterioration in the Cobb angle of ≥ 6. Statistical analyses were performed to identify patient characteristics that were associated with progression. The mean age of the 54 included cases was 14.1 years, and the male to female ratio was 8:46. Scoliosis progressed in 8 (14.8%) cases within 2 years of follow-up. Female patients with progression were more likely to have recently gone through menarche than those without progression (p &lt; 0.01). There was a slight statistical difference in age (p &lt; 0.05), but no significant differences in sex, Risser-sign Stage, initial Cobb angle or main curve between adolescent patients with and without progression. We recommend brace treatment for cases of adolescent idiopathic scoliosis with a Risser sign ≥ 3 who have recently gone through menarche." }, { "id": "pubmed23n0800_14524", "title": "In favour of the definition \"adolescents with idiopathic scoliosis\": juvenile and adolescent idiopathic scoliosis braced after ten years of age, do not show different end results. SOSORT award winner 2014.", "score": 0.012258209626630679, "content": "The most important factor discriminating juvenile (JIS) from adolescent idiopathic scoliosis (AIS) is the risk of deformity progression. Brace treatment can change natural history, even when risk of progression is high. The aim of this study was to compare the end of growth results of JIS subjects, treated after 10 years of age, with final results of AIS. prospective observational controlled cohort study nested in a prospective database. outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. idiopathic scoliosis; European Risser 0-2; 25 degrees to 45 degrees Cobb; start treatment age: 10 years or more, never treated before. secondary scoliosis, neurological etiology, prior treatment for scoliosis (brace or surgery). Groups: 27 patients met the inclusion criteria for the AJIS, (Juvenile Idiopathic Scoliosis treated in adolescence), demonstrated by an x-ray before 10 year of age, and treatment start after 10 years of age. AIS group included 45 adolescents with a diagnostic x-ray made after the threshold of age 10 years. Results at the end of growth were analysed; the threshold of 5 Cobb degree to define worsened, improved and stabilized curves was considered. Mean and SD were used for descriptive statistics of clinical and radiographic changes. Relative Risk of failure (RR), Chi-square and T-test of all data was calculated to find differences among the two groups. 95% Confidence Interval (CI) , and of radiographic changes have been calculated. We did not find any Cobb angle significant differences among groups at baseline and at the end of treatment. The only difference was in the number of patients progressed above 45 degrees, found in the JIS group. The RR of progression of AJIS was, 1.35 (IC95% 0.57-3.17) versus AIS, and it wasn't statistically significant in the AJIS group, in respect to AIS group (p = 0.5338). There are no significant differences in the final results of AIS and JIS, treated with total respect of the SRS and SOSORT criteria, in adolescence. Brace efficacy can neutralize the risk of progression." }, { "id": "pubmed23n0708_15954", "title": "School screening and point prevalence of adolescent idiopathic scoliosis in 4000 Norwegian children aged 12 years.", "score": 0.011848013816925735, "content": "School screening for adolescent idiopathic scoliosis (AIS) is discussed. The aim of the present study was to describe the point prevalence of AIS and to evaluate the effectiveness of school screening in 12-year- old children. Community nurses and physical therapists in the Southern Health region of Norway including about 12000 school children aged 12 years were invited to participate. All participating community nurses and physical therapists fulfilled an educational course to improve their knowledge about AIS and learn the screening procedure including the Adam Forward Bending Test and measurement of gibbus using a scoliometer. Sub-regions including 4000 school children participated. The prevalence of idiopathic scoliosis defined as a positive Adam Forward Bending Test, gibbus &gt; 7° and primary major curve on radiographs &gt; 10°, was 0.55%. Five children (0.13%) had a major curve &gt; 20°. Bracing was not indicated in any child; all children were post menarche; four had Risser sign of 4, and one with Risser 1 did not have curve progression &gt; 5° at later follow-up. In one of these 5 children however, the major curve progressed to 45° within 7 months after screening and the girl was operated. The point prevalence of AIS in 12- year old children is in agreement or slightly lower than previous studies. The screening model employed demonstrates acceptable sensitivity and specificity and low referral rates. Screening at the age of 12 years only was not effective for detecting patients with indication for brace treatment." }, { "id": "pubmed23n1138_9600", "title": "Does Risser Casting for Adolescent Idiopathic Scoliosis Still Have a Role in the Treatment of Curves Larger Than 40°? A Case Control Study with Bracing.", "score": 0.011786600496277916, "content": "<bBackground</b: The most common conservative treatment for Adolescent Idiopathic Scoliosis (AIS) is bracing. However, several papers questioned the effectiveness of bracing for curves between 40° and 50° Cobb: the effectiveness in preventing curve progression could be as low as 35%. Seriate casting is considered a standard approach in early onset scoliosis; however, in the setting of AIS, cast treatment is seldom utilized, with only few studies reporting on its effectiveness. <bAim of the study:</b The main aim of the study is to determine whether a seriate casting with Risser casts associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. Furthermore, the secondary endpoints were: (1) is there a difference in effectiveness of casting between Thoracic (T) and Thoracolumbar/Lumbar (TL/L) curves? (2) Does the 'in cast' correction predicts the treatment outcome? (3) What is the effect on thoracic kyphosis of casting? <bMethods</b: This is a retrospective monocentric case-control study; through an Institutional Database search we identified all the patients treated at our institution between 1 January 2017 and 31 December 2020, with a diagnosis of AIS, Risser grade between 0 and 4 at the beginning of the treatment, at least one curve above 40° Cobb and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Standing full spine X-rays in AP and LL are obtained before and after the cast treatment; only AP standing full spine X-rays 'in-cast' are obtained for each cast made. Patients were stratified according to the curve behavior at the end of treatment (Risser 5): progression was defined as ≥6° increase in the curve magnitude or fusion needed; stabilization is defined as a change in curve by ±5°; and improvement was defined as ≥6° reduction in the curve. <bResults</b: For the final analysis, 55 compliant patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 27 (4 M, 23 F, mean age 13.6 ± 1.6) in the CG. Eight (14.5%) patients in the SG failed the conservative treatment while 14 (51.3%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1, 3-2.6, <ip</i = 0.001), and the Number Needed to Treat was 2,4. No significant difference was found between the T and TL/L curves concerning the 'progressive' endpoint (z-score 0.263, <ip</i = 0.79). The mean percentage of 'in cast' curve reduction was 40.1 ± 15.2%; no significant correlation was found between the percentage of correction and the outcome (Spearman Correlation Coefficient 0.18). Finally, no significant differences between baseline and end of FU TK were found (32° ± 16.2 vs. 29.6 ± 15.8, <ip</i = ns). <bDiscussion:</b Seriate Risser casting for AIS with larger curves (&amp;gt;40° Cobb) is effective in reducing curve progression when compared with full time bracing alone in treatment compliant patients. The treatment is equally effective in controlling T and TL/L curves; furthermore, a slight but non-significant decrease in TK was observed in patients treated with casting. This type of treatment should be considered for AIS patients who present with large curves to potentially reduce the percentage of surgical cases. <bShort Abstract</b: The aim of the study is to determine whether seriate Risser casting associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. This is a retrospective monocentric case-control study; we identified all the patients treated at our institution with a diagnosis of AIS, Risser grade 0-4 at the beginning of the treatment, at least one curve above 40° Cobb (35° if treated with bracing alone) and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Fifty-five patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 30 (5 M, 25 F, mean age 13.9 ± 1.7) in the CG. Eight (14,5%) patients in the SG failed the conservative treatment while fifteen (50%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1.3-2.6, <ip</i = 0.001), and the Number Needed to Treat was 2,4. Seriate Risser casting for AIS with larger curves (&amp;gt;40°) is effective in reducing curve progression when compared with full time bracing alone. This type of treatment should be considered for AIS patients who present with large curves." }, { "id": "wiki20220301en007_12922", "title": "Scoliosis", "score": 0.011751275852806876, "content": "For example, a person who is still growing with a 17° Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29° Cobb angle and a Risser sign three or four might not need to be braced because the potential for progression is reduced. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. Scoliosis braces are usually comfortable, especially when well designed and well fitted, also after the 7- to 10-day break-in period. A well fitted and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position." }, { "id": "pubmed23n0321_19357", "title": "Preliminary results and worst-case analysis of in patient scoliosis rehabilitation.", "score": 0.0116325846463292, "content": "The purpose of this study was to assess the effectiveness of a scoliosis-specific rehabilitation programme as it is carried out in the Katharina Schroth Spinal Deformities Rehabilitation Center. Physiotherapy in the treatment of scoliosis patients is still regarded as ineffective since the study by the American Orthopedic Association in 1941, which showed that general exercises could not influence the natural history of scoliosis. However, specific exercise programmes were not known in the USA at that time. This preliminary study started in 1989 with the following inclusion criteria: (1) diagnosis of idiopathic scoliosis; (2) risser sign &lt; 4; (3) no treatment other than physiotherapy; (4) first control after 1-3 years during repeated in patient treatment; (5) standing AP radiograph taken not more than 6 months before the first in patient treatment. A total of 181 scoliosis patients, with an average age of 12.7 years and an average angle of curvature of 27% according to Cobb, were included in this study. The average risser sign was 1.4, the average follow-up 33 months. The Cobb angle of the major curve was measured in a standardized way. The results of our preliminary study were compared to natural history as known from literature. For the worst-case analysis additionally a questionnaire was sent to the non-repeaters treated at our centre at the same time (1989 and 1990) as the patient sample described above, taking into account the same inclusion criteria for this patient sample except point 4. Results showed that progression as usually defined (increase in curvature of 5 degrees or more per year) has not been found in the preliminary study. The patient sample of this study was divided into different age groups and different groups of curve magnitude, for comparison with other studies. Additional to the patient sample of the preliminary study, 116 of the patients from the years 1989 and 1990 fulfilled the inclusion criteria of the preliminary study with the exception of point 4. These patients formed the questionnaire sample for the worst-case analysis showing that the progression rate of the 181 patients from the preliminary study and the 116 patients of the questionnaire sample together was still better than natural history even if all drop-outs were considered to be failures. The fact that there was no relative progression in our patients sample treated solely by physiotherapy (preliminary study), seems to show the effectiveness of the inpatient rehabilitation programme even in cases with a bad prognosis, severe angles of curvature and unfavourable curvature patterns. A worst-case analysis does not prevent this conclusion, even if all dropouts from the non-repeaters group were considered as failures." }, { "id": "pubmed23n0548_4535", "title": "[Is it too late to start orthopedic treatment for idiopathic scoliosis with Risser scores of 4?].", "score": 0.011393429357501214, "content": "Orthopaedic treatment for idiopathic scoliosis in adolescence is indicated with a curve of &gt; or =20 degrees and a Risser score&lt; or =4, because progression of curve is low with Risser scores &gt;4. We present the case of a young man with a left lumbar idiopathic scoliosis (T12-L4) with a curve of 10 degrees, which was stable from 13 years (Risser 0) to 16 years old (Risser 4). The scoliosis progressed quickly after a Risser score of 4 was achieved. The man had been wearing a lift on the left foot since he was 13, because of a leg length discrepancy, and had been under clinical and radiological monitoring. When the boy reached 17 years, the scoliosis rapidly progressed, to a curve of 22 degrees and a Risser score of &gt;4. The scoliosis was effectively treated with a Boston brace. At 20 years, the Risser score was 5, and the left lumbar curve was 13 degrees after discontinuing the use of the brace. To our knowledge, no scientific reference indicates a time limit to orthopaedic treatment for idiopathic adolescent scoliosis. Despite the experts' recommendations, a brace might be indicated with a Risser score &gt; or =4 to stop the progression of the curve." }, { "id": "pubmed23n0685_19719", "title": "Idiopathic scoliosis patients with curves more than 45 Cobb degrees refusing surgery can be effectively treated through bracing with curve improvements.", "score": 0.010473788111427944, "content": "It is a broad consensus today that scoliosis curves cannot be improved through bracing, and the Scoliosis Research Society (SRS) methodological criteria for bracing have the avoidance of progression as their only objective. Consequently, in curves more than 45°, fusion is considered as basically the only possible treatment. The purpose of the study was to verify in a series of patients who utterly refused surgery if it was possible to achieve improvements of scoliosis of more than 45° through a complete conservative treatment (bracing and exercises). Retrospective cohort from a prospective database. Out of 1,148 idiopathic scoliosis (IS) patients at the end of treatment, the sample comprised 28 subjects older than 10 years, still growing, with at least one curve above 45°, who had continually refused fusion. The group comprised 24 females and four males, including 14 in which previous brace treatments had failed; at the start of treatment, the age was 14.2±1.8 years and Cobb degrees in the curve were 49.4° (range, 45°-58°). Subgroups considered were gender, bone age, type of scoliosis, treatment used, and previous failed treatment. Self-report measurement: SRS-22; physiological measures: Cobb degrees, Bunnell angle of trunk rotation (ATR), aesthetic index (AI), and sagittal plumb line distances. The methods comprised full-time treatment (23 or 24 hours per day) for 1 year with Risser cast, Lyon, or Sforzesco brace; weaning of 1 to 2 hours every 6 months; with strategies to maximize compliance through the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) management criteria applied and specific scientific exercises approach to scoliosis exercises (SEAS) performed. Reported compliance in the 4.10±1.2 treatment years was 94%, with satisfaction regarding treatment and excellent results at the SRS-22. Two patients (7%) remained above 50° Cobb but six patients (21%) finished between 30° and 35° Cobb and 12 patients (43%) finished between 36° and 40° Cobb. Improvements have been found in 71% of patients and a 5° Cobb progression in one patient. Statistically, we found highly significant reductions of the main (-9.25°), average (-6.6°), thoracic (-7.8°), and lumbar (-15.9°) curves. Statistically significant improvements have been found for the AI and ATR, with a general decrease in plumb line distances. Bracing can be successfully used in patients who do not want to undergo operations for IS with curves ranging between 45° and 60° Cobb, given sufficient clinical expertise to apply good braces and achieve great compliance. Future studies could demonstrate the percentages at which this result can be achieved." }, { "id": "pubmed23n0504_7732", "title": "Three-dimensional action of Chêneau brace on thoracolumbar scoliosis.", "score": 0.00980392156862745, "content": "We treated 18 girls for idiopathic thoracolumbar scoliosis with Chêneau brace. The apex of the curve was at Th12 or at L1 or at the disc Th12/L1. The initial Cobb angle varied from 21 to 42 degrees, mean 28. The follow up period was of 2 years and 6 months on the average. We noted the rib hump height on Adams' forward bending test. We measured Cobb angle, apical vertebra transposition and apical vertebra rotation (according to Perdriolle method) on antero-posterior standing radiograms before the treatment had started and at the moment of the best correction. We digitized antero-posterior and lateral standing radiograms with sonic digitizer GP-9 and we prepared computed reconstruction of the transversal plane of the spine with Hecquet and Graf's software RACHIS 91TM. The best clinical and radiological correction was achieved after 3 to 8 months of treatment (mean 5,5 months). We considered it as the fitting period and we analysed the correction achieved at that moment and at last follow-up. Cobb angle in brace ranged from 0 to 18 degrees, mean 9 degrees. The correction of apical vertebra transposition ranged from 51% to 100%, mean 80%. The correction of apical vertebra rotation ranged from 0% to 100%, mean 52%. The correction of rib hump ranged from 0 to 100%, mean 42%. Normal sagittal contour was established in 15 patients. important correction was present in each of the three planes." }, { "id": "pubmed23n0609_6199", "title": "SpineCor vs. natural history - explanation of the results obtained using a simple biomechanical model.", "score": 0.009708737864077669, "content": "In the recent peer reviewed literature the SpineCor is described as an effective method of treatment for patients with scoliosis. However until recently no prospective controlled end-result study is presented comparing the results obtained with this soft brace to natural history. The objective was to determine whether the results obtained by the use of the SpineCor are better than natural history during pubertal growth spurt. The method employed prospective comparison of the survival rates of SpineCor treatment vs. natural history with respect to curve progression during pubertal growth spurt. 12 Patients with Cobb angles between 16 and 32 degrees (at average 21 degrees) during pubertal growth spurt are presented as a case series treated with the SpineCor. Survival rate of this sample is described and compared to natural history (SRS brace study 1995). All girls treated in both studies were at risk for being progressive with the first clinical signs of maturation (Tanner 2-3). During the pubertal growth spurt most of the patients (11/12) with SpineCor progressed clinically and radiologically as well (at least 5 degrees). Progression could be stopped changing SpineCor to the Chêneau brace in most of the sample described (7/10). The avarage Cobb angle at the start of treatment with the SpineCor was 21.3 degrees, after an average observation time of 21.5 months 31 degrees. At 24 months of treatment time 33% of the patients with the SpineCor where still under treatment with their original bracing concept, at 72 months follow-up time 8 % of the patients with the SpineCor survived with respect to curvature progression. Survival proportion in the SpineCor sample, though was 0.08, while in the natural history cohort it was 0.34. The SpineCor treatment during pubertal growth spurt seems to lead to a worse outcome than observation only. The use of a simple biomechanical model explains that in the brace the compression forces exceed the lateral forces used for the corrective movement. Therefore SpineCor does not seem to be indicated as a treatment during pubertal growth spurt." }, { "id": "pubmed23n0958_18606", "title": "Effect of the Chêneau Brace in the Natural History of Moderate Adolescent Idiopathic Scoliosis in Girls: Cohort Analysis of a Selected Homogenous Population of 100 Consecutive Skeletally Immature Patients.", "score": 0.009615384615384616, "content": "Α series study. To evaluate the relationships between the effectiveness of brace in reduction of scoliosis angle, axial trunk rotation (ATR), and patients' compliance, in skeletally immature females with moderate adolescent idiopathic scoliosis (AIS), treated with Chêneau brace for a minimum of three years. According to some authors, braces are ineffective, whereas others find that braces stop scoliosis progression and that the outcome has been related to patient's compliance. From the 100 patients who were initially recruited, 88 patients were included in the final analysis. The average ± SD primary scoliosis angle before brace application was 36.8° ± 9.9°, 32.7° ± 6.3°, and 33.5° ± 11.5° for major thoracic, thoracolumbar, and lumbar curvatures, respectively. All patients were aged ≥10 years at treatment initiation, and their Risser index varied from 0 to II. Eighty-eight patients were followed for at least three years with brace treatment, whereas 43 patients were reevaluated 31 ± 7 months after brace weaning. In baseline and while in brace, the scoliosis Cobb angle, Risser index, menarche age, ATR, and patient's compliance were recorded. In the 88 patients, the brace reduced the major thoracic, thoracolumbar, and lumbar scoliosis one month after brace onset while \"in brace\" to 26° ± 11° (29% ± 18%, p = .0006), 23° ± 8° (31% ± 20%, p = .00001), and 24° ± 11° (34% ± 21%, p = .00043), respectively; thereafter, no significant decrease of the curves was recorded. Total bracing time averaged at 45 ± 19 months (range 36-96) and brace weaning averaged at 17 ± 2 years (range 15-19). Six of the 88 (6.8%) individuals underwent surgery for scoliosis progression. In the 43 patients who were reevaluated 31 ± 7 months after brace weaning, scoliosis angle and ATR increased insignificantly, compared to the three years' values. Chêneau orthosis reduced while \"in brace\" AIS in girls with sufficient compliance, with a low rate (6.8%) of patients who underwent surgery. Level 3." }, { "id": "pubmed23n0211_15462", "title": "Progression in scoliosis. A 360 degrees change in 75 years.", "score": 0.009615384615384616, "content": "With the proliferation of school screening programs for spinal deformity, attention has been directed to methods of scoliosis evaluation and follow-up that avoid serial x-ray exposure. An historical review of the scoliosis literature prior to the extensive use of x-ray in scoliosis care has demonstrated much that is now being \"rediscovered.\" By 1900, screening for spinal deformity in the schools had been instituted, pertinent findings of the physical examination in patients with scoliosis had been well described, and early natural history information had been obtained regarding the behavior of small curves and curves associated with thoracic lordosis. Recordings of surface contours and rib humps, using inclinometers, lead rulers, and other measuring devices, were used to assess the progression of curves. Low contour braces were widely available. Although our orthopaedic forefathers had many erroneous ideas, a perusal of the early orthopaedic writings from around the turn of the century has shown how little is \"new\" (other than changes in material and spinal instrumentation techniques) from what was recognized 75 years ago." }, { "id": "wiki20220301en506_25265", "title": "Management of scoliosis", "score": 0.009599005570645918, "content": "Indications for Scoliosis Bracing: Scoliosis professionals determine the proper bracing method for a patient after a complete clinical evaluation. The patient’s growth potential, age, maturity, and scoliosis (Cobb angle, rotation, and sagittal profile) are also considered. Immature patients who present with Cobb angles less than 20 degrees should be closely monitored and proactively treated based on their risk of progression as surgery can be prevented with early intervention of conservative treatment. Immature patients who present with Cobb angles of 20 degrees to 29 degrees should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. Immature patients who present with Cobb angles greater than 30 degrees should be braced. However, these are guidelines and not every patient will fit into this table. For example, an immature patient with a 17-degree Cobb angle and significant thoracic" }, { "id": "pubmed23n0802_13523", "title": "The effectiveness of combined bracing and exercise in adolescent idiopathic scoliosis based on SRS and SOSORT criteria: a prospective study.", "score": 0.009523809523809525, "content": "Recently an RCT confirmed brace efficacy in adolescent idiopathic scoliosis (AIS) patients. Previously, a Cochrane review suggested also producing studies according to the Scoliosis Research Society (SRS) criteria on the effectiveness of bracing for AIS. Even if the SRS criteria propose a prospective design, until now only one out of 6 published studies was prospective. Our purpose was to evaluate the effects of bracing plus exercises following the SRS and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) criteria for AIS conservative treatment. prospective cohort study nested in a clinical database of all outpatients of a clinic specialized in scoliosis conservative treatment. seventy-three patients (60 females), age 12 years 10 months ±17 months, 34.4±4.4 Cobb degrees, who satisfied SRS criteria were included out of 3,883 patients at first evaluation. Cobb angle at the end of treatment according to SRS criteria : (unchanged; worsened 6° or more, over 45° and surgically treated, and rate of improvement of 6° or more).Braces were prescribed for 18-23 hours/day according to curves magnitude and actual international guidelines. Weaning was gradual after Risser 3. All patients performed exercises and were managed according to SOSORT criteria. Results in all patients were analyzed according to intent-to-treat at the end of the treatment. Funding and Conflict of Interest: no. Overall 34 patients (52.3%) improved. Seven patients (9.6%) worsened, of which 1 patient progressed beyond 45° and was fused. Referred compliance was assessed during a mean period of 3 years 4 months ±20 months; the median adherence was 99.1% (range 22.2-109.2%). Employing intent-to-treat analysis, there were failures in 11 patients (15.1%). At start, these patients had statistically significant low BMI and kyphosis, high thoracic rotation and higher Cobb angles. Drop-outs showed reduced compliance and years of treatment; their average scoliosis at discontinuation was low: 22.7° (range 16-35°) at Risser 1.3 ± 1. Bracing in patients with AIS who satisfy SRS criteria is effective. Combining bracing with exercise according to SOSORT criteria shows better results than the current literature." }, { "id": "wiki20220301en007_12903", "title": "Scoliosis", "score": 0.009460547504025765, "content": "Treatment depends on the degree of curve, location, and cause. Minor curves may simply be watched periodically. Treatments may include bracing, specific exercises, posture checking, and surgery. The brace must be fitted to the person and used daily until growing stops. Specific exercises, such as exercises that focus on the core, may be used to try to decrease the risk of worsening. They may be done alone or along with other treatments such as bracing. Evidence that chiropractic manipulation, dietary supplements, or exercises can prevent the condition from worsening is weak. However, exercise is still recommended due to its other health benefits. Scoliosis occurs in about 3% of people. It most commonly develops between the ages of ten and twenty. Females typically are more severely affected than males with a ratio of 4:1. The term is from which means \"a bending\". Signs and symptoms" }, { "id": "wiki20220301en007_12914", "title": "Scoliosis", "score": 0.00943417217364217, "content": "The standard method for assessing the curvature quantitatively is measuring the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. For people with two curves, Cobb angles are followed for both curves. In some people, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves. Congenital and idiopathic scoliosis that develops before the age of 10 is referred to as early-onset scoliosis. Progressive idiopathic early-onset scoliosis can be a life-threatening condition with negative effects on pulmonary function. Scoliosis that develops after 10 is referred to as adolescent idiopathic scoliosis. Screening adolescents without symptoms for scoliosis is of unclear benefit." } ] } } }